Article

Nursing Ethics
2014, Vol. 21(6) 673683
Swedish nurses perceptions of The Author(s) 2014
Reprints and permission:
sagepub.co.uk/journalsPermissions.nav
influencers on patient advocacy: 10.1177/0969733013515488
nej.sagepub.com
A phenomenographic study

Anna Josse-Eklund
Karlstad University, Sweden
Marie Jossebo
Karlskoga Hospital, Sweden

Ann-Kristin Sandin-Bojo
Karlstad University, Sweden; Varmland County Council, Sweden
Bodil Wilde-Larsson
Karlstad University, Sweden; Hedmark University College, Norway
Kerstin Petzall
Karlstad University, Sweden; Gjvik University College, Norway

Abstract
Background: A limited number of studies have shown that patient advocacy can be influenced by both
facilitators and barriers which can encourage and discourage nurses to act as patient advocates.
Objective: This studys aim was to describe Swedish nurses perceptions of influencers on patient
advocacy.
Research design and context: Interviews with 18 registered nurses from different Swedish clinical
contexts were analysed using the phenomenographic method.
Ethical considerations: Ethical revisions were made in accordance with national legislation and guidelines
by committees for research ethics at Karlstad University.
Findings: Three levels of hierarchically related influencers on patient advocacy were found in the
descriptive categories. The fundamental influencer, the nurses character traits, was described in
the perceptions that advocacy is influenced by nurses having a moral compass, having control over the
care situation, being protective and feeling secure as a nurse. The second most vital influencer, the
nurses bond with the patient, was expressed in the perceptions of knowing the patient and feeling
empathy for the patient. The third level of influencers, the organisational conditions, was described in the
perceptions that the organisational structures and organisational culture influence patient advocacy.
Discussion: The results correspond with findings from earlier research but add an understanding that
influencers on patient advocacy exist at three hierarchically related levels.
Conclusion: The nurses character traits are the fundamental influencer to patient advocacy, but in order
to be comfortable and secure when advocating for patients, nurses also need to be familiar with both the

Corresponding author: Anna Josse-Eklund, Department of Health Sciences, Faculty of Health, Science and Technology, Karlstad
University, 651 88 Karlstad, Sweden.
Email: anna.eklund@kau.se

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674 Nursing Ethics 21(6)

patient and the situation. A supposition could be that all influencers interact, which needs to be further
addressed in future studies.

Keywords
Nursepatient relationship, nursing qualities, organisation, patient advocacy, phenomenography

Introduction
A vital function in contemporary nursing is that of patient advocacy,1 to act on patients unmet
needs.2 This may include actions such as informing, protecting, speaking for patients,2,3 acting against
incompetent and unethical treatment,4 and monitoring the nursing process.5 Although patient advo-
cacy can be considered to be an important nursing action, it is imperative to acknowledge that advo-
cacy should always be carried out in the patients best interests, not in the interests of the nurses.6
Nursing actions should be based on an acknowledgement of a patients human rights,7 the right to
self-determination and personal integrity8 in order to empower the patient.9 Although nurses ethical
guidelines do not often explicitly state that nurses should advocate for patients, the International
Council of Nurses code of ethics10 implicitly describes elements of advocacy, such as providing
patients with sufficient information to be able to make informed decisions and safeguarding patients
when their health is threatened by others.
Of the more recent theories and theoretical models about patient advocacy, Hanks11 model and Bu
and Jezewskis12 mid-range theory are especially noteworthy. Hanks11 sphere of nursing advocacy
model states that when patients are unable to speak for themselves or are in vulnerable situations,
nurses create a protective shield around the patient. The sphere is semi-permeable so that the patient,
when able, can self-advocate. In Bu and Jezewskis12 mid-range theory, patient advocacy is defined as
a process or strategy with a set of actions to maintain and monitor patients rights, best interests and
values in healthcare. With this theory, there are three core attributes that signify patient advocacy: to
safeguard patients autonomy, to act on behalf of patients and to champion social justice in the pro-
vision of healthcare.
Patient advocacy can be influenced by facilitators and barriers.13 One of the most frequently described
facilitators is the nursepatient relationship.1315 Nurses characteristics are also considered as facilitators
of advocacy. Professional competence1316 with components such as organisational skills,17 high job
motivation18 and experience15 is recurrently depicted as a facilitator of advocacy. Nurses personal char-
acteristics, including a capacity to create relationships as well as persistence and credibility, are described as
necessary for effective advocacy.16 The workplace environment is also described as a facilitator19 as well as
an organisation where nurses work together in teams with physicians.13
Barriers to patient advocacy have been described mainly within organisations. Lack of support from
nurse managers,13,20 time constraints and limited communication within the organisation13 inhibit patient
advocacy. Nurses have stated that they run the risk of burnout,21 being considered bad colleagues by other
nurses,22 being relocated within the organisation21 and wage reduction13 when advocating. The risks that
nurses may face when advocating limit their ability and willingness to advocate.6,13,14,23
Studies of influencers on patient advocacy have shown that they can both facilitate and act as barriers to
advocacy. These findings are from a limited number of cultural and clinical settings and need further clar-
ification. Conducting a qualitative study of influencers on patient advocacy in a Swedish clinical and cul-
tural context, with a healthcare system which may differ from other contexts, could provide some additional
enlightenment.

