Received: 21 December 2022  | Revised: 25 April 2023  | Accepted: 5 June 2023
DOI: 10.1002/nop2.1907  
E M P I R I C A L  R E S E A R C H  Q U A L I T A T I V E
Health advocacy role performance of nurses in underserved 
populations: A grounded theory study
Luke Laari1  |   Sinegugu Evidence Duma2
1School of Nursing and Midwifery, College 
of Health Sciences, University of Ghana, Abstract
Accra, Ghana Aim: Nurses' health advocacy (HA) role requires them to speak up for patients, clients, 
2College of Health Sciences, University of 
KwaZulu- Natal, Durban, South Africa and communities in relation to healthcare. Various studies report the importance of 
the HA role of the nurse in healthcare. However, nurses' performance in this role is 
Correspondence
Luke Laari, Department of Public Health not clear yet. The present study aims to identify and explain how nurses perform their 
Nursing, School of Nursing and Midwifery, HA role in underserved populations.
College of Health Sciences, University 
of Ghana, P.O. Box LG 43, Legon, Accra, Design: Qualitative grounded theory by Strauss and Corbin.
Ghana. Methods: Data were gathered from three regional hospitals in Ghana with 24 regis-
Email: laariluke@yahoo.com
tered nurses and midwives as participants through purposive and theoretical sam-
pling techniques. Face- to- face in- depth semi- structured interviews were conducted 
from August 2019 to February 2020. The data were analysed using Strauss and 
Corbin's method and Nvivo software. The reporting follows Consolidated Criteria for 
Reporting Qualitative Research guidelines.
Findings: The HA role performance theory emerged from data with role enquiry, role 
dimension, role context, role influence, role reforms and role performance as building 
blocks. Data analysis showed that the main concerns of the nurses during their daily 
practice were mediating, speaking up, and negotiating. Among others, the intervening 
conditions were clientele influence and interpersonal barriers, whereas the outcome 
was a balance between role reforms and role performance.
Conclusion: Although some nurses proactively initiated biopsychosocial assessment 
and performed the HA role, most of them relied on clients' requests to perform the 
role. Stakeholders should prioritise critical thinking during training and intensify men-
toring programmes in the clinical areas.
Relevance for Clinical Practice: The present study explains the process by which 
nurses perform their roles as health advocates in their daily activities as nurses. The 
findings can be used to teach and guide clinical practice for the HA role in nursing and 
other health care fields. There was no patient or public contribution.
K E Y W O R D S
grounded theory, health advocacy, nursing role, nursing theory, underserved populations
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, 
provided the original work is properly cited.
© 2023 The Authors. Nursing Open published by John Wiley & Sons Ltd.
Nursing Open. 2023;00:1–11.  wileyonlinelibrary.com/journal/nop2  | 1
2  |    LAARI and DUMA
1  |  INTRODUC TION thus establishing a theoretical basis for future studies on patient ad-
vocacy in nursing. Their process of synthesising and analysing the 
The International Council of Nurses (ICN) and the American Nurses advocacy literature identified three core attributes of the concept 
Association (ANA) consider advocacy as a vital role of a nurse of patient advocacy, including safeguarding patients' autonomy, act-
(ANA, 2010; ICN, 2010). In its position statement on ethics and ing on behalf of patients, and championing for social justice in the 
human rights standards, the ANA (ANA, 2015) declared nurses re- provision of healthcare (Bu & Jezewski, 2007). The core attributes 
sponsible for advocating for all individuals in the areas of health and identified by Bu and Jezewski require nurses to be proactive in as-
healthcare rights. Yet most nurses remain silent when witnessing sessing their clients for information, as suggested by Ceesay (2018). 
unsafe practices, with only 10% of nurses speaking up when 50% of Listening, observing, and questioning skills are important in nursing 
nurses described situations that should have resulted in them speak- care assessment to elicit proactive data (Merisier et al., 2018; Phillips 
ing up (Moss & Maxfield, 2007; Rainer, 2015). et al., 2017). However, most nurses are only seen to react to clients' 
The few who speak up do so without a guide and hence per- needs (Rossiter et al., 2017). The high levels of emotional reactiv-
form the role haphazardly with frustration (Hanks, 2008; Vaartio ity to issues are debatably linked to a lack of assertiveness within 
et al., 2009). This indicates a lack of clarity regarding the descrip- the nursing profession, as reported by Vaupot and Železnik (2018). 
