CLINICAL FOCUS
Barriers deterring patient advocacy
in a Saudi Arabian critical care setting
Manfred Mortell, Khatijah L Abdullah and Chean Ahmad
P
atient advocacy is not a new role for nurses, or
a new obligation for the nursing profession. The
role of a patient advocate is an ethical ideal for
professional nurses based on the notion that nurses
provide continuity of care, and therefore have a
greater intimacy with the patient (Matthews, 2012).This is an
ideal that is supported and endorsed by numerous international
nursing codes of practice (American Nurses Association
(ANA), 2015; Canadian Nurses Association (CNA), 2017).
Nevertheless, the decision to be a patient advocate has
undeniable consequences, in that it does provide benefits for
the nurse–patient partnership but also exposes the professional
nurse to numerous potential barriers and challenges (McGrath
et al, 2006; Matthews, 2012; Kupperschmidt, 2014) This is
especially true for the nurse advocate when a duty of care
requires intervention on behalf of the patient, when they are
at risk or in harm’s way (Matthews, 2012).
Background
Nurses in the critical care setting perform a vital role as a
patient advocate to ensure that the treatment and care provided
is appropriate and safe (Selanders and Crane, 2012; Canadian
Association of Critical Care Nurses, 2013). However, the barriers
that confront nurses as patient advocates are often problematic
and well documented in the literature (Negarandeh, 2007; Davis
and Konishi, 2007;Thacker, 2008; Zomordodi and Foley, 2009;
Sack, 2010; Murray, 2010; Black, 2011; Davoodvand et al, 2016).
The dilemma for Saudi Arabian intensive care unit (ICU)
nurses, however, is multi-dimensional, in that the concept of
patient advocacy and the associated barriers has been derived
primarily from the perspective of Western beliefs. This means
that questions and concerns related to patient advocacy in an
indigenous Islamic culture such as Saudi Arabia may be different
compared with other cultures.
Methodology the National Guard Health Affairs, Nursing Services, Center of
Design
A constructionist grounded theory design was selected for this
study to explore the perceptions of patient advocacy among
Saudi Arabian intensive care nurses. The essential elements
© 2017 MA Healthcare Ltd
included theoretical sampling, the constant comparative
technique, coding and categorising, and memo writing, all of
which generated data, which gave insight into the phenomenon
of patient advocacy (Charmaz, 2006).
British Journal of Nursing, 2017, Vol 26, No 17
ABSTRACT
Aim: To explore the perceptions of patient advocacy among Saudi Arabian
intensive care unit (ICU) nurses. Background: Despite advocacy being
a crucial role for nurses, its scope is often limited in clinical practice.
Although numerous studies have identified barriers to patient advocacy, their
recommendations for resolution were unclear. Method: The study employed a
constructivist grounded theory methodology, with 13 Saudi Arabian registered
nurses, working in critical care, in a tertiary academic teaching hospital.
Semi-structured interviews, with broad open-ended questions, and reflective
participant journals were used to collect data. All interviews were concurrently
analysed and transcribed verbatim. Results: Gender, culture, education,
subjugation, communal patronage, organisational support and repercussions,
and role-associated risks were all revealed as factors affecting their ability
to act as advocates for critically ill patients. Conclusion: Saudi Arabian ICU
nurses in the study believed that advocacy is problematic. Despite attempting
to advocate for their patients, they are unable to act to an optimal level,
instead choosing avoidance of the potential risks associated with the role, or
confrontation, which often had undesirable outcomes. Patient advocacy from
a Saudi Arabian nursing perspective is contextually complex, controversial
and remains uncertain. Further research is needed to ensure patient safety is
supported by nurses as effective advocates.
Key words: Patient safety  ■ Patient advocacy  ■ Saudi Arabia 
■ Intensive care units  ■ Critical care  ■ Organisational culture
Setting of the study
This study was carried out in the critical care setting in a hospital
in the Kingdom of Saudi Arabia. The patients cared for in this
ICU are admitted due to illness or injury that requires nurses
to provide continuous invasive haemodynamic monitoring,
intravenous high-dose vasopressor and inotropic medications,
Manfred Mortell, Nurse Specialist Critical Care, Ministry of
Nursing Education, King Abdulaziz Medical City, Riyadh, Saudi
Arabia, mannymortell@gmail.com
Khatijah L Abdullah, Associate Professor, Department of Nursing
Studies, Faculty of Medicine, University of Malaya, Kuala Lumpur,
Malaysia
Chean Ahmad, Professor, Postgraduate Nursing Studies,
MAHSA University, Kuala Lumpur, Malaysia
Accepted for publication: September 2017
965
 high-flow oxygen therapy administration, invasive and non-
invasive mechanical ventilation, continuous renal replacement
therapy, and venous-venous extracorporeal membrane
oxygenation therapy.As the study advanced, theoretical sampling
was employed, and the setting of the study changed to include
the trauma ICU, cardiac surgical ICU, medical cardiac ICU,
surgical ICU and the neurology ICU.
