Recidivism in Nursing: A Concept Analysis Paper

Recidivism in Nursing: A Concept Analysis Paper

Purpose
A concept analysis is designed to make the student as familiar with a concept as possible. A concept is usually one or two words that convey meaning, understanding or feelings between or among individuals within a same discipline. Some concepts relevant to mental health are stigma and recidivism
Activities and Directions
To begin the process, choose a concept you are interested in, a term you encounter with your work or one with which you would like to research. Look for the measurable quality in your topic of interest, problem or question.
- Write down all of the words you can think of which relate to or express your concept. Recidivism in Nursing: A Concept Analysis Paper
- Search the literature for journal articles and books related to the concept to get a sense of the beliefs and thoughts of others in the discipline regarding the concept.
- Begin the analysis paper with a introductory paragraph expressing what the concept is and why it is significant to you and mental health.
- Develop the Model Case. The model case is a brief situational description validating the concept including all of the characteristics you have listed which describe or make up the concept. The model case should be able to
reflect that If this is not an example of (concept), then nothing is.
- Close with a summary. Recidivism in Nursing: A Concept Analysis Paper.

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CONCEPT ANALYSIS PAPER
EVALUATION FORM (100 points).
I. Introduction (10 points)
A. Includes the aims & purposes of the analysis (0-3)_______
B. Justifies concepts significance to mental health (0-7)_______
II. Definition of Concept (20 points)
A. Describes derivation of definition from common usage, &
nursing use (0-6)_______
B. Describes & cites a variety of appropriate authoritative
sources from the literature regarding nature of concept (0-6)_______
C. Definition of concept reflects synthesis &
evaluation of definitions from appropriate sources (0-8)_______
III. List of defining characteristics (25 points)
A. Each attribute is clearly stated as succinctly as possible (0-5)_______
B. Each attribute is logically an essential element of the
concept as defined (0-5)Recidivism in Nursing: A Concept Analysis Paper._______
C. Each attribute is stated in as measurable a form as the
abstractness of the concept allows (0-5)_______
D. The listed attributes comprise all essential attributes of the
concept as defined (0-10)______
IV. The Model Case (25 points) Recidivism in Nursing: A Concept Analysis Paper.
A. Is a logical example of the concept (0-5)_______
B. Includes all listed attributes of the concept (0-10)______
C. Includes no attributes of other concepts (0-5)_______
D. Is concisely stated (0-5)_______
V. Reference List (10 points)
A. Contains a variety of resources (0-2)_______
B. Resources are authoritative, classic resources are evident (0-3)_______
C. Nursing resources are explored (0-3)_______
D. Resources are sufficient in number to justify analysis (0-2)_______
VI. Layout and Presentation of Paper (10 points)
A. Precise APA format (0-5)_______
B. Grammar, spelling & typing at professional scholarly level (0-5)_Recidivism in Nursing: A Concept Analysis Paper.

Nursing Forum Volume 42, No. 4, October-December, 2007 171
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ORIGINAL ARTICLES
Barriers to Nursing Advocacy: A Concept Analysis
AUTHORS RUNNING HEAD:
Barriers to Nursing Advocacy: A Concept Analysis
Barriers to Nursing Advocacy: A Concept Analysis
Robert G. Hanks, RN, C, MSN, FNP-C
Advocacy for clients is viewed as an essential
function of nursing; however, to be effective
advocates for patients, the nurse must often
overcome barriers to being an effective advocate.
This concept analysis of barriers to nursing
advocacy uses the Walker and Avant method of
concept analysis.Recidivism in Nursing: A Concept Analysis Paper. By analyzing the barriers to
effective nursing advocacy for clients, nursing can
then find strategies to manage those barriers and
maximize the nurse’s advocacy efforts.
Search terms
:
Barriers, concept analysis,
nursing, patient advocacy
Robert G. Hanks, RN, C, MSN, FNP-C, is a Clinical
Instructor at the School of Nursing, University of Texas at
Arlington, Arlington, TX.
