Review Article

Exploring the Emergent Concept of Patient Advocacy in Acute and Perioperative Settings: A Scoping Review

Introduction

Advocacy originates from the Latin term advocatus, meaning “one who is called to aid or defend another”.¹ Although other health professionals defend their patients, nursing as a profession has incorporated the concept of advocacy since 1973, introduced by the International Council of Nurses (ICN) in the profession’s Code of Ethics, considering that nursing promotes respect for human rights, including the right to life and to be treated with respect.² In the Declaration of Alma-Ata, drawn up by the World Health Organisation (WHO) in 1978, people were recognised as having the capacity and possibility to be agents and partners in their therapeutic decisions. Until then, patients were seen as passive agents without active participation in decision, and decisions about their health were the sole and exclusive responsibility of health professionals.³However, it is important to highlight that Nightingale presented characteristics of patient advocacy in her work, considering nursing professionals as protectors of life, which included patient advocacy, the promotion of human rights, and the protection of vulnerable groups.⁴

Evidence shows that advocating for the patient is central to nursing practice. It encompasses acting in favor of the person’s best interests, promoting their well-being,⁵ providing adequate information,⁶ protecting their rights,⁶ and defending them from inappropriate practices exercised by other health professionals, and guaranteeing the quality of care.⁷ However, nurses face some challenges when exercising this advocacy, including individual and institutional barriers, and actions of this nature vary according to culture, clinical situations and professional practice environments.⁸

Various studies have attempted to analyse and clarify this concept over time, due to the varied interpretations that have developed with the consolidation of patients’ rights. Bu and Jezewski based their work on Walker and Avant’s conceptual analysis method, combined with an extensive literature review, from which they developed a mid-range theory. This theory attributed three adjacent characteristics to patient advocacy, namely: protecting the patient’s autonomy; acting in the patient’s defense and promoting social justice in healthcare.⁹ More recently, Abbasinia et al,¹⁰ starting from the premise that this concept was not yet clearly conceptualised, developed a comprehensive conceptual analysis of the concept from 1850 to 2016. The author’s analysis was categorical in stating that the concept of patient advocacy is defined by the following attributes: safeguarding; mediating and being the voice of patients; defending social justice in healthcare provision.¹⁰

In acute and perioperative settings, patient advocacy is particularly critical due to the heightened vulnerability of patients undergoing surgical or intensive treatments. The evidence already reveals the need for patient advocacy to be developed in the perioperative period, because there is a need for nurses to communicate with and protect people who are unable to do so themselves. It centres on people being informed about the surgery they are about to undergo, not just by signing the informed consent form, but that they have understood the interventions involved, in so far as the the lack of information may be perceived as a violation of patient autonomy; as well as enhancing communication among healthcare team members, contributing to increasing the safety of the person being cared for.^8,11,12Research indicates that advocacy interventions in perioperative care often focus on direct patient education, utilizing consultation-based approaches that incorporate written, digital, or multimedia materials. These educational efforts aim to empower patients with knowledge about their procedures and recovery processes, thereby enhancing their autonomy and engagement in care decisions.^13,14

In the context of patient advocacy in ICUs, four key themes emerge in nursing discourse: the responsibility to uphold patient autonomy in treatment decisions, the duty to protect patients from potential harm caused by physicians, the role of acting as an intermediary between the patient and the physician, and the obligation to support the overall well-being of the patient.¹⁴

Recognizing these contextual differences allows nurses to tailor their advocacy strategies, ensuring that patients receive the appropriate level of support based on their specific healthcare setting.⁹ The novelty of this study lies in its updated conceptual analysis of patient advocacy in the post-pandemic context, where rapid clinical changes demand renewed ethical frameworks. Findings from a previous study,⁷ which revealed significant associations between demographic factors and nurses’ advocacy behavior, ethical decision-making, and whistleblowing intentions, underscore the urgent need to deepen and clarify the concept. This work also addresses that need, exploring how advocacy is understood and practiced in acute care settings today, and offering a foundation for more targeted, ethical, and effective nursing interventions. Analysing the concept of patient advocacy can, therefore, provide valuable insights in this context. Given the broad and evolving interpretations of advocacy, a scoping review is warranted to map its conceptual boundaries and applications in acute care. This study aims to map the concept of patient advocacy in nursing, identifying its key attributes, antecedents, and consequences in acute and perioperative settings, contributing to its update and integration into the current healthcare paradigm.