Sample
Participants were practising registered Saudi Arabian ICU
nurses, and were selected based on the following criteria:
being a Saudi Arabian registered nurse, being proficient in
the English language as all research was conducted in English,
being an ICU nurse working in a critical care setting, and
being willing to participate in this study. All 13 participants in
the study were contacted individually, and were provided with
a participant booklet, which included an invitation letter, an
information sheet, an informed consent form, and the purpose
and significance of the study. Following confirmation of their
interest to participate in the study, the researcher (the first
author) met with all 13 participants as they were recruited and
explained their role as participants in the study in more detail.
Data collection
The data collection process consisted of digitally recorded
single participant semi-structured interviews and focus
group discussions, approximately 45-60 minutes in duration.
Interview questions were generated from grounded theory
recommendations (Charmaz, 2006: 30). Therefore, each
interview commenced with the broad open-ended question
about patient advocacy: ‘What do you understand by the
concept of patient advocacy?’ During each interview, memos
were written directly onto the participant interview sheets.
According to Glaser (1978: 82), ‘memos are the theorizing
write-up of ideas about codes and their relationships as they
strike the researcher’. As a result, writing memos prompted the
researcher to be more reflective and insightful while constantly
comparing the data being collected and analysed from the Saudi
Arabian ICU nurses (Glaser and Strauss, 1967; Glaser, 1978;
Charmaz, 2006). Following each interview the participants were
provided with a reflective journal, which was collected by the
researcher one week later. All were returned as requested.This
was part of a triangulation strategy for data collection (McGhee
et al, 2007; Bodrick, 2011).
Ethical considerations
Ethical approval to commence the research study was obtained
from the Ethics Committee of MASHA University in Kuala
Lumpur, Malaysia; the participating organisation; and the
King Abdullah International Medical Research Center,
Riyadh. In accordance with ethical approval requirements,
each participant was asked to sign an informed consent
form, which included authorisation for use of transcripts for
publication.The participants were also informed that all names
and identifiable data would be changed within the transcript
to ensure confidentiality and anonymity, and that all data
collected would be confidential. They were also informed
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that their participation was voluntary and that they could
withdraw from the study at any time, without needing to
provide any explanation.
Data analysis
All interviews were transcribed verbatim, in order to identify
themes in each participant’s contextual experience, which led
to the creation of codes and categories.The coding process was
divided into two phases: the initial phase and the subsequent
focused theoretical phase (Glaser, 1978; Charmaz, 2006). The
initial coding phase involved analysing the ‘raw’ data ‘line by
line’ after each interview, in order to explore all the participants’
conceivable beliefs, thoughts, impressions, or feelings that were
being revealed.As recommended by grounded theory academics,
the initial codes were then grouped into categories as repetitive
patterns, similarities and relationships emerged (Glaser and
Strauss, 1967; Charmaz, 2006; Corbin and Strauss, 2008). Data
collected from the reflective journals were analysed using the
grounded theory line-by-line method, in conjunction with
the grounded theory constant comparative method in order to
identify data similarities in the themes, codes and subcategories.
Memos were also written by the researcher to provide additional
insight into the phenomenon of advocacy from the participants’
perspective.
Rigour
The four criteria employed to validate rigour in this qualitative
grounded theory study were: uniqueness (Charmaz, 2006),
trustworthiness, also referred to as credibility (Charmaz, 2006; Leedy
and Ormrod, 2013), usefulness or transferability/fittingness, and
quality, also known in the literature as resonance (Charmaz, 2006).
