Facilitators and Challenges of Client Advocacy

Experts and leaders may agree that client advocacy is not only an ethical and legal expectation, but it also is a philosophical foundation and guiding principle for case management practice. Advocacy as an integral component of every aspect of the case manager’s role, regardless of care setting and professional discipline, is not a choice; it is rather an ideal and a moral obligation. Case managers apply advocacy as a necessary strategy to build effective and respectful relationships with clients and their support systems and to serve as liaisons between them and the complex health care system, especially when they attempt to navigate it seeking timely access to care.

The case manager’s role already presents some challenges, often because of its primary focus on the provision of safe, quality, timely, and affordable care while ensuring a client’s experience of care that is optimal and free of any conflicts, delays, or disappointments. Advocacy adds to such challenge, especially because case managers usually advocate on behalf of those who feel powerless, voiceless, less fortunate, vulnerable, victimized, and resigned to the status quo. Failure to effectively advocate for these clients may further compromise their safety, rights, welfare, deciding on care options, self-management, and ultimately health and care outcomes.

It is an expectation that case managers face some risks and obstacles when advocating for clients and their support systems. It is also important to acknowledge that certain characteristics in the context of case management practice may facilitate successful client advocacy. Table 2 lists examples of facilitators and obstacles in client advocacy from the perspectives of both the case manager and the client and/or support system.

TABLE 2 – Sample Facilitators and Challenges of Client Advocacy

Facilitators	Challenges/Obstacles
Case manager-related
Trusting, respectful, open, and productive case manager–client relationship	Reluctance to embrace the advocacy role
Feeling accountable	Absence of a code of ethics and professional conduct to guide practice and decision making
Demonstration of essential competencies in advocacy	Unclear policies, procedures, and standards of care
Case management standards, practice knowledge, and skills	Limited time
Interdisciplinary or interprofessional collaboration, cooperation, and consensus-building	Unavailable experts, especially in the area of ethics
Presence of a code of ethics and professional conduct	Lack of peer or supervisor support
Open, timely, and transparent communication	Competing or conflicting priorities
Honoring client’s right to choice, self-determination, and autonomy	Conflicting opinions and inability to reach consensus
	Lack of responsiveness of involved stakeholders
	Lack of attentive listening and empathy
Client and support system-related
Ability to self-identify needs, desires, and preferences	Feeling powerless, voiceless, and lacking confidence
Ability to articulate problems and priorities	Lack of clarity on goals, issues, and priorities
Engaged and empowered client and client’s support system	Compromised condition (e.g., cognitive impairment)
Motivated and of positive attitude	Fear and anxiety
Ability to make informed decisions and clearly articulate goals	Passive attitude
Mutual trust	Resignation to the status quo
Client-driven approach to conflict resolution	Language barrier
	Sense of entitlement

Note. © Copyright 2016, Hussein M. Tahan, PhD, RN.

Establishing a trusting, respectful, functional, and authentic case manager–client relationship is fundamental to effective advocacy. Such relationship is characterized by interacting with the client as the case manager’s number one priority, understanding the client’s goals in order to successfully act on their behalf, and projecting the belief that the client is capable of self-identifying own needs and desires and is empowered enough to be actively engaged in self-care and own health. Other facilitators of client advocacy are availability of a code of ethics and professional conduct; assuming accountability for the role of advocate; demonstrating knowledge, skills, and competence in this role; and dealing with the client as an active participant in advocacy rather than as a passive recipient of it. In addition, client advocacy is easier to accomplish when the case manager is skilled at interprofessional practice and the development of effective and collaborative relationships with members of the interdisciplinary health care teams and other key stakeholders especially those who represent community-based resources and agencies.

One may argue that absence of the facilitators of client advocacy including those described earlier translates to barriers and challenges to developing effective client advocacy. From the case manager’s vantage point, absence of a code of ethics and professional conduct to guide practice and decision making; unclear policies, procedures, and standards of care; limited time; unsupportive or missing peers and supervisors; and competing priorities all contribute to suboptimal and ineffective advocacy, which ultimately may place the client at increased risk for unsafe care and poor-quality outcomes. On the contrary, when clients and/or their support systems feel powerless, voiceless, and lacking confidence, disengaged, act in a passive manner, and resign to the status quo, they also contribute to ineffective advocacy, suboptimal care, and poor outcomes.

The health care organizational culture (and the specific culture of the individual care area or setting) is a major influencing factor of client advocacy. It may facilitate or hinder the case manager’s ability to advocate for clients. For example, a culture that promotes transparency and teamwork and empowers case managers to handle client advocacy as a top priority contributes to successful advocacy and ultimately optimal clients’ care experience. In contrast, a culture that breeds conflict, hierarchy, and lack of support disempowers case managers, is indecisive about the standards and procedures that relate to ethical practices, and lacks clear focus on clients’ needs and preferences, challenges client advocacy, and results in disengaged and dissatisfied clients due to ineffective or completely absent client advocacy. Regardless however, if a case manager lacks professional responsibility toward client advocacy and is unable to demonstrate competencies and comfort in this role, presence of a culture conducive to the development of effective client advocacy still will not work. Case managers lacking in advocacy are unable to thoroughly use the cultural characteristics that support advocacy for the benefit of the client. Advocacy is dependent on being an integral component of professional practice, a context for the establishment of client–case manager trusting relationship, and an obligation of every case manager toward clients/support systems.