NURSING AND HEALTH ADVOCACY: DEVELOPMENT PROCESS OF AN EDUCATIONAL MANUAL

ENFERMERÍA Y DEFENSA DE LA SALUD: PROCESO DE ELABORACIÓN DE CARTILLA EDUCATIVA

ABSTRACT

Objective:

to describe the development and validation of an educational manual for nurses on the practice of health advocacy in their professional experience.

Method

the method used to develop the manual was composed of three stages carried out from 2018 to 2020: an integrative review of studies published from 2010 to 2018, development of the content, and validation of the educational manual by experts.

Results:

based on the integrative literature review, 91 final articles related to the theme of advocacy in health and nursing were selected, which subsidized the definition of four themes: The meaning and fundamental elements for the practice of advocacy in nursing; Advocacy in teaching and the involvement of other care actors; Advocacy as a professional, moral, and ethical obligation; Advocacy about specific population groups. The themes contributed to the development of the educational manual content. After submission and validation by specialists, it was possible to define the layout, size, number of pages, and final design of the educational manual, which will be printed and handed out to nursing professionals and students, and made available online.

Conclusions:

the elaboration and validation of the manual help to build knowledge related to the professional practice of the nursing team and the exercise of advocacy in health.

DESCRIPTORS:
Health advocacy; Nursing; Patient rights; Ethics in nursing; Nursing Continuing Education

RESUMEN

Objetivo

describir la elaboración y validación de una cartilla educativa para enfermeros sobre el ejercicio de la abogacía en salud en su práctica profesional.

Método

para la elaboración de la cartilla se utilizó el método compuesto de tres etapas realizadas de 2018 a 2020: revisión integradora de estudios publicados en el período de 2010 a 2018, construcción del contenido y valoración de la cartilla educativa por parte de especialistas.

Resultados:

a partir de la revisión bibliográfica integradora, se seleccionaron 91 artículos finales relacionados con el tema de la abogacía en salud y enfermería, que subvencionaron la definición de cuatro temas: Del significado y elementos fundamentales para la práctica de la abogacía en enfermería; La abogacía en la enseñanza y la participación de otros actores del cuidado; La abogacía como obligación profesional, moral y ética; La abogacía en relación con grupos de población específicos. Los temas contribuyeron a la construcción de los contenidos del folleto educativo. Tras la presentación y validación por parte de los expertos, se pudo definir la maquetación, el tamaño, el número de páginas y el diseño final del folleto educativo, que se imprimirá y distribuirá a los profesionales y estudiantes de enfermería, y estará disponible en línea.

Conclusiones

la elaboración y validación del cuaderno contribuye a la construcción de conocimientos relacionados con la práctica profesional del equipo de enfermería y el ejercicio de la abogacía en salud.

DESCRIPTORES:
Abogacía en salud; Enfermería; Los derechos de los pacientes; La ética en la enfermería; Formación continua en enfermería

RESUMO

Objetivo:

descrever a elaboração e validação de uma cartilha educativa para enfermeiros sobre o exercício da advocacia em saúde em sua prática profissional.

Método

para a elaboração da cartilha foi utilizado o método composto de três etapas realizadas de 2018 a 2020: revisão integrativa de estudos publicados no período de 2010 a 2018, construção do conteúdo e validação da cartilha educativa por especialistas.

Resultados

com base na revisão integrativa de literatura, foram selecionados 91 artigos finais relacionados ao tema de advocacia em saúde e enfermagem e que subsidiaram a definição de quatro temas: Do sentido e elementos fundamentais para a prática de advocacia em enfermagem; Advocacia no ensino e o envolvimento de outros atores do cuidado; Advocacia como obrigação profissional, moral e ética; Advocacia com relação a grupos específicos da população. Os temas contribuíram para a construção dos conteúdos da cartilha educativa. Depois de realizar o envio e a validação por especialistas, foi possível definir a diagramação, dimensão, quantidade de páginas e o design final da cartilha educativa, que será impressa e distribuída aos profissionais e estudantes de enfermagem e disponibilizada online.

Conclusões:

a elaboração e validação da cartilha contribui para a construção de conhecimentos relacionados à prática profissional da equipe de enfermagem e o exercício da advocacia em saúde.

