Health Science

Communication

Biosci. Biotech. Res. Comm. 9(4): 884-890 (2016)

Nurses attribution to the role of patient advocacy in

intensive care units of hospitals of Tehran University of

Medical Sciences

Maryam Beigzadeh

, Fariba Borhani

, Farzane Ahmadi

and Abbas Abbaszadeh

MS Student of Intensive Care Nursing, Department of Medical-Surgical Nursing, School of Nursing &

Midwifery, Shahid Beheshti University of Medical Science, Tehran, Iran

Associate Professor, Medical Ethics and Law Research Center, School of Nursing & Midwifery, Shahid

Beheshti University of Medical Sciences, Tehran, Iran

Ph.D student, Department of Biostatistics School of Paramedical Medicine, Shahid Beheshti University of

Medical Sciences, Tehran, Iran

ABSTRACT

One of the key concepts in nursing ethics, is patient advocacy that can bring bene ts to patients, nurses and nurse

treatment system to be followed, but for various reasons are not able to play a full role. Thus, knowing their attitudes

towards their role as patient advocate can be a way to improve the performance of nurses in this role. This study

aimed to investigate nurses’ attitudes about their role as patient advocate in intensive care units of teaching hospitals

depended to medical universities in Tehran. This cross-sectional study on 259 adult ICU nurses working in hospitals

dependent medical universities in Tehran was conducted in 2015. The questionnaire was used to collect data. Data

signi cance level of 5% with independent t test, Pearson correlation coef cient and ANOVA were analyzed. Regres-

sion analysis also combined effect of demographic variables on nurses’ attitude of defense was used. This study

showed that the overall attitude of critical care nurses to patient advocacy role was relatively positive (3.68). between

attitude advocacy mark and some demographic characteristics such as age, economic status, general work experience,

educational experience and a special section there was a signi cant relationship (p <0/05).It seems that strategies

such as workshops for nursing education can help to improve the role and thereby improve patient satisfaction.

KEY WORDS: PATIENT ADVOCACY, NURSING ETHICS, NURSING CARE

884

ARTICLE INFORMATION:

Received 22

Nov, 2016

Accepted after revision 29

Dec, 2016

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2015: 3.48 Cosmos IF : 4.006

reserved.

Online Contents Available at: http//www.bbrc.in/

Maryam Beigzadeh et al.

INTRODUCTION

Patient satisfaction with nursing care is as an important

indicator of the quality and effectiveness of health care

systems, (Peyrovi etal 2013). One of the most important

factors in improving quality of care and patient satisfac-

tion defend the rights of patients. Nurses are one of the

main pillars of the rights of children in hospitals (Gos-

selin et al 2007). The role of patient rights protection is

not a new role for nurses, (Borhani et al 2014). Nelson

argues that the emergence of the role of advocacy in

nursing to nursing was pioneer to Florence Nightingale

time, (Borhani and Briggs 2005). Many infection control

standards exist in hospitals, such as providing clean air,

clean water, clean hands and advocacy efforts of Flor-

ence Nightingale sterile equipment are one of the best

health care reforms, (Godkin 2006).

This concept has been discussed since 1973 in nurs-

ing literature (Vaarito and Kilpi (2005), however, there

is still ambiguity in the concept. After logging in to the

system for different clients need help with the process.

Their nurses to ensure with respect to their rights, receive

quality care and timely, engaging (partnership) will help

in decision making, (Loghmani et al 2014. The positive

results (Ward 2013) are associated with many advocacy

roles for various reasons, including the structure and

organizational culture (Ekland et al 2014), which are

not able to do advocacy role or have any in uence on

patient advocacy, (Negarandeh (2006).Attitude towards

the behavior is a predictor of behavioral intentions and

actual behavior. According to this theory it seems that

the attitude about the role of patient advocate by nurses’

beliefs that determine nurses’ behavior who will be

affected and also if there is a defense perspective, which

will be given appropriate care and assistance (Jahromi et

al 2012, Laney 2013 ). There are theoretical and empiri-

cal evidences that show the person’s attitude about a

particular behavior which can signi cantly affect the

actual performance of that behavior. So we can say

that the perspective of nurses determines their ability to

advocate effectively and can be a way to ful ll this role,

(Borhani et al 2014).

Laney in 2013 showed that an important part of health

care is the patient advocacy and registered nurses at the

forefront of the health care system go for safe care, and

appropriate quality of patient factors are high ( Laney

2013). Earlier studies in 2012 have determined nurses’

attitudes towards the role of defending the patients, the

results showed that the average general attitude of nurses

to protect the patient’s role has been relatively positive,

(Jahromi et al 2012 and Hojatoleslami and Qodsi 2012).

