Key messages

What is already known on this topic?

• Advocacy is one of the main roles for nursing professionals.

• Patient advocacy is vital to protect patients when practitioners engage in unsafe practices, mistakes are witnessed, caregivers are incompetent, and support is lacking.

• Advocacy improves public health, the safety of vulnerable patients, access to health care, and the quality of care.

What this study adds?

• Although advocacy is their main role, a significant number of nurses have an unfavorable attitude towards patient advocacy.

• Working in a primary hospital, poor cooperation with others, being dissatisfied with the job, and having an having an unfavorable perception towards the supervision of work are factors that make nurses have an unfavorable attitude towards patient advocacy.

• This study warrants hospitals having regular supervision activities and trying to improve the job satisfaction of nurses.

Introduction

Advocacy is being a patient representative, defending the patient’s rights, protecting the interests of the patient, and contributing to decision-making [1]. It is a process with specific actions to preserve patients’ rights, best interests, and values in the healthcare structure [2]. It has three core features, which are safeguarding a patient’s autonomy, acting on behalf of patients, and championing social justice in the provision of health care [3]. Safeguarding a patient’s autonomy is concerned with actions, respect, and promoting a patient’s self-determination [3, 4]. Acting on behalf of patients involves performing for patients who are unable to represent themselves or who do not wish to represent themselves, such as unconscious patients [1]. Championing social justice in the provision of health care is concerned with nurses actively struggling to make changes to address inequalities and inconsistencies related to the delivery of healthcare [5, 6].

Florence Nightingale laid the foundation for patient advocacy by consistently insisting on quality of care, including a safe and clean environment, and basic human rights for all [7]. Patient advocacy is vital to protect patients when practitioners engage in unsafe practices, mistakes are witnessed, caregivers are incompetent and support is lacking [8]. It is required in situations where there is a lack of teamwork, disrespectful or disruptive behavior happens, and poor management is present [9].

Due to highly fragmented healthcare services, patients need patient advocates who can help them to talk with the health care organization [3, 10]. A method for nurses to engage in the process of serving the healthcare needs of patient is through patient advocacy [10]. Nurses often find themselves in the position of supporting vulnerable people who are not able to speak up for themselves because of factors such as illness [11]. Patients may be neglected, helpless, complaining, or disinterested in their care. This also protects clients from the profit-oriented health system and the paternalist attitude of some health professionals [3, 12].

Nurses’ attitude towards patient advocacy represents a nurse’s personal judgment that the nurse is in favor of or against performing a series of specific actions. Unfavorable attitudes of nurses would result in poor patient care outcomes, and could severely challenge the ability of the healthcare system to provide quality care and improve the outcomes of patients [10, 13].

Globally, nurses’ attitude towards patient advocacy is an indicator of their forthcoming behaviors and future performances in patient care [13, 14]. Studies showed that many patients were subjected to preventable complications, including estimates that range from 98,000 to 440,000 deaths per year, which could be prevented by patient advocacy [6, 15]. African healthcare practitioners still tend to run through paternalistic treatment, with little patient participation in the decision-making of management options [16]. This could be due to unfavorable attitude of nurses towards patient advocacy that would result in poor patient care outcomes [17, 18]. In a large study, 50% of nurses described situations that should have resulted in patient advocacy (speaking up for patients), and only 10% of the time nurses find patients’ voice [19]. Mostly nurses found to have difficulty of not speaking out regarding issues and concerns that can potentiate patient injury [20]. In accordance with a study in Ghana, fatigue and dissatisfaction delayed the nurses’ realization of patient advocacy role [12, 20].

Patient advocacy improves public health, the safety of vulnerable patients, and access to quality health care. It also lowers health care gaps, decreases costs of complications, and increases patient satisfaction [21, 22]. To advocate properly for patients, nurses should have a favorable attitude towards patient advocacy. Despite this fact, the attitude of nurses towards patient advocacy was not documented and well-known. This study was aimed to assess nurses’ attitude towards patient advocacy and its associated factors in East Gojjam Zone Public Hospitals, Northwest Ethiopia.

