Workforce advocacy is a pro-active, energetic, constructive and comprehensive approach for registered nurses to improve their:

                     capacities to advocate for quality patient care

                     workplace and learning environments

                     abilities to practice to their full legal and professional scope

                     relationships with colleagues and coworkers

                     satisfaction with nursing and their workplace positions

                     state healthcare network

Workforce advocacy encompasses:

                     the nurses in all workplaces in which registered nurses are employed or volunteer

                     an understanding of the internal factors that contribute to work satisfaction

                     an appreciation of the external social, technological, economic, environmental and political factors which impact practice (STEEP)

                     a mindset that says, I am a registered nurse who believes I should work for quality patient care and my abilities to practice as a professional.

                     tools, resources and education to support RNs in these efforts

                     collaboration with appropriate individuals, associations and boards

                     lifelong learning

                     competence in the area of practice, education, administration or research in which one is involved

Assumptions that underpin a strong workforce advocacy program:

                     There are multiple contributing factors to healthcare problems and solutions; some individual, some discipline, and some system based.

                     Consumers/patients/clients are an integral part of the healthcare system and need to be included in problem identification/resolution and healthcare improvement.

                     Healthcare is provided by a team effort; in which registered nurses are an integral part.

                     Each discipline and each person within a healthcare system deserves to be valued, respected and trusted.

                     Each person, discipline and position within a system brings creativity, knowledge, skills and expertise to enhance patient care and improve work environments.

                     Each person has a responsibility to contribute to continuous quality improvement both in healthcare for our citizens and in workplace environments.

                     No one of us as an individual or a group can assume to know what another individual needs or wants.

                     Opening communication/dialogue/negotiation among people will increase understanding of their expertise, needs and wants.

                     Diversity of values, life views, perspectives, knowledge, skills, wants and needs enriches healthcare and the opportunity for improving its quality and satisfaction to all participants.

                     The role of advocacy encompasses diverse approaches that can be utilized to respond to problems that arise in the workplace.

Words are powerful tools for advocates of personal rights. Abraham Lincoln and Martin Luther King, Jr., are examples of people who used them well-by making their words clear to everyone; their messages became effective tools for change."If words are not carefully chosen or well understood, their message holds little meaning to very few. As the noise regarding workplace issues rises to a mind-numbing din, nurses need clear, meaningful messages," says Anna Atteberry, MSN-S, BSN, RN, a member of the South Dakota Nurses Association and a staff nurse at the Gregory Healthcare Center in Gregory, South Dakota. "Before determining how workplace advocacy strategies can be used by nurses, we must be clear about what these words mean."

Atteberry, who sits on the ANA's Commission on Workplace Advocacy, says workplace advocacy empowers nurses to solve issues in their own practice settings. In addition to addressing issues such as practice and occupational health and safety, advocacy can be applied to education, professional development, and legal concerns. "I can't stress enough the importance of using workplace advocacy strategies in professional nursing practice," says Atteberry. "Often these activities include the resources and strength of a national professional association like the ANA and its 54 constituent member associations."

Violence, ethical dilemmas, mandatory overtime, and environmental and ergonomic risks also concern other professions. By forming new alliances and partnerships, a larger pool of strategies can be created to address these issues.


A strong economy, technological advances, and workplace restructuring have changed how employers and employees negotiate. For example, many rights that were previously only available to unionized employees are now found in nonunion zed work settings.

In July 2000, the National Labor Relations Board (NLRB) decided to expand such a right. In its decision, entitled Epilepsy Foundation of Northeast Ohio (331 NLRB 92 [2000]), the NLRB reversed a longstanding precedent by determining that employees not represented by a union have the right to have a coworker present at an investigatory interview that the employee reasonably believes could result in disciplinary action.

The decision came as a result of a charge of unlawful dismissal brought in front of the NLRB by Arnis Borgs and Ashrafel Hasan against their former employer, the Epilepsy Foundation of Northeast Ohio. Borgs and Hasan, who worked together on a school-to-work transition program for teens with epilepsy, had ongoing problems with their supervisor. Together, they penned a letter to him, sending a copy to the executive director of the agency, stating they no longer required his supervision. Days later, in a memo addressed directly to the executive director, the two criticized the supervisor's involvement in the program and cited examples in which he had acted inappropriately. Soon after the memos were written, the supervisor and executive director requested a meeting with Borgs. He asked that Hasan attend this meeting, but the request was denied. When he continued to express his opposition to meeting alone with the supervisor and executive director, Borgs was sent home and fired the next day for gross insubordination. (Hasan was terminated nearly two months later.)