Results
There was a general belief among the study’s participants that
Saudi Arabian nurses would be the most effective patient advocate
for their indigenous patients.The justification for this belief was
that, as Saudi Arabian nurses, they were culturally aware, sensitive
and competent, and therefore a cultural protector, providing
culturally appropriate compassion and caring (Wujcik, 2011;
Almutairi and Rodney, 2013;Almutairi et al, 2013;Almutairi et
al, 2015a; 2015b). However, some participants were sceptical of
this claim. During the concurrent data collection and analysis,
as each theme was emerging, so were the potential or actual
barriers that would or did affect patient advocacy and the role of
advocate in a Saudi Arabian context.As a critical care nurse and
a novice researcher, the first author was at times overwhelmed by
the work involved in listening and rationalising the participants’
situations and dilemmas when also attempting to provide safe
and effective patient care.The obstacles that emerged will now
be reviewed, as each one could have an impact on the role of
the patient advocate in a Saudi Arabian context.
© 2017 MA Healthcare Ltd
Gender as a barrier
During the interviews, participants indicated that in Saudi Arabia,
nursing is considered a new profession and there is still considerable
cultural resistance against nursing. This traditional resistance is
especially valid for Saudi females, because having contact with
British Journal of Nursing, 2017, Vol 26, No 17

males outside the family is considered to be unacceptable and
forbidden.The following transcripts will provide insight into the
potential barriers that relate to gender issues.
‘Gender is a big cultural issue in Saudi Arabia;
men are not allowed to be with any women not
in their family … It is simple things like this
that affect patient advocacy … it could be a
barrier.’
Male participant E
‘When I graduated … it was really challenging
for me, because I had to speak with a lot of
men, not only patients, but doctors, nurses,
pharmacists … healthcare providers … I had
only ever been close to my family.’
Female participant A
‘My father and brothers were not happy about
me being a nurse … I would be working with
men and they were worried that I could be
hurt.’
Female participant C
Another aspect related to gender as a potential barrier for
advocacy was the ability for female nurses to speak on behalf of
the patient in the event of potential or actual problems. Saudi
Arabian nurses may have difficulty in this regard, as demonstrated
by female participant C above, and the following excerpt:
‘Everything that we do in Saudi Arabia is a part
of our culture … Females in our society do not
talk outside their homes … in the public … so
they are shy and embarrassed to speak up for
the patient.’
Male participant E
Community barriers
As an adjunct to the barriers related to culture were those related
to the societal perceptions of nursing, which were provided by
selected participants:
‘They [the community] don’t consider nursing
a profession … not like medicine or other
healthcare professions … The Saudis consider
nurses to be like servants, under a doctor, an
assistant … but nursing is evolving in Saudi
Arabia, especially in the ICU.’
Male participant D
‘The media portray nurses as uncaring, with no
compassion … they make the doctors’ coffee …
make their chairs comfortable … they are very
© 2017 MA Healthcare Ltd
inferior to physicians.’
Female participant I
Participants acknowledged that nursing is predominantly
a female profession in Saudi Arabia and globally, and as such
will be challenged by the cultural views and perceptions that
British Journal of Nursing, 2017, Vol 26, No 17
CLINICAL FOCUS
were also endorsed by Mansour (1992) and Albishi (2004).
They also believed that the image of Saudi Arabian nursing
will change in the future, especially in the ICU. This has been
shown in Western literature with nurses being selected by public
opinion as the most trusted of professions (Long 2005; Buresh
and Gordon, 2006).
Medical dominance as a barrier
Nursing in Saudi Arabia is a new profession, which is
predominantly female, as it is internationally.The organisational
culture is patriarchal, and physician autocracy prevails. Participants
revealed that sometimes being a nurse and a patient advocate
causes problems, because the doctors do not like having their
authority challenged and may not accept a nurse’s point of
view. Participants stated that:
‘Everything is dominated by physicians …
everything must go through a physician … If his
is not the best thing for the patient … how does
the nurse convince him?’
Female participant G
‘Doctors are the decision makers … have a high
voice in the organisation … People listen to
them … they have power.’
Female participant I
When the first author questioned this belief about medical
dominance in Saudi Arabia, since he had not experienced it
himself, a typical response was:
‘Saudi nurses do not have the autonomy or
status that you have as Western nurses … we are
dominated by doctors who think we are nothing
and know nothing.’