Materials and Methods

This scoping review emerged from the need to analyze the available evidence on the definition of patient advocacy. Scoping reviews can map out the main concepts underlying the research area and clarify a topic’s working definitions and/or conceptual boundaries.¹⁵ We followed the five scoping review steps outlined in the methodological framework of Arksey and O’Malley¹⁵ and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.^16-18The protocol was registered on Open Science Framework (https://doi.org/10.17605/OSF.IO/UQVPH).

Step 1: Identifying the Research Questions

Firstly, as this is a conceptual review, the research questions were constructed by defining the concept, as they are based on some of the central premises of the conceptual analysis model proposed by Walker and Avant.19 We used the Population-Concept-Context (PCC) model, according to the JBI, as the study design, where “Population (P)” refers to “nurses”, the “Concept (C)” refers to “Patient Advocacy” and the “Context (C)” designates “nursing care”. The research questions are as follows:

Research question 1: How is the concept of patient advocacy, defined in nursing practice in acute and perioperative settings??

Research question 2: What are defining attributes of the concept?

Research question 3:What are the antecedents and the consequences of the concept?

Step 2: Identifying Relevant Studies

Search Strategy

Two researchers with expertise in conducting literature reviews were responsible for developing and executing the search strategy. Boolean operators were used to combine search terms, which included: “nurses”, “patient advocacy” and “nursing care” which were expanded through their similarities. The following databases were systematically searched: CINAHL, PubMed, Scopus, Web of Science, and Google Scholar.

Data Inclusion and Exclusion Criteria

We included studies published in English, Spanishand Portuguese. To capture recent developments in practice, we included studies published in the last five years, from 2019 to 2024. Given that the last comprehensive review of the concept of patient advocacy was published in 2020,¹⁰ with studies before that date, we consider it pertinent to cover these last few years, also as a way of surfacing intra- and post-pandemic results. Thus, studies whose population consisted of nurses were included, focusing on patient advocacy in acute and perioperative settings. Articles were excluded if they did not align with the concept of patient advocacy or if they focused exclusively on advocacy performed by non-nursing professionals, students, or self-advocacy. Opinion pieces, case reports, and editorials were also excluded. However, studies involving interprofessional advocacy (e.g., nurse-physician collaborations) were included, provided the nurse’s role in the advocacy process was clearly identifiable. This review includes primary studies with a qualitative, quantitative, or mixed design, as well as secondary studies. A search was conducted using the databases CINAHL, PubMed, Scopus, Web of Science and Google Scholar for articles published in peer-reviewed journals using the following search terms “Nurses” AND “Patient Advocacy” OR “Patient Rights” OR “Patient Navigation” AND “Nursing Care” OR “Nursing Practice” OR “Nursing Role” AND “Acute Care” OR “Perioperative Care”.

Step 3: Study Selection

The search result identified a total of 640 articles. We excluded 210 duplicates and we screened the titles and abstracts of 430 articles. From the grey literature, 45 articles emerged, totalizing 475 articles for screening. Of those 475 articles, 405 did not meet the criteria. Hence, only the full texts of 70 articles were reviewed. Of these 70 articles, we excluded 26 with the ineligible study design, 9 without the eligible language, 6 not target nurses, 13 were not related to patient advocacy and 2 were not available (Figure 1).

The selection of studies was carried out by two independent reviewers and took place in two phases: in the first phase, the titles and abstracts were read, and in the second phase, the texts were read in full to determine whether the inclusion and exclusion criteria were met. Duplicates were removed using the Rayyan® tool.

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Figure 1.

PRISMA diagram for conceptual analysis of patient advocacy in nursing. Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Scopus, Web of Science and Google Scholar

Figure 1.

