Fluent Essays

please see below NRSE 4570 RUBRIC: M3 A6 WA: CULTURALLY APPROPRIATE CARE PLANNING (40 pts) Last updated: 06/07/2017 © 2017 School of Nursing - Ohio University Page 1 of 2 Criteria Levels of Achievement Accomplished Needs Improvement Not Acceptable Introduction 7 to 7 Points  Clearly states the purpose of the paper.  Provides a comprehensive overview of topic or questions.  Engages the reader.  Organized and has easy follow. 2 to 6 Points  Overview is provided, but key points/ideas are missing.  Purpose statement is not clear.  Does not engage the reader.  Somewhat disorganized but still comprehensible 0 to 1 Points  Does not provide an overview of the paper or is absent.  No purpose statement. Body Key Requirement 1 7 to 7 Points  Describe the key components of a comprehensive cultural assessment  Evidence of critical thinking 3 to 6 Points  One or two elements missing or are not fully described  Lacking some evidence of critical thinking. 0 to 2 Points  Missing half of the elements  Not enough depth to demonstrate understanding of the components of a comprehensive cultural assessment. Key Requirement 2 7 to 7 Points  Chooses two components of the cultural assessment, reflect on one’s own culture in terms of those components  Discusses how one’s own culture potentially affects how one provides nursing care 3 to 6 Points  Chooses one component or is missing at least one area discussed in the instructions  Lacks critical thinking and depth. 0 to 2 Points  Writer does not fully discuss two components or consider his or her own culture  Does not discuss how culture could affect care. Key Requirement 3 6 to 6 Points  Creates two nursing diagnoses that reflect cultural diversity  Gives rationale for each diagnosis and describes how you would intervene and evaluate for success of your plan of care. 3 to 5 Points  Created two nursing diagnoses but did not give rational or intervention/evaluation of success. 0 to 2 Points  Only one nursing diagnosis, or did not fully answer the assignment questions. Conclusion 7 to 7 Points  Summarizes paper and reflects on what the reader has learned from the paper.  Demonstrates persuasive thought and is well organized. 2 to 6 Points  Merely summarizes the introduction or contains new ideas not present in the paper contents.  Somewhat disorganized but still comprehensible 0 to 1 Points  Simply restates the introduction or is absent.  Disorganized to the point of distraction. NRSE 4570 RUBRIC: M3 A6 WA: CULTURALLY APPROPRIATE CARE PLANNING (40 pts) Last updated: 06/07/2017 © 2017 School of Nursing - Ohio University Page 2 of 2 Criteria Levels of Achievement Accomplished Needs Improvement Not Acceptable Stylistics 6 to 6 Points  APA Citations are appropriate.  Formatted correctly.  Reference page is complete and correctly formatted.  At least 4 references provided: Two (2) references from required course materials and two (2) peer-reviewed references. *References not older than five years.  More than 600 words excluding title and reference pages. 3 to 5 Points  APA Citations are appropriate and formatted correctly.  Reference page is formatted correctly.  References are not professional or is not formatted correctly.  Missing 1 professional reference.  At least 600 words or more excluding title and reference pages. 0 to 2 Points  No citations are used or citations are made but not formatted correctly  Reference page is missing.  Less than 600 words excluding title and reference pages. Peer-reviewed references include professional journals (i.e. Nursing Education Perspectives, Journal of Professional Nursing, etc. –), professional organizations (NLN, CDC, AACN, ADA, etc.) applicable to population and practice area, along with clinical practice guidelines (CPGs - National Guideline Clearinghouse). References not acceptable (not inclusive) are UpToDate, Epocrates, Medscape, WebMD, hospital organizations, insurance recommendations, & secondary clinical databases. *All references must be no older than five years (unless making a specific point using a seminal piece of information) Note: You will have three (3) attempts to submit a written assignment, only the final attempt will be graded. For each attempt you will receive a SafeAssign originality report. This will give you a chance to correct the assignment based on the SafeAssign score. Click here to view instructions on how to interpret SafeAssign originality report. https://help.blackboard.com/Learn/Instructor/Assignments/SafeAssign/SafeAssign_Originality_Reports Debriefing You have completed the study. During the Implicit Association Test (IAT) you just completed: Your responses suggested a slight automatic preference for White people over Black people. Disclaimer: These IAT results are provided for educational purposes only. The results may fluctuate and should not be used to make important decisions. The results are influenced by variables related to the test (e.g., the words or images used to represent categories) and the person (e.g., being tired, what you were thinking about before the IAT). How does the IAT work? The IAT measures associations between concepts (e.g., White people and Black people) and evaluations (e.g., Good, Bad). People are quicker to respond when items that are more closely related in their mind share the same button. For example, an implicit preference for White people relative to Black people means that you are faster to sort words when 'White people' and 'Good' share a button relative to when 'Black people' and 'Good' share a button. Studies that summarize data across many people find that the IAT predicts discrimination in hiring, education, healthcare, and law enforcement. However, taking an IAT once (like you just did) is not likely to predict your future behavior well. Does the order in which I took the IAT matter? The order in which you take the test can influence your results, but the effect is small. We minimize this effect by giving practice trials after the categories switch sides. We also randomly assign the order of the IAT so that some people get one order and other people get the reverse order. I still have questions about the IAT. If you have questions about the IAT, please consult the links at the top of the page, where you will find answers to frequently asked questions, links to related research, and additional information about implicit associations. You may also email us (mailto:[email protected]) with questions or comments. Please answer the following questions about your results: 1. What brought you to this website? -- Choose an option -- 2. What do you think of the IAT? mailto:[email protected] Print Page · Background Information (/implicit/backgroundinformation.html) · Privacy Information (/implicit/privacy.html) · Project Implicit Home (/implicit) Click "Submit" to submit your answers. Submit Not at all Slightly ModeratelyVery Extremely To what extent did you enjoy trying the IAT? To what extent did the IAT score you received change your view of yourself? To what extent are you skeptical of the IAT score that you received?     https://implicit.harvard.edu/implicit/backgroundinformation.html https://implicit.harvard.edu/implicit/privacy.html https://implicit.harvard.edu/implicit Print Page · Background Information · Privacy Information · Project Implicit Home Debriefing You have completed the study. During the Implicit Association Test (IAT) you just completed: Your responses suggested a moderate automatic preference for Straight people over Gay people. Disclaimer: These IAT results are provided for educational purposes only. The results may fluctuate and should not be used to make important decisions. The results are influenced by variables related to the test (e.g., the words or images used to represent categories) and the person (e.g., being tired, what you were thinking about before the IAT). How does the IAT work? The IAT measures associations between concepts (e.g., Straight people and Gay people) and evaluations (e.g., Good, Bad). People are quicker to respond when items that are more closely related in their mind share the same button. For example, an implicit preference for Straight people relative to Gay people means that you are faster to sort words when 'Straight people' and 'Good' share a button relative to when 'Gay people' and 'Good' share a button. Studies that summarize data across many people find that the IAT predicts discrimination in hiring, education, healthcare, and law enforcement. However, taking an IAT once (like you just did) is not likely to predict your future behavior well. Does the order in which I took the IAT matter? The order in which you take the test can influence your results, but