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Josse-Eklund et al. 675

Aim
The aim was to describe nurses perceptions of influencers on patient advocacy.

Method
Design
A qualitative approach with a phenomenographic method was used, based on interviews. Phenomenogra-
phy is a method used to describe variations in peoples perceptions of the world around them24 and how
these perceptions appear and create meaning.25 Research questions in phenomenography are formulated
from a second-order perspective, to describe perceptions of the world, rather than from a first-order perspec-
tive where the world, as such, is described.24 The researcher identifies qualitatively different perceptions of
a phenomenon and categorises these in order to describe the collective experience of the phenomena of
interest. Each of these categories must be logically related to one another, be parsimonious and clearly asso-
ciated with the phenomena. The category structure creates a larger whole, the outcome space, as a repre-
sentation of the phenomena.25

Setting, participants and data collection

The overall clinical settings were the healthcare organisations in two Swedish county councils and three
communities. Both settings are regulated by law,26 which stipulates that all citizens are entitled to health-
care on equal terms at a low cost. The registered nurses were strategically selected with regard to variations
in sex, age, nursing experience, postgraduate specialist nursing education and the clinical setting in which
they worked. The inclusion criteria were that the participants had nursing experience of 3 years or more, and
that they were able to communicate in Swedish. A total of 21 nurses were approached about participating in
the study and 3 nurses declined. Consequently, 18 registered nurses (hereinafter referred to as nurses) were
interviewed in two rounds. Of these, 12 nurses were initially interviewed as part of a masters degree thesis
in 2005, followed by 6 nurses who were interviewed in 2011 to widen the sample. Out of the final sample,
2 of the participants were men and 16 were women.
The nurses ages ranged between 34 and 60 years (mean 46.2 years), and their nursing experience var-
ied between 4 and 37 years (mean 13.5 years). In all, 12 nurses had a 2-year university basic nursing edu-
cation and 6 had a 3-year basic nursing university education, including a bachelors degree. Of these,
9 participants had postgraduate specialist nurse training. They had nursing experience from a variety of dif-
ferent clinical contexts covering acute to long-term care in county councils and community healthcare.
The interviews started with the participants articulating their meaning of patient advocacy in order to
ensure a mutual understanding of the phenomenon in question. They were then asked about what they per-
ceived to be influencers on patient advocacy and how they perceived their influence. To deepen the under-
standing of the perceptions further, the informants were asked to describe one or more occasions when they
had acted as a patient advocate. All interviews were carried out in a secluded place of the participants
choice (private homes, meeting rooms and conference rooms in the workplace) and lasted from 23 to 55
min (mean 39 min). The interviews were digitally recorded and transcribed verbatim.

Data analysis
The analysis was based on the seven steps of phenomenographic data analysis described by Dahlgren and
Fallsberg.27 In the first step, familiarisation, we read the transcripts repeatedly to become familiar with all
the details of the interviews. Second, a condensation was carried out. The most significant statements

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676 Nursing Ethics 21(6)

regarding the nurses perceptions of influencers were selected to represent the entire dialogue about the phe-
nomenon. Third, we compared these perceptions in order to identify sources of variation and agreement.
In the fourth step, the perceptions that seemed to be similar were grouped together. In the fifth step, an
attempt was made to articulate the similarities within each of the groups of perceptions. The fourth and the
fifth steps of analysis were repeated until the analysis was considered to be sufficiently thorough. In the
sixth step, we labelled the categories of perceptions to illustrate them with appropriate linguistic expres-
sions. In the seventh step, contrasting, the categories were compared in terms of similarities and differences
and arranged in the outcome space.