Methods and materials

Study area and period

The study was conducted in East Gojjam Zone Public Hospitals. East Gojjam Zone had eleven public hospitals, including one comprehensive specialized hospital, one general hospital, and nine primary hospitals. These are, namely, Debre Markos Comprehensive Specialized Hospital, Dejen Primary Hospital, Bichena Primary Hospital, Motta General Hospital, Yejubie Primary Hospital, Debre Work Primary Hospital, Debre Elias Primary Hospital, Lumamie Primary Hospital, Bibugn Primary Hospital, Shebel Berenta Primary Hospital, and Merto-Lemariam Primary Hospital. The eleven public hospitals had a total of 820 nurses. The study was conducted from March 1 to April 30, 2023.

Study design

Institutional based cross-sectional study design was conducted.

Population

All nurses employed in East Gojjam Zone Public Hospitals were source population. All nurses of East Gojjam Zone Public Hospitals who were available in hospitals during the data collection period were study population.

Eligibility criteria

Inclusion criteria

All nurses who had been permanently recruited and worked in East Gojjam Zone Public Hospitals were included.

Exclusion criteria

Nurses who were on sick leave, maternal leave, or off-site training were excluded. Furthermore, nurses who are newly recruited (less than six months) were excluded.

Sample size determination

The sample size was calculated by using single population proportion formula by considering 95% confidence interval, 5% margin of error, and proportion of unfavorable attitude. Because of the absence of a previous study in Ethiopia, 50% was taken as a proportion.

n = (Z α/2)2 P (1-P)/ d2

Where n = minimum sample size

P = the proportion of the study 50%

d = Margin of error = 0.05

(Z α/2) = Standard deviation = 1.96 (at 95% confidence level)

n = (Z α/2)2 P (1-P)/ d2 = (1.96)2 (0.5 × 0.5)/ (0.05)2 = 384

Sample size for the second objective was calculated by using the StatCalc of Epi-Info software version 7.2.5 with the assumptions: Confidence level = 95%, Power = 80%, and Ratio of un-exposed to exposed almost equivalent to 1. However, the larger sample size was obtained by the first objective. Thus, the final sample size was 423 by adding 10% non-response rate.

Sampling technique and sampling procedure

A simple random sampling technique was used in all hospitals to select study participants. Study participants were selected with proportional allocation of sample size to each hospital by using lists as sampling frames at each hospital. From Shebel Primary Hospital and Debre-Elias Primary Hospital, 22 participants were selected from each. Dejen Primary Hospital, Debre Work Primary Hospital, and Mertole Mariam Primary Hospital each constituted 24 participants, 164 from Debre Markos Comprehensive Specialized Hospital, 43 from Mota General Hospital, 31 from Bichena Primary Hospital, 21 from Bibugn Primary Hospital, 23 from Lumamie Primary Hospital, and 25 participants from Yejubie Primary Hospital were selected (Fig. 1).

Fig. 1
figure 1

Sampling procedure for nurses’ attitude towards patient advocacy and its associated factors in East Gojjam Zone Public Hospitals, Northwest Ethiopia, 2023

Full size image

Study variables

Dependent variable

Nurses Attitude towards patient advocacy (unfavorable/favorable).

Independent variables

  • Socio-demographic variables: age, sex, marital status, educational level, work experience, working unit, current position and participation in patient support group.

  • Nurse related variables: cooperation, knowledge of nurses on patient advocacy, job satisfaction and fatigue of nurses.

  • Organization related variables: Hospital level, availability of patient support group, training on patient advocacy, working environment and perceived supervision of work.

Operational definition

Patient Advocacy is being a patient representative, defending the patient’s rights and interests having three core attributes (safeguarding a patient’s autonomy, acting on behalf of patients, and championing social justice) in the provision of health care [3, 4].

Nurses’ Attitude towards patient advocacy was measured based on the median of the sum of thirty-three attitude questions which was 97 points with minimum and maximum scores of 33 and 165 points, respectively. The attitude score was dichotomized as favorable and unfavorable.

