Advocating for Patients:

Honoring Professional Trust

LEE GALUSKA, PhD, RN, NE-BC

ABSTRACT
Perioperative nurse leaders create conditions for nurses in all health care settings that allow them to
advocate for patients when they are unable to advocate for themselves; these conditions also enable
nurses to enter into therapeutic relationships with patients and their families and establish trust. The
nursing leadership practices that facilitate this advocacy include promoting continuity of care and
patient relationships; helping to ensure practice environments support teamwork and collaboration;
providing behavioral expectations for communication and conflict management; and supporting
practices that promote self-care and ongoing professional development, flexibility, creativity, and
innovation to meet patient care needs. A comprehensive professional practice model provides a
framework for nurses to practice more fully and to skillfully care and successfully advocate for patients.
AORN J 104 (November 2016) 410-416. ª AORN, Inc, 2016. http://dx.doi.org/10.1016/j.aorn.2016.09.001
Key words: patient advocacy, nurse-patient relationship, patient-centered, professional practice,
leadership.

T he connection between a perioperative nurse and

a patient often begins with a smile, touch, or
reassuring word. Deepening this connection
enables the nurse to form a therapeutic relationship and deliver
relationship-based care.1,2 Patients and their families trust that
the relationship with a nurse, who is not only caring but also
knowledgeable and skilled, will help them safely navigate the
perioperative experience and the health care system to achieve
better outcomes.2 One exemplary nursing team at a Magnet-
designated academic medical center in southern California
was recently acknowledged for excellent nursing care during
a hospital recognition event. This team was recognized for
their advocacy for Kalynn, a young woman who required a
second lung transplant and eventually succumbed to her
illness. The nurses’ story inspired the author to explore how
relationships, trust, and advocacy intersect in nursing settings
in complex health care systems. Kalynn’s story illustrates how
nurses in the critical care and perioperative settings uniquely
exercised their advocacy roles to deliver relationship-based care
for this patient and her family.
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FOUNDATIONS FOR ADVOCACY
Nursing, by definition, includes an expectation for advocacy.
According to the American Nurses Association (ANA),
Nursing is the protection, promotion, and optimization of
health and abilities, prevention of illness and injury, allevia-
tion of suffering through the diagnosis and treatment of human
response, and advocacy in the care of individuals, families,
communities, and populations.3
Advocacy is similarly described in the ANA’s Nursing: Scope
and Standards of Practice4 and the Code of Ethics for Nurses.5
Leah Curtin’s seminal work established advocacy as the
“philosophical foundation and ideal of nursing.”6(p2) She
stated that nurses share a common humanity with patients and
families that allows them to see patients as unique individuals
with rights and needs that are magnified after they become ill
and vulnerable. Nurses are ideally positioned in the health care
system and possess the scientific knowledge to provide care,
share information, and advocate for patients. Nurses also are
positioned to advocate for a system that is respectful of patient
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ª AORN, Inc, 2016
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rights and needs and that supports their autonomy and
decision-making abilities. Advocacy is not only a professional
expectation but a moral and ethical obligation.
For perioperative nurses, ANA’s Code of Ethics for Nurses5 and
the AORN “Explications for perioperative nursing”7 provide a
framework for ethical decision making and advocacy in this
unique environment. Examples of perioperative nurse advo-
cacy align with universal moral principles and include respect
for human dignity, support for patient rights and safety, and
accountability. Perioperative nurses use this ethical foundation
as they advocate for vulnerable patients who are sedated or
anesthetized and need nurses to take action on their behalf.2
In her work on existential advocacy, Sally Gadow8 focused on
the unique nature of the nurse-patient caring relationship in
supporting the patient’s fundamental right to self-determination.
Developing this therapeutic relationship and knowledge of
the patient as a person enables the nurse to assist patients
with clearly expressing their individual values and desires and
making care and treatment decisions. Gadow emphasized
the importance of nurse engagement and “participation of
the entire self”8(p46) to fully understand patients’ perspectives.