DESCRITORES:
Advocacia em saúde; Enfermagem; Direitos do paciente; Ética em enfermagem; Educação continuada em enfermagem

INTRODUCTION

Health advocacy constitutes actions that aim to inform, understand, and seek means for the exercise of rights related to the health of individuals and groups in society, with emphasis on the population in vulnerable situations. It represents, in this context, an important initiative for the promotion of better conditions for health, and seeks to build actions together with health professionals guided by the principles of justice and equity1.

Since it is a theme related to the enforcement of the right to health, it is important to reinforce the difficulties of its achievement, despite being an inalienable right. Thus, not all people benefit from the same access to health due to the inequalities existing in Society2. Health inequalities cause situations of disadvantage and social injustice and contribute to vulnerability through persistent social exclusions, poverty, access barriers, and health inequities3.

The term health advocacy can be considered a philosophical principle in nursing, related to nursing competence, mainly related to moral issues and ethical dilemmas faced in daily situations by the nursing team in population health care in different health services4. Nursing is considered one of the ideal professions for the practice of health advocacy because of its close relationship with users, and its defense is understood as a professional obligation, a moral good, and an ethical ideal5. Health advocacy represents ethics in the work actions of the nursing professional, related to quality care, and also to the defense of the rights and needs of each user of the health servisse6.

Nurses are considered, among professionals working in the healthcare field, as the ones who have an understanding of the preferences and concerns of healthcare users. Based on decision-making and other competence as happens in nursing team contexts, the nurse is identified as a professional capable of engaging in the team's approach to the user and, then, promoting care according to the user's needs7. Thus, there is the building of the team-user relationship.

Given the importance of knowledge about the role of advocacy in nursing, the development of an educational manual for nursing team professionals aims to contribute to the practice of actions related to the topic. The construction, validation, and use of educational materials have been relevant to facilitate the organization and teaching-learning related to health8. This resource can provide elements for the development and construction of actions in health education programs because it makes communication easier and, consequently, the work of the nursing and multi-professional team. Given this scenario, and considering the few studies carried out in Brazil checked in the review stage, this study aimed to describe the process of developing and validating an educational manual aimed at nursing professionals about the performance of actions related to health advocacy in their professional practice. Based on the scope of the theme, specificities of nursing practice contexts were not considered. However, this tool facilitates the professional's contact in contexts of health services that need guidance, to promote the exercise of health advocacy in situations of professional practice in Nursing9.

METHOD

It is a methodological study, which relates to the development, validation, and evaluation of research tools and methods. In addition, it includes the methods of obtaining and organizing data and conducting rigorous Research10. For the development of the educational manual, the proposed method was used, in which the educational material should be applicable, useful, and enlightening, covering important and easy-to-read contente11. To this end, the process of developing the educational manual occurred in the period from September 2018 to August 2020 and was divided into three stages identified (Figure 1).

Figure 1 -
Flowchart of the steps performed in the method.

First stage - Integrative literature review

The integrative review allows the synthesis of previous research, aiming to obtain conclusions that allow the analysis of scientific knowledge about the subject to be researched12.

The integrative literature review was performed following the methodology suggested in a developed study, which defines specific methodological strategies for integrative reviews with evidence-based practices13 and also based on the PICo14 strategy (P: patient or problem [nursing practice]; I: intervention [health advocacy]; Co: context [relationship between advocacy and nursing]). Thus, the question designed to guide the research was: what is the relationship between health advocacy and nursing practice?

The databases used for the search were: Biblioteca Virtual de Saúde [Virtual Health Library] (BVS), PubMed, SciVerse Scopus, Web of Science, and Cumulative Index to Nursing and Allied. Health Literature (CINAHL), and the descriptors used for the search were: "nurses", "nursing" and "health advocacy". The inclusion criteria for the articles were those published in national and international journals, in Portuguese, English, and Spanish, and that addressed the theme of advocacy in health and nursing, in addition to articles published in the period between 2010 and 2018. Exclusion criteria included literature review articles, those classified as editorials, and those that did not answer the guiding question. The Rayyan app for systematic reviews was used for filtering, organizing, and choosing the articles. This step was carried out by a team composed of three researchers.