tion of health advocacy (HA) and the definition of clinicians' scope They reported low levels of assertiveness among nurses towards 
of responsibility (Hubinette et al., 2017). Consequently, a descrip- their clients and other professionals, which they argue prevents 
tion of the process of nurses' roles as health advocates is required, some nurses from initiating care. Furthermore, Haley et al. (2017) 
particularly in developing countries such as Ghana, a country with see active listening as an integral part of nursing and believe that it 
a fractured health system (Laari & Duma, 2021), where many rural is significantly associated with empathy, whereas Laging et al. (2018) 
folks live with an inequitable distribution of health facilities and poor believe that deficient observation skills during assessment will make 
social amenities. subtle issues and changes in the client's condition go unnoticed.
Good listening and observation skills are arguably integral to ho-
listic nursing assessment. However, Fusner et al. (2020), found that 
2  |  BACKGROUND even nursing faculty perceive physical assessment skills associated 
with anatomy and physiological systems as the most critical skills, 
Advocacy, although it originated in legal practice where solicitors neglecting the biopsychosocial and spiritual needs of the client. It 
spoke on behalf of their clients who could not speak for themselves, is argued that bureaucratic barriers (Figueira et al., 2018) and the 
is deemed an integral role of the nurse today (Alexis et al., 2022). workload of nurses (Alamri & Almazan, 2018) are responsible for 
Advocating for health is an act of pleading in favour of a disadvan- nurses' inability to perform physical assessments in clinical settings 
taged individual or a community concerning health (Ezeonwu, 2015). to elicit client situations that require advocacy. Though holistic as-
It includes educating an individual or group that is disadvantaged to sessment is needed to facilitate the proactive HA role of the nurse, 
speak out for their rights concerning health and healthcare (Yanicki nurses are limited in carrying this out.
et al., 2015). Hubinette et al. (2017), in describing differences in ap- Apart from the unassertiveness of some nurses and the lack of 
proaches to health advocacy (HA) reported a lack of clarity in the biopsychosocial assessment, there are barriers such as the covert 
description of HA and the definition of clinicians' scope of responsi- nature of HA in the nursing curriculum (van Staden & Duma, 2022), 
bility. They argued that, regardless of the success of isolated inter- the overlooking and not acknowledging of nurses in some devel-
ventions, understanding HA still requires a broader examination of oping countries during health policy development and reviews 
the processes, practices, and values throughout the health system to (Acheampong et al., 2021), and the lack of a framework to guide 
provide direction for possible HA activities and to establish shared nurses to perform the HA role (Adjei et al., 2023) are impediments. 
language in communication and collaboration across disciplines. These issues have culminated in the nurses' silence in performing the 
Over the decades, there have been some general frameworks HA role, especially in Ghana.
related to but not specific to HA. As such, a study in Ghana by Adjei The authors, in structuring the current study for the develop-
et al. (2023) reported there were no specific documented guidelines ment of the HA role performance for nurses and to explain the 
or framework on advocating for clients, which leaves nurse advo- meaning of HA (Burm et al., 2023), considered the arguments by 
cates disappointed and frustrated by failed advocacy attempts. Dang and Dearholt (2017) and Markey et al. (2018). These studies 
Carlisle (2000) developed a conceptual framework for health argue for the inclusion of culture and environment as having a im-
promotion, advocacy, and health inequalities that underscored the portant role in shaping nursing practice and should be considered in 
concepts of protecting the vulnerable and empowering the disad- theory development, and they assert that nurses must remain cul-
vantaged. Though essential to an HA role, the study did not address turally sensitive in their daily nursing practice. As such, the authors 
the nurse's HA role performance. developed a culturally sensitive and contextual HA theory that ex-
Through synthesising the advocacy literature in nursing, Bu plains the HA role to empower nurses to understand and embrace 
and Jezewski developed a mid-r ange theory to clarify and refine the HA role and to answer the question of how nurses understand, 
the concept of patient advocacy (which is a subset of HA) in 2007, accept, and practice their HA role in their daily practice in Ghana.
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LAARI and DUMA     |  3
3  |  METHODS to the potential participants verbally and in the information sheet. 
Potential participants asked questions for clarification purposes, and 
3.1  |  Design answers were provided by the first author. Participants were asked 
for voluntary participation, and those who agreed were recruited. 
