BOX 3.2
Advocacy Practice

Interventions in environmental health problems often require nurses and other health care professionals to assume the roles of advocate, activist, and policy planner on behalf of a single patient or population of patients. Patient advocacy within the health care setting is familiar to most, if not all, nurses; for example, bringing a patient's concerns to the attention of the physician. However, advocacy that goes beyond the health care system is a new kind of activity for many nurses, who may feel ill equipped to translate research and practice issues into health policy terms.

Most nursing professionals are comfortable with the idea of case advocacy on behalf of an individual patient, even when it involves aggressive action in the interests of the patient. Where ambivalence occurs is over policy-level (class) advocacy aimed at changing environmental conditions that are detrimental to populations of patients. For some members of the profession, the latter kinds of activity will seem unprofessional, overly political, and inappropriate for nurses. Others will regard it as an expression of nursing's true mission, going back to the profession's origins as crusaders for social justice, as embodied in the practice Florence Nightingale and Lillian Wald. Nurses interested in advocacy practice will find many pressures and incentives encouraging them to define this activity around the needs of individual patients. Policy-level advocacy for structural change is not emphasized in nursing education, not fully legitimized by the field's professional associations (although it is popular among student members), and not welcomed by the majority of employers and hospital administrators. In the area of environmental health, however, nurses are likely to be drawn into a fuller range of advocacy activities whether they are prepared for these roles or not. Therefore, the issue is not whether to undertake policy advocacy, but rather how to do it in a way that is sophisticated, realistic, and constructive. Anxiety about advocacy roles can be lessened considerably by building familiarity with a wider range of advocacy techniques, not all of which are necessarily adversarial.

There are many ways to conceptualize and practice advocacy in health and human services, and there are many heated debates about what true advocacy means. Different starting premises are possible. For example, who determines what is needed: the professional or those directly affected? Should professionals acting as advocates aim simply to solve the current problem, or should they, in addition, try to empower patients and communities to solve similar problems for themselves in the future? Is public conflict something always to be avoided in advocacy efforts, or is it sometimes useful? In thinking about such questions, nurses can draw on literature from other professional fields with advocacy dimensions such as social work, city planning, education, public health, law, and mediation. Based on a review of advocacy literature, Appendix F presents some useful conceptual frameworks for understanding different forms of advocacy and different advocacy strategies.

Advocacy that goes beyond helping an individual patient and enters the realm of health policy is not yet acceptable and expected practice for all nurses. To prepare the profession for a broader range of advocacy activities, nursing curriculum and continuing education programs may come to include content on lobbying, use of media, mediation, expert testimony, community organizing, and the like. In the meantime, whether with institutional support or on their own, nurses who are stretching the definitional boundaries of advocacy practice will need to build skills that were likely not part of their basic nursing education. Appendix F lists some of the self-training and support resources available for health and human services professionals interested in advocacy practice at the policy level.

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