The second stage - Composing the manual content

Based on the reading of the studies included in the integrative review, a thematic analysis was performed to identify the thematic nuclei related to advocacy in nursing and their categorization, using the instrument developed in an integrative review study15. Based on the analysis, we defined the main themes: 1) The meaning and fundamental elements for the practice of advocacy in nursing; 2) Advocacy in teaching and the involvement of other care actors; 3) Advocacy as a professional, a moral, and ethical obligation; 4) Advocacy regarding specific population groups. The content of the manual was developed according to the proposed method13 and based on the advocacy assessment tool "Protective Nursing Advocacy Scale (PNAS) for Brazilian nurses."16.

Third stage - Validation of the manual content

An assessment tool was developed to evaluate the adequacy of items related to the content and composition of the manual, adapted from the "Assessment for the validation of educational material"17 after permission of the author, who translated and adapted the content of the original "Suitability Assessment of Materials" (SAM)11. Thus, the aspects evaluated were: organization, writing style, the manual layout, understanding, interaction, and motivation, thus analyzing the relevance of each item.

The first version of the manual was submitted to expert evaluation, and nursing professionals with experience in the development of educational materials were chosen as well as professionals with expertise in health advocacy, verified by the Lattes curriculum and could be reached by e-mail. These specialists were invited to participate in the study via e-mail. At first, six specialists were selected and received by e-mail a formal invitation to participate in the study, as well as the link to the "Forms" document, including the Informed Consent Form (TCLE) and the questions related to the manual, according to the educational material validation tool. In the e-mail, the evaluators also received, as an attachment to the TCLE, the first version of the educational manual in PDF format. The deadline set for the return of the answered instrument via e-mail was ten days from receipt.

After receiving the specialists' analyses, the educational manual was reformulated based on the modifications and suggestions indicated. After this evaluation, the same criteria of sending the invitation, the TCLE, and the questions were followed to invite the other six nursing professionals to evaluate the structure and composition of the manual text, so that they could analyze the writing form, interact with the reader (nursing professionals), and use of images, highlighting the need for changes about understanding and writing style. After this evaluation, there was a new manual adaptation. At the end of the evaluations, the final version was sent to the specialized sector of the educational institution to define the layout, the size, and the number of pages for later printing.

RESULTS

Integrative literature review

Through the literature review, 2179 articles were found in the researched databases, and after removing duplicate texts and sorting them by title and abstract, 310 articles were read in full. The final sample was composed of 91 articles. Figure 2 summarizes the results of this phase in the PRISMA18 diagram.

Figure 2 -
Results of the literature review (Favorite items for systematic reviews and Meta-Analyses diagram [PRISMA]).

After the final sample was constituted, the data were extracted and synthesized, coded, and categorized as previously mentioned. The thematic categories identified were: 1) Of the meaning and fundamental elements for the practice of advocacy in nursing: highlights nursing as an essential profession for the practice of advocacy in health due to its close relationship, active listening, communication, promotion of safety and care, political participation, and leadership; 2) Advocacy in teaching and the involvement of other care actors: presents the role of nurses as educators of other agents that assist in care, in the theoretical-practical exercise in the training of students, in acting in schools and in stimulating the autonomy of patients; 3) Advocacy as a professional, moral and ethical obligation: highlights the ethical responsibility of the nursing profession, such as respect for individualities and decision-making in the search for better results; 4) Advocacy with regard to specific population groups: emphasizes the performance and actions of nurses in different levels of health care, as well as in conditions of vulnerability, aiming at equity.

The Figure 3 indicates such themes and the respective numbers of selected articles.

Figure 3 -
Identified categories and respective numbers of articles read in full by using the integrative review.