This is a grounded theory based on Strauss and Corbin (1990). In all, 24 nurses and midwives participated, comprising 15 for open 
Grounded theory was first advanced by Glaser and Strauss (1967) sampling and nine for theoretical sampling. The researchers com-
and later explained by Strauss and Corbin (1990) and Corbin and pensated the participants with transportation fares and a snack for 
Strauss (2014). Grounded theory is a systematic methodology used those who were off duty but came because of the meeting.
in theory construction that involves inductive, comparative, inter-
active, and iterative data analysis techniques (Charmaz, 2011). The 
goal of grounded theory, which is most used in social sciences and 3.4  |  Sampling and data collection
qualitative studies, is to understand reality from the perspective of 
the meaning people place on specific contexts or objects to gen- Open and theoretical sampling methods were used to recruit partici-
erate knowledge, improve understanding, and provide an essential pants for face- to-f ace, in-d epth interviews. These sampling meth-
guide for action (Morse, 2001). The grounded theory method was ods are core to grounded theory sampling (Corbin & Strauss, 2014). 
chosen since it provided the blueprint for this qualitative study and Open sampling was used based on inclusion criteria to recruit the 
assisted with inductive theory development by constructing the HA first 15 participants, consisting of nurse managers and clinical unit 
role performance theory from the real- world environment of the heads from each of the three participating regional hospitals. After 
nurses (Strauss & Corbin, 1990). To report our findings, we followed the initial sample of 15 nurses was taken using open sampling, tran-
the Consolidated Criteria for Reporting Qualitative Research (Tong scription, and analysis of the data from the initial sample, a theo-
et al., 2007). retical sampling process was initiated. Theoretical sampling is data 
gathering that is driven by concepts that emerge from an evolving 
theory and is based on the concept of making comparisons (Corbin 
3.2  |  Setting & Strauss, 2014). Theoretical sampling was driven by constant com-
parison of initial data with the purpose of establishing situations and 
This study took place in three public hospitals in three different re- events that maximised opportunities. Theoretical sampling helped in 
gions of Ghana. These hospitals were selected purposefully in the the discovery of variations among concepts and densified categories 
northern, middle, and coastal zones among the 16 regions of Ghana. in terms of their properties and dimensions (Corbin & Strauss, 2008). 
These regional hospitals were selected because they have similar in- To achieve this theoretical sampling, an additional three nurses were 
frastructure and human resources, thus ensuring similarity in the se- identified from each of the three participating hospitals, making a 
lected hospitals as the research setting yet a diverse cultural setting. total of twenty- four (24) participants.
The range and scope of nurses' duties in these zones vary depending The location for the interview chosen by the participants was a 
on the location and culture of the people where each of these hos- nurses' office with the researcher alone. The first author, who was 
pitals is located. As such, the selection facilitated constant compari- a PhD candidate then and a trained qualitative research male nurse, 
son during data analysis, which is a key feature of grounded theory. conducted the interviews using an interview guide developed by the 
These hospitals are engaged in training nurses and other health pro- researchers based on the research objectives. These interviews all 
fessionals and receive referrals from district hospitals for specialised started with an open-e nded question: “Can you tell me what expe-
care. Nurses and midwives working in these facilities are recruited riences you have had where health advocacy was used or required 
from both the health training institutions (HTI) with 3-y ear diploma to be used?” After the first interview, analysis started, which gener-
certificates and the universities with 4- year bachelor's degrees in ated additional questions in further interviews; for instance, “other 
nursing. Data were collected between August 2019 and February nurses mentioned victimization as a barrier to advocating; what is 
2020. your opinion about that?” Each interview lasted between 50 and 
70 min and was audio recorded with the participants' permission. 
During the interview, field notes were taken, which made it easier to 
3.3  |  Participants remember what was said, where it was, and how nurses acted when 
they were not talking. The interviews went on until data saturation 
The inclusion criteria were registered nurses and registered mid- (Braun & Clarke, 2021).
wives who have worked for more than 5 years in the respective 
hospitals, irrespective of type of unit. Nurses and midwives who 
have observed situations requiring HA or who have performed HA 3.5  |  Data analysis
during their practice were included. For interviews, a formal meet-
ing for recruitment was organised with assistance from the nurse The recorded interviews were transcribed verbatim, read through, 
managers, and full disclosure of the study information was given and uploaded into NVivo software to facilitate the data analysis, 
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4  |    LAARI and DUMA
quick retrieval, and safe storage. Using a grounded theory by Strauss TA B L E  1  Categorises and subcategories.