Thus, according to studies in the  eld of patient advo-

cacy is a positive attitude to the role and acting in this

role can be many positive effects for nurses, patients and

health systems yet nurses for this role in the treatment

system are faced with many contradictions. Thus, know-

ing their attitudes towards patient advocacy can be a

way to facilitate this role.

Given the importance of this role in order to help

patients and treatment system according to the study on

nurses' attitudes about the role of defender of vulner-

able patients in intensive care units that are not found

in internal investigations, this study aimed to investi-

gate the attitude towards the role of patients in intensive

care units of hospitals af liated to medical universities

in Tehran.

METHODOLOGY

This descriptive cross-sectional study in 1394 on 259

nurses working in intensive care unit (CCU, ICU and dial-

ysis) 20 teaching hospitals af liated with medical uni-

versities in Tehran, capital of Iran (Tehran University of

Medical Sciences, Shahid Beheshti and Iran). Randomly

selected hospitals and nurses eligible to participate in

the study is available from the adult intensive care units

were included hospitals. Assuming the required sam-

ple size

= 0/05, 80/0 and d= 1/0 equal to 245

obtained by taking 20 per cent of the total 300 people

were unanswered. Inclusion criteria in the study for at

least 2 years of clinical practice nurses in intensive care

units, respectively. Inclusion criteria in the study for at

least 2 years of clinical practice nurses in intensive care

units, respectively.

Research after research plan (the number SBMU2.

REC.1394.167) and permission of the Department of

School of Nursing and Midwifery and issuing letters of

introduction from the Department of Tehran University

of Medical Sciences, Medical Sciences Shahid Beheshti

and Iran Medical Sciences Hospitals referred to the uni-

versity who were selected randomly and after obtaining

written permission from the authorities, hospitals (nurs-

ing of ce and supervisor education) in intensive care

units of hospitals to introduce after the of cial part of

the research objectives and oral permission to start sam-

pling available nurses eligible to participate in the study.

According to the questionnaires were distributed among

the participants by the researcher, researcher with good

communication and explanations about the purpose of

the study, participants consent to complete question-

naires to all questions on the questionnaire and research

drew been answered. Participation in the study is vol-

untary, and individuals who wish to participate in the

study responded to a questionnaire. We tried as much

as possible when completing the questionnaire does not

interfere with nurses’ work hours and nurses at a time

when work less and have more free time to respond and

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS NURSES ATTRIBUTION TO THE ROLE OF PATIENT ADVOCACY 885

Maryam Beigzadeh et al.

a total of 300 questionnaires were distributed among

nurses, of which 259 were fully completed.

All this research was made through a questionnaire

to determine their attitudes towards the role of patient

advocacy is collected. This questionnaire has been used

in 2012 to determine nurses’ attitudes toward the role of

patients in teaching hospitals of Medical Sciences. The

questionnaire consists of two parts: the  rst part Demo-

graphic data including age, sex, marital status, work

experience, education level, years of being in patients’

rights and the second part of the workshop was mod-

erated attitude questionnaire. The scale consisted of 19

items, 9 positive items and 10 negative items shown that

all items rated with Likert scale of 1 to 5 for strongly

agree (of 5) strongly disagree (1 equivalent) ratings and

negative statements Conversely been scored.

In order to determine the scienti c validity (validity)

tool was used in this study, qualitative narrative. For

this purpose, a questionnaire to the 12 members of the

faculty members of Shahid Beheshti University of Medi-

cal Sciences, School of Nursing and Midwifery. After

collecting opinions, the monitoring supervisor question-

naires were reviewed and amended. To determine the

reliability and validity of the questionnaire by interclass

correlation coef cients Cronbach’s alpha coef cient was

used. The Cronbach alpha coef cient of 0.79 caregiver

advocacy approach is that it demonstrates the reliability

of the questionnaire is appropriate.

To analyze the data, SPSS software was used both

descriptive and analytical statistics were extracted.

The average score for each question to determine the

sequence Indicator (2-1) negative attitude, (3-2) rather

negative attitude, (3) a neutral attitude, (4-3) and rela-

tively positive attitude (5-4) were positive attitude. Nor-

mal distribution of data using the Kolmogorov - Smirnov

test was used to compare parametric t-test and Pearson

correlation coef cient and advocacy attitude of nurses

in the ICU, CCU and dialysis using one-way analysis of

variance respectively. Regression analysis also combined

effect of demographic variables on nurses’ attitude was

defense. Signi cance level of 5% was considered.