the effect is small. We minimize this effect by giving practice trials after the categories switch sides. We also randomly assign the order of the IAT so that some people get one order and other people get the reverse order. I still have questions about the IAT. If you have questions about the IAT, please consult the links at the top of the page, where you will find answers to frequently asked questions, links to related research, and additional information about implicit associations. You may also email us with questions or comments. Please answer the following questions about your results: 1. What brought you to this website? -- Choose an option -- 2. What do you think of the IAT? Not at all Slightly Moderately Very Extremely To what extent did you enjoy trying the IAT? To what extent did the IAT score you received change your view of yourself? To what extent are you skeptical of the IAT score that you received? Click "Submit" to submit your answers. Submit � Try a study Take a test Background Tech Support The Scientists Donate https://implicit.harvard.edu/implicit/backgroundinformation.html https://implicit.harvard.edu/implicit/privacy.html https://implicit.harvard.edu/implicit http://www.projectimplicit.net/index.html Print Page · Background Information · Privacy Information · Project Implicit Home Debriefing You have completed the study. During the Implicit Association Test (IAT) you just completed: Your responses suggested a moderate automatic preference for Arab Muslims over Other People. Disclaimer: These IAT results are provided for educational purposes only. The results may fluctuate and should not be used to make important decisions. The results are influenced by variables related to the test (e.g., the words or images used to represent categories) and the person (e.g., being tired, what you were thinking about before the IAT). How does the IAT work? The IAT measures associations between concepts (e.g., Other People and Arab Muslims) and evaluations (e.g., Good, Bad). People are quicker to respond when items that are more closely related in their mind share the same button. For example, an implicit preference for Other People relative to Arab Muslims means that you are faster to sort words when 'Other People' and 'Good' share a button relative to when 'Arab Muslims' and 'Good' share a button. Studies that summarize data across many people find that the IAT predicts discrimination in hiring, education, healthcare, and law enforcement. However, taking an IAT once (like you just did) is not likely to predict your future behavior well. Does the order in which I took the IAT matter? The order in which you take the test can influence your results, but the effect is small. We minimize this effect by giving practice trials after the categories switch sides. We also randomly assign the order of the IAT so that some people get one order and other people get the reverse order. I still have questions about the IAT. If you have questions about the IAT, please consult the links at the top of the page, where you will find answers to frequently asked questions, links to related research, and additional information about implicit associations. You may also email us with questions or comments. Please answer the following questions about your results: 1. What brought you to this website? -- Choose an option -- 2. What do you think of the IAT? Not at all Slightly Moderately Very Extremely To what extent did you enjoy trying the IAT? To what extent did the IAT score you received change your view of yourself? To what extent are you skeptical of the IAT score that you received? Click "Submit" to submit your answers. Submit  https://implicit.harvard.edu/implicit/backgroundinformation.html https://implicit.harvard.edu/implicit/privacy.html https://implicit.harvard.edu/implicit http://www.lww.com ● Seventh Edition Margaret M. Andrews, PhD, RN, CTN-A, FAAN Director and Professor of Nursing School of Health Professions and Studies University of Michigan-Flint Flint, Michigan Joyceen S. Boyle, PhD, RN, MPH, FAAN Adjunct Professor of Nursing College of Nursing University of Arizona Tucson, Arizona Adjunct Professor of Nursing College of Nursing Georgia Regents University Augusta, Georgia Transcultural Concepts in Nursing Care 0002491983.INDD 1 7/10/2015 12:53:53 PM Acquisitions Editor: Christina C. Burns Product Development Editor: Christine Abshire Development Editor: Elizabeth Connolly Editorial Assistant: Cassie Berube Marketing Manager: Dean Karampelas Production Project Manager: Joan Sinclair Design Coordinator: Joan Wendt Illustration Coordinator: Jennifer Clements Manufacturing Coordinator: Karin Duffield Production Service: SPi Global 7th edition Copyright © 2016 by Wolters Kluwer Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA LWW.com All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above- mentioned copyright. Printed in China Library of Congress Cataloging-in-Publication Data Transcultural concepts in nursing care / editors, Margaret M. Andrews, Joyceen S. Boyle. — Seventh edition. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4511-9397-8 I. Andrews, Margaret M., editor. II. Boyle, Joyceen S., editor. [DNLM: 1. Transcultural Nursing. 2. Culturally Competent Care. WY 107] RT86.54 362.17'3—dc23 2015015790 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongo- ing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott Williams & Wilkins on the Internet: at LWW.com. Lippincott Williams & Wilkins customer service rep- resentatives are available from 8:30 am to 6 pm, EST. 10 9 8 7 6 5 4 3 2 1 0002491983.INDD 2 7/10/2015 12:53:53 PM iii Contributors Margaret M. Andrews, PhD, RN, CTN-A, FAAN Director and Professor of Nursing School of Health Professions and Studies University of Michigan-Flint Flint, Michigan Martha B. Baird, PhD, APRN/CNS-BC, CTN-A Assistant Professor School of Nursing University of Kansas Medical Center Kansas City, Kansas Joyceen S. Boyle, PhD, RN, MPH, FAAN Adjunct Professor of Nursing College of Nursing University of Arizona Tucson, Arizona Adjunct Professor of Nursing College of Nursing Georgia Regents University Augusta, Georgia Joanne T. Ehrmin, PhD, RN, CNS Professor Department of Health Promotion College of Nursing University of Toledo Toledo, Ohio Patricia A. Hanson, PhD, RN, APRN-BC, GNP Professor College of Nursing and Health Madonna University Livonia, Michigan Jana Lauderdale, PhD, RN, FAAN Assistant Dean for Cultural Diversity School of Nursing Vanderbilt University Nashville, Tennessee Patti Ludwig-Beymer, PhD, RN, CTN-A, NEA-BC, FAAN Vice President and Chief Nursing Officer Edward Hospital and Health Services Naperville, Illinois Margaret A. McKenna, PhD, MPH, MN Clinical Associate Professor Department of Health Services University of Washington Seattle, Washington Margaret Murray-Wright, MSN, RN Associate Director, Undergraduate Programs and Clinical Assistant Professor of Nursing University of Michigan-Flint Flint, Michigan Dula F. Pacquiao, EdD, RN, CTN-A, TNS Cultural Diversity Consultant Education, Research and Practice Lecturer, University of Hawaii Hilo School of Nursing Hilo, Hawaii Maureen J. Reinsel, MA, MSN, APRN, AGPCNP-C Technical Writer for Patient and Program Monitoring Improving Data for Decision-Making in Global Cervical Cancer Programs (IDCCP) Jhpiego Corporation Baltimore, Maryland Barbara C. Woodring, EdD, CPN, RN Professor Emerita Byrdine F. Lewis School of Nursing and Health Professions Georgia State University Atlanta, Georgia Andrews7e9781451193978-FM.indd 3 3/16/2016 12:16:43 PM iv Foreword I am pleased for the opportunity to write the Foreword to Drs. Margaret Andrews and Joyceen Boyle’s seventh edition of their book, which illu- minates the historical and theoretical foundations and evolution of transcultural nursing emerging from the disciplines of nursing and anthropology. I have been asked to “fill the shoes” of our men- tor and colleague, the late Dr. Madeleine Leini- nger, who wrote the previous Forewords to their book. Dr. Leininger, the first nurse anthropologist and the “mother” of transcultural nursing, passed away in 2012 leaving us a legacy of transcultural nursing scholarship and a body of knowledge that has accelerated exponentially from its earli- est beginnings in Cincinnati, Ohio, in the 1950s to its adoption in most nations of the world. Le- ininger addressed the human condition through knowledge of what it means to be human, caring, understanding, and open to all cultural traditions by creating the discipline of transcultural nurs- ing. At the outset of the programmatic develop- ment of the discipline of Transcultural Nursing, Joyceen Boyle and I were asked by Dr. Leininger to become her first two doctoral students in 1977 at the University of Utah, College of Nursing, Salt Lake City, Utah. Both of us had backgrounds in public health or anthropology and a great inter- est in the study of diverse cultures. As friends and students, Joyceen and I felt privileged to be pioneers as Dr. Leininger put into motion her be- liefs, and values of transcultural nursing, focusing on nursing and human science, caring science, theory development, anthropology, culture, and transcultural nursing. Leininger advanced her theoretical understanding developing The World- wide Nursing Theory of Culture Care Diversity and Universality and her Ethnonursing method- ology. Her transcultural beliefs and values have been infused into nursing program objectives for education, research, administration, and practice and were the foundation for the development of standards of practice for culturally competent care for individuals, groups, local and global communities, and organizations. Dr.  