Female participant A
They also added that, when a Saudi nurse does question a
medical intervention or order, the doctors’ typical response is,‘I
am the doctor and you are the nurse’. This type of response is
intimidating and often threatening to the nurse who speaks out,
and can be a barrier for the patient advocate. One such occasion
was during a grand round in the ICU, when a medical order
was queried by a participant who was the charge nurse that day:
‘The doctor said in front of everyone, “I know
the patient and I have a higher knowledge than
you … I am in charge … know your place …
who are you anyway, a nurse?” ’
Female participant A
An additional barrier that augments this type of autocratic
response from physicians is organisational support, which results
in such responses to nurses’ concerns as:
‘He is the doctor … he knows what he is doing
… and you are just a nurse … do your job …
and let him do his.’
Female participant A
The participants were all agreed that if the organisation
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supports this type of unprofessional behaviour, then patient safety
could be compromised and patient advocacy is a myth. In such
circumstances nurses may no longer be willing to take on the
advocate role if it meant they put themselves in the position of
being embarrassed and humiliated, with the risks of compromising
their careers and future promotions, harassment by colleagues
and other repercussions.
Suppression of the actions of nurses
Participants revealed misconceptions regarding nursing and
nurses among Saudi Arabian people (as discussed earlier under
‘community barriers’).The participants were displeased about
being perceived as servants, as uncaring, and as handmaidens
to the physician. This erroneous perception of nurses being
inferior has also been discussed in the literature (Altun and Ersoy,
2003; Ferrell, 2006; Hanks, 2007; Black, 2011).The participants
also revealed issues that pertained to self-worth, and loss of
self-esteem, which ultimately created a self-fulfilling prophecy
regarding their subservience as nurses.
‘Saudis believe that she is a maid who only
cleans away the urine and the stool.’
Female participant H
‘Sometimes the patient’s family doesn’t even
speak to me … they treat me like the maid and
say, just call the doctor … so I think that many
of us just give up.’
Female participant M
‘When I came to this hospital, the nurses just
did what the doctor says to do … right or
wrong … This is the reality, and if she doesn’t
have a voice, how can she be the voice for the
patient?’
Male participant F
‘Even though we have the knowledge and know
that what the doctor is saying is not the best
thing … Your title is really important to the
organisation, the patient and the family.’
Female participant B
‘I felt that I was useless, it is like you see the bad
thing and you cannot do anything about it …
Useless.’
Female participant A
It was interesting that the less experienced nurses in the
study tended to accept the idea that they were inferior to the
physicians, which became a self-fulfilling prophecy.
‘I think the doctors are very clever… they do
have good knowledge… more than nurses…
patients want them, family too… and there is
a lot of headache associated with it [being a
patient advocate] … why should I try… when
they are better?’
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Female participant C
The more experienced nurses were more likely to believe
that sometimes their knowledge of a patient or situation was
superior to that of the doctors.
Organisational barriers
Participants stated categorically that healthcare organisations
must support nurses as patient advocates, and condemned
organisations that failed to endorse patient advocacy because
this compromised patient safety. They believed that, in order
for a patient advocate to function effectively, there must be
an administrative policy and procedure (APP) that provides
guidelines for the advocacy role.
‘Leadership is what supports patients and nurses
at the bedside … Some nurses are now so scared
because they believe the system will not support
them … so patient advocacy is really rare and
seldom practised.’
Female participant G
‘Everyone in the clinical area is really afraid to
be a patient advocate … and I would still not
report any patient advocacy issues because then
I will be in trouble.’
Female participant B
‘If you advocate for your patient you will be
in trouble … the role is vague … it is not clear
… there is no APP … this discourages staff
from reporting … the system does not support
patient advocacy.’
Female participant A
The participants were very critical about an organisation
that does not recognise the importance of patient advocacy,
and one that does not help Saudi Arabian nurses implement
the advocacy role. Their primary concern was about the
repercussions associated with the role, and also a belief that
if the nurse does not have the autonomy or the authority to
act as a patient advocate with organisational support, then
the nurse’s wellbeing and the patient’s safety were likely to
be compromised.
Educational barriers
Lack of advocacy knowledge both in the universities and
in clinical practice rotations revealed that the participants,
acknowledged a ‘theory-practice gap’. There was also a lack
of Saudi role models who could provide insight into how to be
an effective advocate.The following excerpts from participants’
interviews were chosen because they were recent graduates
of Saudi Arabian nursing degree programmes, highlighting an
educational deficit:
© 2017 MA Healthcare Ltd
‘The teachers in the university do not teach us
about patient advocacy. Therefore, Saudi nurses
have no teachers in theory or role models in
practice.’
