EMPIRICAL STUDIES
doi: 10.1111/scs.12505
A practice model for rural district nursing success in
end-of-life advocacy care
Frances M. Reed RN BN (hons) HC H (G Nurs.) HC HPPC (PhD Student) , Les Fitzgerald RN RM Dip. Teach
Nurs B.Ed. MNurs. Stud. PhD (Senior Lecturer) and Melanie R. Bish RN BN (hons) BCN MN PhD (Head of Department)
La Trobe School of Rural Nursing and Midwifery, La Trobe University, Bendigo, Victoria, Australia
Scand J Caring Sci; 2018; 32; 746–755
A practice model for rural district nursing success in
end-of-life advocacy care
Aim: The development of a practice model for rural district nursing successful end-of-life advocacy care.
Background: Resources to help people live well in the end
stages of life in rural areas can be limited and difficult to
access. District nurse advocacy may promote end-of-life
choice for people living at home in rural Australia. The
lack of evidence available internationally to inform practice in this context was addressed by exploratory study.
Method: A pragmatic mixed method study approved by
the University Faculty Ethics Committee and conducted
from March 2014 to August 2015 was used to explore
the successful end-of-life advocacy of 98 rural Australian
district nurses. The findings and results were integrated
then compared with theory in this article to develop concepts for a practice model.
Results: The model illustrates rural district nurse advocacy
success based on respect for the rights and values of people. Advocacy action is motivated by the emotional
responses of nurses to the end-of-life vulnerability people
experience. The combination of willing investment in
Introduction
Personal rights and equitable access to services are at the
forefront of international health policy directing care in
the end stages of life (1, 2). A focus on the values and
rights of individuals and their family carers may improve
the experiences of people both giving and receiving endof-life care (3–5). In this context, end-of-life (EoL) care
refers to care provided for people affected by life-limiting
illness or disability (3). Effort is particularly needed to
plan and provide for care choices when people may be
Correspondence to:
Frances M. Reed, La Trobe School of Rural Nursing and
Midwifery, La Trobe University, Bendigo, Victoria, Australia.
E-mail: fmreed@students.latrobe.edu.au
746
relationships, knowing the rural people and resources,
and feeling supported, together enables district nurses to
develop therapeutic emotional intelligence. This skill promotes moral agency in reflection and advocacy action to
overcome emotional and ethical care challenges of access
and choice using holistic assessment, communication,
organisation of resources and empowering support for
the self-determination of person-centred end-of-life goals.
Recommendations are proposed from the theoretical concepts in the model.
Limitations: Testing the model in practice is recommended
to gain the perceptions of a broader range of rural people
both giving and receiving end-of-life-care.
Conclusion: A model developed by gathering and comparing district nursing experiences and understanding using
mixed methods and existing theory offers evidence for
practice of a philosophy of successful person-centred
advocacy care in a field of nursing that lacks specific
guidance.
Keywords: advocacy care, end-of-life, community,
district nurse, emotion, moral agency, palliative care,
practice model, rural.
Submitted 18 May 2017, Accepted 20 June 2017
vulnerable to EoL changes that threaten their rights and
values.
Background
To meet the needs of an ageing population, greater support and easier access to effective primary health care in
the home setting are proposed by the Australian Government (6, 7). Australia is made up of vast, sparsely populated remote areas, small, heavily populated urban areas
and large rural regions where almost one-third of the
population live (8). In rural regions, many people
approaching the EoL are affected by socio-economic and
geographical barriers that limit access to services and
reduce the availability of supportive and specialist care
(8).
© 2017 Nordic College of Caring Science
A practice model for successful advocacy
Nurses caring for people living and dying at home in
rural areas expand their generalist primary healthcare
roles to reduce service gaps (9–11). Commonly referred
to as community or district nurses (DNs) in Australia,
these nurses cover large areas delivering care to people
with diverse needs (11). The rising demand for complex
care for people living at home increases the pressure on
DN services with limited resources to focus on the medical interventions they provide (11, 12). This may affect
care satisfaction by reducing time spent in therapeutic
relationship development and teamwork (9, 13). To create greater opportunity for choice and well-being in rural
areas, DNs need to advocate for access to person-centred
EoL care (14). This requires a focus on the holistic needs
of individuals, families and their community of informal
and formal caregivers (14).