Trustworthiness
In order to ensure full integrity of the results,28 several measures were considered. To achieve credibility, it
is important to use a recognised method, which phenomenography can be considered to be within nursing
research. The method proved successful in serving the purpose of describing the nurses various perceptions
of influencers on patient advocacy. The purpose of strategic sampling to obtain a variation in perceptions
was achieved with respect to the nurses age, nursing experience and workplace. We also considered the
clinical nursing context. In the first round of interviews, we interviewed mainly nurses from county council
care. Since much of the nursing in Sweden takes place in local communities, we decided to interview only
community care nurses in the second round, so that the final sample would consist of an even distribution of
nurses from county council and community care contexts. Although these considerations were taken, the
idea that only nurses with an interest in the subject, patient advocacy, are likely to participate in the study
must, of course, be considered.29
As Sandberg30 points out, it is essential in phenomenography to be as faithful as possible to the partici-
pants perceptions in order to really understand the aspect of interest, in this case influencers of advocacy.
Several steps were taken to be faithful to the nurses perceptions, to secure conformability. Besides the main
questions about influencers of advocacy, some probing questions had been prepared prior to the interviews
to help the interviewer to understand the nurses perceptions fully.29 In addition, all transcripts of the inter-
views were scrutinised by the authors, separately and jointly. If there was any doubt about a statement, the
authors listened to the interview again, and the statements meaning was discussed until it could be con-
firmed or rejected. The description categories that emerged were discussed in the research group until con-
sensus was reached that they were trustworthy, qualitatively different, parsimonious and were influencers
on patient advocacy.24 This continuous review of the data by the authors should also strengthen the studys
dependability together with the audit trail that was established during the planning of the study and main-
tained throughout the process. We have provided the reader with some quotes to improve confirmability.29
These quotations should also facilitate the readers assessment of the potential for transferring the results to
another cultural context together with the descriptions of the clinical and cultural context in which the study
was performed.

Ethical considerations
The study was performed in accordance with the Northern Nurses Federations31 ethical guidelines for nur-
sing research. Ethical revisions were made for both data collection rounds in accordance with current
national legislation and guidelines by committees for research ethics at Karlstad University at the time. The
managers of each participant gave their written permission before the interviews. The interviews com-
menced by obtaining each participants oral and written consent to participate in the study. All nurses were
informed about the studys aim, confidentiality, voluntary participation and that they could withdraw from
the interview at any time without giving a reason.

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Josse-Eklund et al. 677

III.
The
II.
organisational
I. The nurses
conditions
The nurses bond with the
characteristics patient
The
organisational
Knowing the structures
patient
Having a
The
moral compass
organisational
Feeling culture
empathy for
Having control the patient
over the care
situation

Being
protective

Feeling secure
as a nurse

Figure 1. The nurses perceptions of influencers of patient advocacy. Structured hierarchically from level I to III.

Results
The outcome space shows that influencers on patient advocacy can be described at three levels, in a hier-
archy of influencers from I to III. The first level is the nurses character traits, which is the fundamental
influencer. The nurses bond with the patient is the second influencer on patient advocacy, while the third
level is the organisational conditions. The levels build on each other and are interrelated. (Figure 1). On
each level, the nurse can choose to advocate or not.

I. The nurses character traits

The nurses character traits are perceived as the first level of influencers of advocacy, and are fundamental,
since if there is no willing nurse, there is no patient advocacy. The descriptive category includes the percep-
tions of having a moral compass, having control over the care situation, being protective and feeling secure
as a nurse.

Having a moral compass. It is the nurses inner beliefs, their moral compass, that direct them when they advo-
cate for their patients. This motivates them to advocate for patients when needed, since they perceive that it
is part of their duty as nurses:

. . . those who are the most vulnerable . . . old and frail . . . weak groups . . . then Ive felt that they dont have
anyone, it is my duty . . . to do it (to advocate) . . . (Nurse 3)

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678 Nursing Ethics 21(6)

Courage, philanthropy and altruism, as well as a capacity for reflection of their own values and humanity
and a sense of justice, are vital qualities in nurses who advocate for patients:

One more thing that makes you advocate for the patient is . . . that you like people, that you want to do good . . .
(Nurse 2)