Introduction and Concept Selection
Advocacy for clients is an important aspect in
current professional nursing care and is considered
to be a fundamental value of professional nursing by
several nursing scholars. Since the origin of the
client advocate in the 1970s (Annas & Healey, 1974),
nursing has been viewed as the ideal profession to
take on this advocate role (Annas, 1974) due to the
intimate relationship of the client and nurse. The
main act of advocating is viewed as part of nursing
ethics by supporting patient autonomy (Gadow,
1989). Advocacy is found in all ethical codes for
nursing (Hamric, 2000), including the American
Nurses Association (ANA) Code of Ethics for Nurses
(2001)Recidivism in Nursing: A Concept Analysis Paper.
Nursing has not always practiced advocacy;
rather, it is a relatively new role for nursing,
emerging in the United States in the 1980s (Hamric,
2000). Barriers exist that prevent nurses from advocating
for their clients, which will be examined in
this article. For nurses to be effective advocates,
an examination of the barriers that prevent nurses
from fully realizing their role as nursing advocates
must be performed in order to overcome these
barriers.
Aim of Analysis
The aim of this analysis is to analyze critically
the concept of barriers to nursing advocacy in
order to provide clarity and direction for future
inquiries into this subject. In addition, examining
the barriers to nursing advocacy may result in
more effective nursing education and interventions
regarding nursing advocacy and the possibility of
overcoming the barriers to provide effective nursing
advocacy.Recidivism in Nursing: A Concept Analysis Paper.
172 Nursing Forum Volume 42, No. 4, October-December, 2007
Barriers to Nursing Advocacy: A Concept Analysis
Methodology
The methodology used in this concept analysis is
the Walker and Avant (2005) concept analysis method
(Table 1), which is derived from Wilson’s (1963)
classic concept analysis procedure (Table 2). The
Walker and Avant method was selected because it
was determined to be more suitable for this novice
author to use.
Sample Selection
Articles for this concept analysis were selected
using searches of Cumulative Index of Nursing and
Allied Health (CINAHL), MEDLINE, PsychInfo, and
Sociological Abstracts. The databases chosen encompass
the literature associated with the keyword combinations
used. The combination of keywords used for the
searches included the following: (a) patient advocacy,
(b) nursing, (c) subservience, and (d) barriers. By
including PsychInfo and Sociological Abstracts, a larger
sample of literature was uncovered. The time period
for the literature searches were as follows: (a) CINAHL
1982–2005, (b) MEDLINE 1966–2005, (c) PsychInfo
1967–2005, and (d) Sociological Abstracts 1963–2005,
which are the limits of the databases at the library
used. The resulting 55 abstracts were reviewed for
content about nursing advocacy and barriers to
advocacy with a total of 36 articles used for this analysis.
Each of the selected articles from the literature was
read for themes and contribution to the body of
literature about nursing advocacy and barriers to
nursing advocacy.
Relevance of Literature Reviewed to
the Selected Concept
The literature used for this concept analysis reflects
the historical progress of nursing advocacy and,
imbedded in this progress, the barriers to nursing
advocacy. An examination of the barriers to nursing
advocacy will help to focus nursing on overcoming
the barriers and provide more effective nursing
advocacy for clients.Recidivism in Nursing: A Concept Analysis Paper.
Relevance to Nursing
Most nursing scholars and many nonnursing
scholars agree that nursing advocacy for clients is
a fundamental part of nursing practice (Annas, 1974;
Curtin, 1979). This concept is reflected in ethical codes
for nurses that include advocacy for clients (ANA, 2001;
Hamric, 2000). If nurses are to be effective at nursing
advocacy for their clients, then an understanding of
barriers, both actual and potential, will help the nurse
realize effective nursing advocacy.
Table 1. Walker and Avant Concept Analysis
Method (2005, p. 65)
1. Select a concept
2. Determine the aims or purposes of analysis
3. Identify all uses of the concept that you can discover
4. Determine the defining attributes
5. Identify a model case
6. Identify borderline, related contrary, invented, and
illegitimate cases
7. Identify antecedents and consequences
8. Define empirical referents
Table 2. Wilson Concept Analysis Procedure (1963,
pp. 23–36)Recidivism in Nursing: A Concept Analysis Paper
1. Isolate questions of concept
2. Right answers
3. Model cases
4. Contrary cases
5. Related cases
6. Borderline cases
7. Invented cases
8. Social context
9. Underlying anxiety
10. Practical results
11. Results in language
Nursing Forum Volume 42, No. 4, October-December, 2007 173
Most nursing scholars and many nonnursing
scholars agree that nursing advocacy for
clients is a fundamental part of nursing
practice (Annas, 1974; Curtin, 1979).