Promoted internationally for ethical care provision
(15), nursing advocacy remains a poorly understood concept that has not previously been explored in rural home
nursing. This lack of specific evidence-based knowledge
prompted exploration of experiences that could inform a
model to guide the practice of rural DNs in successful
EoL advocacy (14, 16). Practice guidance can be used by
services to promote DN advocacy and improve opportunities for choice and the well-being of rural people whilst
living at home in the end stages of life.
Method and results
Aim
The aim is to develop a practice model from a study
exploring how DNs advocate successfully for the end-oflife goals of rural Australians and a comparison with
existing theory.
Ethical approval
The study was approved by the University Ethics Committee, and further approvals were gained when required
by specific organisations.
Design
The sequential mixed methods study used a pragmatic
philosophy and nurse agency theory (17). Pragmatism
offers a framework for studying complex problems using a
mix of study methods to provide credible evidence for
practice (17, 18). Dewey’s philosophy of pragmatism promotes the agency of people to reflect intelligently on the
wide range and sources of knowledge and the possible
outcomes of action (18). Nurse agency refers to the reflection–action process that promotes effective care (19).
The use of a flexible, iterative mix of methods
acknowledges the multiple facets of understanding and
© 2017 Nordic College of Caring Science
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the need for practical, ethical solutions that fit the complexity of rural practice situations (18). The opportunity
given to DNs to reflect on the ways they understand and
action advocacy promoted their agency in the exploration
of successful EoL care experiences (17). Nursing advocacy
was defined for the study as action taken to support the
health goals of people at the levels of the person, the
community and the health system (20). The purposive
self-selection criteria for the study sample included Registered Nurses with experience in providing successful EoL
advocacy in rural generalist home care roles.
In the first qualitative phase, DNs from rural Victoria,
Australia (N = 7), provided reflective written experiences
of successful advocacy before taking part in follow-up
semi-structured 1 hour interviews, between July and
September 2014 (21). Participants were asked to reflect and
write about one successful advocacy experience (21). The
information pack included a written example from a different field of practice to indicate the detail required (21).
Reflective questions arising from the written examples and
an interview guide developed from a review of DN EoL care
studies were used to explore advocacy experiences in the
follow-up interviews (14, 21). The combination of qualitative written and interview narrative techniques increased
the understanding and scope of the data (21).
Data analysis was iterative, beginning with reflection
on the written experiences in the first phase to inform
the interviews (21). Descriptive interpretation was facilitated by coding the written and interview transcripts in
NVivo QRS 10 to produce thematic networks that explain
how successful advocacy is enabled and actioned (21,
22). The thematic description was confirmed by the
informants, then tested and complemented using a survey for the second study phase.
The survey was designed with a questionnaire that
included psychometric scales and open-ended question.
Two scales were developed using items identified from
the qualitative data: the first scale to test how advocacy
is enabled, and the second scale to test how advocacy is
actioned in rural EoL DN. Open-ended questions
explored concepts, which required clarification, and provided the opportunity to add alternate views. The Brief
Emotional Intelligence Scale (BEIS10) developed by
Davies et al. (23) tested the findings of emotional care
ability identified in the qualitative phase. Piloting of the
survey assisted refinement and re-ordering of the scale
items to improve the response quality. Email invitations
to participate sent to health services in rural regions of
Australia from March to August 2015 included an online
link to the survey available using Qualtrics (24). Some
services required further ethical approval prior to offering
the survey to nurses. The responses (N = 91) came from
each State and Territory, except Queensland, where ethical approval could not be gained within the survey
timeline.
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The results of the survey were analysed using quantitative and qualitative methods. The Statistical Package for
Social Sciences (SPSSâ) IBM Windows version 21 generated descriptive statistics from the scale responses. The
qualitative answers to the open-ended questions were
coded to assess fit and identify additional understanding
of the Phase 1 themes. The results confirmed and complemented the Phase 1 findings, further validating the
interpretative description of successful DN EoL advocacy
for the goals of rural Australians (21).