Having a moral compass also includes the qualities of being committed and having an ability to speak up.
The nurses perceive that they have to be persistent and willing to try different ways of achieving the desired
outcome for their patients. The nurses upbringing and social background are regarded as important for
them to recognise the vulnerable, to develop the quality of solidarity and their moral compass.
Sometimes nurses make their decision to advocate in a state of emotion, such as moral indignation over
an unacceptable healthcare or social situation when patients needs are unmet or unconsidered. Despite the
potential risks they face and despite the impossibility of predicting the result for the patients, they perceive
advocacy at this point as being worth it, since the patients need for an advocate is urgent:

. . . then there is no fear of what I dare to do or say or how I dare to act either . . . I become very, very straightfor-
ward and very clear . . . there is nothing to hesitate about . . . (Nurse 10)

Having control over the care situation. The desire to have control over the care situation influences the nurses to
advocate for patients in order to provide good and safe care according to the patients needs and wishes:

I want to be the one who pulls the strings . . . I dont like to be in charge only of parts, but I like to have full view of
what I do . . . (Nurse 10)

Having control means that nursing practice needs to be systematic, flexible and energetic. An advocate
should be a thorough and ambitious problem-solver who does not hesitate to make contact with other care-
givers and social services outside standard procedures where necessary.

Being protective. Being protective and wanting to safeguard vulnerable patients are perceived by the nurses as
important influencers on patient advocacy. The driving force is the responsibility they consider themselves
to have for their patients well-being and they want to fulfil their commitments to these patients. They need
to be perceptive and accepting of patients needs, and have a desire to take care of and protect the patients
best interest against non-supportive relatives, social workers or other healthcare personnel:

I want to take care of everything and everybody, to take responsibility for their lives . . . and I do think that this is
a nurses role . . . isnt this what we are here to do, to take care of, or aid, our patients . . . those who cant speak
for themselves . . . (Nurse 11)

Feeling secure as a nurse. Nurses perceive that professional experience and knowledge make them feel secure
and give them the courage to stand up for their beliefs to advocate for patients. They point out that they trust
their nursing intuition to know when and how to advocate for patients. As they gain experience, their per-
spective broadens and they get a clearer perception of the need for advocacy. The nurses perceive that they
are in search of more knowledge in order to advocate more ably for their patients. Moreover, they believe
that self-knowledge and feeling secure as a nurse make it easier to advocate, since these traits give them
stamina:

. . . I think that Ive obtained a rather good clinical eye over the years, as well as a clinical ear, when someone
(a patient) tells me something . . . usually it feels as if I make the right decisions, yes . . . (Nurse 14)

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The nurses feel secure enough to advocate in situations that are familiar to them, since they know what to
do and when. In unfamiliar situations, they feel insecure and can choose not to advocate since they do not
have a frame of reference or do not know how to act to promote patients interests.

II. The nurses bond with the patient

The second level of influencers is the nurses bond with the patient, since nurses perceive that in order to
advocate for someone it is essential to know the patient and feel empathy for the patient.

Knowing the patient. Knowing the patient is trying to see the individual as a whole, as a person who is part of a
larger context than the healthcare context. The nurses need to know the patients, their wishes and needs if
they are to advocate for them. Consequently, they try to build a trusting relationship with their patients.
They emphasise not only the importance of good verbal communication on the patients terms if they are
to be able to bond with the patients, but also the value of recognising unspoken communication through
body language. They want to be close to their patients, in person, on a regular basis:

I didnt study to be a nurse in order to get away from patients, it was to gain a deeper knowledge, and contact with
the elderly is really important to me . . . (Nurse 13)

Regardless of whether the nurses know a patient or not, they state that they aim to advocate for all
patients in need. However, they indicate that it is easier to advocate for patients they know, and that they
can choose not to advocate if they perceive that they do not know a patients needs and wishes well enough.
They acknowledge that as nurses, they are in a position of power over patients and that they have to be
careful not to override their patients wishes and integrity by relying solely on their own goodwill, since
they do not know everything about their patients and their lives.