Borgs appealed to the NLRB. The judge who heard the case found that Borgs had been discharged for "his persistent refusal to comply with [the executive director's] directive to meet alone with her and [the supervisor]." The judge noted that under the U.S. Supreme Court's 1975 case NLRB v. J. Weingarten (420 U.S. 251), employees in unionized work settings are entitled to representation in an investigatory interview that the employee reasonably believes could result in disciplinary action, but under NLRB precedent, employees in nonunionized workplaces didn't have the same right.

Accordingly, the judge found that Borgs had no statutory right to condition his attendance at the meeting on the presence of Hasan.

After considering the case, however, the NLRB reversed the judge and overruled its precedent, finding that the employer's termination of Borgs for his attempts to have a coworker present at the meeting was unlawful. The NLRB's decision recognized that "the right to the presence of a representative is grounded in the rationale that the [National Labor Relations] Act generally affords employees the opportunity to act together to address the issue of an employer's practice of imposing unjust punishment on employees."

The NLRB held that "the ability to avail oneself of this protection doesn't depend on whether the employees are represented by a union." This decision is consistent with the growing trend of recognizing and acknowledging individual rights in the work setting.


Workplace protections for nurses also exist at the state level. For example, Texas has both a state whistleblower law and a whistleblower clause in the state nurse practice act. These provided the legal defense for emergency department nurse Stephanie Hohman, RN. Her employer, the University of Texas Medical Branch, retaliated against her when she witnessed the trauma team forcing unnecessary treatments on patients and reported her concerns to the Board of Nurse Examiners. During her trial, the Texas Nurses Association (TNA) testified to an RN's duty to report potential harm to patients as well as to her rights under the whistleblower laws. As a result of this support, and because Hohman documented her acts and subsequent treatment, she won the case and received back wages, compensatory damages, and coverage of incurred legal fees.

Sometimes, legislation doesn't need to become law to be used as an effective workplace advocacy strategy. For example, in New Jersey, mandatory overtime legislation "brought agreement among a number of health care groups that are often opposing or competing with each other," according to Andrea Aughenbaugh, RN, CS, CAE, chief executive officer of the New Jersey State Nurses Association (NJSNA). "The NJSNA, the Patient First coalition (consisting of health care worker unions), the Organization of Nurse Executives of New Jersey, and the New Jersey Hospital Association all agreed that a safety issue existed and needed to be addressed by the government. Further, the publicity regarding this legislation and the governor's conditional veto prompted facilities to voluntarily examine their policies and make changes."


The examples in Texas and New Jersey illustrate a key strategy in workplace advocacy-using the power of nursing organizations and broad coalitions to maximize workplace protections.

"Membership in your state nurses association supports the creation of meaningful advocacy strategies, for you, the nurse, and ultimately the consumers, our patients," notes Clair Jordan, MSN, RN, executive director of the TNA and chair of the ANA's Commission on Workplace Advocacy.

"To make workplace advocacy work for you and to secure a better workplace, learn more about the growing treasure trove of resources in your state and enjoy a ready-made source of professional partners."

The following are rules that govern employees' right to bring a representative with them into investigatory meetings:

The right arises only when the employee requests the presence of a coworker.

If the employee requests representation, the employer can't insist on questioning the employee without a coworker present. Moreover, the employer can't discipline the employee for making the request or for refusing to participate in the interview without the presence of the coworker. If an employee is discharged or otherwise disciplined for asserting his or her rights, the employer can be ordered to reinstate the employee and provide back pay.

Employees can request representation only in situations they reasonably believe will result in disciplinary action.

The employer has no obligation to justify its refusal to allow representation at the interview. Employers are free to carry on their inquiry without meeting with the employee.

Employees can't insist on coworker representatives who are absent at the time of the meeting and can't bring in attorneys or nonemployees. As long as there is another coworker available to accompany the employee, the meeting need not be postponed.

Representatives can't engage in a debate with investigators or tell the employee not to answer a question.