Uses of Concept
For the purposes of this article, the definitions
have been narrowed to the nursing context according
to the most recent version of the Walker and
Avant method of concept analysis (2005). In order to
understand the complex nature of the concept of
barriers to nursing advocacy, nursing advocacy
and barriers to nursing advocacy were analyzed
separately.
Advocacy is derived from advocate, which is a
“person that pleads a case on someone else’s behalf”
(Oxford Online, 2006). Another source defines advocacy
as “the act or process of advocating or supporting
a cause or proposal” (Merriam-Webster Online, 2006a).
Advocacy has been defined as correcting a deficit of
a client by another (Grace, 2001)Recidivism in Nursing: A Concept Analysis Paper, informing a person
of their rights and providing information (Segesten,
1993), supporting the client (Kohnke, 1982), and giving
voice to silent patients (Gadow, 1989).
Nurse is defined as “a person who is skilled or
trained in caring for the sick or infirm especially
under the supervision of a physician” (Merriam-
Webster Online, 2006c). The ANA (2003) defines
nursing, in part, as “provision of a caring relationship
that facilitates health and healing” and “attention to
the range of human experiences and responses to
health and illness within the physical and social
environments.” However, in nursing literature, nursing
advocacy is a combined term that has been used to
define nurses advocating for their clients (Curtin,
1979). Most definitions of nursing advocacy in the
nursing literature sample are describing attributes
rather than actual definitions.
Barriers are defined as “something immaterial
that impedes or separates” (Merriam-Webster Online,
2006b). Barriers are not defined per se in the sample of
nursing literature, but rather are qualified by the
attributes of barriers.
Defining Attributes
Nursing Advocacy
The attributes of nursing advocacy vary in the
sample. The nurse advocate is most commonly
associated with protector of patient rights (Bandman,
1987; Becker, 1986; Foley, Minick, & Kee, 2000; Gadow,
1980; Gadow, 1989; Kubsch, Sternard, Hovarter, &
Matzke, 2003). In this role, the nurse is protecting the
fundamental rights of the patient’s self-determination
over the patient’s care. Congruent with this concept is
the informer role of the nurse advocate in which the
nurse provides information to the patient about the
patient’s care (Chafey, Rhea, Shannon, & Spencer, 1998;
Curtin, 1979; Kohnke, 1980; Watt, 1997). Empowerment
is also cited as an attribute of nursing advocacy
(Chafey et al.; Lindahl & Sandman, 1998; Smith &
Godfrey, 2002). The role of patient supporter is also
contained in the nurse advocate role (Kohnke, 1982;
Watt, 1997), with a related term, partnership, also
being used in the literature (Gadow, 1983; Lindahl &
Sandman; Snoball, 1996). A similar attribute, representative,
is suggested by Copp (1986)Recidivism in Nursing: A Concept Analysis Paper. Finally, the
attribute therapeutic relationship has been recommended
by Snoball.
Barriers to Nursing Advocacy
The attributes of barriers to nursing advocacy are
infrequently found in the literature. The most common
attribute is conflict of interest between the nurse’s
174 Nursing Forum Volume 42, No. 4, October-December, 2007
Barriers to Nursing Advocacy: A Concept Analysis
responsibility to the patient and the nurse’s duty to the
institution where the nurse is employed (Jenny, 1979;
Miller, Mansen, & Lee, 1983; Pullen, 1995; Robinson,
1985; Walsh, 1985). Similar attributes of institutional
constraint (Kohnke, 1980), including lack of support
(Millette, 1993) and lack of power (Hewitt, 2002;
Miller et al.), have been identified as barriers. An
additional barrier to nursing advocacy is the nurse’s
lack of education (Pankratz & Pankratz, 1974; Penticuff,
1989) and time (Miller et al.; Segesten, 1993). Threats
of punishment are also considered an attribute of
barriers to nursing advocacy (Mallik, 1997). Finally,
a historical barrier of nursing being a feminine profession
with a tradition of subservience to the medical
profession is also considered a barrier to nursing
advocacy (Hamric, 2000; Winslow, 1984).