In the final stage of the study, the findings and results
from both phases were integrated in thematic inferences
(18). These inferences were compared with nursing literature to identify similarities and new understandings in
how advocacy is enabled, and actioned successfully in
the home care setting. The comparison provided further
confirmation that the inferences were suitable for use as
concepts to build a practice model representing the process that enables advocacy development and action, and
leads to success.
Results and discussion
A practice model for rural DN success in end-of-life advocacy
The theoretical concepts informed by the study together
represent the practice of nursing advocacy as a learned
philosophy of care. The concepts originated from the
qualitative exploration and analysis during the first phase
of study (21) and were confirmed and complemented by
the qualitative and quantitative results in the second
phase. Examples of data from each phase are provided in
Table 1 to indicate how the concepts were informed and
validated. These concepts are used in a hierarchical process model of practice that illustrates how DNs advocate
successfully for the EoL goals of rural Australians
(Fig. 1).
Development of the therapeutic self for advocacy
Respect. Successful end-of-life advocacy care is founded
on the concept of respect for the rights and diverse values
of all people. DNs who practice this ‘respect’ (Table 1)
can recognise the vulnerability people experience to loss
of rights and lack of support for values in the end stages
of life (25–29). Identifying this type of vulnerability in
people arouses emotions of empathy and sympathy that
work together to drive nursing action (29). These emotional responses motivate DNs to develop the ability for
advocacy, which is enabled by being willing to invest in
person-centred care, knowing the people and feeling supported (21).
Willing. The concept of being ‘willing’ identifies DNs
who are prepared to invest effort in respectful personcentred relationships (21, p. 7). Being willing to use the
SUCCESSFUL
End-of-life
Nurse
Advocacy Care
for personcentred goals
Sasfacon
Provision of Support
Empowering people
Organising Resources
Communicaon at all levels
Holisc assessment
Promoon of Access to rural resources
for choice at mulple levels
Posive
Outcomes
Barriers
Risks
MORAL AGENCY
A process of reflecon that morally guides advocacy
acon to successfully overcome barriers to choice
EMOTIONAL INTELLIGENCE
The learned ability to recognize, understand and
manage emoon in one-self and others
WILLING
SUPPORTED
KNOWING
investment in
by self-advocacy,
the rural people
person centred
experience,
care using the
at home,
educaon,
Empathy
autonomy
the self, the Sympathy systems
of health
available,
community and
care and
emoonal energy
the resources
and involvement
informaon,
and
available
with people
other people
Recognion of the VULNERABILTY people experience
to loss of self-determinaon and lack of support for values
RESPECT for all PEOPLE and their rights and values
Figure 1 A practice model for rural district
nursing success in end-of-life advocacy
care.
© 2017 Nordic College of Caring Science
A practice model for successful advocacy
autonomy inherent in home care offers DNs freedom to
respond to feelings with supportive relationship care.
DNs with a preparedness to invest the time and emotional energy required to become involved in personalised caring can give of the self to accommodate the
needs of people and their family (21).
Respectful consideration of feelings, emotions and values enables DNs to personalise therapeutic relationships.
The willingness to be involved with people and their EoL
experiences promotes reciprocated trusting relationships
and the sharing of information for person-centred care
(19, 21). Willing ‘involvement’ provides opportunities for
advocacy that can meet the needs of the people (21, 26)
(Table 1).
Knowing. The concept of ‘knowing’ identifies the specialised knowledge DNs possess about rural people, their
circumstances and the available community resources
(21, p. 7) (Table 1). A personal way of knowing oneself
and others is informed by working with, and being
involved with people. DNs reflect with self-understanding
of personal values and reactions that affect interprofessional and EoL nursing relationships (21, 26). Self-knowing combines with knowing
people and
the
‘circumstances’ in their homes to instil a deeper sense of
the prevailing moods that influence personal reactions.