Andrews teamed up early in her scholarly career with her mentor, Dr. Joyceen Boyle and they, with other major contributors, wrote one of the earliest text- books, Transcultural Concepts in Nursing Care published first in 1989 who also was influenced by Dr. Leininger. Because of their long history of knowledge generation in transcultural nursing, this work of Andrews and Boyle is very comprehensive and shows the depth of their scholarship in terms of culture, theory development and application, research, and their commitment to the delivery of culturally competent care in practice. Rapid changes in science, technology, genetics, health care, economics, geopolitics, transportation, demographics, migration and immigration, reli- gious ideologies, unrelenting wars, and global issues including human rights and social justice have challenged nurses to understand new ways of engaging with clients and families, and also professional colleagues in terms of transcultural nursing. By means of the new sciences of com- plexity and the generation of enormous quanti- ties of research of every affiliation, and diverse philosophical, political, and religious perceptions, we can see the interconnectedness of everything in the universe and the necessity for discernment and evaluation of what is really happening in the world. Theoretical and experiential knowledge about our responsibilities to one another thus is growing and impacts the need for intense com- munication to examine and solve problems both locally and globally. Continuing to identify rel- evant issues to promote health, human safety, and 0002491983.INDD 4 7/10/2015 12:53:56 PM Foreword v improve the quality of life of all people is a major goal of thoughtful national and international health care professionals. For example, we can explore, within the United Nations Millennium Development Goals for 2015 and beyond, the framework for the world community. These devel- opments are now shaping Andrews’ and Boyle’s paradigmatic thinking in the seventh edition and their interest in addressing the challenges of the interconnectedness of all by their Transcultural Interprofessional Practice (TIP) Model with a theoretical foundation. Their model illuminates the necessity for increased collaboration and communication with clients and multiple health care and folk participants to address complex approaches to transcultural issues in the provision of culturally congruent, safe, and competent care. The beginning chapters in their book highlight foundational and evolutionary knowledge of the concepts of culture, subculture, race, ethnicity, context, communication including digital com- munication—the Internet and social media— evidence-based practice and problem solving, culture-specific nursing care, interprofessional collaboration and best practices, transcultural nursing, genetics, and theory development. The chapters focus on culturally competent nursing care by highlighting transcultural nursing across the life span, multicultural health care settings including the culture of organizations, the deliv- ery of mental health care, a focus on family and community, a spotlight on the cultural diversity of the workforce, and the challenges in trans- cultural nursing (religion, ethics, and interna- tional nursing). Each chapter follows with a set of review questions and learning activities that illu- minate what students, faculty, and clinical practi- tioners will have integrated into their plan of care to meet mutual goals presented in the chapter case studies. The seventh edition reflects many of the changes in the concept of the culture-at-large, especially genetics. While giving attention to Leininger’s theory in Chapter 1, what is significant in this seventh edition, as stated, is the develop- ment of their own theory, the Andrews and Boyle Transcultural Interprofessional Practice (TIP) Model. The key concepts identified in the TIP model are context, interprofessional health care team, communication, and problem-solving pro- cess. The cultural context (health-related beliefs and practices that weave together environmental, economic, social, religious, moral, legal, political, educational, biophysical, genetic, and technologi- cal factors), the interprofessional health care team (nurses, physicians, social workers, therapists, pharmacists, and others), cross-cultural commu- nication among client, family, and significant oth- ers, and members of the interprofessional health care team including folk and traditional healers, and religious and spiritual healers facilitate the foundation of the problem-solving process that has five steps. These five steps include compre- hensive holistic client assessment, mutual goal setting, planning, implementation of the plan of action and interventions, and evaluation of the plan for effectiveness to achieve the stated goals, and desired outcomes; provide culturally congru- ent and competent care; deliver quality care that is safe and affordable; and ensure that the care is evidence based with best practices. As I reflect on the work of my colleagues, Andrews and Boyle, not only within the pages of this book but also what each of them has accom- plished over many years as leaders, teachers, researchers, online educators, and as Presidents of the Transcultural Nursing Society, what comes to mind is their deep dedication and devotion to the discipline and profession of Transcultural Nursing. Through their intellectual astuteness and creative actions, they have been and are role models and mentors to students and other lead- ers who have spread and broadened transcultural care knowledge worldwide. They are commit- ted to the primary goal of transcultural nursing to facilitate culturally congruent knowledge and care so that people of the world are understood and their health care needs can be met within the dynamics of their cultures and cultural under- standing. A seventh edition of a book attests to the fact that students, faculty, and other practi- tioners find within its pages relevant and chal- lenging information to learn about cultures and 0002491983.INDD 5 7/10/2015 12:53:56 PM vi Foreword ethnic groups, know how to relate and serve them, conduct research, facilitate the solving of problems, and “making things work.” Today collaboration and communication are the key. Margaret Andrews and Joyceen Boyle have cap- tured that essence in their Transcultural Inter- professional Practice (TIP) theory and model, which is presented in this work. I wholeheart- edly endorse this new edition. I am most proud to call these authors not only my colleagues but also my friends as they move forward in the evo- lution of what can be termed authentic trans- cultural nursing by means of collaboration and interprofessionalism. Nursing students, faculty, other health care professionals, and practitioners of every health care and anthropological disci- pline will be stimulated by the theory and the content expressed by the authors and the many contributors in this new edition to improve the health of and help people of diverse cultures worldwide. Marilyn A. Ray, RN, PhD, CTN-A, FSfAA, FAAN Colonel (Retired), United States Air Force, Nurse Corps Professor Emeritus The Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida 0002491983.INDD 6 7/10/2015 12:53:56 PM vii Preface Given the large number of cultures and subcultures in the world, it’s impossible for nurses to know everything about them all; however, it is possible for nurses to develop excellent cultural assessment and cross-cultural communication skills and to follow a systematic, orderly process for the delivery of culturally competent care. The Andrews/Boyle