Feeling empathy for the patient. Identifying a patient as a vulnerable person help some nurses to understand
and empathise with the patient which, in turn, makes them more able to advocate. Other nurses perceive that
they need to stay neutral in order to advocate:

. . . If you cant feel, you cant participate in an empathetic way in whats happening with the person who is suf-
fering from ill health, then you cant represent or advocate at all . . . (Nurse 17)

Sometimes the nurses identify with their patients and then care for patients in the way they would wish to
be cared for themselves. They also perceive that it is important to advocate for all patients in need, regard-
less of whether they empathise with or like the patient. However, according to the nurses, it would probably
be easier to advocate for a patient they like than for a patient they did not like.

III. The organisational conditions

The third level of influencers portrays the way in which the organisational conditions influence patient
advocacy, since these conditions affect when and whether the nurses advocate for patients. This descriptive
category is expressed in the perceptions the organisational structures and the organisational culture.

The organisational structures. The nurses perceive that working as a part of a team with other professions,
advocacy is not considered to be as necessary as it is in a hierarchic organisation. This is due to teamwork,
where all members of the team are focused on the patients best interests. Advocacy actions are not often
needed when the best possible result for the patients is founded not only on consideration of the opinions of

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680 Nursing Ethics 21(6)

different professions, but also on the patients wishes. By way of contrast, a hierarchic organisation where
the doctors word is law, where the overall healthcare does not run smoothly or where the patients interests
are disregarded encourages nurses to advocate. Some nurses perceive regulations in the workplace as a
good thing since they can use them as an argument when advocating for patients, while others perceive that
regulations can be the reason for advocacy. A lack of financial resources resulting in low staffing and a lack
of time is also described as an influencer of advocacy. Both of these influencers prevent nurses from getting
to know patients well enough to advocate for them:

Sometimes I have the time to get well acquainted with it (the patients situation) and really get into it, and some-
times it gets sloppy and you have to take care of the acute things and hope the situation will keep for a day or two
more . . . (Nurse 1)

An element that influences advocacy negatively is the organisation of the communitys healthcare,
where nurses work on a consultancy basis and only visit patients when needed, which creates an organisa-
tional and sometimes a geographical distance between nurses and patients. This results in nurses having to
rely on second-hand information, which prevents them from getting to know their patients well enough to
feel comfortable advocating for them.

The organisational culture. Supportive colleagues, managers and physicians create a positive influencer on
patient advocacy. Collegial discussions where the nurses are given the time and opportunity to reflect upon
patient situations are also considered to be a positive influencer since they make the nurses more secure in
their decision to advocate. In a positive and permitting organisational culture, the nurses feel confident and
advocate when needed since advocacy is accepted. The nurses advocate less in an unsupportive environ-
ment where they feel insecure and less competent. The risk of conflict with physicians and colleagues is
also perceived by the nurses as limiting their patient advocacy. Even though they decide to act upon
patients needs, they can feel isolated and insecure in the workplace:

. . . the physician refused to come to the nursing home, refused to come . . . then you are alone, very, very alone,
because this was late at night and then you are awesomely alone . . . (Nurse 16)

However, there are nurses who express the view that they have to consider to which extent they would
engage themselves in a patients cause, since involvement in patient advocacy can lead to them being con-
sidered a nuisance by co-workers and could cause burnout in the long run:

. . . psycho-social effects on me as a person of course, and as a nurse, that you lose perspective on yourself and
. . . that you in the classical sense become burned-out . . . advocacy is sometimes a struggle against both func-
tions and people . . . and it wears you down . . . (Nurse 17)

Discussion
The aim was to describe Swedish nurses perceptions of influencers on patient advocacy. The outcome
space shows that influencers on patient advocacy are perceived at three hierarchically related levels: I. The
nurses character traits; II. The nurses bond with the patient; and III. The organisational conditions.
The first, and most fundamental, level of influencers is the nurses character traits, which corresponds
with findings from earlier research.15,16 The nurses in this study perceive that their moral compass directs
them when to advocate as part of their professional duty. This perception connects to the image of the com-
petent nurse as an autonomous professional with an excellent moral character.32 To develop this excellence,
it takes a sensitive and dynamic attitude towards praxis which goes beyond theoretical knowledge.