Unfavorable attitude

is if the score of the nurse was below the median score(97 points) of the sum of attitude questions of 33 items with 5 point responses [strongly disagree(1) through strongly agree(5)] with a range of scores of 33–165 points [23].

Poor cooperation

if the nurse’s score was below the median (61 points) of the sum of 21 cooperation questions, with a minimum and maximum of 21 to 105 points, respectively [24, 25].

Fatigued

if a nurse scores above or equal to the median score (24 points) from the sum of 10 fatigue questions with range of scores 10 to 50 points [26].

Poor knowledge

if the nurse’s score was below the median(4) score of knowledge questions.

Not satisfied with job

if a nurse scores below the median score (< 59 points) from sum of 20 job satisfaction items with range of values 20 to 100 points [27].

Good working environment

if the score of nurse was above the median score which was 30 points from sum of 10 working environment questions with values from 10 to 50 points [28].

Poor perceived supervision of work

if the score was below the median score (42 points) from sum of 15 supervision questions with range of values 15 to 75 points [29].

Data collection tool

The data collection tool was adapted from different research studies. It includes four parts (socio-demographic characteristics, nurse related characteristics, organization related characteristics and attitude of nurses’ characteristics).

Sociodemographic characteristics

It contains 8 questions about sociodemographic characteristics of nurses.

Protective nursing advocacy scale

It was developed by Hanks RG [30] and original scale consists of 43 questions, answered by means of a Likert-type frequency scale of five points, using 1 for “strongly disagree”, 2 for “partially disagree”, 3 to “neither agree nor disagree” 4 to “partially agree” and 5 for “strongly agree”. Scale has 4 subscale: acting as an advocate, which reflects actions of nurses when advocate in health for patients, work situations and advocacy actions, which reflects possible health advocacy consequences in the work environment, environment and educational influences, which includes items measuring the influence of knowledge and internal environment of nurses, such as personal values, beliefs and confidence to work in health advocacy, support and barriers to advocacy, which consists of items indicating the facilitators and barriers to health advocacy in nursing, including the work environment as a whole. The scale version used in this study was adapted from 2014 Protective Nursing Advocacy Scale [15, 31] and had 33 items with 5 point responses, from strongly disagree(1) to strongly agree(5) and three sub-scales.

  • Cooperation of nurses assessed by 21 items with tool adapted from the 2010 Nurse-physician Collaboration Scale [32].

  • Knowledge of nurses was assessed with 10 items regarding patient advocacy with reliability (Cronbach’s alpha = 0.92).

  • Job satisfaction was measured by a tool with 20 items, has reliability of (Cronbach’s alpha = 0.92).

  • Fatigue of nurses was assessed with 10 items by a tool adapted from Michielsen, 2012 FAS with reliability of (Cronbach’s alpha = 0.93).

  • Organization related characteristics have 4 items including training on advocacy, availability of patient support group, working environment, and supervision of work.

  • Work environment was measured by a tool with 10 items adapted from Practice Environment Scale of the Nursing Work Index of 2017 and modified Work environment scale, 1 for never to 5 for always [28, 33].

  • Perceived supervision of work was measured by a tool with 15 items adapted from supportive supervisory scale with responses (1) for response of (never) through (5) for (always) [34].

The validity of this tool was assessed by different experts. The nursing ethical issues were considered to be seen, and experts agreed on the reasonable content validity and face validity of the current tool. The reliability of the tool was estimated to inspect the internal consistency of the items and calculated in a previous study to be 0.96. The reliability was reexamined for this study by pretest (Cronbach’s alpha = 0.95), indicating that the tool was highly reliable. The whole questionnaire, with a total of 129 items and an overall reliability of (Cronbach’s alpha = 0.94), was prepared in English and distributed as hard copies to study participants. Those questions having opposite implications for the computed items were inversely coded with respect to each tool for the measured variable.