Cases
Model Case
F.N. is a new graduate from an associate degree
program and she has obtained her first nursing position
at a small, private, community hospital. F.N. is very
grateful to her new employer for a position, as it is
the only hospital within 80 miles, and openings for
registered nurses have been curtailed in the past
year. The supervisor of F.N. is domineering, and is
constantly reminding F.N. of her obligation to the
hospital and physicians. The client load is heavy,
often leaving F.N. with little time to discuss issues
with her clients.
Mr. J. is a new client that has been admitted for
renal disease and cellulitis of the left foot. The
physician orders meperidine for pain management,
which Mr. J. requests and receives each hour. After
a day of this therapy, Mr. J. starts to have twitching
movement in his arms. Concerned, F.N. discusses this
issue with the supervisor. The supervisor tells F.N.
to continue to administer the meperidine and “not
ask questions.” The supervisor further informs F.N.
that meperidine is the hospital standard and that
the hospital has “been using it for years.” Mr. J. is
having muscle cramps due to the continuous
twitching and requests that F.N. call the physician.
However, F.N. has 10 other clients to care for, and
fearing a reprisal from her supervisor, F.N. administers
another dose of meperidine without consulting the
physician.Recidivism in Nursing: A Concept Analysis Paper
Borderline Case
P.M. is an experienced nurse with 20 years’
experience in the surgical area. She is caring for
10 clients that are postoperative. One of the patients,
W.M., complains of incisional pain, but is concerned
about the side effects of the medication that is ordered.
P.M. administers the pain medication anyway, telling
W.M. that she will come back later and discuss his
concerns.
Related Case
Q.D. is a nurse working in a large long-term care
facility. The length of employment for the nursing
staff is less than 1 year, leaving the facility chronically
short staffed. The facility is also undergoing budget
constraints due to lower Medicare payments. Q.D. has
been working two shifts per week of overtime during
the past month, and is fatigued. Her supervisor asks
her to work another shift of overtime on her only day
off. Q.D. politely states that she needs to rest on her
day off and spend time with her family. The supervisor
reminds Q.D. how short the facility is of nursing staff.
Q.D. replies that although she understands the facility’s
position, Q.D. must first assure that she remains
healthy and able to provide the best care to her clients
by allocating sufficient rest periods from work.
Contrary Case

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P.D. is a clinical nurse specialist working on a surgical
ward. The floor nurses have asked her to come and
evaluate the pain management of Mr. J., a new client
Nursing Forum Volume 42, No. 4, October-December, 2007 175
that has been admitted for renal disease and cellulitis
of the left foot because, according to the floor staff, the
charge nurse “won’t do anything.” Mr. J. is receiving
large amounts of meperidine and has now developed
muscle twitching. P.D. is aware of the neurotoxic
metabolites of meperidine. After performing a detailed
examination and having Mr. J. express his concerns,
P.D. calls the prescribing physician and asks the
physician to discontinue the meperidine, even though
this is the preferred pain medication at the hospital
and this particular physician’s preference. The
meperidine is discontinued and morphine is ordered
as the pain medication for Mr. J. After 24 hr, Mr. J. is
rating minimal pain, and the muscle twitching has
subsided.Recidivism in Nursing: A Concept Analysis Paper.
Invented and Illegitimate Cases
The invented and illegitimate cases are not required
using this method of concept analysis (Walker &
Avant, 2005). The concept of barriers to nursing
advocacy has been sufficiently demonstrated using the
model, borderline, related, and contrary cases.
Antecedents
The antecedents to barriers of nursing advocacy are
related to the need for nursing advocacy for the
client. Advocacy for patients stems from a vulnerable
population that loses power to represent or defend
itself (Copp, 1986) or an individual that is neglected
or intimidated (Chafey et al., 1998). The antecedents of
barriers include employment conditions, fear of loss of
employment, fatigue, frustration, and burnout (Chafey
et al.). Inadequate education has been cited as a barrier
to nursing advocacy (Copp; Jenny, 1979; Pankratz &
Pankratz, 1974).