In a recent systematic review, Munday et al2 described how
the foundational work of Curtin, Gadow, and others provides
the underpinnings for advocacy in the perioperative environ-
ment. Although perioperative nurses have a limited time with
patients, they can establish a connection and understanding,
effectively advocate, and provide a voice for “silent
patients”9(p535) (ie, patients unable to speak for themselves).
The researchers recognized that ethical principles, patient
rights, vulnerability, relationships, and trust drive the advocacy
activities of all nurses. However, the unique conditions in the
perioperative environment require greater emphasis on the
nurse’s role in advocating on behalf of patients for safety and
communication. Munday et al2 based the categories of their
findings on nurses’ experiences speaking up for patients;
providing reassurance to and connecting and communicating
with patients and their families; and providing comfort while
maintaining safety, dignity, and an evidence-based care plan.
The researchers viewed all of these interventions as everyday
evidence of nurse advocacy. Walker et al described nurse
perceptions of “everyday advocacy”10(p67) as actively taking
part in practice, leadership, education, and professional orga-
nizations. Nurses embrace advocacy as a core value of the
profession and an essential element of their practice.
Bu and Jezewski developed a midrange theory for patient
advocacy that they defined as “a process or strategy consisting
of a series of specific actions for preserving, representing and/
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Honoring Professional Trust
or safeguarding patients’ rights, best interests and values in the
health care system.”11(p104) They offered three core attributes
of patient advocacy:
 safeguarding patient autonomy,
 acting on behalf of patients, and
 championing social justice in the provision of health care.11
Safeguarding patient autonomy includes actions to support the
right to self-determination when patients are able and willing
to participate in their own care and related decisions. When
patients are unable to actively participate, perioperative nurses
take action to best represent and defend their patients’ values
and desires based on individual patient needs and circum-
stances. The idea of championing social justice via the provi-
sion of health care is based on a model of social advocacy that
calls upon nurses to work toward system changes to address
larger issues pertaining to health and well-being. For nurses in
the perioperative arena, this advocacy involves risk taking,
professional confidence, and empowering each other to address
conditions in the system that may compromise patient safety.2,12
BENEFITS AND CHALLENGES OF
ADVOCACY
When nurses fulfill the role of advocate at the individual,
clinical, system, and societal levels, there are many benefits. At
the individual level, as the nurse-patient relationship develops,
trust is established. With trust comes the patient’s expectation
of competence, belief in the nurse’s goodwill, and an accep-
tance of vulnerability along with some element of risk.13 The
patient trusts that the nurse is knowledgeable and skilled, but
also that any actions taken by the nurse on behalf of the
patient will reflect the nurse’s understanding of the patient and
an earnest commitment to help.
At the clinical level, perioperative nurse advocacy results in
recognition and improvement of structures and processes that
affect patient rights and safety. Examples include processes for
maintaining asepsis, ensuring patient identity and informed
consent, instrument counts, and procedural technique.2 At the
system level, perioperative nurses “see the big picture beyond
the doors of the OR.”2(p18) Nurses consider the continuum of
care for patients and their families, including processes for
patient and family education, management of materials and
equipment, and relationships with colleagues and departments
that affect the care of surgical patients.
At the societal level, nursing has held a long-standing position
as the profession most trusted by the public.14 This trusted
status comes from the belief in nurses’ ability to connect with
patients in meaningful ways, help them achieve better health
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outcomes, and influence quality in the health care system.15 The
public holds nurses in high esteem for their trustworthiness
and advocacy.
Advocacy in the nurse-patient relationship is influenced by the
nurse’s character traits, including the nurse’s moral compass,
protectiveness over patients, and security as a professional
nurse.16 Other advocacy facilitators are the nurse’s knowledge
of the patient; ability to empathize with the patient; and
organizational conditions such as leadership support, healthy
interprofessional relationships, cultural norms, and evidence-
based communication practices.