Data collection procedures

The data were collected by eleven trained data collectors who have bachelor’s degrees in nursing using a structured, self-administered questionnaire given to participant nurses. The data collectors were supervised by two supervisors and the principal investigator. Two days of training were given to each of the data collectors on the meaning of every item of the questionnaire and the techniques of data collection, such as ways of greeting participants and approaches to taking informed consent. The data collectors explained the objective of the study to the participants before they let them fill out the questionnaire. The data collectors clarified any ambiguous and unclear questions when necessary for respondents.

Data quality control

To ensure the quality of the data, the data collection process was supervised, including properly designing the questionnaire and training data collectors and supervisors about the data collection procedures. The questionnaire was pretested on 5% of the sample at Dembecha Primary Hospital to check acceptability and consistency before the actual data collection. After reviewing the results of the pretest, modifications to the questionnaire were performed for clarity and completeness. Continuous supervision of data gathering and daily checking of the collected data were performed by supervisors and the principal investigator. To maintain the quality of the data, training was given to all data collectors and supervisors for two days by the principal investigator about the objective of the study and method of data collection. The confidentiality of information was maintained in the study.

Data processing and analysis

After data collection, each questionnaire was checked visually for completeness. The collected data were numerically coded, and entered into EpiData software version 4.6 and exported to SPSS software version 26 for analysis. Binary logistic regression model fitness was performed by the Hosmer and Lemeshow test, which shows model fitness when it is found not statistically significant (p-value > 0.05). Higher values of Negalkerke R2 were observed, which shows that adding the independent variables to the model significantly increased the ability to predict the outcome variable. In order to show any possible significant correlation between independent variables, Spearman’s correlation analysis was carried out. To identify the variables to be entered from bivariable logistic regression to multivariable logistic regression analysis, a p-value < 0.25 was used. Multivariable logistic regression analysis was done by using the backward likelihood ratio and variables whose p-value was less than 0.05 at a 95% confidence interval with the AOR of the predictor variables, which were declared the relationship of the dependent variable with independent variables in the model. The normality test was performed by Kolmogorov-Smirnov and Shapiro-Wilk, which showed a non-normal data distribution. The median with interquartile range (IQR), frequency, and percentages were calculated, and the results were presented by tables, statements, and graphs.

Results

Socio-demographic characteristics of study participants

A total of 385 nurses were involved, which gives a response rate of 91%. The median age of nurses was 37 (IQR = 15) years. From the total nurses, 227 (59%) were female, and 20 (5.2%) had participated in the patient support groups in the hospital (Table 1).

Table 1 Socio demographic characteristics of nurses working in East Gojjam Zone Public hospitals, May, 2023 (n = 385)
Full size table

Nurse related characteristics of study participants

The median score of nurses’ cooperation was s 61 (IQR = 32 and 165 (42.9%) of participants did not cooperate to avoid conflicts and reach the most possible agreement. The median score of knowledge about patient advocacy was 4 (IQR = 4). The median score of fatigue among nurses was 24 (IQR = 9). The median score of job satisfaction was 59 (IQR = 28). Of the total study participants, 183 (47.6%) were not satisfied with their job as nurses (Table 2).

Table 2 Nurse related characteristics of participants for attitude and associated factors of patient advocacy among nurses working at east Gojjam Zone public hospitals, northwest Ethiopia, 2023 (n = 385)
Full size table

Organization related characteristics of respondents

The median score of the working environment was 30 (IQR = 5) points. The median score for perceived supervision of work was 42 (IQR = 22). In this study, 188 (48.8%) of participants perceived poor supervision of work within their hospitals, and 100 (26%) of study participants had taken training on patient advocacy (such as trainings related to patient rights, empowerment, infection prevention, and patient safety) (Table 3).

Table 3 Organization related characteristics of participants for attitude and associated factors of patient advocacy among nurses working at east Gojjam Zone public hospitals, Northwest Ethiopia, 2023 (n = 385)
Full size table

Nurses’ attitude towards patient advocacy

The median score of nurses’ attitudes on the dimension of ‘Acting on Behalf of Patients’ was 29 (IQR = 19) points. The median score of nurses’ attitudes on the dimension of “safeguarding patients’ autonomy’ was 35 (IQR = 25) points. The median score of nurses’ attitudes on the dimension of championing social justice’ was 28 (IQR = 18) points. The unfavorable attitudes of nurses towards patient advocacy on the dimensions of acting on behalf of patients, safeguarding patients’ autonomy, and championing social justice in the provision of healthcare were 49.6%, 46.5%, and 47.3%, respectively (Fig. 2).

