Levels of Advocacy: Case and Class

In thinking about what advocacy means in the context of nursing practice, a clear distinction needs to be made between "case advocacy" directed at individual patients, and "class advocacy" directed at changing policies and social conditions.

Case advocacy is well known to nursing professionals, being part of the field's traditions and continuing professional values (Cary, 1992; Gadow and Schroeder, 1995; Nelson, 1988; Kohnke, 1982; Winslow, 1984; Marks, 1985). Nurses are accustomed to advocating for individual patients and families to secure needed services and solve problems related to the particular case. Over the years the concept of case advocacy has undergone an important evolution in nursing practice, gradually coming to include more emphasis on client empowerment. Shifting from its early meaning of interceding on behalf of those who could not or would not help themselves, advocacy for patients has now come to involve a more complex set of activities placing the nurse in mediator and promoter roles (Cary, 1992). These contemporary case advocacy roles emphasize client self-determination. They put a premium on informing and supporting clients, enabling them to define and act in terms of their own best interests (Kohnke, 1982). While in principle the "client" can be a community as well as an individual, the skills and objectives of case advocacy tend to stress better coping strategies, negotiation, and increasing access to existing resources in order to get health problems solved in the absence of major system change.

Class advocacy, a more overtly political approach, is quite different. Instead of focusing mainly on the client's opportunity choices, class advocacy focuses on changing the system of opportunities itself to further the interests of larger groups, organizations, or communities. The advocate acts as a catalyst to alter existing policies, institutional systems, laws, or patterns of resource allocation in ways that potentially benefit many individuals. This kind of advocacy can be done in ways that challenge the system directly, or it can be done indirectly behind the scenes (see Needleman and Needleman, 1974).

The following example, borrowed in part from Cary (1992), is a good illustration of how both case advocacy and class advocacy might be used by nurses faced with an environmental health problem:

A community health nurse doing immunizations at a homeless shelter encounters a resident with serious environmental health concerns. All three of the resident's children are asthmatics. From the time the family was forced to seek residence in the shelter, the children—particularly the youngest—have had multiple, acute episodes of asthma. The shelter manager is unwilling to correct the building's problems of dust, mold, and inadequate heating, and has in fact told residents that they will be evicted if they complain to the city about the conditions. There is a waiting list for the shelter, the only one available within the city limits. The mother sees no way out for herself and her children. Anxious and distraught, she asks the nurse for help.

On a case advocacy level, the nurse might empower client decision-making by providing information and support in the following ways (discussed further in Cary, 1992):

• —set up an appointment with the mother to explore the situation further and provide support;
• —give her "user friendly" information about causes and care measures for asthma, and answer her questions;
• —get more information about the mother's financial status, legal status as a resident, her relationship with the shelter manager and other residents, and her abilities for decision making and autonomy;
• —get more information about the shelter environment and the timing and intensity of the children's asthma episodes;
• —based on the information discussed, help the client explore other housing options, make her aware of relevant supports such as legal aid organizations, and assist her in moving toward decision making to solve the problem;
• —provide on-going encouragement as the mother attempts to implement her problem-solving plan.

In this example, let us say that the mother gains confidence and decides to discuss her concerns with the shelter manager. It becomes clear that no immediate changes are likely, but the mother is now more able to consider her other options realistically. She chooses to readjust her goals and moves to a group-home which is less conveniently located, but provides a healthier environment for her children.

So far, so good. But suppose the nurse, having helped this one family, becomes concerned that other families in the shelter may have similar problems. She may wonder how the manager gets away with providing substandard housing conditions that threaten his residents' health. She may wonder why a city of this size does not offer more than one shelter. Maybe she would like to see some publicly or privately financed programs to help homeless individuals and families make easier transitions from temporary shelters, group homes, and street living into permanent housing. This is where class advocacy at the policy level comes into the picture, as the nurse begins to act as a social change agent on behalf of a whole class of clients. What kind of advocacy strategies and techniques can she use for these aspects of the problem?

Strategy Options

One particularly useful framework for conceptualizing advocacy strategies is a model formulated by Jack Rothman during the 1960s, at a time when many health and human service professionals were working with communities in controversial, quasi-political roles. Rothman (1968) outlined three very different types of policy advocacy (or "community organization practice"), which he termed locality development, social planning, and social action.