RESULTS

A total of 300 questionnaires were distributed among

259 nurses fully completed the questionnaire (response

rate was 86.3 percent). Relative frequency in the table

below are based on demographic characteristics of the

subjects.

According to Table 1 individual characteristics of

nurses working in intensive care units of hospitals af li-

ated to Tehran University of Medical Sciences in 1394

showed that the majority of nurses (35.9 percent) younger

than 30 years with a mean (SD) 34/21±6/67, women

Table 1: Distribution of absolute and relative

subjects based on demographic characteristics

Variableabsolute

frequency

The relative

abundance

Age(year) (n = 259)

Less than 309335.9

37-309235.5

Older than 377428.6

Sex (n = 259)

Male4417

Female21583

Marital status (n = 259)

single9436.3

Married16563.7

Education (number: 259)

Bachelor24092.7

MA197.3

Economic status (number: 259)

Good or excellent7227.8

Average or poor18772.2

Job history (number: 259)

Less than 79436.3

7-128131.3

More than 128432.4

In the current job experience (number: 259)

Less than 310440.2

7-37428.6

More than 78131.3

Teaching experience (number: 259)

Yes18069.5

NO7930.5

Patient history and previous hospitalization (n = 259)

Yes7127.4

No18772.6

Section(n=259)

ICU13451.7

CCU7629.3

Dialysis4918.9

(83 percent) and married (63.7 percent). 92.7 percent of

nurses with a bachelor’s degree and 7.3 percent are with

MA degree. According to the results the most special part

of Tehran’s public hospitals nurses working in intensive

care units female, married, has a bachelor’s degree and

were under the age of 30 years. According to studies in

the  eld of patient advocacy attitude to age, sex, marital

status, educational level nurses can be one of the factors

in uencing the attitude of nursing advocacy.

886 NURSES ATTRIBUTION TO THE ROLE OF PATIENT ADVOCACY BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Maryam Beigzadeh et al.

Overall job experience of nurses participating in the

study, most (36.3 percent) less than 7 years, with mean

(SD) 10/74 ± 6/16 and less than 3 years of work experi-

ence in the current section. Of the 259 nurses partici-

pated in the study, 41 persons(15.8%) of the hospitals

af liated to Tehran University of Medical Sciences, 100

persons(38.6 percent) of Shahid Beheshti University of

Medical Sciences and 118 persons (45.6 percent) Iran

University of Medical Sciences were included. 134 per-

son (51.7 percent) in the ICU, 76 (29.3%) in the CCU and

49 (18.9 percent) were working in the dialysis section.

overall job experience of majority (36.3 percent) were

less than 7 years job experience in the current major-

ity (40.2 percent) were less than 3 years. The majority

of nurses (69.5 percent) reported having a workshop on

nursing ethics or have rights of patients. The majority of

nurses (72.6 percent) of hospitalization or disease or had

relatives. (Table 1).

According to Table 2 compares the average attitude

score of his role as an advocate for patients' demo-

graphic characteristics revealed that attitude there was

no signi cant difference between male and female

advocacy nurses (p> 0/05). Nurses defense relationship

between attitude and age was signi cantly (p <0/05)

in such a way that with increasing age of nurses has

increased its advocacy attitude. Nurses with a bachelor's

degree graduate nurses attitude is better, but the differ-

ence was not signi cant (p> 0/05). Married nurses' atti-

tude is better than single nurse, but the difference was

not signi cant (p> 0/05). Nurses and economic status of

Table 2: Comparison of attitudes toward nursing advocacy groups

VariableAverage

attitude

Standard

deviation

The amount

of P

Age (years) amount of solidarity: 0.10.031

Sex (n = 259)

male3.660.670.995

female3.660.54

Marital status (n = 259)

Single3.570.600.492

Married3.720.54

Education (number: 259)

Bachelor3.680.570.170

MA3.510.47

Economic status (number: 259)

Good or excellent3.820.560.005

Average or poor3.600.56

Total job experience (n = 259) correlation

value:0. 89

0.024

experience in the current

job (n = 259)

correlation value:0.06

0.071

Teaching experience (number: 259)

Yes3.730.560.002

No3.500.56

Patient history and previous hospitalization (n = 259)

Yes3.660.530.922

No3.670.58

Section (n = 259)

ICU3.650.57

0.033

CCU3.570.49

Dialysis3.840.64

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS NURSES ATTRIBUTION TO THE ROLE OF PATIENT ADVOCACY 887

Maryam Beigzadeh et al.

the relationship between attitude advocacy signi cant

(p <0/05). Advocacy between nurses' attitude and work

experience overall there was a signi cant relationship (p

<0/05) but there was no signi cant relationship with job

experience in the current section (p> 0/05).

