Facilitators of the health advocacy role practice of the nurse in Ghana: A qualitative study

Abstract Background Identifying facilitators of health advocacy role practice of nurses is important in reducing health disparities and inequities in Ghana. The struggle to reducing these disparities and inequities needs a combination of bravery, courage, and professionalism. In many instances, many barriers hinder nurses from practicing their health advocacy role in Ghana. Facilitators that motivate nurses who would perform this health advocacy role have not been identified and adequately described in Ghana. Aim To explore and describe the facilitators of the health advocacy role of nurses in Ghana. Methods This qualitative study used Strauss and Corbin's grounded theory approach to collect and analyze data from 2018 to 2019 in three regions in Ghana. Semistructured interviews (n = 24) and field notes were used to collect data. Results Professional influence emerged as a core category among other three facilitators that motivate nurses to perform the health advocacy role. The other three are clientele influence, intrinsic influence, and cultural influence. Conclusions Facilitators to the health advocacy role practice of nurses are multidimensional and hidden. In this respect, educating hospital managers on these facilitators should be done through workshops and seminars to enhance the managers' strategies of motivating nurses to advocate for the less privileged and the disadvantaged of the society.


| INTRODUCTION
Nurses are health advocates who safeguard their clients' autonomy, act on behalf of clients and champion social justice in the provision of healthcare. 1 The dearth of literature to facilitators for health advocacy role practice is aligned to most nurses' inability to speak up for the less privileged and the disadvantaged. The silence of the nurse in the health system has the potential to perpetuate disparities and inequities in an already fractured health system in Africa. These prevailing health disparities and inequities in some African countries including Ghana increase the demand for health advocates. Nurse managers working in these fractured health systems require information to facilitators for the health advocacy role, to motivate nurses in situations that demand the nurses' intervention. As health advocates that show impartiality and courage in speaking up, nurses health advocacy role is required when vulnerable clients are needing the nurses' protection. 2,3 To conduct themselves in this fashion, nurses need to remain motivated and informed. However, the dearth of literature for factors that facilitate and enhance nurses' diligent practice of their health advocacy role is lacking. This qualitative study explored, identified, and described facilitators nurses in Ghana used in performing their role as health advocates.

| BACKGROUND
Literature on health advocacy role by nurses in underdeveloped and developing countries in Africa is lacking. Facilitators to the health advocacy role practice by nurses are defused in Africa leaving nurse managers with no information on what would have facilitated nurses to advocate. In developed countries, the literature has identified a wide range of contextual conditions and resources that help to make health advocacy possible. This includes education, professional development, and leadership training for the health workforce. 4,5 Cultural sensitivity, the orientation of the relevant stakeholder groups, communication, action-oriented mindsets, and dissemination of information have also been identified as equally significant in facilitating health advocacy role practice among health practitioners. 6,7 Josse-Eklund et al 8,9 reported five facilitators that are relevant in influencing health advocacy role practice. These include the nurse's character traits, the nurse's bond with the client, the organizational and cultural facilitators, and the nurse's desire to prioritize disadvantaged and vulnerable clients. The literature further reports empathy, understanding, being sympathetic with and feeling close to the patient, prioritization of patients' health needs, commitment to giving holistic care, and protection of patients' rights as elements that facilitate the health advocacy role practice. 10  For health advocacy to be more productive, nurses need to be assertive rather than aggressive in their communication style. 12 Speaking up as a professional requires an informed and knowledgeable workforce, 13,14 more than the nurse speaking his or her mind.
Speaking up requires knowing and understanding the best practices and scientific rationale. 15 Speaking up as a nurse is an essential role to provide expert knowledge about clinical practices that result in safe, effective, and high-quality care. 16

| Study design
This study used an inductive descriptive qualitative design with grounded theory as a methodology based on Strauss and Corbin (1990). A descriptive design was used because of its suitability in identifying issues with current nursing practice to justify and make a recommendation as proposed by Grove et al. 23 The design, therefore, was appropriate for the objective of this study, which was to explore and describe the facilitators of the health advocacy role of nurses to make recommendations.

| Study area
The study was carried out in Ghana, where three selected regional hospitals were chosen representing three of the 16 regions. This was purposively carried out to include participants from the upper, middle, and southern parts of the country. This was also done to ensure that the findings were accepted by all nurses in the various ethnic groups across the country as the range and scope of nurses' duties are slightly different depending on the location and culture where each of these hospitals is located. The selection was also meant to facilitate constant comparison during data analysis, which is a crucial feature in grounded theory.
Regional hospitals were used because they were equally equipped with similar infrastructure and human resources, thus ensuring similarity even though located in different geographical cultural settings. These hospitals selected serve as referral, research, and teaching hospitals where health professionals of various categories are trained. Theoretical sampling was based on the concepts derived from the evolving categories to assist in comparisons during preliminary data analysis. The main purpose was to determine events that maximized opportunities, and this aided in the discovery of variations among concepts to densify categories in terms of their properties and dimensions. 24 To densify these categories, three additional participants from each of the three selected regions were considered purposively based on the emerging categories as the theoretical sample. This means that the researchers continuously identified and compared emerging categories of nurse's views on their understanding of facilitators and returned to the field and recruited more participants to extend categories of the emerging categories. 25,26 Thus, theoretical sampling allowed the researchers to look for data through the views of nurses who knew the facilitators of health advocacy, resulting in nine participants being considered for theoretical sampling.