Insight into the meaning that each person attributes to
life provides the aesthetic knowledge to intuitively refine
nursing relationships (21) (Table 1). Reflection on the
values of self and others informs ethical care to help people identify their end-of-life goals. Combined with the
experience of rural living and work, these ways of knowing inform the adaptation of nursing practice to suit the
particular social determinants of health and the individual meaning of EoL experiences and situations (16, 21).
DNs bring the ways of knowing together in advocating
for a person-centred approach to EoL care. Knowing the
social and environmental context of the person’s life and
relationships offers greater insight into the threats to selfdetermination. Knowing the people involved in giving
and receiving care, recognising the effect of their values,
emotions, reactions, relationships and the environment,
and understanding how to access the limited resources
can enable EoL planning (16, 21). This holistic knowledge increases ‘intuition’ in a situated way of knowing to
inform the development of personalised therapeutic
advocacy and convey respect for person-centred goals
(21) (Table 1).
Supported. Feeling ‘supported’ whilst working as a sole
practitioner with limited resources is the third enabler of
person-centred advocacy (21, p. 8). Support is found in
two forms: self-advocacy and the respect received from
others. DNs prepare and equip the self for advocacy using
a combination of ‘education’, ‘experience’, reflective
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practice and ‘self-care’ that promote ability for a competent personal response to EoL needs (20, 21) (Table 1).
The resulting self-reliance DNs develop as advocates is
enhanced by health system resources. These include
‘policies’, ‘care plans’ and information to facilitate personalised health promotion and goal setting, together
with the technology to access information, education and
communication (21) (Table 1).
DNs are encouraged in personal advocacy efforts by
the respect of others for the knowledge acquired with
person-centred care (21). Advocacy for individual rights
and values is strengthened by trusted informal and formal support networks, which may include family,
friends, ‘colleagues’, ‘managers’ and other health professionals (Table 1). Feeling supported by these people
increases self-confidence in the ability to assess situations
and take action to promote individual EoL goals that
may conflict with dominant cultures. This support
encourages DNs to stand by the person when there is dissent resulting from competing values affecting the situation (21). Taking a justifiable stand that may be at odds
with the beliefs of others requires courage in the conviction that person-centred care for EoL goals is a priority.
DNs feel validated as advocates when the privileged
understanding gained by working closely with people in
their homes is acknowledged.
Emotional intelligence. The combination of respect, willing,
knowing and supported underpins the emotional skill
development of DNs for person-centred EoL advocacy
(21). The development of emotional intelligence increases
the ability to recognise, understand and manage the
emotions of self and others (30). Critical reflection on the
feelings and understandings about the people and situations DNs encounter assists the navigation of involvement in EoL relationships that provide ‘emotional
support’ for person-centred goals (Table 1).
DNs who develop emotional intelligence are able to give
more of self in the therapeutic use of emotions to
improve the experience of EoL care (19, 26). This ability
enables DNs to manage personal reactions in the emotional care of people; identify the degree of involvement
required in nursing relationships (31); and understand
the impact of emotions on the values of others involved
in care (21). The resulting consideration for the effect of
emotions on possibilities for choice in each situation
assists DNs to act as moral agents (21).
Moral agency. Emotional intelligence is a prerequisite for
the moral agency of DNs in EoL advocacy. A moral agent
attends, reflects and takes action based on respect and
understanding of the person’s wishes (32). The moral
response of ‘reflection’ on action from DNs in rural EoL
care is required to negotiate the risks and barriers to
advocacy for self-determination (Table 1). The lack of
Support
‘We need to try and support. . .’ (1)
Support peers 100% Support the person/family
97% Defending rights 96%
Empowerment of the person/family 100% Enabling
self-determination 94%
Phase 1 For a detailed description of findings see Author Reed et al. 2016 (21).
Phase 2 The examples given in percentages represent the full range of agreement resulting from all the scale items.