Nurses’ relationships with members of the health care team
and organization have a powerful influence on their advocacy
practice. According to Bergum,17 relationships and relational
competencies are as critical to the effectiveness of nurses as
clinical competencies and scientific knowledge. In the
perioperative setting, Hudek describes finding voice with
colleagues as a key competency that requires “a combination of
moral courage, empowerment, and mutual respect accompa-
nied by communication skills.”12(p649)
Recommended strategies for ensuring the efficacy of nurse
advocacy include recognition and management of institutional
and interdisciplinary constraints, focused education and
competency development, and empowerment and intentional
support from formal leaders.2,10,12,16,18 One strategy for
supporting nurses and recognizing their advocacy efforts is to
celebrate their efforts10 through awards ceremonies, such as
the one that recognized “Team Kalynn,” and to disseminate
their exemplary work through professional publications.
The following case exemplar describes the experiences of
nurses in both the critical care and perioperative settings as
they cared for Kalynn, a patient undergoing transplant surgery.
Kalynn’s story illustrates the similarities and differences
between the advocacy practices of perioperative versus critical
care nurses. How nurses approach their ethical obligations to
patients like Kalynn are different based on their practice
setting. The therapeutic relationship established with patients
in both settings provides a foundation of trust enabling nurses
to advocate effectively for vulnerable patients and their fam-
ilies. Greater understanding of how to best implement the
nursing role in different practice settings may foster collegial
relationships, collaboration, and teamwork in organizations
that will benefit all patients and their families.
ADVOCATING FOR KALYNN
Kalynn was 27 years old when she was hospitalized in the
intensive care unit (ICU) while awaiting her second lung
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transplant. She had cystic fibrosis, but according to the nurses
on Team Kalynn, she refused to let her disease define her. She
was independent, intelligent, and able to articulate her
preferences and needs most of the time. She also required
complex, intensive medical support and highly skilled nursing
care. She had a supportive and involved family. Team Kalynn
established a deep and caring relationship with both Kalynn
and her family.
To create the case study, I began by interviewing members
of the ICU team who cared for Kalynn to gain an under-
standing of their experiences and how they aligned with de-
scriptions in the literature. The nurses’ relationship with
Kalynn was a special one because of her lengthy hospitalization
and the similarity in age and interests she shared with many
of her nurses. Their relationship evolved to the point where
they were very close to her family, including Kalynn’s twin and
older sister.
Nurses on the ICU team tailored Kalynn’s plan of care and
their interventions using their knowledge of her unique indi-
vidual needs. Nurses described meaningful interventions such
as giving Kalynn greater control over her diet and providing
favorite foods from home or local restaurants. They under-
stood the importance of nutrition in ensuring readiness for
transplant surgery, and they knew that their care plan would
be more successful if they understood Kalynn’s preferences.
Their focus on listening and understanding enabled them to
provide relationship-based care. The nurses’ description of this
experience is reflective of “knowing the patient,”16(p679) a key
influencer of advocacy practice.
Along with the development of this meaningful relationship,
the nurses established trust with Kalynn and her family
members, which in turn allowed them to trust in the com-
petency of the nurses and other team members. Consistent
with the findings of Bell and Duffy,13 the trust of Kalynn and
her family members was characterized by an expectation of
competence, a reliance on the goodwill and relationship with
the members of the ICU Team Kalynn, an acceptance of their
own vulnerability, and a willingness to accept the risk as they
entrusted themselves to this team.
Kalynn and her family also trusted that this nursing team
knew how the system worked and could navigate through
it on their behalf based on the nurses’ established re-
lationships with other members of the health care team.
Kalynn’s family trusted that the nurses would not only care
for her like a family member but also help ensure that
enough oxygen, supplies, and other resources were available;
be prepared to respond in an emergency; and advocate
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to ensure that Kalynn’s voice was heard as decisions
were made.