PRISMA diagram for conceptual analysis of patient advocacy in nursing. Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Scopus, Web of Science and Google Scholar

Step 4: Charting the Data

The data were extracted into a table containing the following elements: author/year of publication/country; type of study; population; defining attributes; antecedents and consequences of patient advocacy. This thematic categorization followed some of the crucial steps of Walker and Avant’s¹⁹concept analysis framework, which emphasises the identification of defining attributes, antecedents and consequences as essential components in clarifying a concept.

Two reviewers independently coded the extracted data, identifying recurring concepts across studies. Discrepancies were resolved by consensus, with input from a third reviewer when necessary. Themes were validated if supported by findings from multiple studies. The final themes were synthesized into a conceptual map to visually represent the interrelationships and contextualize patient advocacy within acute and perioperative nursing care.

Step 5: Collating, Summarizing, and Reporting Results

The summarized results and the distribution of articles across key themes are presented in a table and a conceptual map within the results section. Conceptual maps serve as a valuable graphic representation, facilitating the organization and visualization of knowledge.²⁰ They provide an effective means for mapping and clarifying complex concepts such as patient advocacy.

Results

General Characteristics

Regarding the years of publication, of most studies were published in 2019 (n = 5), 2020 (n = 3), 2021 (n = 1), 2022 (n = 1), 2023 (n = 3) and 2024 (n = 1). The studies included in the document were conducted across a total of 9 different countries. Specifically, in Ghana (n = 2), Spain (n = 1), Iran (n = 2), Brazil (n = 4), Turkey (n = 2), Saudi Arabia (n = 1), United States (n = 1) and Australia (n = 1). The studies used a variety of research methodologies, with most being qualitative designs (n = 8). Other methods included quantitative studies (n = 4) and secondary research, such as integrative reviews or systematic reviews (n = 2). All studies focused on nursing professionals as the primary sample, exploring various aspects of patient advocacy across different healthcare settings. Regarding the contexts of the studies, they include medical-surgical inpatient units (n = 4), intensive care units (n = 4), emergency departments (n = 1), and less frequently settings focused on cardiopulmonary resuscitation (n = 1). Additionally, (n = 4) of the studies were conducted with nurses from various units, such as surgical, medical, children’s wards, maternity and ICU’s. All studies had nursing professionals as a sample (Table 1).

Thematic Characteristics

Analysis of 14 studies (Table 1) revealed five key attributes of patient advocacy, along with five facilitators and five barriers. Additionally, the review identified four consequences of advocacy for nurses and four for patients, which are illustrated in a conceptual map (Figure 2).

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Figure 2.

Conceptual map with the attributes, antecedents, and consequences of patient advocacy

Figure 2.

Conceptual map with the attributes, antecedents, and consequences of patient advocacy

Attributes

The key attributes of advocacy that emerged include: safeguarding,^{10,21,24,27,29} effective communication,^{10,22,25,30,33} empowerment,^10,24and supporting ethical decision-making.^{21,24-25,29-32}

Concerning safeguarding, priority is given to safety,^21,24,29 supporting,²² collaboration²⁸ and the promotion of quality care.^21,32 Effective communication is vital for ensuring that patients understand their treatment options and that their preferences are communicated to healthcare providers, with the nurse acting as the voice of the patient,²¹ and integrating the family into care.³¹ Access to information^24,27,33 and maintaining communication^25,30,33 with healthcare professionals were identified as essential factors in promoting patient empowerment. Support for ethical decision-making is also important when it includes patients’ rights,^22,25,29-31 and values,²⁵ situations of increased vulnerability^22,31 and the end of life.²²

Antecedents

Through the literature review, facilitating and hindering factors emerged as antecedents for developing patient advocacy. Facilitating factors include professional motivation,^10,23 which drives nurses to advocate for their patients; interprofessional collaboration²¹; spiritual care³²; professional training,^23,27 higher education; ongoing training were reported to improve nurses’ confidence and advocacy skills, competencies, and professional autonomy.²⁹

On the other hand, several barriers factors can obstruct patient advocacy. One major barrier identified was the conspiracy of silence,²² often surrounds sensitive issues such as end-of-life care, preventing transparent discussions and shared decision-making. Similarly, some studies have identified a lack of interprofessional collaboration²³ as a major barrier, limiting the teamwork necessary for effective advocacy. Religion, culture, and illiteracy^10,24were also cited as barriers that may conflict with medical recommendations. Additionally, ineffective communication,^25,33 makes it difficult for nurses to advocate effectively. Finally, lack of time,²⁵ due to heavy workloads and time constraints was another limiting factor in nurses’ ability to engage in advocacy.