Transcultural Interprofes- sional Practice (TIP) Model, which we are intro- ducing in this seventh edition of Transcultural Concepts in Nursing Care and describe in more detail in Chapters 1 and 2, emphasizes the need for effective communication, efficient, client- and patient-centered teamwork, and collaboration among members of the interprofessional health care team. The TIP Model has a theoretical foundation in transcultural nursing that fosters communication and collaboration between and among all mem- bers of the team and enables multiple team mem- bers to manage complex, frequently multifaceted transcultural care issues, moral and ethical dilem- mas, challenges, and care-related problems in a collegial, respectful, synergistic manner. The process used in the TIP Model is an adap- tation and application of the classic scientific problem-solving method used to deliver nursing and health care to people from different national origins, ethnicities, races, socioeconomic back- grounds, religions, genders, marital statuses, sex- ual orientations, ages, abilities/disabilities, sizes, veteran status, and other characteristics used to compare one group of people to another. The Commission on Collegiate Nursing Edu- cation, the American Association of Colleges of Nursing’s Essentials of Baccalaureate Education for Professional Nursing Practice, the National League for Nursing, most state boards of nursing, and other accrediting and certification bodies require or strongly encourage the inclusion of cultural aspects of care in nursing curricula. This, of course, underscores the importance of the purpose, goal, and objectives for Transcultural Concepts in Nurs- ing Care, Seventh Edition. Purpose: To contribute to the development of theoretically based transcultural nursing knowl- edge and the advancement of transcultural nurs- ing practice. Goal: To increase the delivery of culturally competent care to individuals, families, groups, communities, and institutions. Objectives: 1. To apply a transcultural nursing framework to guide nursing practice in diverse health care settings across the lifespan. 2. To analyze major concerns and issues encoun- tered by nurses in providing transcultural nursing care to individuals, families, groups, communities, and institutions. 3. To expand the theoretical bases for using con- cepts from the natural and behavioral sciences and from the humanities to provide culturally competent nursing care. 4. Provide a contemporary approach to trans- cultural nursing that includes effective cross- cultural communication, team work, and interprofessional collaborative practice. We believe that cultural assessment skills, combined with the nurses’ critical thinking abilities, will provide the necessary knowledge on which to base transcultural nursing care. Using this approach, nurses have the ability to provide culturally competent and contextually meaningful care for clients—individuals, groups, families, communities, and institutions. 0002491983.INDD 7 7/10/2015 12:53:56 PM The editors and chapter authors share a com- mitment to: ●● Foster the development and maintenance of a disciplinary knowledge base and expertise in culturally competent care. ●● Synthesize existing theoretical and research knowledge regarding nursing care of different ethnic/minority/marginalized and other disen- franchised populations. ●● Identify and describe evidence-based practice and best practices in the care of diverse indi- viduals, families, groups, communities, and institutions. ●● Create an interdisciplinary and interprofes- sional knowledge base that reflects hetero- geneous health care practices within various cultural groups. ●● Identify, describe, and examine methods, theo- ries, and frameworks appropriate for developing knowledge that will improve health and nursing care to minority, underserved, underrepresented, disenfranchised, and marginalized populations. Recognizing Individual Differences and Acculturation We believe that it is tremendously important to recognize the myriad of health-related beliefs and practices that exist within the population catego- ries. For example, the differences are rarely rec- ognized among people who identify themselves as Hispanic/Latino: this group includes people from along the U.S.–Mexico border, Puerto Rico, Mexico, Spain, Guatemala, or “little Havana” in Miami, as well as other Central and South American countries, who may share some similari- ties (speaking Spanish, for example) but who may also have distinct cultural differences. We would like to comment briefly on the terms minority and ethnic minorities. These terms are perceived by some to be offensive because they connote inferiority and marginalization. Although we have used these terms occasionally, we prefer to make reference to a specific subculture or culture whenever possible. We refer to categorizations according to race, ethnicity, religion, or a combi- nation, such as ethnoreligion, but we make every effort to avoid using any label in a pejorative man- ner. We do believe, however, that the concepts or terms minority or ethnicity are limiting, not only for those to whom the label perhaps applies but also for nursing theory and practice. We believe that concept of culture is richer and has more the- oretical usefulness. In addition, we all have cultural attributes while not all are from a minority group or claim a particular ethnicity. Critical Thinking Linked to Delivering Culturally Competent Care We believe that cultural assessment skills, com- bined with the nurse’s critical thinking ability, will provide the necessary knowledge on which to base transcultural nursing care. Using this approach, we are convinced that nurses will be able to provide culturally competent and contextually meaning- ful care for clients from a wide variety of cultural backgrounds, rather than simply memorizing the esoteric health beliefs and practices of any spe- cific cultural group. We believe that nurses must acquire the skills needed to assess clients from virtually any and all groups that they encounter throughout their professional life. Many educational programs in nursing are now teaching transcultural nursing content across the curriculum. We suggest that Transcul- tural Concepts in Nursing Care can be used by fac- ulty members to integrate transcultural content across the curriculum in the following manner: Chapters 1 to 4 in the first clinical courses when students are learning how to conduct health his- tories, health assessments, and physical examina- tions; Chapters 10 and 11, mental health nursing and family and community nursing, in the appro- priate specialty nursing courses; Chapters 5 to 8, which include nursing care across the lifespan, in courses that focus on the nursing care of the childbearing family, children, adults, and older adults; Chapters 9, 12, and 14, which concern cul- turally competent organizations, diversity in the viii Preface 0002491983.INDD 8 7/10/2015 12:53:57 PM multicultural health care workforce, and compe- tence in ethical decision making, in courses that focus on nursing leadership and management; Chapter 13, which examines religion, culture, and nursing, an excellent resource throughout the curriculum; and Chapter 15 in courses that focus on global health/community health nursing. New to the Seventh Edition All content in this edition was reviewed and updated to capture the nature of the changing health care delivery system, new research studies, and theoretical advances, emphasis on effective communication, team work, and collaboration, and to explain how nurses and other health care providers can use culturally competent skills to improve the care of clients, families, groups, and communities. In writing the seventh edition, we have been impressed with the developments in the field of transcultural nursing. The Trans- cultural Nursing Society and the American Acad- emy of Nursing (AAN) have moved ahead with developing Standards of Practice for Culturally Competent Care that nurses around the world are using as a guide in clinical practice, research, education, and administration. In addition, a special task force from the Transcultural Nurs- ing Society has developed a Core Curriculum for Transcultural Nursing that is being used as a basis for certification in transcultural nursing and for instructional purposes by faculty and students in educational programs. The recognition of the Standards of Practice and Core Curriculum for transcultural nursing enhances the development of cultural competence in nursing, thus improv- ing the care of clients. Lastly, the Andrews/Boyle Transcultural Interprofessional Practice Model is introduced in