Comparison of attitudes between the groups with and

without history of hospitalization of hospitalization or

disease or relatives or patients showed that there was no

signi cant difference between the two groups (p> 0/05).

Educational experience and attitude between the two

groups, there was no history of signi cant difference (P

<0/05). Comparison of attitudes in three groups of nurses

in ICU, CCU and dialysis showed a relatively positive atti-

tude of all three groups (4-3) and there were signi cant

differences between the three groups (P < 0 / 05).

In order to investigate the effects of variables

on the mean attitude advocacy nurses according to

Table 3 Regression analysis was used that the analysis

of gender, age, marital status, education level, economic

status, general job experience, educational history, his-

tory of illness or hospitalization and ICU were entered

into the model. Due to the high correlation between the

variables “age and experience in current” and “general

job experience and experience in current section” will

be to avoid the linear variables included in the model

were age and overall experience. The results of regres-

sion analysis showed that the attitude of the Advocacy

nurses 0.19 with medium to high socioeconomic status

were more average economic status to low. In nursing

education, average attitude nursing advocacy 0.21 were

more than nurses without training. The nurses in dialy-

sis nurses 0.25 were more Posts advocacy attitude of

nurses in CCU.

DISCUSSION

The results of this study showed that the attitudes of

nurses in intensive care has been relatively positive on

the role of patient advocacy and advocacy between the

attitude of some variables, there was a signi cant rela-

tionship. This study showed that with increasing age of

nurses has increased their attitude. The average attitude

was older than the rest of the ages, and this difference

was signi cant. Saleh et al. in a study titled Evaluation

of the professional role of nurses in teaching hospitals in

Mashhad in 2012 showed the nurses’ professional roles

have been low, with an average 47 percent a supportive

role and between the age and experience of the profes-

sional roles of nurses there have been signi cant posi-

tive correlation, (Saleh et al 2013).

It seems that with the increasing age of nurses atti-

tude in their defense gets better and better and it is bet-

ter target group to improve the attitude of nurses of all

ages, especially nurses are with lower age. In the present

study between attitude and work experience of nurses

Advocacy There was a signi cant relationship. Abbas-

zadeh et al. studied 10 patients with a history of 20 years

have a better attitude and this difference was statisti-

cally signi cant. In a study by Tucker as nurses novice,

experienced and skilled nursing care of patients in the

 nal stages of life advocacy behaviors in 2006 showed

that no signi cant differences between groups advocat-

ing for the novice to understand the behavior (of less

than one year), there was no experienced and specialist

because it is stated that novice nurses considering this

is still not enough clinical experience have responded

to the questionnaire based on the theory of knowledge

Table 3: results of the regression model to determine the effect of

demographic variables on the mean attitude advocacy nurses

VariableRegression

coef cient

The standard

error

The amount

of test

p- value

Intercept4.300.2914.97<0.001

Gender-0.010.09-0.160.877

marital status0.130.071.720.087

education-0.150.13-1.120.262

The economic situation-0.190.08-2.390.018

Experience in current

section

0.010.010.950.342

Education history-0.210.08-2.810.005

History of illness or

hospitalization

0.010.080.170.863

ICU

CCU

sections

-0.160.10- 1.640.103

-0.250.10-2.410.017

888 NURSES ATTRIBUTION TO THE ROLE OF PATIENT ADVOCACY BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Maryam Beigzadeh et al.

and the reason is that non-clinical setting behavior and

thus promotes advocacy group experienced in a realistic

manner have responded to the questionnaire (Thacker

2006) however, it seems to increase nurses’ work expe-

rience moral and ethical aspects as well as understand

the illness and nurse the other hand, by increasing the

stability of the nursing work will be better able to deal

with patient advocacy role, (Jahromi et al 2012).

This study showed that nurses with education than

nurses without training have had a better attitude and

this difference was statistically signi cant. In the study

Dehghan et al entitled barriers to professional ethical

standards in nursing in 2013, 61.6 percent administra-

tive barriers, including lack of experienced nurses and

teachers of ethical and legal issues in nursing school

and lack the necessary training in the  eld of ethical

issues have been agreed, (Dehghani et al 2013). Another

important obstacle in the way of professional nursing

roles gap between theory and practice is what nursing at

the university have learned to say and what is different

which is encountered in clinical practice (Nikpeima and

Torab 2012).