and Corbin (1990), open coding, axial coding, and selective coding, Categories Subcategories
two independent coders (the first author and a qualitative expert) 
performed a step-b y-s tep analysis of the data, and a meeting was Role enquiry Listening
arranged with the intercoder to discuss and work on the intercoder Observing
reliability score in the presence of the second author. The coding Questioning
stages between the open and axial coding were performed concur- Role dimension Proactive advocacy practice
rently, using a recursive line- by-l ine analysis. Open coding was used Reactive advocacy practice
as a process to discover and identify concepts and their proper- Role context Institutional advocacy context
ties from data involving in vivo coding, labelling, and categorisation Non-i nstitutional advocacy context
(Corbin & Strauss, 2014). Open coding was done by recording impor- Role influence Barriers to advocacy
tant concepts and keywords in the research question correspond- Facilitators to advocacy
ing to each of the facts raised by the participants using NVivo node Role reforms Training reforms
options. These were then grouped into individual tables to provide 
Practice reforms
a general picture of the contents of each interview, keeping in mind 
Practitioner reforms
the research question and objectives. The groups created a prelimi-
nary open-c oding framework, which consisted of word descriptors Policy reforms
gathered inductively from the data. Similar conceptual abstracts Role performance Mediating for clients
emerging from each interview were organised and grouped follow- Speaking out for clients
ing the various codes to make up categories that described nurses' Negotiating for clients
views on HA.
During the analysis, certain questions were asked continuously: 
What is this study about? What is happening in the data? What is abstraction levels. At the end of the process of concept generation, 
the main idea behind the nurses' practice? Using constant compari- 55 sub-s ubcategories, 16 subcategories, and six categories emerged 
son, modifying, and renaming, and sorting memos written, the core from the data, as shown in Table 1.
category emerged, ‘Role performance’. The arrangement of the core 
category and other categories represented the initial building blocks 
of HA theory. For selective coding, data were coded in relation to 3.6  |  Ethics statement
the core category. A theoretical sampling was carried out to den-
sify the categories. A constant search was done to ascertain a rela- Ethical approvals were obtained from the Humanities and Social 
tionship that existed among the concepts from the data, and these Sciences Research (HSSREC) of the University of KwaZulu–N atal 
concepts were reviewed, compared, validated, and refined. The with approval number HSS/0289/018D and the Ghana Health 
relationships among the concepts defining nurses' views of HA at Services Ethics Review Committee with reference number GHS– 
different levels of interactional and structural contexts, action strat- ERC 007/. Participation was voluntary. Anonymity and confidenti-
egies, and consequences were then examined. Selective coding was ality were adhered to during and after data collection. Before the 
carried out with theoretical coding; memos were sorted, memos on participants signed the informed consent form, they were given 
memos were written to increase levels of abstraction and to clarify, information sheets about the study and told what the goals of the 
integrate, refine, and describe the concepts, using the discriminate research were.
sampling process. This discriminate sampling process maximised the 
opportunity for comparative analysis to integrate the categories 
along the dimensional level to form a theoretical scheme, validate 3.7  |  Trustworthiness
the statements of the relationship among concepts and fill in any 
categories in need of further refinement (Corbin & Strauss, 2008) Credibility, confirmability, dependability, and transferability, as 
until data saturation. described by Lincoln and Guba (1986), were ensured. The cred-
The first author analysed the data and discussed the codes with ibility of the findings of this study was ensured through member 
the last author, who is experienced in the method of grounded the- checking by returning to 12 of the participants to read the inter-
ory and later performed the audit trail. The number of initial codes view transcripts for scheme validation, whereas for confirmabil-
extracted from the 24 participants was 829, which fell to 385 after ity, transcripts and codes were presented to an intercoder who is 
repeated codes emerged. The data reduction went on with constant an expert in qualitative research for input, and the second author 
comparison and interaction with the data. Initially, 66 subcategories performed an audit trail. Peer debriefing was carried out for con-
were extracted and, through continuous refining, reduced to 56. firmability, whereas for dependability, data analysis procedures 
As the data analysis process continued, labels related to the same and software for data analysis procedures are declared. Actual ap-
concepts were put together to form conceptual categories on higher plications of each of the procedures in the study are provided to 
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LAARI and DUMA     |  5
demonstrate the accuracy of the implementation of the principles by listening, observing, and questioning to identify issues requir-
of grounded theory. The participants' information, the research ing their intervention, and, as such, they proactively intervened. 