The first of these types, locality development, is appropriate where a high degree of consensus exists about a social problem. Here advocacy is a matter of mobilizing slack resources and energizing the interested parties around a common concern. An example of locality development would be a rural health nurse working with community residents and local organizations to monitor and safeguard the quality of local well water. A professional practicing this kind of advocacy needs skills in organizing, program development, communications and public speaking, coalition building, and mediation. The individuals and communities being helped are seen as clients, and the interactions between service providers and service recipients are warm and process-oriented. The effort is inclusive and cooperative. Any conflicts that arise are settled by empathetic understanding and compromise.

The second type, social planning, also presumes considerable consensus on the nature of the problem. This kind of advocacy effort tends to be highly technical—determining the optimal distribution of a scarce resource, or the most cost-effective technology for achieving an agreed-upon service outcome. The effort might well involve high-level inter-disciplinary collaboration with other health and human service professionals. For instance, nurses might be involved in a planning a program to address radon exposure in the community. Working with other technical experts, they would help plan and carry out surveys and epidemiologic studies to characterize the problem; design testing and remediation procedures; plan a risk communication strategy; and evaluate the intervention's effects. The skills needed emphasize scientific expertise, program planning, and evaluation research. In this kind of effort, those being helped are viewed as end consumers, who need to be consulted and kept informed but not necessarily involved in the technical details. The interactions among planners in this approach are usually task-oriented and somewhat impersonal. If conflicts should arise, they are (in theory) resolved rationally in the public interest, based on the best available expert opinion.

The third type, social action, applies to situations with strong disagreement over the nature of the problem, serious interest conflicts among the parties affected, and large power imbalances among different factions with a stake in the issue. Here value-based allegiances come into play, and advocacy activity is likely to become highly partisan, taking on the flavor of a crusade. An example would be a nurse who concludes that toxic emissions from a local industrial plant pose a danger to residents in a surrounding minority community, and need to be stopped. The nurse's next steps might include contacting appropriate regulatory agencies and persuading them to take urgent action; enlisting the aid of journalists to do an expose on the company's disregard for public health; advising community activists on how best to document the health damage; contacting and enlisting support from other health professionals; helping citizen groups explore legal action against the company; lobbying for stronger public policy on ''environmental justice"; speaking at community meetings; and helping to organize rallies and protest demonstrations. In this kind of advocacy, experts come under pressure to take sides and to get actively involved in the tactics of power politics. Those being helped are seen as citizens asserting legitimate rights, and allies in a social justice cause. The effort is passionate, emotional, and often conspiratorial. Conflict is seen as inevitable and warfare metaphors are common.

Rothman's formulation underscores the important idea that policy advocacy can be done in various ways, all legitimate in their own terms. Health professionals often feel most comfortable staying within the social planning model, an advocacy role that maximizes their own technical contribution and does not involve them in activities that feel more like community politics. Locality development and social action styles of advocacy may seem unprofessional, counterproductive to problem solving, and possibly detrimental to one's career interests. But in reality, what can be accomplished through the planning approach alone is often fairly limited. In almost any environmental health problem, all three advocacy styles are likely to be relevant. For example, workers who have been occupationally exposed to carcinogenic chemicals will certainly benefit from medical surveillance, a social planning approach. But they may also need help with locality development efforts such as setting up support groups to deal with the emotional and family stress aspects of the problem, and social action advocacy to get the hazard abated and pursue their legal rights to compensation.

Another relevant construct is a typology of social change strategies formulated by Roland Warren (1963). He distinguishes among collaborative approaches (as in planning and advisory committees) in which citizens and authorities work cooperatively to reach an agreed-upon goal; campaign approaches (as in lobbying and public information) in which citizens act singly or collectively to persuade authorities that new problem definitions and solutions are needed; and contest strategies (as in picketing and protest marches) in which citizens organize to force attention to community problems that they feel are being ignored or mishandled by authorities.

The value of Warren's model lies in emphasizing that community concerns can take conflictual and troublesome forms and still represent a positive contribution toward problem solving. Being only human, nurses may feel tempted to "advocate" mainly with those who use collaborative approaches for problem solving, because interaction with them is comfortable and affirming. Those using campaign or contest strategies are easy to dismiss as unhelpful, obstructive, and irrational. But in environmental health issues, militant approaches may be seen by those immediately affected as necessary aspects of problem solving (Alinsky, 1989). Nurses' advocacy roles will need to connect with this reality.