Empowerment
‘. . .she felt so empowered. . .’ (3)
Communication
‘document these goals so all can follow’ (5)
Organisation
Holistic assessment 100% Identifying person and
family goals 100%
Documenting/sharing goals 100% Talk/plan for
dying 100% Teaching care 100%
Case managing/liaising with others 100% Planning
care 100% Providing equipment 100%
Holistic assessment
‘. . .having a family meeting’ (6)
‘It was me, from here, that organised it all’ (2)
Promoting quality care/collaboration on a broader
scale 99%
Access
Emotional
intelligence
Moral agency
‘. . .energy and emotion. . .’ (2)
‘mindfulness in that moment with them’ (3)
‘. . .trying to get it right’ (3) ‘. . .looking at it
from the other side’ (5)
‘. . .judging if my advocacy. . .’ (6)
‘. . . try and show that there is another way to
look at things’ (4)
‘. . .it’s a lot about the whole collective
situation’ (2)
‘. . .asking what they want to do’ (1)
Supported
‘. . .protective self-care’ (6) ‘. . .teleconferences’ (3)
‘. . .my boss is good with palliative care’ (7)
‘I was brought up to respect people’ (7)
Trying hard 99% Being flexible 99% I feel good
about giving EoL care 87% Making time, giving
self, going beyond duty 52%
Willing
Knowing the person’s end-of life goals 100%
Knowing self and abilities 92%
Knowing the person/family 98% Intuitive knowing
75%
Being able to inform/support oneself 98%
Education 99% Experience 99% Documents,
policies, care plans 85% Support from other
health professionals 98%
BEIS scale (10 items total) 84%
Respect for individual differences 100%
Phase 2 Quantitative/qualitative
Psychometric scale items and agreement percent
Respect
Knowing
ADVOCACY ENABLERS
AND ACTIONS
Concept
‘knowing and understanding what’s important
to them’ (6) ‘. . .thinking’ . . . (3)
‘belief in your experience’ (1)
‘1 respected her decisions’ (3)
‘Be mindful, your goals and wishes are
different’ (6)
‘We are really passionate about this. . . you have
just got to try’ (3)
‘I am lucky to be able to do that’ (7)
Phase 1 Qualitative
Written and interview data (Informant number)
Table 1 A comparison of data set examples from the phases of study used to explore, then test and complement the concepts of successful advocacy
‘Comprehensive assessment. . .and
establishment of goals’
‘Excellent team communication’
‘Effective communication skills’
‘Organising advanced care planning’ ‘Referrals
to palliative care for specialist support if
required’
‘. . .the right to have. . .control over their
lives. . .’ ‘. . .clients fully in control of how they
wish their life to end’
‘Provide on call support’
‘. . .staying overtime to support family’
‘. . .more proactive in engaging people’
‘. . .advocating for adequate resources’
‘Advocating for policy that supports. . . rights’
‘Giving emotional support’ ‘Strong empathy’
‘. . .understanding feelings’
‘Thinking around/outside the square’ ‘Reflection
and clinical review’
‘Self-care’ ‘Experience’ ‘Any education’
‘Colleagues’ ‘GP’s, Pall care’ ‘Life experience’
‘Policies’, documentation/care plans, brochures’
‘. . .trying’ ‘This involves giving of oneself and
not just. . . clinical care’ ‘Strong desire to help’
‘. . .close involvement’ ‘Commitment to
providing quality’
‘Knowing when. . .’ ‘Local knowledge’ ‘Intuition
and knowing the client and family’ ‘Knowing
yourself understanding. . .circumstances’
‘Respect. . . recognition of individuality’ ‘. . .show
them respect’
Answers to the open-ended questions
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A practice model for successful advocacy
resources, conflicting values and misunderstanding of the
DN role can increase the emotional reactions arising in
EoL care and limit advocacy (16, 21). Emotional burden,
under- and overinvolvement and moral conflict in rural
professional and personal relationships are risks to successful person-centred advocacy care that DNs can manage using moral agency (20, 21).
As a moral agent DNs can respond constructively to
emotions, ethical dilemmas and misperceptions that limit
EoL choice by thinking ‘outside the square’ and ‘looking
at things from the other side’ (16, 19–21) (Table 1). The
moral response to the EoL vulnerability of people can
result in DNs going beyond the expectations; some people have of their role to improve access to choice and
overcome the limits of the rural service resources provided (10, 21). Respectful person-centred EoL care for
people in the rural home setting requires development of
the ability of ‘judging’ one’s own actions in use of personal therapeutic resources to advocate successfully
(Table 1).