British Journal of Nursing, 2017, Vol 26, No 17

Female participant L
‘We are told about the terminology … But …
we focus on the routines of work and when
we graduate … we forget about the concept of
patient advocacy.’
Female participant B
‘I heard the word advocacy in my basic
curriculum in nursing … actually even then I
did not get it … I did not know what it meant.’
Female participant A
‘Yes, the educators in the university said … that
as a nurse, you are a patient advocate… But,
that was all… we had no idea what that means,
what those words meant… In reality, it was like
trying to understand a foreign language with no
interpreter.’
Female participant C
‘Saudi nurses … If they have some notion
about advocacy, they still do not realise the
importance and value of the role … They don’t
realise that there is a difference in taking care of
the patient, compared to giving patient care …
They think it is the same thing.’
Female participant B
‘Saudi nursing students really need Saudi role
models to tell them the facts … from real life
experiences … and from patients too … then
it would be clear … many of them don’t even
know what advocacy is … so how can they do it?’
(Female participant A)
The lack of education and role preparation was revealed
as a crucial barrier to effective advocacy, which participants
believed would result in failure to comprehend the importance
of the role. This topic has also been repeatedly addressed in
the literature (Snowball, 1996; Snelgrove and Hughes, 2000;
McSteen and Peden-McAlpine, 2006; Schroeter, 2007; Ulrich
et al, 2010; Matthews, 2012).
Vocational ‘ethical’ barriers
Potential barriers associated with specific career advancement
goals were also identified from the participants’ interview
data. This became transparent when the first author received
responses to questions such as,‘How do you think Saudi Arabian
ICU nurses perform in their role as a patient advocate?’ Most of
the responses from the participants revealed that their colleagues
were not really interested in bedside nursing as a career, which
© 2017 MA Healthcare Ltd
impacted on their role as a patient advocate.
‘Many just want a job … after graduation; they
want to be employed in an accredited hospital
… they come from wealthy families … they
British Journal of Nursing, 2017, Vol 26, No 17
CLINICAL FOCUS
have money, have a housemaid, they have a
driver … they have what some would consider
a luxury life … maybe this is a contributing
factor.’
Male participant E
‘They want the high positions; being a manager
… not doing the hard work of bedside nursing
… they don’t want to go through the bad
experiences of the patients either.’
Female participant A
‘The only reason most of them become ICU
nurses is because it opens doors for them in
their career and they just want the salary and
make money.’
Female participant B
These vocationally directed responses, not identified in the
literature, were considered by the participants to be a major
contributing factor as a potential barrier for advocacy.
Advocacy repercussions
The consequences for nurses who act in the advocacy role
are well documented in the nursing literature, whether from
physicians (Zomorodi and Foley, 2009; Sack, 2010; Curtis et al,
2011), from their nursing colleagues (Davis et al, 2003; Sack,
2010; Black, 2011) or from the employing organisation (Davis
and Konishi, 2007; Lachman, 2007;Thomas and Willman, 2012).
The Saudi Arabian nurses in this study, just as their multinational
colleagues in the literature, are cognisant of the fact that patient
advocacy is important to ensure effective and safe health care.
They also acknowledge, as do their international contemporaries,
that being a patient advocate can be a responsibility that may
expose the nurse to conflicts and controversies, which can have
serious ramifications, both personally and professionally. With
only the best of intentions, related to patient advocacy and safety,
participants in the study revealed numerous difficulties that
were unexpected consequences of their altruistic efforts. Two
situations have been selected here that highlight the potential
for repercussions.
The first event involved a physician. The nurse had spoken
to a patient’s family as the ICU nurse in charge that day, about
them talking to the doctor about the possibility of ending life
support for their father. The family’s father was terminally ill,
with no hope of survival; he was on advanced life support
interventions, which were adding to his problems, and was also
suffering and in severe pain.The family subsequently spoke to
the physician and the following transpired:
‘The consultant agreed to their decision and
said to the family … who told you about this?
… He found me, and he took it very personally
… he reported me to the manager … I did
something that he thinks is not a nurse’s job.’
Female participant G
Another event involved a safety issue with nurses in the
969

ICU regarding a continuous intravenous medication.The nurse
stated that:
‘Because I did see a bad thing could happen …
I spoke to the nurse manager … which resulted
in lots of stress for me … which affected a
promotion that I had applied for.’
