CHAPTER 5 CONCLUSION AND RECOMMENDATIONS Summary of the study This descriptive study aimed to describe nurses perception of their moral actions in patient advocacy in regional hospitals, Ministry of Public Health, southern Thailand. The sample was 260 registered nurses, with at least one-year experience in nursing practice, who took care of hospitalized adult patients in medical and surgical departments of the targeted hospitals. The instruments were a demographic data form, a self-report questionnaire, and a semi-structured interview guide. Descriptive statistics were used to analyze demographic data and nurses perception of their moral actions in patient advocacy. In addition, the content analysis approach of Waltz, Strickland, and Lenz (1991) was used to analyze the qualitative data from the semistructured interview. The results were summarized as follows: 1 Nurses perception of their moral actions in performing patient advocacy roles The average score of nurses perception of their moral actions in patient advocacy was at a high level as reflected by the average total score of nurses moral actions in patient advocacy of 3.08 (S.D.=0.38). All of the roles of patient advocacy were also found at a high level ( x =2.79-3.45). When considering each role, it was found that supporting had the highest mean score ( x =3.45, S.D.=0.40), followed by 101
informing ( x =3.23, S.D.=0.44), while respecting had the lowest mean score ( x =2.79, S.D.=0.37). 2 Factors influencing nurses in performing patient advocacy roles Findings from semi-structured interviews, showed that the factors facilitating nurses in performing patient advocacy roles were: good organizational culture, good will, positive outcomes, positive feedback, knowledge/experiences of nurses, and being expected to be a role model. On the other hand, the factors inhibiting nurses in performing patient advocacy roles were poor co-operation, being confronted with negative feedback or unpredictable outcomes, low authority, and staff shortages. Contributions to nursing ethics literature Performing a patient advocacy role, nurse advocators must concerned with all five important roles: supporting, informing, protecting, facilitating, and respecting. Diminishing consideration in one role could result in patients not being given holistic care and their rights could be violated. Nurse should advocate for patients so they are not put at risk for being violated, and should help patients be able to advocate for themselves if they can, to know their values and beliefs, and make decisions by themselves based on their values. Then, encourage patients to speak on behalf of themselves. Also, nurse should advocate for patients when they are at risk or when their rights have been violated. Performing a patient advocacy role, nurse may face undesirable outcomes such as being confronted with negative feedback. Thus, nurse must be competent in 102
the many skills used in performing patient advocacy roles such as communication, negotiation, collaboration, and conflict management. Implications and recommendations Based on the findings of this study, the following possibilities for nursing practice, nursing administration, nursing education, and nursing research are suggested. 1. Implications and recommendations for nursing practice 1.1 The findings of this study indicated that the mean score of respecting was found to have the lowest mean score. Thus, nurses who work in regional hospitals, Ministry of Public Health, southern Thailand may need to be encouraged to have greater respect for patient autonomy. 1.2 The findings of this study indicated that the experience of nurses was one factor facilitating nurses in performing patient advocacy roles. Thus, nurses who have more nursing experience should share with other colleagues their experiences, knowledge, and skills in advocating for patients. 1.3 To advocate for patients, nurses must pay attention to all five roles of patient advocacy. Lacking of performing one roles could result in patients not being given holistic care and patients rights could be violated. 2. Implications and recommendations for nursing administration 2.1 Nurse administrators in the hospitals can continue to promote nurses to perform patient advocacy roles by maintaining good organizational culture, giving positive feedback to those who advocate for patients, and enhancing the nursephysician relationship and nurse-patient relationship. 103
2.2 The subscale items which were rated at a moderate level and the respecting role receiving the lowest mean score showed that nurses feel uncomfortable when performing patient advocacy roles which involve other health care team members due to their low authority and fear of negative feedback. Thus, to promote nurses performing patient advocacy roles, nurses moral commitment to advocate for patients should be encouraged by hospital administrators, head nurses, and senior nurses.. 2.3 To promote nurses moral actions in performing patient advocacy roles, hospital administrators should state clearly the nurses roles in advocating for patients, give nurses authority to do that, facilitate nurses to advocate for patients by reducing the process by which nurses contact people in authority, and establish a patient advocacy team to provide counseling for nurse advocators. 2.4 Hospital administrators should state clearly the policy in investigating nurses errors regarding patient advocacy and provide ways to help nurse advocators in situations where they face any difficulties due to their advocating for patients. 3. Implications and recommendations for nursing education 3.1 These findings can be used as baseline data in teaching patient advocacy roles for nursing students and also for other nurses. It is recommended that nurse educators should provide students with the basic concept of patient advocacy and skills in performing patient advocacy roles: such as communication, negotiation, collaboration, and conflict management, so that the students can apply it in their nursing practice. Also, nurse educators should establish nurses moral commitment to perform the patient advocate role in their students and other nurses. 104
4. Implications and recommendations for further research 4.1 To determine the level of advocacy throughout Thailand the same study should be done in the other regional hospitals of Thailand. 4.2 To see if the perceptions of nurses and patients are similar in regard to the need for advocacy the study on nurses moral actions in performing patient advocacy roles should be extended to explore patients perception. 4.3 A cross- sectional study should be done to explore the predictor of nurses performing patient advocacy roles. 4.4 The instrument self-report questionnaire, Patient Advocacy Questionnaire, should be developed to be a standardized instrument to measure patient advocacy in further studies. 105