| Sample size determination
The sample size for this study followed the concept of saturation, a major principle of qualitative research. 27  After open sampling, to densify the categories, nine nurses were recruited using theoretical sampling, making a total sample size of 24 participants. This was an appropriate sample size for qualitative research to obtain and generate sufficient data, as supported by Charmaz. 28,29

| Data collection process
The interviews were conducted once with each participant by the first author, who is a male nurse educator and holds a PhD in nursing. A one-on-one semistructured interview guide was used to collect data, as the interview questions asked were based on the research objective. The semistructured interviews approach was useful as it allowed for in-depth probing while allowing the interviewer to keep the inter-

| Data management and analysis
The recorded interviews were transcribed verbatim within 24 hours after the interviews by the researchers and saved in Word documents.
These were read over methodically to carefully review the contents for analysis and refine the interview questions to ensure that the phenomenon under investigation was clear and understandable following the principles of Noiseux et al. 30 After cleaning the transcripts, data analysis was done immediately using colored pens, paper, and sticky notes, which provided a platform to maintain constant interaction with the data. These were subsequently imported into the QSR international NVivo version 12 computer software to facilitate storage and quick retrieval. The initial data analyzed assisted constant comparative analysis and theoretical sampling. The general guidelines used for data analysis were from the Strauss and Corbin 31 framework, and Duma. 32 This recursive line-by-line data analysis was carried out following the paradigm model, which, according to Strauss and Corbin 31 entails three stages, namely, open coding, axial coding, and selective coding.
Even though these are mentioned as units on their own for clarity, the researchers perform these synchronously between the open and axial coding in most cases.

| Ethical considerations
Before starting data collection, ethical clearance was sought and obtained from the UKZN Ethics Review Committee in South Africa and the GHS Ethics Review Committee in Ghana, with approval numbers HSS/0289/018D and GHS-ERC 007/05/18, respectively. The study information sheets were given, and the objectives explained to the participants. Participants were assured of their freedom to participate and to leave anytime without prejudice before signing informed consent forms. Anonymity and confidentiality were adhered to during and after data collection. Participation was voluntary.

| Scientific rigor and trustworthiness of the study
Trustworthiness in qualitative research is judged through the criteria of credibility, confirmability, dependability, and transferability. 33 These strategies were applied as discussed below.
The credibility of the findings of the current study was ensured through member checking, where the researchers went back to nine of the participants with the transcripts for their validation and confirmation. Confirmability was ensured as raw data and codes, including field notes, were presented to the coauthor for inputs and to perform the audit trail. In addition to confirmability, the services of an intercoder were used with peer debriefing, as recommended by Morse. 34 For dependability, data analysis procedures and other complementary data analysis procedures adopted in the study and the actual applica-

| Participants
The study participants were nurses who were then registered with the regulatory body in the country to practice and were working in the selected three regional hospitals. These 24 nurses had a minimum qualification of a diploma in registered general nursing and a maximum of a PhD, but the majority were first-and second-degree holders. The participants' ages were between the ages from 22 to 58 years (mean = 42, SD = 13). Seven participants were male and 17 were female. Years of nursing experience ranging from 5 to 36 years (mean = 24, SD = 11).
The findings emerged with four categories as facilitators from data namely, clientele influence, intrinsic influence, professional influence, and cultural influence (Table 1).

| Clientele influence
The nurses expressed that clientele readiness and clientele vulnerability are factors that motivate them to perform the health advocacy role. Client's readiness to be assisted, client openness to ask for help,

| Intrinsic influence
The innate traits of the nurse that facilitates their health advocacy role practice were considered as an intrinsic influence. The nurses reported empathy as the ability to understand and share the situation of the client. This intrinsically influences and drives the nurse to perform the health advocacy role such as being a sister keeper and the need to help "a fellow man" as depicted in the extracts below: You feel for the patients, and putting yourself in the patients' situation and circumstances, you are in haste

| Professional influence
The inspiration that a nurse gets to advocate based on his/her profes-

| DISCUSSION
The present study aimed to explore and describe facilitators to the health advocacy role practice of nurses in Ghana. The described facilitators to health advocacy role of the nurse offer the nurse and the nurse manager a substantial insight into areas of health advocacy facilitators. These facilitators were categorized into four main influencers from the perspective of the nurses.
Clientele influence comprising of client readiness and vulnerability were issues nurses considered and rendered the health advocacy role. The nurses interviewed believed that clients' own readiness to be assisted was a necessary influencing factor for health advocacy role performance. Clients' openness to ask for help or calling on the nurse to explain their current situation was emphasized. These findings are consistent with Barlem et al, 3 where the vulnerability of a client was reported as elements that facilitated the advocacy role practice. Similar findings were also reported by Josse-Eklund et al, 9

| Limitation
Data collection for this study was done in regional hospitals located in the regional capital; nurses in private hospitals and clinics in the rural areas of the country were not interviewed. Information from these categories would have given more insight into the topic.

| CONCLUSION
Facilitators of the health advocacy role are multifactorial emerging from the professionals' intrinsic traits, clientele, and cultural influences. In all the facilitators, the professional plays the central role as he/she serves as a link to the other facilitators to accelerate health advocacy role performance.
There is a need for health facility management to offer continuous professional development to nurses to update their knowledge in health advocacy role performance and to empower them to speak out. Continuous professional education of nurses should be encouraged, as the findings suggest that educational level influences the nurse ability to advocate.

RECOMMENDATION AND FURTHER RESEARCH
Based on these findings, the authors recommend further studies on religion and the health advocacy role, especially in Ghana.