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Josse-Eklund et al. 681

Although the nurses in this study do not explicitly describe that they practise nursing with a code of nursing
ethics in mind at all times, they convey the sense that their ethical values are essential in their daily practice.
The nurses also perceive that they want to have control and to feel secure as a nurse in order to advocate
for their patients, elements which also relate to nursing competence. Research has proved that experience15
reinforces nurses capacity to advocate for patients. Previous studies have also shown that it is important for
nurses to keep themselves up-to-date to be able to advocate for patients,15,33 which coincides with the find-
ings from this study. In summary, one could assume that in speaking of experience, nurses implicitly mean
nursing competence consisting not only of experience in terms of years of nursing, but also of knowledge,
reflective intuition and personal character. Together, these factors may influence nurses responsiveness to
a patients need for advocacy.
The second level of influencers, the nurses bond with the patient, affects advocacy and relates strongly
to theoretical models of patient advocacy as well as to previous research. The common human values that
the nurse and the patient share are the base upon which the ideals of advocacy rest according to Curtins8
human advocacy model. The nurse forms a unique relationship with the patient since he or she spends con-
siderable amounts of time with the patient, getting to know even the most intimate details about the patient
as a person. In this study, the nurses perceive that it is easier to advocate for patients they are acquainted
with, than for patients they do not know. Bandman and Bandman34 also highlight the importance of the
nursepatient relationship, since the contact between the two creates a natural alliance from which
the nurse, as part of her professional duty, can advocate for the patient when needed. This corresponds
to the findings from this study, where nurses perceive that patient advocacy is part of their professional duty.
The above relates to the third level of influencers, that the organisational conditions influence advocacy.
A hierarchic organisation is a specific negative influencer, which agrees with findings from Negarandeh
et al.s13 study. Iranian nurses state that when physicians take the lead, it prevents them from advocating,
since they are not allowed to express their opinions openly. According to Churchman and Doherty,23 nurses
will not advocate for patients when they risk coming into conflict with physicians or if they are frightened of
them. None of the nurses in this study stated that they are discouraged by physicians, managers or relatives
who may affect advocacy negatively. Rather, they convey the perception that these negative influencers are
obstacles, both large and small, that have to be overcome if they feel advocacy is necessary. The exception
here is the perception that there is ultimately a limit to advocacy if nurses run the risk of being worn out if he
or she advocates for patients in an unpermitting organisation. This is, perhaps, interesting in that Swedish
healthcare organisations are considered to be a safe working environment since employees have extensive
rights regulated by law.35,36 This means that Swedish nurses are not threatened by relocations and dismis-
sals if they advocate for patients, as may be the case for nurses in other cultures.21,37
Two other negative influencers on the organisational level are geographical distance and time constraints
as these decrease the nurses opportunities to form a relationship with the patient. This result relates to the
second level of influencers, that the nurses bond with a patient influences advocacy, and demonstrates that
nurses need to be close to patients not only in spirit but also in person, and for long enough to establish the
necessary bond. The results from this study resemble findings from Sellins38 study but deepen the knowl-
edge about the relationship between influencers.

Conclusion
The results show that influencers on patient advocacy exist at three hierarchically related levels. A supposi-
tion could be that all influencers interact. First, the fundamental influencer on patient advocacy should be
the nurses character traits since there would be no advocacy without a willing, competent and ethically
aware nurse, regardless of a patients needs. The nurses bond with the patient emerges as the second most
vital influencer of advocacy and is emphasised by the nurses perceptions that it is the patients needs that

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682 Nursing Ethics 21(6)

direct them to advocate or not. This could be connected to the first level of influencers in that it takes a cer-
tain level of nursing competence to identify the need for advocacy. The third level of influencers, the orga-
nisational conditions, influences patient advocacy even though these Swedish nurses perceive that they
advocate for patients when needed, regardless of the organisational influencers, unless they run the risk
of being worn out. This third level of influencers could be connected to the two previous levels since these
influencers create the surroundings where the nurses work and bond with the patient.
The strong connection between patient advocacy and ethics permeates the studys results, as it suggests
that the key driver of patient advocacy is patients unmet or unconsidered needs. Another conclusion is that
nurses need to be familiar with both their patients and the situation in order to be comfortable and secure
when advocating for patients. Since several parts of the findings correspond with, and deepen, existing
knowledge about influencers on patient advocacy from different cultural and clinical contexts, the transfer-
ability should not be doubted. However, the results of this study contribute a new understanding about the
relationship between influencers of advocacy, since three levels of influencers have been highlighted.

Acknowledgements
Gratitude is expressed to Assistant Professor Lena Roty for support during the conception of the study and to
all nurses that participated in the study.

Conflict of interest
The authors declare that there is no conflict of interest.

Funding
This research received grants from Hilda and Rune Nilssons foundation for the transcription of the last six
interviews.

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