Composing the manual content

In the second phase, the content of the manual was developed according to the previously identified thematic categories and the main aspects related to them. A draft of the contents to be addressed in the manual was built into eleven pages with topics divided into four parts. The first would be the presentation, explaining the research conducted; the second would be the manual contextualization, highlighting the relationship between nursing and health advocacy; the third, the introduction, with explanatory subtopics: "what is advocacy?", "What is advocacy in health?", "What is advocacy in nursing?", "Nursing and the right to health", "The role of the nurse and its practice areas", and "Nurse as a patient advocate? "; and the fourth part, entitled "Advocacy in health: nurse's actions", addressed the following five themes identified by the literature review: "1) Advocacy practice in nursing", "2) Teaching and advocacy", "3) Advocacy: professional, moral, and ethical obligation", "4) Advocacy: defense of specific groups", and "5) Challenges and benefits of advocacy in health for nurses."

The content was written in text format, topics and subtopics, attractive and interactive illustrations and images developed by the author, and also elaborated through an online graphic editor.

Validation of the manual content

The third phase involved the validation of the manual content developed in two evaluation stages. The evaluations in the first stage were answered by three of the six experts invited. Two experts were professors of nursing courses and one was a master's student in a nursing program, all with experience in the development of educational material and the theme of health advocacy. After the experts' evaluations, the educational manual was reformulated based on the suggestions shown in Chart 1.

Chart 1 -
Suggestions indicated by experts in the first evaluation of the stage validation of the educational manual content.

Aspects evaluated	Highlighted Item	Suggestions
Arrangement	Cover Topics Content	Evaluator 1: presentation of graphical elements. Reviewer 3: reorganization, to "make it more attractive and with less overloaded pages." Evaluator 3: correction of typos and formatting errors. Adjusting the sequence and focus on the different health services. Evaluator 3: reducing the amount of contente.
Writing style	Text	Evaluator 2: revision of the text in the excerpt about the concept of health advocacy. Adaptation of the concept of equity. Fix wording: "favored, missing the F."
Manual layout	Illustrations	Evaluator 2: greater harmony of colors. Use of less amount of colors so as not to make reading "tiresome and heavy." Evaluator 3: non-specific illustrations.
Motivation		Evaluator 3: "the educational manual still requires investments in text and layout to be material that is accessible, attractive and able to reach nurses working in different health services."

After the reformulation phase of the manual based on suggestions related to the illustrative elements and content arrangement, a new evaluation was performed by inviting other nursing professionals, of which two professionals accepted and performed the evaluation, the first with a master's degree in nursing and the second a doctoral student in nursing, both from the southeastern region of Brazil and with experience in building and developing educational materials. In this second evaluation, the criticisms were more related to the manual layout and its graphic elements, which were again reorganized as indicated in Chart 2.

Chart 2 -
Suggestions were given by experts in the second evaluation of the validation stage of the educational manual content.

Aspects evaluated	Highlighted Item	Suggestions
Arrangement	Content	Evaluator 1: "the information is great, but I suggest shortening some topics that come up more than once or are too long, such as those referring to vulnerability and specific groups, advantages, among others."
Writing style	Text Language	Evaluator 1: summarize the text without losing the content and put more illustrations to make it lighter for those who are reading. Evaluator 2: "the fact that Health Advocacy is a new content, it becomes necessary a less technical language, so I agree with the writing style."
Motivation	Audience interaction	Evaluator 1: more illustrations that interact with the audience.

After the two evaluations, the results got were compared. Among the 13 evaluation items of the developed instruments, in 5 items there was an alteration in the results obtained, as shown in Chart 3.

Chart 3 -
Comparison of the modified items after two evaluations in the content validation stage of the educational manual.

Modified Items	Before Evaluations	After Evaluations
Contents	Large content.	Rewriting of content in a shorter, clearer, and simpler way. Addition of topics and subtopics.
Writing/Language	Missing punctuation and writing erros.	Spelling adjustment.
Text	Large texts.	Rewriting and adjustment of the topics and texts.
Layout	Dull colors and lack of interactive images.	Modification of the manual design (colors, illustrations, and backgrounds).
Motivation	Little interaction with readers and few examples.	Inclusion of interactive texts, symbols, and images.

Thus, the construction of the final version of the educational manual included the changes and suggestions indicated. In the end, the structure of the manual included the following topics and subtopics:

Cover with Title: Nursing and Health Advocacy

Presentation;

Introduction;

What is Advocacy?

What is health advocacy?