It should be noted that both case advocacy and class advocacy involve some thorny ethical dilemmas (see Gilbert and Specht, 1976; Needleman and Needleman, 1974). For example, if the advocacy goals as defined by clients and communities differ sharply from the advocacy goals as defined by the nurse who is acting as advocate, what should happen? Also, advocacy may in principle be a poor way to allocate resources equitably within a social system, because the clients and issues with the most effective advocates will not necessarily be the same ones with the greatest need. But despite such unsettling second thoughts on an abstract level, the questions confronting nurses on the front line of practice remain immediate and compelling: how to help as much as possible with the human problems at hand. In relation to environmental health issues, the answers often lead in the direction of advocacy, particularly advocacy at the policy level.

Resources for Building Advocacy Skills

At present, policy advocacy for structural change is not emphasized in nursing education, leaving nurses somewhat on their own for exploring strategy options and developing the necessary skills. Fortunately, a great many self-training guides and manuals are available for health and human service professionals interested in advocacy practice related to environmental health issues. Box F.1 below lists some good starting points.

Box F-1

Basic Bookshelf for Advocacy Practice at the Policy Level Related to Environmental Health. Bagwell, Marilyn and Sallee Clements. A Political Handbook for Health Professionals. Boston: Little, Brown and Company, 1985. Legator, Marvin S. and Sabrina F. (more...)

Many resources also exist for particular skill areas. Box F.2 lists a small sample of the voluminous self-training literature available on the nuts and bolts of advocacy practice techniques such as lobbying, use of mass media, working with community groups, organizing, coalition building, community research projects, giving expert testimony, and program development.

Box F.2

Additional Resources for Advocacy Practice at the Policy Level Related to Environmental Health. American Nurses Association. Handbook for Political Media. Washington, DC: American Nurses Association, undated. American Association of University Women. (more...)

Networking with Others

Finally, keep in mind that you don't have to work alone. Those interested in policy advocacy should get in touch with appropriate organizations and clearing houses, many of which can offer advice, moral support, and technical assistance as well as useful publications, slides, films, and speakers. Some particularly relevant organizations are listed in Box F-3.

Box F.3

Organizations Doing Policy Advocacy Related to Environmental Health. Nurses' Environmental Health Watch 181 Marshall Street

For contact information on many similar organizations, see Appendix D of this report, and also these directories:

The Directory of National Environmental Organizations, St. Paul, Minnesota: U.S. Environmental Directories, 1988.

The U.S. Environmental Protection Agency, Office of Information Resources Management, Information Resources Directory, Fall 1989.

References

• Alinsky S. "Of Means and Ends," in Rules for Radicals. New York: Vintage Books, 1989.
• Cary A. "Promoting continuity of care: Advocacy, discharge planning, and case management." Pp. 681–706 in Stanhope M and Lancaster J, Community Health Nursing: Process and Practice for Promoting Health. St. Louis, MO: Mosby Year Book, 1992.
• Gadow S and Schroeder C. "An Advocacy Approach to Ethics and Community Health." Chapter 4 in Anderson ET and McFarlane J, Community As Partner: Theory and Practice in Nursing. Philadelphia: J.B. Lippincott, 1995. (in press).
• Gilbert N and Specht H. "Advocacy and Professional Ethics." Social Work, 288–293, July 1976.
• Kohnke MF. Advocacy: Risk and Reality. St. Louis: The CV Mosby Co., 1982.
• Marks JH, editor. (ed). Advocacy in Health Care. Clifton, NJ: Humana Press, 1985.
• Needleman M and Needleman C. Guerrillas in the Bureaucracy: The Community Planning Experiment in the United States. New York: John Wiley, 1974.
• Nelson ML. Advocacy in nursing. Nursing Outlook, 36(3):136–141, 1988. [PubMed: 3368348]
• Rothman J. "Three Models of Community Organization Practice," from the proceedings of the 1968 National Conference on Social Welfare, Social Work Practice 1968. New York: Columbia University Press, 1968.
• Warren RL. "A Community Model," pp. 9–20 in Warren RL, The Community in America. Chicago: Rand McNally & Company, 1963.
• Winslow GR. "From loyalty to advocacy: A new metaphor for nursing." Hastings Center Report, 14 (6):32–40, 1984. [PubMed: 6746274]

Footnotes

*

Appendix F, Nursing Advocacy at the Policy Level: Strategies and Resources, was written by Carolyn Needleman, an IOM committee member, for this report. Dr. Needleman is a Professor at the Graduate School of Social Work and Social Research at Bryn Mawr College.