Female participant H
The researcher probed further and asked ‘What was the staff
response to your distressing situation?’ She replied:
‘They [the staff] will not do any more …
because they are so scared … from losing their
jobs … from my experience… they are afraid
to act as advocates … to be honest, I don’t trust
the organisation now.’
Female participant H
The repercussions for nurses as patient advocates that were
revealed by the Saudi Arabian participants in this study were
not dissimilar to those that have been reported in the literature.
As an obstacle for nurses being patient advocates, repercussions
remain a valid concern.
Recommendations
The data gathered show that Saudi Arabian ICU nurses who
attempt to practise patient advocacy may not have the education
or the experience to manage patient advocacy situations, or be
officially recognised as patient advocates. Based on these insights,
the following recommendations are proposed to facilitate Saudi
nursing in education, training, development of leadership and
assertive skills, and offering organisational support. First, the
structure of future nursing curricula—culturally appropriate
clinical training modules should be offered by Saudi Arabian role
models. Second, Saudi Arabian ICU nurses working in critical
care units should be provided with continuing education, so
that they are suitably and ethically situated to fulfil the role of
patient advocate that is congruent with Muslim customs in
Saudi Arabia. Third, there is need to establish organisational
administrative policies that make clear the scope of practice
for nurses who advocate.
Limitations
As with any study, several factors could have impacted on the
research process. These limitations included the first author’s
concern for the participants who experienced a particularly
heavy workload at the time of data collection. These were
due to unforeseeable events that related to two ‘code blacks’
(disaster activation) because of an outbreak of Middle East
respiratory syndrome-coronavirus. In addition, nurses were also
stressed because they were preparing for re-credentialing by the
Joint Commission International. Another potential limitation
could be the retrospective nature of the study, since it required
participants to recall their advocacy experiences. Therefore,
the accuracy of recall may have been poor given the time
frame (1–7 years) associated with the recollection. However,
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the authors are confident these situations did not compromise
data collection or affect the study findings. All interviews were
conducted in English, which was not the nurses’ mother tongue.
However, proficiency in English comprehension and speech
was a requirement to work at the hospital.All participants were
proficient in English.
Future research agenda
Exploration by Saudi Arabian nurse researchers would augment
the understanding of the phenomenon of patient advocacy not
only in critical care settings, but in nursing more generally Such
research should also be directed towards determining nurses’
perceptions and attitudes regarding their spiritual and religious
perspectives, their cultural customs, and the association of these
influencing dynamics when implementing the role of advocate
for seriously ill Muslim patients and their families. It may also
be worthwhile to consider researching the perspectives held by
Saudi Arabian Islamic scholars on the topic of patient advocacy.
These research findings would be pertinent and potentially
contribute to a review and re-emphasis of the importance of
the advocacy role for Saudi Arabian ICU nurses.
Conclusion
The nursing profession worldwide declares that patient advocacy
is an essential fundamental principle of nursing practice, therefore
within the context of Saudi Arabia this premise is also valid.
The implications for nursing practice are, simply, that nurses
require support and sponsorship to overcome the obstacles that
limit or prevent them from being effective patient advocates.
This study has raised several issues and concerns that suggest
the need for further investigation and research on the topic of
patient advocacy in a Saudi Arabian context. It is anticipated
that the findings and recommendations from this study will
encourage Saudi Arabian nurse researchers to focus not only
on the importance of the patient advocacy role, but also the
entrenched impact that Saudi Arabian cultural and religious
viewpoints have on ICU nurses, and how this affects their
decisions to implement the role. BJN
Declaration of interest: none
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CPD reflective questions
■■ After reflecting on this article, consider what patient advocacy means to you
■■ Think about how you can be more effective as a patient advocate
■■ Consider how all the members of your nursing team could act as patient advocates—what barriers exist to acting in
this role in your organisation and how could you overcome them?
Have an idea for BJN?
© 2017 MA Healthcare Ltd
Get in touch with the team:
( 020 7738 5454  8  bjn@markallengroup.com    @BJNursing
British Journal of Nursing, 2017, Vol 26, No 17
CLINICAL FOCUS
KEY POINTS
■■ Patient advocacy is essential for patient safety
■■ Without patient advocacy, patient safety is a myth
■■ Nurses are in an ideal position to advocate for their patients. Nurses
in this Saudi Arabia study believed their ability to act as the patient’s
advocate was undermined by doctors’ views of the nurse’s role and by
wider cultural issues
■■ To be effective as advocates, nurses must be supported by the
organisation
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