The median score of nurses’ attitude towards patient advocacy was 97 (IQR = 35) points. The overall magnitude of the unfavorable attitude of nurses towards patient advocacy was 49.9% [95% CI = (45.2-55.3%)].

Fig. 2
figure 2

Nurses’ Attitude score on dimensions of patient advocacy in East Gojjam Zone Public Hospitals, Northwest Ethiopia, 2023(n = 385)

Full size image

Factors Associated with attitude of nurses towards patient advocacy

In bivariable logistic regression, the twelve variables, including hospital level, marital status, work experience, level of education, working unit, current position, training on patient advocacy, cooperation of nurses, fatigue of nurses, job satisfaction of nurses, working environment of nurses, and perceived supervision of nurses’ work, were found to be significant at a P value < 0.25 and entered into multivariable logistic regression. In the multivariable logistic regression analysis, at p-value < 0.05, variables such as hospital level (primary), poor cooperation of nurses, being not satisfied with the job, and poor perceived supervision of nurses’ work were found to be significantly associated with the attitude of nurses towards patient advocacy.

Accordingly, those respondent nurses who were working in primary hospitals were two times more likely to have an unfavorable attitude towards patient advocacy as compared to nurses working in referral hospitals [AOR = 2.3; 95% CI: 1.4–3.8]. Those nurses who had poor cooperation with other health care providers were two times more likely to have an unfavorable attitude towards patient advocacy as compared to those who had good cooperation [AOR = 1.7; 95% CI: 1.1–2.8%]. Those nurses who were not satisfied with their job were two times more likely to have an unfavorable attitude towards patient advocacy as compared to those who were satisfied with their job [AOR = 1.7; 95% CI: 1.1–2.7)]. Those nurses who had poor perceived supervision of work were six times more likely to have an unfavorable attitude towards patient advocacy as compared to those who had good perceived supervision of work [AOR: 6.1; 95% CI: (3.7–9.8)] (Table 4).

Table 4 Bivariable and multivariable logistic regression outputs of association between nurses’ attitude and factors in East Gojjam Zone Public hospitals, Northwest Ethiopia, 2023 (n = 385)
Full size table

Discussion

Among nurses’ primary responsibilities is advocacy. Nurses who wish to discharge advocacy roles should be internally committed and have a positive attitude towards it. It is impossible to put into practice without having an optimistic view. Despite this fact, the level of nurses’ attitude towards patient advocacy in Ethiopia is not known. Understanding nurses’ attitudes is essential before encouraging them to take on the role of patient advocate. Thus, this study will give information about nurses’ attitudes and help stakeholders design interventions that improve nurses’ attitudes towards patient advocacy.

The result of this study showed that, the magnitude of unfavorable attitude of nurses towards patient advocacy was 49.9% [95% CI = (45.2-55.3%)]. This finding was higher than studies conducted in Saudi Arabia [5], United States of America [10] and Iran [13] where 18%, 3.6% and 27% of nurses respectively, having unfavorable attitude towards patient advocacy. The inconsistency might be due to cultural and socio-economic factors such as differences among nurses, differences in the level of health care services used for patient care, and differences in the economic status of the countries. In addition to this, this study included nurses from all departments, unlike the study done in Saudi Arabia, which included only nurses from the oncology department. The other possible justification could be that those nurses abhorring their profession with payment would not be eager to advocate for patients with consequences. These nurses are less likely to monitor medication faults with responsibilities and would be less protective for patients from incompetent healthcare providers. Due to this, they have a high score for unfavorable attitudes towards patient advocacy.