recognition of the need to put the client or patient first and of the changing com- plexion of the health care workforce. New Chapter Contributors We welcome two new colleagues in the sev- enth edition, both from the University of Michigan-Flint School of Health Professions and Studies. Margaret (Margie) Murray-Wright, Associate Director of Undergraduate Programs and Clinical Assistant Professor of Nursing, infused state-of-the art content on genetics and genomics and coauthored Chapter 3, Cultural Competence in the Health History and Physical Examination. An Adult-Gerontology Nurse Prac- titioner, Maureen J. Reinsel has extensive expe- rience in global public health and international development in Asia, Africa, and Europe. In addi- tion to her nursing background, Maureen earned her MA degree in International Affairs from the Johns Hopkins University School of Advanced International Studies. She wrote Chapter 15, Nursing and Global Health, which is available online. Chapter Pedagogy Learning Activities All of the chapters include review questions as well as learning activities to promote critical thinking. When relevant web-based information is available to supplement the chapter content, references are provided on . In addition, each chapter includes chapter objectives and key terms to help readers understand the purpose and intent of the content. Evidence-Based Practice Current research studies related to the content of the chapter are presented as Evidence-Based Practice boxes. We have included a section in each box describing clinical implications of the research. Case Studies Case Studies based on the authors’ actual clinical experiences and research findings are presented to make conceptual linkages and to illustrate how concepts are applied in health care settings. Case studies are oriented to assist the reader to begin to develop cultural competence with selected cultures. Preface ix 0002491983.INDD 9 7/10/2015 12:53:58 PM Text Organization Part One: Foundations of Transcultural Nursing This first section focuses on the foundational aspects of transcultural nursing. The develop- ment of transcultural nursing frameworks that include concepts from the natural and behavioral sciences are described as they apply to nursing practice. Because nursing perspectives are used to organize the content in Transcultural Con- cepts in Nursing Care, the reader will not find a chapter purporting to describe the nursing care of a specific cultural group. Instead, the nursing needs of culturally diverse groups are used to illustrate cultural concepts used in nursing prac- tice. Chapter 1 provides an overview of the theo- retical foundations of transcultural nursing, and Chapter  2 introduces key concepts associated with cultural competence using the Andrews/ Boyle Transcultural Interprofessional Practice Model as the organizing framework. In Chapter 3, we discuss the domains of cultural knowledge that are important in cultural assessment and describe how this cultural information can be incorpo- rated into all aspects of care. Chapter 4 provides a summary of the major cultural belief systems embraced by people of the world with special emphasis on their health-related and culturally based values, attitudes, beliefs, and practices. Part Two: Transcultural Nursing: Across the Lifespan Chapters 5 through 8 use a developmental frame- work to discuss transcultural concepts across the lifespan. The care of childbearing women and their families, children, adolescents, middle-aged adults, and the elderly is examined, and information about cultural groups is used to illustrate common trans- cultural nursing issues, trends, and concerns. Part Three: Nursing in Multicultural Health Care Settings In the third section of the text (Chapters 9 through  12), we explore the components of cultural competence in mental health and in fam- ily and community health care settings. We also examine cultural competence in health care orga- nizations and cultural diversity in the health care workforce, two very critical and current topics of concern. The clinical application of concepts throughout this section uses situations commonly encountered by nurses and describes how transcultural nursing principles can be applied in diverse settings. The chapters in this section are intended to illustrate the application of transcul- tural nursing knowledge to nursing practice. Part Four: Contemporary Challenges in Transcultural Nursing In the fourth section of the text, Chapters 13 to 15, we examine selected contemporary issues and chal- lenges that face nursing and health care. In Chapter 13, we review major religious traditions of the United States and the interrelationships among religion, cul- ture, and nursing. Recognizing the numerous moral and … Overview  This week, you will consider your own cultural background and how it impacts the care you provide to your patients.  For this written assessment we will focus on cultural competency, humility, and health inequities. First, complete this week's readings and learning activities.  Then, address the following questions on the template provided.   1. Define and describe health inequalities. How would you advocate for patients, families, and communities?  2. Discuss your results for each of the test (a brief response for all 6 of the tests).  3. Discuss if you are culturally competent or have cultural humility. Or are you not there yet? Why? What are your next steps?  References Minimum of four (4) total references: two (2) references from required course materials and two (2) peer-reviewed references. All references must be no older than five years  Chapter 11 and 13 https://www.who.int/news-room/facts-in-pictures/detail/health-inequities-and-their-causes Original Manuscript Patient advocacy in nursing: A concept analysis Mohammad Abbasinia , Fazlollah Ahmadi and Anoshirvan Kazemnejad Tarbiat Modares University, Iran Abstract Background: The concept of patient advocacy is still poorly understood and not clearly conceptualized. Therefore, there is a gap between the ideal of patient advocacy and the reality of practice. In order to increase nursing actions as a patient advocate, a comprehensive and clear definition of this concept is necessary. Research objective: This study aimed to offer a comprehensive and clear definition of patient advocacy. Research design: A total of 46 articles and 2 books published between 1850 and 2016 and related to the concept of patient advocacy were selected from six databases and considered for concept analysis based on Rodgers’ evolutionary approach. Ethical considerations: This study was approved by the Research Ethics Committee of Tarbiat Modares University. Findings: The attributes of patient advocacy are safeguarding (track medical errors, and protecting patients from incompetency or misconduct of co-workers and other members of healthcare team), apprising (providing information about the patient’s diagnosis, treatment, and prognosis, suggesting alternatives of healthcare, and providing information about discharge program), valuing (maintaining self- control, enabling patients to make decisions freely, maintaining individualization and humanity, maintaining patient privacy, and acting in the patients’ values, culture, beliefs, and preferences), mediating (liaison between patients, families, and healthcare professionals, being patients’ voice, and communicate patient preferences and cultural values to members of the healthcare team), and championing social justice in the provision of healthcare (confronting inappropriate policies or rules in the healthcare system, identifying and correcting inequalities in delivery of health services, and facilitating access to community health services and health resources). Discussion and conclusion: The analysis of this concept can help to develop educational or managerial theories, design instruments for evaluating the performance of nurses in patient advocacy, develop strategies for enhancing patient advocacy, and improve the safety and quality of nursing care in the community and healthcare system. Keywords Evolutionary concept analysis, nursing, patient advocacy, patient rights Corresponding author: Fazlollah Ahmadi, Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, P.O. Box. 14155-4838, Tehran, Iran. Email:[email protected] Nursing Ethics 2020, Vol. 27(1) 141–151 ª The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions 10.1177/0969733019832950 journals.sagepub.com/home/nej Introduction Rapid changes in the medical sciences and technologies resulted in the development of new methods of care delivery and changes in healthcare policies. 