What is advocacy in nursing?

Why is nursing considered one of the ideal professions for practicing health advocacy?

Nursing and the right to health - what is it?

Health Advocacy - Nursing Team Actions

01) Nurse Advocacy Practice

Patient Advocacy

Relations and defense of the professional’s rights

02) Advocacy: a professional, moral, and ethical obligation

03) Teaching and Advocacy

Nurses at School

Training nursing students

Involving other care actors

04) Advocacy: defense of specific groups

Types of groups

Nursing action: the protagonism of invisibilized groups

05) Challenges and benefits of health advocacy for the nursing team

Challenges and difficulties

Benefits

Acknowledgments

References

Back cover with logos of the Educational Institution, Research Group, and Study Center that facilitated the research.

It is noteworthy that the educational manual has images and illustrations from the graphic design used that interact with the text. The predominant colors were: dark yellow, dark blue, and teal. Besides these, the following colors were also used: dark green, light green, light blue, dark pink, and red. The layout was with the following characteristics: open format 420mm x 148mm (width x height), closed format 210mm x 148mm (width x height), with folding on the smaller side, totaling 48 pages, with 46 pages plus the front cover printed on the front and back cover on the back, 4x4 colors. Cover and inside material in couché 150g matte and finishing: trimming, folding, and stapling.

DISCUSSION

Nursing is considered the front line in care, in supporting users of health services, and in knowing the difficulties faced by them, is considered fundamental in sharing information and promoting health, seeking that the rights and interests of each person are preserved19. Nurses can develop skills and knowledge that help in the practice of advocacy for the user of health services and in getting the necessary health care, as well as in the defense of rights and quality of care, representing, therefore, a link between them and the health care environment16. Nursing advocacy is considered the voice of the users of the health care service in a system in which the nurse and the nursing team become guides for decisions, helping to face problems, besides being a way to guide individuals in their decision-making and possible moments of misunderstanding in the communication between them and health care professionals20.

The construction of the educational manual allowed the articulation and identification of themes, professional practices, and nursing performance regarding health advocacy. The incorporation of educational materials helps the health team professionals' activities, highlighting the importance of inserting the approached subject into the professional practice21. Therefore, the educational manual developed represents a means of contributing to and strengthening professional practice in nursing and health advocacy.

The development of educational materials makes it possible to formalize guidelines for the target audience, an audience that participates, in a representative way, in the process of adaptation and validation of the material developed8. The evaluation and validation of the content and the form presented are essential for the quality of the material, making the technology more complete, with more scientific rigor and effectiveness. It is in this process that reformulations, exclusion of information, replacement of terms, and changes regarding the illustrations are suggested22.

The evaluators were questioned about the text, content, writing/language, layout, and motivation, which are elements that can facilitate or hinder the reading process of the material23. In the manual built, the evaluators pointed out shortcomings in these elements, especially regarding the amount of text and content indicating the presence of too much information with large content. The evaluations with the suggestions were essential for the adequacy of what is expected from an educational material because it is in this process that we realize what is missing, and what is not understood8.

It is noteworthy that the evaluation elements in educational materials are interconnected because another interesting aspect of this process was related to the layout and motivation of the manual. The material initially delivered for evaluation did not have a positive impact due to the small number of illustrations and the dull colors, leading to suggestions for the insertion of graphics, illustrations, and stronger colors to have more interaction with the public, corroborating Polit and Beck's22 guidelines. Thus, after the evaluations, the manual was reworked to achieve the proposed goal.

The manual addresses the different contexts in which nursing can practice advocacy in health. Political participation is an example of this since the discussion and policy-making environments need health professionals to represent the real needs of professional practice as well as the users of health services24. The practice of advocacy associated with team relationships and the empowerment of other professionals is also noteworthy since nurses are capable of defending their professional class and the profession itself as long as there are skills related to problem-solving, communication, influence, and collaboration24.