This study found that those nurses who were working in primary hospital were two times more likely to have unfavorable attitude towards patient advocacy as compared to nurses working in referral hospitals. This may happen because of the difference in the number of services delivered by higher institutions with new specialties and more consultations could be requested to different units. This would take longer to be a patient advocate with the increasing demands of patients. This could also be explained as those nurses working in primary hospitals were challenged by a higher number of patients due to the higher burden of chronic diseases, making stressful situations more stressful as compared to those nurses in referral hospitals. In addition to this, it may be due to the more options available for patients, such as different private clinics and drug stores near the hospital, that nurses are less concerned about advocating for patients. The other possible reason could be due to fear of conflicts with other members of the healthcare team and experiencing feelings of separation. All of these would lead nurses to be more likely to have an unfavorable attitude towards patient advocacy.

In this study those nurses who had poor cooperation were two times more likely to have unfavorable attitude towards patient advocacy as compared to those who had good cooperation. This finding was supported by a study conducted in Sweden [35], in which collaboration among nurses had a significant association with nurses attitudes towards patient advocacy. Additionally, this study could be justified by a study done in Jimma (48) in 2019, where the nurses’ perception of caring behavior was low, which would make nurses to have an unfavorable attitude towards patient care and advocacy. This may be explained by the fact that those participants who work in the absence of collaboration with other healthcare professionals could be troubled by conflicts and withdraw from patient care. As a result, nurses will have an unfavorable attitude towards patient advocacy.

Those nurses who were not satisfied with their job were two times more likely to have an unfavorable attitude towards patient advocacy as compared to satisfied nurses. This finding was supported by a study done in Eastern Ethiopia (34) in 2017, where 52% of nurses were dissatisfied and influenced patient safety, productivity, quality of care, and the intention to leave the job. This finding was also supported by a study done in Malawi in 2016 that found a link between job satisfaction and the attitude of nurses [23]. A study in Pakistan in 2021 also supports this finding, which showed that, strong relationship existed between nurses’ job satisfaction and patient safety attitudes [36]. In addition to this, this finding is strongly supported by a study in Turkey (49) in 2015 that found that being unsatisfied with a job among nurses made them more likely to leave the nursing profession. This is due to the fact that those nurses who were dissatisfied would search for other job opportunities, not be involved in patient care, and then have a strongly unfavorable attitude towards advocating for patients.

Those nurses with poor perceived supervision of work were six times more likely to have an unfavorable attitude towards patient advocacy as compared to those nurses who had good perceived supervision of work. This finding was supported by studies done in Sweden [35] and United States of America [20], where supervision of work was associated with nurses’ attitude towards patient advocacy. This may be explained by the fact that, when the activities of nurses were not adequately supervised, those hard-working nurses were not supported actively by their corresponding manager. This would result in more workloads for patient care imposed on a number of nurses. On the other hand, less interested nurses—a nearly higher number of nurses—would go away from hospitals and may be missed out of nursing care areas. This might lead to fatigue and burnout for actively working nurses, while others go searching for extra income or other jobs. On both sides, it will end up with a higher intention to leave the nursing profession (50). All these leads nurses to have unfavorable attitudes towards patient advocacy.

Limitation of the study

This study has its own limitations. Due to the fact that patient advocacy is the major role of nurses, study participants may underestimate and hide the presence of the problem. Furthermore, due to social desirability, study participants gave biased responses. Thus, it is difficult to generalize the finding. Moreover, methodologically, this study cannot show the cause-and-effect relationship since it is a cross-sectional study.

Conclusion

A significant number of nurses had an unfavorable attitude towards patient advocacy. Being working in a primary hospital, poor cooperation of nurses, not being satisfied with the job, and poor perceived supervision of work were the factors significantly associated with the unfavorable attitude of nurses towards patient advocacy.

Recommendations

  • Nurses had better put emphasis on cooperation with other healthcare professionals and other workers to enhance their shared experiences regarding patient advocacy and other nursing roles.

  • Hospitals should have a system of good supervision for nursing activities and support the nurses in different ways to increase their job satisfaction.

  • Amhara Regional Health Bureau and hospital managers should consider the rotation of nurses between primary, general, and referral hospitals.

  • Researchers should study the practice of patient advocacy among nursing staff for better interventions in solving the problem.