Nurses' experiences of advocacy in the perioperative department: a systematic review

Patient advocacy is central to nursing practice; acting as a patient advocate in the perioperative environment requires the care of patients that are highly vulnerable and unable to speak up for themselves, in a busy and often highly pressurized environment involving multiple professional groups providing care simultaneously. This can present particular challenges for nurses, particularly those unfamiliar with the expectations of being a patient advocate.

The objective of this review was to identify the meaningfulness of perioperative nurses' experiences of advocacy. The specific objectives were to explore the following questions: • What are perioperative nurses' experiences as patient advocates? • How do perioperative nurses define advocacy? • What are the barriers to and strategies for promoting advocacy in the perioperative environment?

Registered nurses, enrolled nurses, licensed practical nurses, licensed vocational nurses, and midwives working in the perioperative department, including anesthetic, scrub/scout and post-anesthetic care room nurses, were eligible for inclusion.

Perioperative nurses' experiences of acting as patient advocates were the phenomena of interest in this review. This includes experiences of the barriers to nursing advocacy, strategies used, and explorations of how nursing advocacy benefits perioperative patients.

The perioperative department, including preoperative, intraoperative and postoperative recovery areas, was of interest in this review. TYPES OF STUDIES: This review aimed to consider all qualitative studies that sought to examine perioperative nurses' experiences of advocacy including but not limited to phenomenology, ethnography, hermeneutics, action research, grounded theory, feminist research and naturalistic inquiry.

Searches were conducted across 13 databases, including four for unpublished studies, with no language restriction, and with the date range of 1985 to April 2014. Studies were assessed for relevance to the review using a Verification of Relevance form developed by the reviewers and based on the recommendations of the Cochrane Collaboration.

Papers selected for retrieval were assessed by two independent reviewers for methodological validity using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument. A third reviewer was used to assess three papers where disagreements between the first two reviewers could not be resolved through discussion.

Data were extracted from papers included in the review using the standardized data extraction tool from Joanna Briggs Institute Qualitative Assessment and Review Instrument.

Findings were pooled using Joanna Briggs Institute Qualitative Assessment and Review Instrument. Findings were assembled and rated according to their quality, and categorized on the basis of similarity in meaning. These categories were then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings. The ConQual approach for grading the synthesized findings was used.

Nine studies were included in the review. From these, 31 findings were aggregated into five categories, which were then meta-synthesized into two synthesized findings which provide evidence for nursing practice. The two synthesized findings are: safeguarding from harm - being the patient's voice; and challenges of patient advocacy can be alleviated by experience and training.

Perioperative nurses identify being a voice, communicating with, and safeguarding the patient as key advocacy activities that they undertake within their roles. Establishing trust between the nurse and patient is an important aspect of patient advocacy in this environment. Acting as a patient advocate can expose perioperative nurses to workplace conflict and cause them distress. While professional experience prepares nurses to be patient advocates, less experience in the perioperative environment and time pressures were reported as barriers to the role.