To respect her autonomy and right to self-determination, the
nurses on ICU Team Kalynn helped ensure that she had an
opportunity to speak and advocate for herself in interdisci-
plinary rounds. They did not attempt to speak for her except
during times when she could not. She was the expert on
herself and her needs and was knowledgeable about her disease
and treatment. Making space for the patient’s voice to be
heard is consistent with Gadow’s theory of existential advo-
cacy8 and a position of authentic knowing and valuing of the
patient’s perspective and rights.
The nurses from ICU Team Kalynn navigated a fine line be-
tween advocacy and paternalism19 by advocating during times
when Kalynn was unable to do so for herself. One nurse spoke
of a time when she advocated for Kalynn with a medical resi-
dent who “was going to put his foot down and discontinue
lorazepam at bedtime.” The nurse knew that although the dose
was small, it was of significant value to Kalynn in helping her
to fall asleep at night in the ICU setting. Understanding the
importance of sleep to Kalynn as she maintained her readiness
for transplant surgery, the nurse successfully advocated for her
and avoided a change in the medication order.
The nurses identified leadership and collegial support as two
elements that allowed them to advocate effectively. Leaders
were advocates in that they created the conditions that sup-
ported the nurses and patient. By respecting patient and family
preferences and understanding the benefits of continuity of
care, leaders formed an intentional plan. Along with the patient
and family, they created a team of nurses to care for Kalynn
and helped ensure that the team had the resources it required
to meet Kalynn’s needs. Leadership and collegial practices
supported nurse autonomy and allowed nurses the ability to
speak up as needed to meet patient and family needs.
The actions of leaders in this organization reflected best
practices for conscious leadership in advocacy for nurses and
nursing.10,12,20 They demonstrated a commitment to excel-
lence and to “a sense of shared purpose enabling people to
derive meaning from their work.”21(p184) They provided
opportunities for growth, supported the development of
others, and were willing to make difficult decisions based on
their moral compass. These nurse leaders advocated for the
appropriate resources to help prevent staffing inadequacies and
ensured that scheduling aligned with the goals for continuity
of care. They also supported advocacy by fostering a healthy
work environment characterized by open communication,
collaboration, and conflict management. Leaders supported
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Honoring Professional Trust
nurses to help meet the patient’s needs by skillfully and
effectively advocating for Kalynn with other members of the
health care team. Their actions as conscious leaders were
intentional, evidence based, and supportive.
Leaders also made sure that Team Kalynn members’ needs for
rest and self-care were met. The formation of a care team
enabled nurses to take breaks as needed from the intensity of
this patient’s care demands. This approach also allowed the
nurses to maintain skills and competencies with patients
needing other types of care. Nurse leaders supported nurse
creativity and innovation in meeting the unique care needs
presented by patients and their families. They created an
environment of flexibility and support for nurses to flourish in
their professional roles. With the skilled support and role
modeling of their nurse leaders, the nurses on Team Kalynn
were also able to lead and fully engage as advocates.
Perioperative Nurse Advocacy
When it was time for Team Kalynn ICU members to hand
over Kalynn’s care to their colleagues in the perioperative
setting, they had to trust in their colleagues in the same
manner as Kalynn and her family did. They described an
expectation of collegial competence and goodwill but also a
feeling of vulnerability as they handed over Kalynn’s care.
Kalynn’s ICU nurse accompanied her and provided a detailed
hand over so that her perioperative nurses could effectively
care and advocate for Kalynn during her surgery. Their
colleagues in the perioperative environment became the peri-
operative extension of Team Kalynn.
After interviewing the ICU team, I asked the perioperative
nurses how they fulfill their ethical obligation to preserve the
dignity of individuals like Kalynn, establish trusting relation-
ships, and advocate for patients’ unique needs and safety.
Perioperative nurses only have a brief opportunity to establish
a connection with patients and family members. Nurses in
perioperative settings and across health care systems encounter
challenges and barriers in their roles as leaders and advocates.