1 Therefore, obtaining health-related information and decision-making are difficult for patients2 and they need someone to advocate them.3 Due to the long periods of time spent with the patients and the chance to build a relationship; and the duty to care with no harm, nurses have the best position to advocate for patients.4 Advocacy was first utilized since the 1970s, when the International Council of Nurses (ICN) introduced this concept in its Professional Codes.5 Subsequently, many nursing organizations such as the American Nurses Asso- ciation (ANA), Nursing and Midwifery Council (NMC), Japanese Nursing Association (JNA), and Australian Nursing and Midwifery Council (ANMC) have integrated the role of “patient advocate” into their codes of ethics.6 Through effective patient advocacy, nurses can preserve patients’ values, benefits, and autonomy; and increase their safety, self-control, and quality of life.7 Also, if nurses provide good advocacy for patients, their own power, professional status, and job satisfaction will be increased.3,7 In ordinary English, advocacy has two related meanings. One meaning is “public support for or recommendation of a particular cause or policy.” The other meaning is “The profession or work of a legal advocate.”8 A number of empirical studies have examined the concept of patient advocacy from the patients’ and nurses’ perspectives. Based on these studies, attributes of patient advocacy are as follows: empowerment of the client, informing, valuing and respecting, protection, continuity of care, follow-up, empathy with patients, counseling, responding, shielding, and whistle-blowing.9–11 Davoodvand et al.12 also described advocacy from the clinical nurses’ viewpoint and concluded that it has two features as “empathy with patients” (including understanding, being sympathetic with, and feeling close to the patient) and “protecting patients” (including patient care, prioritization of patients’ health, commitment to the completion of the care process, and protection of patients’ rights). These studies examined the nurses’ role as patient advocate, focusing on nurses’ experiences and views. As this concept is extremely context based,7 studies have reported different attributes for it. Bu and Jezewski7 and Choi3 have also reviewed the concept of patient advocacy. Bu and Jezewski7 described advocacy as a safeguarding patients’ autonomy, acting on behalf of patients, and championing social justice in the provision of healthcare. Choi3 showed that the attributes of patient advocacy are safeguarding patient autonomy and promoting self-determination; acting on behalf of patients to protect their rights, values, benefits, and well-being; serving as an intermediary between patients and their families or significant others and healthcare providers; and championing social justice to ensure universal access to adequate nursing care and healthcare in institutions, and in the community or society. As shown, different definitions of advocacy have been provided in various studies and this concept is still poorly understood and not clearly conceptualized.3,12,13 As it was mentioned, several studies are available on the concept of patient advocacy. However, a majority of them only examined the concept based on the nurses’ perspective. Limited studies also reviewed the patient advocacy concept but did not report its evolution over time. Therefore, this study aimed to analyze the concept of patient advocacy through Rodgers’ approach to clarify the concept and its evolution over time. Research objective This study aimed to offer a comprehensive and clear definition of patient advocacy. 142 Nursing Ethics 27(1) Methods Concept analysis There are several methods of concept analysis. Rodgers’ evolutionary concept analysis is an inductive method in which the development of a concept is examined over time.14 The definition of patient advocacy changed over time.15 Hence, Rodgers’ evolutionary concept analysis is appropriate for the analysis of this concept. The steps of Rodgers’ approach are as follows: (1) identifying the concept of interest and asso- ciated expressions; (2) identifying and selecting the appropriate realm for data collection; (3) collecting the relevant data to identify the attributes and contextual bases of the concept; (4) analyzing data to identify characteristics; (5) identifying a model case (an exemplary); and (6) identifying implications and hypoth- eses for further development of the concept.14 The steps implemented in the concept of analysis are explained below (Table 1). Identifying the concept of interest and associated expressions (including surrogate terms) In the first step, based on the literature review, consulting with the research team, and using the MESH database (https://www.ncbi.nlm.nih.gov/mesh), the key terms and phrases related to the concept of patient advocacy were identified as patient advocacy, nursing advocacy, and patient advocate. As we were to define the concept of patient advocacy in nursing, issues related to peer advocacy and self-advocacy were not sought. Moreover, a number of surrogate terms were selected to be used in database searching. The surrogate terms are other words, say the same thing as the chosen concept.14 The surrogate terms found in the literature for patient advocacy included patient representatives, patient support, and patient’s ombudsman. Identifying and selecting the appropriate realm for data collection In this study, disciplines of nursing, medicine, and psychology were the realms of data collection. The databases of Google Scholar, Science Direct, Web of Science, INLM, Wiley, and Scopus were searched for retrieving documents published from 1850 to 2016. The inclusion criteria were access to the full text of the article, being relevant to the antecedents, attributes, and consequences of patient advocacy, and being published in English language. Then, the aforementioned key and surrogate terms were used to search for resources relevant to patient advocacy. Search operators “AND” and “OR” were used while searching if the databases were sensitive to these Boolean terms. Table 1. Rodgers’ steps of evolutionary analysis of the concept of patient advocacy. 1. Identifying the concept of interest and associated expressions (including surrogate terms) Key terms: patient advocacy, nursing advocacy, and patient advocate Surrogate terms: patient representatives, patient support, and patient’s ombudsman 2. Identifying and selecting the appropriate realm for data collection Databases: Google Scholar, Science Direct, Web of Science, INLM, Wiley, and Scopus Inclusion criteria: being published from 1850 to 2016, access to the full text of the article, being relevant to the antecedents, attributes, and consequences of patient advocacy, being published in English languages 3. Collecting the relevant data to identify the attributes and contextual bases of the concept Resources obtained from search: 102 documents Duplicates resources: 39 Non-relevant resources: 15 Relevant resources: 46 articles and 2 books 4. Analyzing data to identify characteristics Attributes, antecedents, and consequences are described in the findings Abbasinia et al. 143 Collecting the relevant data to identify the attributes and contextual bases of the concept After searching the databases, 102 documents were obtained. Thirty-nine duplicated documents were discarded through reviewing the titles and abstracts. The remaining 63 documents were then skimmed to answer the following questions: Is there any explanation in this document about the events, or phenomena that precede the occurrence of patient advocacy? Is there any explanation in this resource about the characteristics of the concept of patient advocacy? Does this document presents any outcomes and consequences of patient advocacy? If the answers were positive, then that document was selected as relevant (to be included in the concept analysis). After discarding irrelevant documents, 46 papers and two books were entered in concept analysis. Analyzing data to identify characteristics Data analysis was performed after the completion of data collection so that the actual attributes of the concept can be extracted from the data set without any bias and to avoid premature data saturation. After selecting the relevant documents, they were arranged based on the year of publication in order to distinguish changes in the definition of patient advocacy. Then, every document was thoroughly and repeatedly read to find the answers to the following questions: What event or phenomenon has been happened before the patient advocate (antecedents)? What are the characteristics of patient advocacy in this/these events/phe- nomena (Attributes)? What happened after or as a result of patient advocacy (consequences)? The semantic units suitable for answering these questions were then identified and recorded in three pre-prepared files namely antecedents, attributes, and consequences. The data in each file were analyzed separately. In this phase, researchers attempt to uncover patterns in the data and allowed main themes to emerge from the data material. To this purpose, the primary codes were extracted from the semantic units. Then primary codes were compared based on the similarities and dissimilarities and were assigned to separate subthemes and themes. The surrogate and related terms were exempted during this process. Ethical considerations The research project has received the confirmation of the Institution Ethics Committee of Tarbiat Modares University with the number of IR.TMU.REC.1395.523. Please be informed that this article is one part of a PhD dissertation and the stated ethical approval is for the whole study. Therefore, we reported it in this concept analysis study. Findings Some concepts related to patient advocacy among the nurses were patient support, compassionate care, and empathy. Patient support usually is undertaken by giving information, caring, dealing with emotional situations, encouraging proximity, opening and maintaining dialogue, and creating a mutual trust. 16 Compassionate care is a process in which the nurse communicates with the patient, tries to understand the patients’ concerns by putting himself in the patients’ situation, and strives to address those concerns.17 Empathy is a process of seeing the world as others see it. It also is a non-judgmental understanding of others’ feelings when they communicate with us.18 Attributes of Patient Advocacy Attributes are clusters of concepts’ characteristics and differentiate it from surrogate terms. 14 According to the results of this study, the attributes of patient advocacy are safeguarding, apprising, valuing, mediating, and championing social justice in the provision of healthcare (Table 2). 144 Nursing Ethics 27(1) The evolution of the concept of patient advocacy is shown in Table 3. As it evident, by 2000, the patient advocacy was mostly defined as tracking medical errors, protecting patients from incompe- tency or misconduct of co-workers and other members of healthcare team, providing information about the patient’s diagnosis, treatment, and prognosis, suggesting alternatives of healthcare, provid- ing information about discharge program, enabling patients to make decisions freely, maintaining individualization and humanity, acting in the patients’ values, culture, beliefs and preferences, liaison between patients, families, and healthcare professionals, being patients’ voice, and communicate patient preferences and cultural values to members of the healthcare team. From 2001 to 2016, attributes such as maintaining patient privacy, confronting inappropriate rules or policies in the healthcare system, and identifying and correcting inequalities in the delivery of health services were added to the concept definition (Table 3). Table 2. Defining attributes of patient advocacy. Defining attributes Sub-attributes Safeguarding Track medical errors,19,20 protecting patients from incompetency or misconduct of co-workers and other members of healthcare team21,22 Apprising Providing information about the patient’s diagnosis, treatment, and prognosis,23,24 suggesting alternatives of healthcare,25 providing information about discharge program9 Valuing Maintaining self-control,26–28 enabling patients to make decisions freely,29–32 maintaining individualization and humanity,23,33 maintaining patient privacy,34 acting in the patients’ values, culture, beliefs,35 and preferences36 Mediating Liaison between patients,37 families, and healthcare professionals,38 being patients’ voice,39–41 communicate patient preferences and cultural values to members of the healthcare team3 Championing social justice in the provision of healthcare Confronting inappropriate policies or rules in the healthcare system,7,32,42 identifying and correcting inequalities in delivery of health services,32,43,44 facilitating access to community health services and health resources45,46 Table 3. The evolution of patient advocacy. Until 2000 2001–2016 Track medical errors Maintaining patient privacy Protecting patients from incompetency or misconduct of co-workers and other members of the healthcare team Confronting inappropriate rules or policies in the healthcare system Providing information about the patient’s diagnosis, treatment, and prognosis Identifying and correcting inequalities in the delivery of health services Suggesting alternatives of healthcare Providing information about discharge program Enabling patients to make decisions freely Maintaining individualization and humanity Acting in the patients’ values, culture, beliefs, and preferences Liaison between patients, families, and healthcare professionals Being the patients’ voice Communicate patient preferences and cultural values to members of the healthcare team Promoting self-control Abbasinia et al. 145 Antecedents of Patient Advocacy Antecedents are situations, events, or phenomena that precede the occurrence of something or a concept.14 According to the findings, the events happened prior to patient advocacy can be categorized into three categories of patient-, nurse-, and organization-related antecedents, according to their nature. Patient-related antecedents Some patients may not able to express their needs, wishes, and values, due to impairments in conscious- ness47 or speech.38,48 Others have lost their independence and cannot make the decisions on their own lives,42 due to illiteracy, socio-cultural weakness, or the lack of knowledge in health issues.7 Hospitalization also makes the patient separated from family and friends and impairs their support network.23 Therefore, most patients are vulnerable and need someone to advocate them. Nurses-related antecedents Nurses should have special individual and professionals features to be able to advocate their patients. The needed individual characteristics are work motivation,40 professional commitment,22,41,49 independence,50 and self-confidence.51 The required professional features include legal knowledge,4 professional knowl- edge47,52 and skills,31,53 adequate knowledge of the patients’ needs, wishes, and values,9,31,54 having the ability to interact properly with patients and other healthcare team members,26,51 and having the ability to participate in the healthcare policy decision-making.55 The organization-related antecedents Supporting the patient’s rights requires the existence of laws56 and the authorities who support nurses in their role as patient advocate.22,50 Consequences of Patient Advocacy Consequences are the outcomes or the results of the concept. 14 This study showed that the patient advocacy has effects on both nurses and patients. For patients, the consequence is that improving patient safety33,56 and quality of care,57 development of a sense of self-determining3 and empowering,58 improving collabora- tion among patients, families, and the healthcare team,9 improving access to health and social services,44 and improving the public health.59,60 For nurses, the consequences of patient advocacy could be positive and negative. The positive consequences for nurses are experiencing a sense of being worthwhile,22 improving self-concept,7 job motivation,9 job satisfaction,22 and enhancement of the public image of nursing.7 However, the negative consequences are conflicts with other members of health team,26,50 being labeled as a troublemaker, whistle-blower, 61 and bad co-workers, 7 experiencing feelings of isolation and frustration,22 moral distress or dilemmas,7 quarrel with the organization’s authorities,3 receiving oral/ written admonitions,21 and loss of one’s job, reputation, and professional status.3,62 Discussion The study tried to provide a clear and comprehensive definition of patient advocacy. The analysis of the literature demonstrated that patient advocacy is a dynamic concept, beyond mere support, compassionate care, and empathy. The attributes of patient advocacy included safeguarding, apprising, valuing, mediating, and championing social justice in the provision of healthcare. These characteristics are similar to the ICN’s 146 Nursing Ethics 27(1) Code of Ethics for Nurses, which describes that nurses should respect for human rights, ensure that the individual receives accurate, sufficient, and timely information, meet the health and social needs, champion for equity and social justice in access to