Consequences
The consequences of the barriers to nursing advocacy
are of great importance but also seem simplistic. The
major consequence of the barriers to nursing advocacy
is ineffective advocacy for the client by the nurse
(Mallik, 1997). A secondary but related consequence
of the barriers to nursing advocacy is continuing
unresolved issues about patient care (Andersen, 1990).
Empirical Referents
The barriers to nursing advocacy are found in
the literature; however, the literature identifies few
research studies or instruments on nursing advocacy
or the barriers to nursing advocacy. In 1991, Hatfield
explored the relationship between a nurse’s level of
ethical reasoning and the factors that influence the
nurse as an advocate, namely, autonomy and agency
support. Hatfield authored the “Nursing Advocacy/
Beliefs & Practices” (NABP) scale for her dissertation
study. The NABP scale measures the constructs of
patient autonomy, nursing autonomy, and agency
support (Hatfield, 1991). The correlation coefficient for
the relationship between nurses’ beliefs about patient
autonomy and ethical judgment was statistically
significant (
r
= .5040;
p
= .01)Recidivism in Nursing: A Concept Analysis Paper, leading to a conclusion
that a nurse’s perception of autonomy in practice is
influenced by ethical judgment.
Ingram (1998) modified the NABP scale into the
“Patient Advocacy Scale” for use with nurses in the
UK. Although this scale was developed in 1998, it
has yet to be utilized in studies (Ingram, personal
communication, October 6, 2005). With a convenience
sample of acute care nurses in the UK (
n
= 86), Ingram
concluded that two factors, educational level and
attendance in ethics courses, were predictive of PAS
scores. However, the relationships between the two
variables and PAS were weak: educational level
(
r
= .3333;
p
= .002), and ethics course attendance
(
r
= .2561;
p
= .017) (Ingram). Further exploration
into nursing advocacy was performed in a study by
Millette (1993) by asking nurses to choose from three
models of advocacy (institutional, physician, and client)
in a survey format with the client advocate model
being chosen most frequently.
176 Nursing Forum Volume 42, No. 4, October-December, 2007
Barriers to Nursing Advocacy: A Concept Analysis
Although the direct measurement of barriers to
nursing advocacy has not been found in the literature,
it may be possible to measure the barriers that have
been identified by various authors cited in this article.
Three attributes—education, time, and threats of
punishment—could be measured without further
delineation. Other attributes, including conflict of
interest, institutional constraint, lack of support, and
lack of power, may require additional inquiry to be
measurable.
. . . it may be possible to measure barriers
that have been identified by various authors
cited in this article. Three attributes—
education, time, and threats of
punishment—could be measured without
further delineation.
Implications for Nursing Practice and Education
The implications for nursing practice are that
nurses need to overcome barriers to become effective
nursing advocates for their clients. Although this is
an ideal situation, the threat of job loss, retribution,
intimidation, or ostracism can be real barriers (Jenny,
1979; Miller et al., 1983; Pullen, 1995; Robinson, 1985;
Walsh, 1985). Nurses need strategies to overcome
barriers so that they can seek what is best for the
client, including advocating in light of institutional
and interdisciplinary constraints (Hewitt, 2002; Kohnke,
1980; Miller et al.; Millette, 1993).
Nursing education has an important role in educating
student nurses on the role of client advocacy in
nursing and how to effectively manage the barriers to
be successful nursing advocates for the client (Jenny,
1979; Pankratz & Pankratz, 1974). This educational
approach could include not only the student nurse in
the prelicensure program but continuing education for
the practicing nurse.
Conclusion
Nursing has claimed client advocacy as an important
core component of nursing practice. Nursing literature
has several articles on philosophical stances on nursing
advocacy. What has been found to be lacking is a clear
understanding of the barriers to nursing advocacy
that have been clearly and separately delineated in the
literature. This article represents a concept analysis on
the barriers to nursing advocacy in order to clarify the
concept and provide a basis for further research into
the barriers of nursing advocacy.
This article represents a concept analysis on
the barriers to nursing advocacy in order to
clarify the concept and provide a basis for
further research into the barriers of nursing
advocacy.
Author contact: rghanks@utmb.edu, with a copy to the Editor:
nursingforum@gmail.com
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