Consequences

The consequences of patient advocacy are significant for both patients and nurses. For patients, advocacy leads to empowerment,^21,22,27,30 self-determination,²¹ and shared decision-making,²¹ allowing them to take control of their care. Some studies emphasize how advocacy strengthens the nurse-patient relationship.^21,33

While advocacy often led to professional satisfaction^10,27,29 and gratification,²⁹failures due to systemic barriers resulted in frustration ²¹and moral distress.^10,27,33

Discussion

The concept of patient advocacy is fundamental to nursing, and through the examination of the latest studies, the scope of advocacy is evolving. The current analysis builds on the foundational definitions provided by earlier works but introduces new dimensions that broaden the understanding of what patient advocacy entails. The studies reveal fundamental insights into the attributes, antecedents, and consequences of patient advocacy.

Attributes of Patient Advocacy

Concerning attributes, safeguarding, effective communication, empowerment, and support for ethical decision-making are particularly prominent. It is irrefutable that one of the central attributes of patient advocacy is safeguarding patients, particularly in clinical settings, where patients are vulnerable to medical errors or inadequate care.²¹ Specifically, in ICU settings, particularly during the COVID-19 pandemic, nurses were pivotal in safeguarding patient rights by preventing harm, ensuring safety, and providing necessary information to patients and their families about treatment options, promoting the presence of the family in the context.^24,31

In recent revisions of the concept, patient advocacy is a process that involves facilitating communication between patients, families, and healthcare providers, ensuring that patients understand their medical conditions and the available treatment options.¹⁰ Effective communication is crucial for ensuring patient safety and quality care, allowing nurses to act as the patient’s voice,^10,21 for promoting patient values and autonomy, particularly in intensive care settings.²⁴ Additionally, maintaining communication between nurses and patients is the key to defending patient rights and ensuring their participation in decision-making about their care.³⁰

During the COVID-19 pandemic, patient advocacy gained heightened relevance, particularly in ICUs where patients were isolated from their families. Nurses played a crucial role in reducing harm and promoting informed decision-making, despite challenging circumstances. Studies highlight how nurses adapted by integrating family presence remotely, ensuring that patients’ social and emotional needs remained part of the care process.^24,31 The results of two studies showed that the pandemic required nurses to adapt their advocacy practices, particularly in ICUs where patients were isolated from their families. New strategies emerged to ensure patient safety and rights, despite the physical absence of family members during treatment.^24,31

However, beyond the pandemic context, patient advocacy remains central in various acute and perioperative scenarios. Empowerment^21,22,27,30 has become a central attribute in recent discussions.Advocacy includes empowering patients to take control of their healthcare decisions. This shift from a purely protective role to an empowering one marks a significant evolution in the way advocacy is understood. These findings suggest that patient advocacy is moving away from being the voice of the patient,^10,21 towards empowering them with information,^10,21,24,30 so that they can decide for themselves, as in the case of signing informed consent. Even in crisis and situations emergencies, it often includes educating patients and ensuring that they can make informed choices about their care.²³

Supporting ethical decision-making is a key aspect of patient advocacy, requiring nurses to respect patient values, especially in complex situations like end-of-life care or resuscitation, where ethical, legal, and cultural factors must be carefully balanced. ²²

Similarly, another study describes how advanced practice registered nurses (APRNs) are required to make ethical decisions daily, often without formal education on patient advocacy, relying instead on their personal and professional judgment to safeguard patient interests.²⁷ In these scenarios, nurses act as ethical agents, ensuring that care aligns with the moral and ethical frameworks that prioritize patient dignity and autonomy.^22,27