healthcare resource.63 “Safeguarding” and “apprising” are integral part of patient advocacy. Hospitalized patients, due to their vulnerability, have less control over their own care and are exposed to various risks, including medical errors, misconducts or negligence of the healthcare team, and inappropriate medical treatments or nursing interventions.64 The results of this study showed that nurses while providing expert care should not only protect their patients of medical errors, but also protect them against misconducts of other healthcare professionals. Nurses also should apprise patients by pro- viding them with information about their medical diagnosis, treatments, and prognosis, suggest them with alternatives of healthcare, and provide them information about discharge planting and post discharge care. In line with this, Sundqvist et al.22 state that protecting, value preserving, supporting, and informing are the characteristics of perioperative patient advocacy. However, Davoodvand et al.12 claimed that the empathy with the patient (understanding, being sympathetic with, and feeling close to the patient) and patient protection (patient care, prioritization of patients’ health, commitment to the completion of the care process, and protection of patients’ rights) are the main themes of patient advocacy. Unlike the current study, Davoodvand et al. did not consider safe- guarding and apprising as attributes of patient advocacy. Although they introduced the patient care as an attribute of patient advocacy, patient care seems to be a more general concept, and patient advocacy might be considered as part of it. “Valuing” is important part of patient advocacy. Maintaining self-control, enabling patients to make decisions freely, maintaining individualization and humanity, maintaining patient privacy, and acting in the patients’ values, culture, beliefs, and preferences are components of valuing. Baldwin23 also placed valuing at the core of her philosophical foundation for patient advocacy. Baldwin argued that valuing involves securing patients’ freedom and self-determination. Mortell35 enriched the valuing component by arguing that advocacy involves providing care according to the patient’s culture and religion, and the advocate should respect the patient’s individuality as a human being. Negarandeh et al.33 also concluded that patient advocacy would occur through respecting the patients’ individuality and their inherent human dignity. However, in patients who are incompetent to judgment, healthcare professionals should override their preferences to prevent harm or to benefit them.65 Another attribute of patient advocacy is “mediating.” Some patients avoid expressing their wishes because of cultural reasons or fear of repercussions.36 Also, patients sometimes do not understand what healthcare providers tell them. In such situations, the nurse must act as a mediator between the patient and the healthcare team.21,22 Rainer48 and Choi3 state that powerlessness patients require people to speak for them and intercede on their behalf. The final attribute of patient advocacy is “Championing social justice in the provision of healthcare” is another attribute of patient advocacy. Governments, private institutes, and charities have created various healthcare institutions to facilitate people’s access to health services. However, many people and especially uninsured ones66 and a majority of patients with chronic conditions are not aware of, or do not have access to these facilities.67 The nurses are responsible to guide people on how to suitably access the needed healthcare services. Then, the quality, continuity, and cost-effectiveness of care would be improved. Choi3 also believed that championing social justice is necessary to ensuring access to the adequate healthcare in the hospitals, community, or society. According to our findings, the events occurring prior to patient advocacy is three folds. They are patient-, nurse-, and organization-related antecedents. In the fold of patient, they are vulnerable and unable to defend their rights. Therefore, they need someone who defends their rights on behalf of them. Baldwin23 com- mented that vulnerable patients might be sometimes facing conflict or requires a decision. In such Abbasinia et al. 147 circumstances, the advocate must enable them to exercise their own right of freedom and self- determination. The nurse-related antecedents of patient advocacy included job motivation, professional commitment, self-concept, having professional knowledge and skills of caring, recognizing the patients’ needs and preferences, and having skills to collaborate with patients and healthcare team. Ezeonwu44 reported these as possessing good knowledge/information about the issue, having public health core com- petencies, and having strong working relations with the community. In addition, health organization– related factors such as the support of nurse managers, as nurses with positional power in the healthcare system, are essential for patient advocacy.50 Ware et al.40 also found that powerlessness, lack of support, and law are barriers to patient advocacy. The current study also showed that patient advocacy has positive consequences for both patients and nurses. The consequences of patient advocacy for patients included improving patient safety and quality of care, development of a sense of being empowered and self-determinant, improved collaboration among patients, families and the healthcare team, improved access to healthcare and social services, and improved the public health. The positive consequences of patient advocacy for nurses include experien- cing a sense of being worthwhile, improved self-concept, job motivation, job satisfaction, and enhance- ment of the public image of nursing. Nurses must increase their participation in healthcare policy-making to improve healthcare policies and thereby improve social justice in the provision of healthcare, facilitate access to health services, improve the quality of healthcare, and enhance the well-being of patients and society in general.7 Also, informing the patients of their rights, medical diagnosis, and possible therapeutic and caring practices can reduce their worries and stresses, enabling them to participate in decision-making, and improve patients’ autonomy.11 Vaartio et al.9 found that patient advocacy will empower patients through improving their own self-care capacity, coping, and compliance. Ezeonwu44 also cited improving access to healthcare, social justice, and empowerment as the consequences of patient advocacy. However, patient advocacy might result in some negative consequence such as conflicts with other healthcare professionals, being labeled as a troublemaker, whistle-blower, or a bad co-worker, experiencing feelings of isolation, frustration, moral distress or dilemmas, quarrels with the organization’s authorities, receiving oral/written admonitions, and loss of one’s job, reputation, and professional status. In line with this, Negarandeh and Dehghan Nayeri21 states that in order to play the role of advocate, the nurses may sometimes be placed against their colleagues and even the hospital officials. This may damage their relationships, and put them at risks for admonitions, and shift or ward changes. Choi3 also found that if a nurse seeks to advocate patients’ interests, their colleagues may label him or her as a problem maker. Choi states that another negative emotional response after patient advocacy include feelings of guilt, fear, and anger, resulting from the damaged relationships and loss of job. Conclusion This analysis defines patient advocacy as an act of safeguarding, apprising, valuing, mediating, and cham- pioning social justice in the provision of healthcare. Advocacy for vulnerable patients is a complex process that requires professional nurses, rules, and supportive managers. The analysis of this concept can help to develop educational or managerial theories, design instruments for evaluating the performance of nurses in patient advocacy, develop strategies for enhancing patient advocacy, and improve the safety and quality of nursing care in the community and healthcare system. Limitations In this study, just English language publications were analyzed. Therefore, some important works in other languages might have been missed. 148 Nursing Ethics 27(1) Author contributions MA, FA, AK: study design and conceptualization; data collection; data analysis and interpretation; manu- script writing. FA, AK: study supervision. Conflict of interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) disclosed receipt of the following financial support for …