The nurse as an advocate
DN advocates are mindful of the EoL vulnerability people
may experience and respond with emotionally intelligent
reflection and morally responsible action. As advocates,
DNs react habitually out of respect with advocacy embedded in actions of holistic assessment, communication, organising resources, empowering and supporting people in the
end stages of life to promote access to care choices (21).
Access to person-centred EoL choice. DN advocates increase
access to resources that promote person-centred EoL
choice for rural Australians. Advocacy care from DNs
extends to the self, the person, the family, colleagues,
other healthcare workers and the community. Working
together, ‘engaging people’, ‘advocating for policy’ and
‘adequate resources’ with a shared understanding of the
values important to the person and the family can
increase access to personalised care and goal planning (20,
21) (Table 1).
DNs advocate for person-centred care uses holistic assessment at the individual level to gain an understanding of
the person and family member’s resources, needs and
values to be able to establish and achieve their goals. The
relational process of sensitive ‘asking’, listening, observing and the ‘establishment of goals’ is used in an ongoing
manner to assess the health and well-being of people
involved in the evolving EoL home care situation (21)
(Table 1). Ongoing holistic assessment informs DNs about
care that is working well, the advocacy required and the
resources people have to achieve their goals as care needs
change (21, 33, 34).
‘Effective communication’ is used by DNs to help people
manage fears, make plans, learn ways of giving and
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receiving care and express goals for living, dying and
grieving (21) (Table 1). Advocacy amongst the care team
is actioned by communicating the person’s self-determined EoL goals in a respectful way to everyone
involved in caregiving (20, 21, 35). At organisational and
community levels, DNs communicate the need for health
service policy, resources and rural relationships that
increase access to care and the quality of life for people
in the rural community (16, 21, 35).
Organising resources for care in a way that assists people
in their self-determined goals is actioned as a result of
assessment and communication. Equipping care in the
home setting, ‘planning’, liaising with, and coordinating
the varied care and referrals to ‘specialist support’ that can
help people in rural areas requires advocacy in a timely
response to empower their goals (16, 21) (Table 1).
Empowering people with self-determination at times
when their rights and respect for their values are threatened is the goal of advocacy care (16, 21). DN advocates
empower people to ‘have control over their lives’ and
greater choice at the levels of the individual and support
network of family, informal and formal caregivers by working to strengthen understanding and ability in both the giving and receiving of person-centred EoL care (Table 1).
Support for people to self-determine and achieve their
EoL goals, and for their family and rural community to
provide assistance, requires compassion for varied needs.
DN relationships support differing levels of emotional, spiritual, physical, psychological, social and environmental
needs with EoL advocacy care for, and about people (21,
34, 35). This support fortifies people who are vulnerable in
the EoL for making difficult choices (16). Support can be
promoted at the organisational level by DNs advocating for
time and resources to develop person-centred rural relationships and reduce the need for additional effort, such as
‘staying overtime to support family’ (Table 1).
Successful nurse advocacy results from the way rights,
and values are respected and person-centred goals for
care are used to direct limited resources and support the
rural community (21). The development of self for therapeutic nurse advocacy enables a way of ‘really caring’ for
and about people that can deliver successful outcomes
and promote satisfaction in giving and receiving care (21,
p. 10). Positive outcomes and emotions resulting from
advocacy care feedback to reinforce the skill development
of DNs with deep personal understanding and respect for
the people and the situation (21, 32, 35): ‘It’s so good
when it works’ (Informant 3, Phase 1).