Antecedents of Patient Advocacy

Several antecedents influence the effectiveness of patient advocacy, such as professional autonomy, as a key factor that enables nurses to advocate for their patients.²⁹ Nurses with greater autonomy are better positioned to make decisions that prioritize patient safety and rights.²⁹ Similarly, the evidence points to interprofessional collaboration as an essential antecedent, where teamwork and trust within healthcare teams, facilitate more effective advocacy.²²

Professional training and competencies are facilitating antecedents as well. Nurses who receive formal education in advocacy, are more confident and capable of handling ethical dilemmas and patient needs.^23,27 In addition, a study on generational differences in the interrelationship between spiritual care and patient advocacy, concluded that younger nurses, especially those from Generation Z, showed greater involvement in patient advocacy, probably due to evolving professional attitudes and skills in spiritual care.³²Spiritual care competencies are another antecedent that has emerged in specialized care settings, particularly in ICUs, where spiritual well-being is increasingly recognized as part of holistic care.³²

However, there are also significant hindering factors. Lack of interprofessional collaboration,²² the emotional burden of advocacy, and time constraints are significant barriers.²³Some authors emphasized the high physical and mental demands on nurses, particularly in ICU settings, as another hindrance.^24,25These demands, combined with heavy workloads, reduce the time and energy that nurses have to engage in advocacy. Similarly, several studies discuss how cultural^22,24 and religious²³ factors pose significant barriers and prevent nurses from effectively developing patient advocacy.

Consequences of Patient Advocacy

The consequences of effective advocacy are overwhelmingly positive, with many studies reporting improved outcomes for both patients and nurses. Some of them illustrate that effective advocacy leads to stronger nurse-patient relationships,²⁹ where patients feel more involved in their care and nurses experience greater job satisfaction.^10,27,29,31 However, unsuccessful advocacy can lead to moral distress^10,27,33 and frustration²⁷ for nurses, particularly when systemic barriers or lack of support hinder their ability to advocate effectively.

On the patient side, evidence shows that advocacy results in better outcomes, greater patient empowerment,^21,22,27,30 satisfaction^10,27,29 and self-determination,^10,21 as it allows them to take an active role in their quality care.^21,32

A limitation of this study that should be taken into account is the fact that it only included publications in English, Spanish and Portuguese, based on the linguistic proficiency of the team. which may have introduced linguistic bias and limited the cultural and geographical scope of the results.

Conclusion

Updating the concept of patient advocacy requires a dynamic and context-sensitive approach, recognizing the intersection of historical foundations and emerging challenges. Since its introduction in the 1970s, patient advocacy has progressively evolved toward greater autonomy and self-determination, reflecting broader societal shifts in healthcare ethics and patient rights. Today, advocacy extends beyond mediation between patients and medical teams, incorporating personalized care, equity promotion, and active family involvement, even in cases of extreme vulnerability.

In acute and perioperative settings, where patients face heightened vulnerability and complex treatments, the role of advocacy becomes even more critical. It involves ensuring informed consent, facilitating effective multidisciplinary communication, and implementing risk-reduction strategies to enhance patient safety. Personalized care and respect for individual preferences are key to improving clinical outcomes, particularly when patients are highly dependent on healthcare professionals.

Patient advocacy must be recognized as a multifaceted and evolving phenomenon, shaped by social, political, and technological influences. In clinical practice, this demands ongoing investment in professional training and institutional policies that empower nurses to act as effective patient advocates. In clinical practice, this requires sustained investment in professional development and institutional policies that enable nurses to advocate effectively for patients. To support this, hospitals should implement structured interprofessional rounds where nurses formally present patient advocacy concerns.

Future research should quantify how advocacy training reduces moral distress in nurses, particularly in perioperative settings.This is essential to ensure that patient advocacy remains a cornerstone of nursing, enhancing safety, equity and high-quality care in an ever-evolving healthcare landscape - particularly in acute and perioperative care.

Acknowledgements

I sincerely appreciate the constant support of my doctoral supervisor and from the Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR).

Competing Interests

There is no conflict of interest for authors.

Data Availability Statement

All data generated or analyzed during this concept clarification are included in this published article.

Ethical Approval

The scoping review was guided by ethical conduct referencing sources and respecting authorship.

Research Highlights

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