picketing and protest marches) in which citizens organize to force attention to community problems that they feel are being ignored or mishandled by authorities.
The value of Warren's model lies in emphasizing that community concerns can take conflictual and troublesome forms and still represent a positive contribution toward problem solving. Being only human, nurses may feel tempted to "advocate" mainly with those who use collaborative approaches for problem solving, because interaction with them is comfortable and affirming. Those using campaign or contest strategies are easy to dismiss as unhelpful, obstructive, and irrational. But in environmental health issues, militant approaches may be seen by those immediately affected as necessary aspects of problem solving (Alinsky, 1989). Nurses' advocacy roles will need to connect with this reality.
It should be noted that both case advocacy and class advocacy involve some thorny ethical dilemmas (see Gilbert and Specht, 1976; Needleman and Needleman, 1974). For example, if the advocacy goals as defined by clients and communities differ sharply from the advocacy goals as defined by the nurse who is acting as advocate, what should happen? Also, advocacy may in principle be a poor way to allocate resources equitably within a social system, because the clients and issues with the most effective advocates will not necessarily be the same ones with the greatest need. But despite such unsettling second thoughts on an abstract level, the questions confronting nurses on the front line of practice remain immediate and compelling: how to help as much as possible with the human problems at hand. In relation to environmental health issues, the answers often lead in the direction of advocacy, particularly advocacy at the policy level.
At present, policy advocacy for structural change is not emphasized in nursing education, leaving nurses somewhat on their own for exploring strategy options and developing the necessary skills. Fortunately, a great many self-training guides and manuals are available for health and human service professionals interested in advocacy practice related to environmental health issues. Box F.1 below lists some good starting points.
Many resources also exist for particular skill areas. Box F.2 lists a small sample of the voluminous self-training literature available on the nuts and bolts of advocacy practice techniques such as lobbying, use of mass media, working with community groups, organizing, coalition building, community research projects, giving expert testimony, and program development.