Implications for nursing
The model represents theory developed from the study of
how DNs advocate successfully for the goals of rural Australians using a philosophy of care. This way of caring is
founded on respect for people, works through the
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development of person-centred relationships and aims to
empower the self-determination of people and achievement of their EoL goals. These basic principles found to
be important to advocacy care in the study align the
model with the seminal nursing literature of Curtin (31)
Gadow (27, 28) Kohnke (20) and Benner (19, 35), focusing on a philosophy of nursing advocacy using respectful
relationships to promote self-determination and communication. The model supports and expands existing nursing theory by revealing the process that leads DN
advocacy from the foundation of respect to care satisfaction using a complex combination of concepts that incorporate theory of how emotions affect success. The model
can inform rural services in the development of successful EoL advocacy with respectful person-centred care,
specialised knowledge, reflective practice and supportive
management and teams.
Respectful nursing care. The model shows respect for the
rights and values of others can foster an emotional
awareness of the social influence on personal goals
affecting care. Without the basis of respect that is learned
and relearned throughout life and in relationships, the
personal self-interests of the nurse or the authority of
medicine can dominate care (27, 32). Advocacy care that
respects and empowers the rights and values of people in
the EoL is learned, supported and reinforced with successful outcomes that are satisfying for people both giving
and receiving care.
This theory contributes to the limited exploration of
how nursing advocacy is developed and promoted by
experience, education and positive role models that foster
respectful, satisfying care and increase DN confidence for
advocacy in adverse circumstances (19, 36, 37). The
employment and retention of nurses possessing this
respect as a foundation for successful advocacy is recommended in recognition of the difficulty in providing positive role models and collegial support for DNs who work as
autonomous sole practitioners in rural EoL care situations.
Specialised knowledge. The model highlights the importance of the specialised contextual knowledge that results
from personal and professional relationships with rural
people. The holistic understanding used to inform effective care provision reflects previous findings in the rural
DN literature (10, 11). The personal, aesthetic, ethical
and scientific ways of knowing for nursing care (38) are
enlightened by the fuller understanding of the people in
their rural homes and community situations. The ways of
knowing offer DNs insight that informs person-centred
advocacy care.
The confidence of nurses in delivering advocacy has
previously been found to increase with the knowledge
gained from experience and education (19, 36). Factoring
in time in DN service planning for a broad range of EoL
and advocacy education and experience, and the development of collegial rural community resources is recommended to increase the understanding of person-centred
advocacy in the home. Access and support for the use of
care planning tools and information technology can promote self-advocacy and reduce the time and effort
involved in travel for education that would alternatively
be required (10, 21).
Reflective practice. Relational care relies on the self-understanding of personal knowing represented in the model.
The need to inform, understand and support the self to
advocate for others is also evident in the advocacy literature (19, 20). Reflection on practice can be used by DNs
to reorient their care and develop the habit of personcentred advocacy (21). The model is recommended as a
resource for individual reflection on practice that can be
used by novice and experienced DNs to identify their
developmental strengths and needs in becoming successful advocates for access, choice and the EoL goals of rural
Australians.
Nursing reflection can also be encouraged using supportive conversations about how to improve care for self
and others (39). DNs who work as sole practitioners have
limited time with colleagues to reflect on concerns they
have about EoL care. The use of peer support in reflective practice with team members and clinical supervision
was suggested during the study to facilitate successful
advocacy (21). Clinical supervision to assist the analysis
and resolution of emotional and ethical dilemmas has
been recommended in previous rural nursing studies (10,
40). Incorporating these resources to support reflective
practice in EoL care is recommended for advocacy
success.
Supportive management and teams. Support from management and other health professionals shown in the model
can encourage DNs to increase self-reliance in advocacy
for resolving conflict. The combination of supportive
resources and knowledge increases the willingness of
DNs to be involved with people and develop their ability
to meet fears about dying and opposition to personcentred goals (21). The literature supports the need for
courage when advocacy may seem difficult to action due
to emotions and circumstances (41, 42), or conflict with
the dominant cultural expectations affecting EoL care
(43, 44).
Interprofessional and nursing relationships require
well-developed communication skills to increase collegial
support and promote teamwork for the person-centred
goals (21). Effective communication has previously been
promoted to reduce role misunderstanding and the risk
of professional conflict arising from advocacy (20). The
misunderstanding of the care DNs provide found in the
study to affect rural relationships and care access reflects
© 2017 Nordic College of Caring Science
A practice model for successful advocacy
earlier study findings (45, 46). Interdisciplinary communication can increase understanding of the potential for
quality care enabled by DN relationships and planning.