Hanks22 described the conflict of interest nurses may experi-
ence as they consider their responsibility to the patient and
their obligations to their institution. Nurses may perceive a
lack of support, power, time, or educational preparation for
their advocacy role. Personal, institutional, and cultural
barriers can have a significant effect on the ability of nurses
and nurse leaders to advocate for patients and patient
care.2,10,12,16,18 Perioperative nurses must help the patients
and family members trust that they will safeguard their
interests and skillfully advocate on their behalf throughout the
surgical experience. Perioperative nurses do not have the
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benefit of a long hospitalization and consistent assignments to
get to know the patient and his or her family members as
unique individuals. They rely on the record, an effective hand-
over report, and a brief interpersonal encounter with the
patient and his or her family members.
Members of the perioperative unit council at this academic
medical center and the nurse who cared for Kalynn during
her surgery participated in interviews where they shared their
perspectives on advocacy and the unique responsibilities and
challenges in this care environment. They reflected on the
need to quickly establish a connection with the patient and
family preoperatively. Introductions, determining the patient’s
preferred name, assurances, and providing information are all
part of that brief initial encounter.
Perioperative nurses recognize the vulnerability of the patient
and his or her family when undergoing a surgical procedure and
strive to provide reassurances that they will care for the patient
as if he or she were their family member. Often during these
moments, patients and family members share information that
they may not have told anyone else, such as small details or
preferences. They trust the nurse to relay the information to the
surgeon and other members of the surgical team. One peri-
operative nurse spoke of being the last person the family sees as
their loved one is taken to surgery and the powerful sense of
responsibility this engenders. Although the preoperative con-
tact is shorter than that of unit nurses, the timing, significance,
and intensity of the encounter creates a bond between peri-
operative nurses and their patients. This bond endures, and the
perioperative nurses interviewed spoke of patients and family
members returning to visit, thank the nurse, and celebrate the
success of the surgery. They also described mourning with
families after they lose a loved one and remembered these pa-
tients as unique and special individuals.
The brief preoperative time with the patient and his or her
family is also an opportunity for the nurse to provide impor-
tant information and to teach. The nurses described being
purposeful about the education they provide during this time.
Kalynn’s perioperative nurse described the need to provide
education about what to anticipate with a second trans-
plantation. Perioperative nurses become the communication
lifeline for family members, keeping them informed about
what is happening with their loved one, and they discussed
how they communicated with Kalynn’s family during the
course of the surgery. It was important to Kalynn’s family that
they received regular communication about her status
throughout her lengthy and complicated surgery. The family
developed trust in the perioperative nurse to keep them
updated as well as to keep Kalynn safe.
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The perioperative nurses shared how seriously they take their
advocacy role in the OR setting. They perform the patient
assessment and relay important information to the surgical
team, taking into consideration the patient’s history and risk
factors. In the OR, they safely position, pad, and prepare the
patient for surgery. They safeguard the patient from harm
related to infection, pressure ulcers, falls, and medication
errors by monitoring the sterile field, checking patient position
and padding, and using patient safety guidelines. In Kalynn’s
case, her perioperative nurses anticipated and planned for what
they would need to address her condition. They made sure
that all equipment and supplies were ready for the procedure,
planned for maintaining her temperature and skin integrity,
and ensured that all appropriate consents were complete.
Kalynn’s perioperative nurse described the patient education
and support she provided while they waited for the procedure
to begin. She created a calm and peaceful environment for
Kalynn to decrease her anxiety while they waited for the
surgeon to verify and visually inspect the donor organ. She
explained all of the steps in the perioperative process and
assured Kalynn that she would remain with her and
communicate with the team and her family.