Thacker’s study has showed that participants who

received training in end of life care to understand advo-

cacy and conduct advocacy have had a higher rating

and participants with a history of advocacy and educa-

tion have a greater understanding of advocacy behav-

iors. After training in positive behavior is more effective

advocacy at the end of life nursing care patients. Borhani

and Briggs in 2005 stated that a gap in the formal and

continuing education that nurses receive recognition for

their defense which makes nurses to carry out this role to

support co-workers, nurse managers and team members

seek treatment (Thacker 2006). As various studies indi-

cate that education can have an important role in chang-

ing attitudes towards the role of advocacy and also have

this role. Mean score of nurses’ attitudes advocacy groups

with a history of hospitalization or illness without history

of hospitalization, and patients showed that there were

signi cant differences between the two groups. 72.6% of

nurses participating in the study did not have a history of

hospitalization or disease or relatives, (Borhani et al 2010

2014). Nikpeima and Torab (2012) in a research found that

personal problems - family and nurses diseases caused

tension in them and on their role in the workplace, which

have negative effect. In this study, the nurses’ attitude

with no history of disease is slightly higher, but the dif-

ference was not signi cant.

The results of comparing the student’s attitude advo-

cacy groups employed male and female nurses showed that

there were signi cant differences between the two groups

and attitude mean score is 3.66 times the two groups. But

in Borhani et al 2012 study of attitudes towards the role

of patients in teaching hospitals of Kerman University of

Medical Sciences in 2012, it was found that the average

attitude was more in men than women, and this differ-

ence was signi cant. Comparing average score advocacy

approach based on education level of nurses showed that

average score attitudes of nurses with a bachelor’s degree

and master’s degree is better, but the difference was not

signi cant. Comparison of average score advocacy atti-

tude and their marital status revealed that married nurses

than single Nurses have better attitude, but the difference

was not signi cant. In the Borhani et al (2014) study, it

was found that married people have a better attitude, and

this difference was signi cant.

As this study showed that nurses’ attitudes to the sta-

tus of medium to high are better than nurses in moderate

to low economic status. According to a study by Nick

Pima et al. about the nurses ‘view about factors affect-

ing nurses’ professional roles in 2012 showed that one of

the most important factors affecting nurses’ professional

roles including advocacy role of nurses in job security

of nurses. The results showed that low salaries, inad-

equate facilities for nurses and nurses’ personal issues

prevented the role of nurses. So it looks to improve the

welfare of nurses in professional nursing roles, includ-

ing the role of defender will have a positive effect.

Comparing the mean attitude advocacy between

nurses care unit ICU, CCU and dialysis showed that all

three have moderately positive attitude (4-3) but the

mean score advocacy attitude of nurses in the dialy-

sis highest and the CCU is at its lowest. The difference

between the two unit of dialysis and CCU was signi -

cant. It seems due to the fact that patients in chronic

dialysis patients who often have repeated visits to the

dialysis unit and often unable to communicate properly,

sometimes because the years are on dialysis and person-

nel relationship of trust and intimacy that leads to better

identify the needs and problems of disease and therefore

will has better support as well as nurses in dialysis seems

that advocacy obstacles highlighted in other parts faced

less. But in the acute care unit CCU patients often are

in a period and less time in CCU stay as well as CCU

workload is high and all of these obstacles is to estab-

lish a strong relationship. Often in ICU CCU see that the

patient is required to take measures to save her/his life,

So that nurses have the opportunity for advocacy (24).

The Paternalistic view that one of the major obstacles in

the way of patient advocacy is seen more in the CCU.

CONCLUSION

According to studies in the  eld of advocacy, advocacy

role of nurses leads to a sense of achievement, promo-

tion and job satisfaction, which ultimately patient care

will affect work ef ciency and patient satisfaction. So

it seems that dealing with the role of patient advocacy

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS NURSES ATTRIBUTION TO THE ROLE OF PATIENT ADVOCACY 889

Maryam Beigzadeh et al.

have many bene ts for patients, nurses and the entire

system of treatment to be followed. But it is necessary to

create the desired behavior on public attitudes to work.

As noted, one of the most important factor in creating a

better approach is to train nurses need to ethical knowl-

edge to care in a changing world the moral, legal and

safety to offer. As the studies mentioned an important

factor in professional nursing roles including patient

advocacy role is nurses welfare and for the nurse to give

this role to the enhanced need not concern. For this pur-

pose, it is necessary to address nurses  nance and wel-

fare issues which play an advocacy role with peace of

mind and many professional roles in the system’s treat-

ment will certainly improve the system of treatment and

patient satisfaction. Patient participation and empower-

ment in care should alert patients of their rights, identify

and respond to the preferences of the patient’s prefer-

ences and this is not possible unless the nurses trained in

ethical issues and patients receive care. In addition, it is

necessary to further investigate the concept of advocacy

because the de nitions of advocacy for the poor and the

sometimes contradictory and potentially parental.

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