Promotion of early referral from other care providers for
DN care is recommended. Managers attending interdisciplinary meetings can educate other workers about the
holistic person-centred care of DNs that supports people
at home.
Advocacy development and action are reinforced when
DNs feel they are supported in their role autonomy to
respond to emotional motivation. Managerial support for
the use of role autonomy has been found to positively
influence emotional care by nurses (47). The emotions
found to drive nursing advocacy in this study are linked
with the motivation of nurses for helping behaviour (28,
29). However, the model shows a further connection
between emotional motivation and supports that assist
the management of emotions generated in EoL care to
enable coping, reduce fears and understand individual
values. Feeling supported to think about the emotional
and social determinants of health that influence thoughts
and actions promotes autonomous advocacy using emotionally intelligent moral agency (21, 32, 48).
Emotional intelligence development for DN advocacy is
supported by informal teamwork (30). This support from
others has been found to help nurses develop advocacy
expertise in critical care (19). In rural situations where
collegial support is less available, the formal support of
clinical supervision together with emotional intelligence
education may facilitate the moral agency of DNs to
manage the emotional stressors that influence EoL care
(10, 21, 40). Moral guidance can reduce the risks inherent with using advocacy within a medically dominated
healthcare system (20). These supports can be promoted
by management to increase understanding and nursing
role autonomy to act ‘freely’ using the moral agency of
advocacy care (32, p. 2).
This model way of caring shows EoL advocacy
involves a person-centred philosophy rather than being
used as a role when required. The possibility of DNs
going beyond the realms of care expected by others to
fulfil the moral responsibilities of this philosophy in an
environment of restricted rural resources needs to be
recognised and acknowledged. Feeling supported in
morally motivated actions that take DNs to a higher
level of perceived duty can reduce the risk of work dissatisfaction. The model shows a combination of DN
advocacy resources that can be fortified with planning
and support strategies. DNs and health services can support advocacy capacity in this specialised field of practice to improve the quality of rural EoL care. Ongoing
research is recommended to inform the potential for the
advocacy care philosophy to promote person-centred
DN and funding that supports community and palliative
care policy direction.
© 2017 Nordic College of Caring Science
753
Limitations
The practice model is drawn from concepts derived
and substantiated by the experience and reflection on
the successful advocacy of rural DNs and comparison
with existing theory. Testing the model in practice to
gain the perspective of others involved in giving and
receiving care can further inform the suitability of the
model to guide DN EoL care in rural Australia. Testing
for broader use could extend the value and application of the advocacy care model to other fields of
practice.
Conclusion
The study gave voice to rural Australian DNs to identify
the process of successful person-centred EoL advocacy
care and develop a model for practice. The model represents new theory for DN practice supported by existing
concepts found in the nursing advocacy literature. Successful advocacy care based on respect and enabled by
willing, knowing and supported rural DNs with emotional
intelligence promotes their action as moral agents for access
to advocacy assessment, communication, organisation, empowerment and the support of people for successful EoL goals.
The satisfaction derived from this way of caring for people motivates further effort to strengthen and empower
rural communities to care, live, grieve and die as well as
possible.
The model can guide health service by understanding
how rural DNs successfully use their specialised generalist
role to advocate for person-centred goals in a way that
meets healthcare policy objectives. This may result in
improved EoL experiences as the needs of an ageing rural
population increase, and new nurses enter the field of
home care.
Acknowledgements
The authors are grateful to the rural nurses who contributed to this study.
Conflict of interest
The authors declare there is no conflict of interests.
Author contribution
Frances M. Reed is the primary author of the manuscript,
responsible for conducting the research and literature
reviews, conceptualising the first draft and subsequent
editing. Les Fitzgerald and Melanie R. Bish have contributed by supervising the process, team discussions of
the model and reviewing and suggesting edits for drafts
of the manuscript.
754
F. M. Reed et al.
Ethical approval
La Trobe University FHEC14/037.
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