As sentries throughout the procedure, perioperative nurses
described ensuring that sterile technique and standards of
practice are maintained. They are constantly watching,
assessing, communicating, and advocating. As conscious
leaders, perioperative nurses have the courage to speak up at
any time in the care process to say “I have a concern.” Nurses
described intervening when needed with concerns for patient
consent, technique, infection prevention, instruments, and
personnel. Kalynn’s nurse described being vigilant about organ
labeling and identity verification, sterility, and blood admin-
istration. She and her colleagues closely monitored their
practice to ensure that evidence-based standards were upheld.
These nurses regularly use their voices to advocate for patients
when they are unable to advocate for themselves. Perioperative
nurses consciously advocate, even during times when inter-
professional or institutional challenges may arise. In the short
time Kalynn’s nurse had to establish a relationship with her,
the nurse acquired a sense of ownership and accountability to
ensure that the team provided excellent care and that the
patient’s voice was heard. The experiences of these perioper-
ative nurses were consistent with the synthesized findings
reported by Munday et al.2 The nurses described their advo-
cacy in terms of
 safeguarding the patient,
 communicating for or giving voice,
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November 2016, Vol. 104, No. 5
 establishing trust, and
 providing reassurance, comfort, and care for patients.
These perioperative nurses view advocacy as inherent in their
everyday practice. They respect and cherish the solemn trust
placed in them and know that patients like Kalynn and their
families are counting on them.
Although the opportunities for critical care and perioperative
nurses to establish relationships and trust and advocate for
patients are very different from facility to facility, nurses in
both specialties fully embrace their professional obligations. In
the Magnet-designated hospital where Kalynn received care,
nurses at all levels and settings serve as conscious leaders who
advocate for patients, families, resources, and healthy envi-
ronments for nursing practice excellence and optimal patient
outcomes. In the event of an unexpected or adverse outcome,
such as the loss of a patient like Kalynn, strong relationships
and trust create opportunities for healthy dialogue, support,
and healing.
PROFESSIONAL PRACTICE ADVOCACY
SUPPORT
An organization’s professional practice model provides a
framework and guidance for actualization of the professional
role in patient-centered care and human flourishing. The
professional practice model of the Magnet-designated hospital
described here makes the patient, family, and community the
central focus of nursing practice. The patients provide the
practice direction for each professional nurse, regardless of
the nurse’s role, title, or setting. Practice is guided by the
organizational mission, vision, and values as the nurse estab-
lishes a human connection in the delivery of relationship-based
care. The ICU and perioperative Team Kalynn exemplified
providing relationship-based care to Kalynn and her family. By
establishing a therapeutic relationship, each nurse on the team
built trust with Kalynn and her family. The team fulfilled their
roles as advocates by following professional practice standards
and meeting expectations, as evidenced by the perioperative
nurses who embraced the opportunity to establish connections
quickly and trust and safeguard the patient.
CONCLUSION
The professional nurse is a practitioner, a scientist, and a
leader; in all of these roles, he or she transfers knowledge to
others.23 As caring, competent practitioners, nurses engage in
the art and science of nursing as they deliver relationship-based
care. The nurses on Team Kalynn serve as professional
exemplars to nurses everywhere as caregivers who consciously
focused on patient care to ensure that their patient’s rights
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Honoring Professional Trust
were protected and her voice was heard. As scientists, the
professional nurses who cared for Kalynn had the opportunity
and fulfilled the obligation to apply current, relevant evidence
in the delivery of care. As conscious leaders, nurses at all levels
and in all settings advocate and will continue to innovate and
lead improvement efforts to produce better outcomes for
their patients, organizations, and the nursing profession as a
whole. Through reflection on their experience with Kalynn,
the nurses’ commitment to honoring the professional

trust placed in them by patients, families, and society has
been reaffirmed.
Editor’s notes: Patient information published with permission
from the family. ANCC Magnet Recognition is a registered
trademark of the American Nurses Credentialing Center, Silver
Spring, MD.
References
1. Koloroutis M, ed. Relationship-Based Care: A Model for
Transforming Practice. Minneapolis, MN: Creative Health Care
Management, Inc; 2004.