Workplace Advocacy and Workplace Issues

          Workplace advocacy to improve the quality of health care

          Issues affecting professional nursing practice

          Resources to assist in improving the workplace

          Advocating for safe and effective workplace environments

          Internal and external workplace strategies for quality patient care

          Nurses are struggling to deliver patient care against many barriers

          Commitment to quality care and advocacy may place nurse in direct conflict with administrators

Professional Practice Advocacy

          Umbrella of activities to promote a professional practice environment:

        Workplace advocacy

        Collective bargaining

          Activities supportive of:

        Patient advocacy

        Professional practice self-determination

        Employment rights and responsibilities

Professional Practice Advocacy Examples

          Promoting occupational safety and health

          Using political processes to influence and protect nurses and patients rights

          Developing public reactions and conflict resolution skills

          Building coalitions and support groups

Workplace Advocacy

          Activities initiated to address workplace challenges

          Safe and effective workplaces are promoted by knowing where to seek information

          American Nurses Associations (ANAs) Commission on Workplace Advocacy supports workplace advocacy

Workplace Advocacy Examples

          Develop conflict resolution models to address patient care concerns

          Identify mechanisms for RNs to affect institutional policies

          Seek legislative solutions for workplace problems

          Develop legal centers for legal support and decision-making advice

Workplace Issues

          Nursing shortage

          Appropriate staffing

          Patient safety

          Workplace safety

Nursing Shortage Overview

          Managed care influenced cyclic shortages in the late 1990s and in early 2000

          Current shortage is more complex and long lasting

          Nursing employment opportunities will grow more rapidly than all other U.S. occupations through 2008

          Planning for an adequate nursing workforce will be a critical challenge

Nursing Shortage Issues

          Health care is no longer a favored employer

          Decline in nursing school enrollments

          Increasing demands for nurses with specific education and skills

          Faculty shortage

Nursing Shortage Issuescontd

          Nurse retention

          Aging workforce

          Foreign nurse recruitment


          Work environment

Appropriate Staffing

          Factors contributing to inadequate nurse staffing:

        Nursing shortage

        Cost-cutting initiatives related to managed care

          Absence of data to quantify effect of staffing on safety and quality

Mandatory Overtime

          Mandatory overtime/mandatory on-call requirements have increased

          Mandatory overtime studies:

        Increased time lost to absenteeism

        Increased injuries

        Required 3 hours of work to produce an additional 2 hours of productivity

Mandatory Overtime Issues

          May alleviate the employers sense of urgency to proactively find more appropriate staffing

          Nurses may feel resentment to bear the personal, professional, and legal burden for the staffing problem


          Nurses increasingly required to float to other patient care units

          Floating issues include:

        Questions regarding knowledge, expertise, and experience needed to work in the area

        Time for orientation and training

        Availability of support from experienced nurses

Shared Governance

          Gives nurses an active role in decision making

          Attributes include independence, accountability, and autonomy over nursing practice

          Results in increased job satisfaction and efficiency and better patient outcomes

          Goes beyond participatory management through creation of structures to govern nursing practice

Patient Advocacy and Safety

          Patient advocacy is the cornerstone of nursing

          Complex systems and complicated technology lead to errors and adverse events

          Nursing must assert its powerful voice to promote safer health care systems

Errors in Health Care

          Two major studies indicate that errors in health care delivery kill 44,000 to 98,000 people in U.S. hospitals annually

          Nursing organizations are attempting to demonstrate the link between nurse staffing and patient adverse events

Whistleblower Protection

          Protects nurses who speak out about unsafe situations through appropriate channels

          Advocated for at the federal level and has passed in some states

          Major changes in care and staffing are occurring with few data to justify the effects on safety and quality

          Professional organizations are working to collect and publicize data to link nurse staffing mix with patient outcomes

ANAs Nursing-Sensitive Indicators

          Mix of RNs, licensed practical nurses (LPNs), and unlicensed staff caring for patients

          Total nursing care hours provided per patient day

          Pressure ulcers

          Patient falls

          Patient satisfaction with pain management

ANAs Nursing-Sensitive Indicatorscontd

          Patient satisfaction with educational information

          Patient satisfaction with overall care

          Patient satisfaction with nursing care

          Nosocomial infection rate

          Nurse staff satisfaction

Workplace Safety


        U.S. health care workers experience 800,000 needlesticks annually

        Legislation is being passed to protect workers

          Ergonomic injuries

        Back injuries affect 38% of all nurses

          Workplace violence

        Major societal issue

Advocating to Prevent Workplace Violence

          Organizational assessments to identify high-risk environments, psychological conditions, and populations that threaten safety

          Staff education to address the identification and response to high-risk behaviors that can lead to violence

ANA's Workplace Advocacy Program

          Advocates for administrative controls:

        Adequate staffing

        Health and safety committees

        Engineering controls such as ventilation and safer needle-stick devices

        Personal protective equipment such as respirators and synthetic gloves


Workplace Advocacy: A Professional Strategy of Advocating for Excellence

Professional nurses have a long history of struggling to deliver patient care against multiple barriers, including dwindling resources. As we speed into the current century, the struggle is increasing in complexity. This struggle affects not only individual nurses, but also patients, organizations, and the nursing profession. Nurses strong commitment to patient care and their role as patient advocates often places them in direct conflict with administrators of health care organizations. How nurses react to this conflict, how they continue to advocate for patients in this environment, and what resources they have available to improve patient care has become an increasingly important focus of the nursing profession and the health care industry. A recent report by the Institute of Medicine (IOM) (2004) entitled "Keeping Patients Safe: Transforming the Work Environment of Nurses" highlights the important role nurses provide in our complex health care system and provides recommendations for improving the workplace partnership between nurses and employing organizations. The ability of nurses and organizations to improve the workplace partnership is vital to the future success of health care.

It is important to the future of health care that ample strategies be identified to provide support for nurses as they take on the challenges of the new century. One organizational strategy that has long been stressed as a mechanism by which nurses can advocate for and manage their professional role is that of shared governance (SG) strategy that promotes power bases that afford nurses optimal work environments is work place advocacy (WPA). This article attempts to identify common denominators that are part of both SG and WPA.

Work Place Advocacy operates at the organizational, local, state, and/or national levels to equip nurses to skillfully use a range of external (macro) and internal (micro) strategies that are complementary in nature.

These strategies focus on strengthening nursings voice and ensuring nurse involvement in workplace decisions that affect nursing care (Green & Jordan, 2002). Developing an effective WPA strategy or program is a complex, multifaceted task involving both individual nurses and professional organizations, such as national and state nurses associations.

Macro level strategies would likely focus on either local, state, or federal policies that are capable of directly impacting professional nursing practice. These types of policy initiatives are usually begun by state or national professional nursing organizations, although they may also be initiated by other stakeholder groups, such as the American Hospital Association. Examples of such initiatives that have resulted in legislation of health policy include: state-regulated, mandatory safe staffing rules and national workplace safety initiatives, such as protection of confidentiality in reporting of workplace injury or illnesses. Individual nurses have a professional obligation to participate in macro level activities, via membership in state or national professional nursing organizations, to improve nursing practice environments and patient care delivery systems.

Advocating for the nursing profession and/or professional practice has been a priority of professional nursing organizations for many years. In particular, the American Nurses Association (ANA) has long been working to define the programs and services intended to promote and support professional practice standards in the workplace. These activities support nurses advocacy for their patients, professional practice self-determination, and the exercise of nurses employment rights and responsibilities.

In 2000, the ANA committed to supporting the profession through WPA with the formation of the Commission on Workplace Advocacy (CWPA). That commitment was further refined in 2003 by structural changes within ANA resulting in the creation of the Center for American Nurses (CAN), formerly the Center for Work Place Advocacy (CWPA). Information about the CAN can be found

The CAN is an independent, national professional association affiliated with the American Nurses Association that was designed to form a partnership between the thirty-eight participating state nurses associations and the practicing registered nurse. Most of the remaining states not involved in the CAN prefer to utilize collective bargaining as their primary strategy for impacting the workplace. The goal of the CAN is to develop cutting-edge strategies, including products and programs that will help nurses to optimize their value in the workplace. As the American workforce changes in the 21st century, nurses will desire new and diverse opportunities to influence their workplace and the CAN will provide the pathways needed to achieve this empowerment.

The CAN has identified many approaches to optimize the voice of the practicing nurse in health care settings. Many of these approaches parallel SG in that they bring the nurse to the decision table. Nurses success at that table will be a function of individual nurses skills and abilities, as well as employers reasons for wanting the nurse present at this table. Nurses can empower themselves by seeking guidance and assistance from the CAN as they strive to strengthen their positions in health care organizations through the use of SG and WPA strategies.

Micro level CAN activities occur at the organizational level where the nurse is employed. Examples of micro level WPA strategies are: advocating for appropriate staffing levels within the organization and developing organizational level workplace safety programs to prevent ergonomic injuries. These improvements occur when individual nurses take leadership in implementing WPA awareness within their organizational settings.

Common Denominators in Shared Governance and Work Place Advocacy

Common Denominators in Shared Governance and Work Place Advocacy include: accountability, empowerment, conflict resolution, and patient advocacy. Each of these denominators will be discussed below.