The contents addressed in the manual contribute to and reinforce the practice based on the role of advocacy, based on beliefs about care, and reasoned actions recognized as ethical in health care16. The legal, moral, and ethical obligations of nurses to provide safe care and make decisions related to ethical dilemmas depend not only on the situation, but also on the organization, culture, and individuality25. Considering the different possibilities and scenarios of the nursing team's performance, the educational material in its printed form and available online makes it possible to bring the team closer to possible situations and environments, highlighting the influence of the organization of health services and the action possibilities. The diagramming of the content in titles, texts, topics, subtopics, and illustrations makes the material more dynamic, facilitates and favors its understanding and the approximation between nursing and the theme of health advocacy.

Therefore, the educational manual allows an approach between nursing and health advocacy based on examples and explanations of everyday situations in different contexts, such as in the primary health care network, in teaching-learning spaces and environments, and with different population groups, as well as in secondary and tertiary- care services, supporting professional practice and the development of knowledge in nursing advocacy.

It highlights the role of nurses as leaders and their importance in promoting health and addressing health disparities26. In these contexts, the use of educational material provides greater knowledge regarding advocacy and actions to defend the users of health services, the community in general, and the health team. In this perspective, together, the performance of nurses and health users is related to facing challenges, providing guidance and protection to these users, and ensuring the quality of care27.

In addition, the manual identifies situations of challenges and benefits in the practice of advocacy in healthcare settings and contributes to the interaction of the topic with professionals. When the nursing team performs actions related to advocacy, it faces the risk of facing difficulties linked to the hierarchy of personal relationships, which are related to the organization of the work environment. Thus, in the attempt to perform advocacy actions for the improvement of user care and access to rights, there may be barriers, failing in the search for rights and health advocacy21. Thus, it is necessary to understand nursing advocacy as a responsibility of the individual who plays the role of a nurse, and also of the team. The nurse’s performance in challenging situations helps to overcome barriers28 and also enables the establishment of confidence, recognition, and improvement of structures and processes that affect the rights and safety of the patient29.

As contributions to practice, we highlight that the educational manual produced in this research addresses different performances and contexts in which nurses can perform health advocacy actions as a moderator material for the interaction between professionals and other actors in the health care process, in addition to the possibility of being used in the teaching-learning process during the training of nurses.

Regarding the limitations of the study, it was identified that most of the studies used for the development of the educational manual came from other countries, with a lack of approach to the subject in studies conducted in Brazil. Therefore, this lack is understood as a limiting factor, considering that the use of the educational manual implies direct interaction between its content and the practice of Brazilian nursing professionals.

It is noteworthy that there were no studies on the development of educational materials on the subject in Brazil.

CONCLUSION

The educational manual was validated as indicated by the evaluators regarding content and relevance, contributing to the identification of themes related to advocacy in health and the actions of the nursing team. The diverse possibilities for the practice of advocacy synthesized in this study allow nursing professionals to recognize, approach the theme, and appropriate the elements related to professional practice, being able to acquire and complement knowledge that will reflect on their actions in different work environments, whether in the educational field or the different levels of care in the healthcare network. It can also contribute to the greater autonomy of nurses who deal with ethical dilemmas, strengthening teamwork and leadership, and encouraging research in this area. The manual will be available online on the website of the Center for Education in Human Rights and Health (CEDiHuS), and also in print, where the monitoring indicator will be the number of downloads on the platform where it will be inserted. The printed versions will be delivered to health and educational institutions in a city in the interior of São Paulo, targeting the nursing staff and nursing students.

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NOTES

• ORIGIN OF THE ARTICLE

  Article extracted from the scientific research - Nursing and health advocacy: the development process of an educational manual [Enfermagem e a advocacia em saúde: processo de construção de cartilha educativa] developed at the Department of Psychiatric Nursing and Human Sciences of the Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, in 2021.

• FUNDING INFORMATION

  The article was translated with resources from the Graduate Program at the Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Research Ethics Committee of the Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Opinion N^o. 2.713.200, Certificate of Submission for Ethical Consideration 90131618.8.0000.5393.

Edited by

EDITORS

Associated Editors: Laura Cavalcanti de Farias Brehmer, Ana Izabel Jatobá de Souza. Editor-in-chief: Roberta Costa.

Publication Dates

• Publication in this collection
  16 Sept 2022
• Date of issue
  2022

History

• Received
  15 Nov 2021
• Accepted
  23 May 2022