2. Munday J, Kynoch K, Hines S. Nurses’ experiences of advocacy in
the perioperative department: a systematic review. JBI Database
System Rev Implement Rep. 2015;13(8):146-189.
3. What is nursing? American Nurses Association. http://www.nursing
world.org/EspeciallyForYou/What-is-Nursing. Accessed June 21,
2016.
4. Nursing: Scope and Standards of Practice. 2nd ed. Silver Spring,
MD: American Nurses Association; 2010.
5. Code of Ethics for Nurses with Interpretive Statements. 2nd ed.
Silver Spring, MD: American Nurses Association; 2015.
6. Curtin LL. The nurse as advocate: a philosophical foundation for
nursing. ANS Adv Nurs Sci. 1979;1(3):1-10.
7. ANA code for nurses with interpretive statements: explications for
perioperative nursing. In: Guidelines for Perioperative Practice.
Denver, CO: AORN, Inc; 2015:711-732.
8. Gadow S. Existential advocacy: philosophical foundations of nursing.
In: Pence T, Cantrell J, eds. Ethics in Nursing: An Anthology. New
York, NY: Jones & Bartlett Publishers; 1990:41-51.
9. Gadow S. Clinical subjectivity. Advocacy for silent patients. Nurs
Clin North Am. 1989;24(2):535-541.
10. Walker DK, Barton-Burke M, Saria MG, et al. Everyday advocates:
nursing advocacy is a full-time job. Am J Nurs. 2015;115(8):
66-70.
11. Bu X, Jezewski MA. Developing a mid-range theory of patient
advocacy through concept analysis. J Adv Nurs. 2007;57(1):
101-110.
12. Hudek K. Finding voice. AORN J. 2012;95(5):648-652.
13. Bell L, Duffy A. A concept analysis of nurse-patient trust. Br J
Nurs. 2009;18(1):46-51.
14. Honesty/ethics in professions. Gallup. http://www.gallup.com/poll/
1654/honesty-ethics-professions.aspx. Accessed June 22, 2016.
15. Rutherford MM. The value of trust to nursing. Nurs Econ. 2014;
32(6):283-289.
AORN Journal j 415
Galuska
16. Josse-Eklund A, Jossebo M, Sandin-Boj€o AK, Wilde-Larsson B,
Petz€all K. Swedish nurses’ perceptions on patient advocacy: a
phenomenographic study. Nurs Ethics. 2014;21(6):673-683.
17. Bergum V. Relational ethics in nursing. In: Storch JL, Rodney P,
Starzomski E, eds. Toward a Moral Horizon: Nursing Ethics for
Leadership and Practice. Toronto: Pearson Education Canada, Inc;
2004:485-503.
18. Rainer J. Speaking up: factors and issues in nurses advocating for
patients when patients are in jeopardy. J Nurs Care Qual. 2015;
30(1):53-62.
19. Zomorodi M, Foley BJ. The nature of advocacy vs. paternalism in
nursing: clarifying the ‘thin line’. J Adv Nurs. 2009;65(8):
1746-1752.
20. Tomajan K. Advocating for nurses and nursing. Online J Issues
Nurs. 2012;17(1):4.
416 j AORN Journal
November 2016, Vol. 104, No. 5
21. Mackay J, Sisodia R. Conscious Capitalism. Boston, MA: Harvard
Business School Publishing Co; 2014.
22. Hanks RG. Barriers to nursing advocacy: a concept analysis. Nurs
Forum. 2007;42(4):171-177.
23. O’Rourke MW. Rebuilding a professional practice model: the
return of role-based practice accountability. Nurs Adm Q. 2003;
27(2):95-105.
Lee Galuska, PhD, RN, NE-BC, is the director of
Nursing Practice, Education, and Research, at UCLA
Health, Los Angeles, CA. Dr Galuska has no declared
affiliation that could be perceived as posing a potential
conflict of interest in the publication of this article.
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