context, and the study area are described to allow transferability However, some nurses were not proactive enough to perform a 
judgements. biopsychosocial assessment to identify unmet needs and, as such, 
were approached by patients or clients who requested assistance 
regarding their unmet needs. These nurses reacted to the request 
4  |  FINDINGS to intervene on behalf of the patient. Most of the nurses, after 
identifying the “role context,” such as the situation needing them 
The theory presented in this study was based on the findings ob- to intervene and location where this situation occurred, attempted 
tained from the open, axial, and selective coding processes. The to perform the role but met barriers. Some of these barriers were 
means for age and years of clinical experience of the participants identified as intrapersonal barriers involving the nurses' innate 
were 37 and 11, respectively. These participants included thirteen traits; interpersonal barriers involving relationships with other peo-
registered nurses and eleven registered midwives. There were eight ple; and structural barriers, which had to do with institutional bu-
participants with diploma certificates: eight with bachelor's degrees, reaucracy and fear of institutional victimisation. Nurses who met 
seven with master's degrees, and one with a PhD in nursing. All par- these barriers were unable to perform the role and requested that 
ticipants reported having performed the HA role or having observed training, practice, practitioner, and or policy reforms be ensured to 
another nurse performing the role. provide them with the ability to perform the role.
The aim of this study was to explore and describe the under- However, nurses who, in an attempt to perform the role, where 
standing, acceptance, and practice of the HA role among Ghanaian there was professional support from their colleagues, had an in-
nurses in their daily practice. In their daily practice, nurses were trinsic influence such as self-m otivation and a clientele influence 
most concerned with their role performance, which included me- where clients were cooperative with and listened to the nurses, 
diating, speaking up, and negotiating. They described the activities proceeded to perform the role by mediating for, speaking up for, 
of HA as “role performance,” which was used frequently in their and negotiating for their patients or clients based on the location 
daily practice. Their concerns arose in a role context involving ei- and the situation of the unmet needs. In the present study, based 
ther the institutional advocacy environment or a non- institutional on the participants' concerns about performing the role and the re-
advocacy environment. In an institutional advocacy environment, sults of the categorisation process, we selected role performance 
situations in which clients were unjustly delayed treatment or as the core category that links to all the concept categories from 
nurses noticed medical omissions or misapplications prompted the participants' data. The theory that emerged from the analysis is 
nurses to speak up. Advocating in a non- institutional advocacy shown in Figure 1. The details of this process are presented in the 
environment, they were concerned about social injustice in com- following sections.
munities where the disadvantaged and the less privileged were 
ignored.
The nurses used various means, such as mediating, speaking 4.1  |  Main concern: role performance
up, and negotiating, as a way of advocating, depending on the con-
text and the situation. Some of these situations were not readily Role performance emerged as a committed step with mediating, 
apparent, and nurses had to perform biopsychosocial assessment speaking out, and negotiating as dimensions.
F I G U R E  1  The Health Advocacy Role 
Performance (HARP) Theory.
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6  |    LAARI and DUMA
4.1.1  |  Mediating for clients Strauss, 2014). In this present study, the contextual conditions were 
role context and role influence emerged as the intervening condi-
This is the ability of the nurse to intervene in a disagreement to bring tions with barriers and facilitators as its dimensions.
about agreement and reconciliation when the client is involved. 
Participants mentioned that this involves facilitating communication 
between individuals and organisations. 4.2.1  |  Role context
When a client comes in, and there are issues with The setting where HA role performance took place and the situa-
them and other professionals, I mediate because I am tions that propelled nurses to stand up or speak out for their clients 
supposed to…sometimes from the laboratory or the emerged as role context. The role context emerged, with institu-
pharmacy or even from the medical officer. The cli- tional advocacy context and non-i nstitutional advocacy context as 
ents come to us to complain to us, and we mediate subcategories.
(PN21, 31- year-o ld male).
The institutional advocacy context
This was mentioned as a situation where nurses were compelled to 
4.1.2  |  Speaking out speak out for their clients in an institution. The nurses interviewed 
said they did this when they noticed unfair treatment of clients, in-
The nurse becomes a voice for the client. Participants noted that cluding medical omissions and misapplications, unjustly delayed cli-
they facilitate clients' speaking for themselves and, in some circum- ent treatment, and when clients were denied their rights.
stances, they represent the client and speak for them. They speak 
for the voiceless or do the accompanying speaking, where nurses Sometimes we go to the authorities because some of 
speak with the voiceless and empower them. It was also pointed out the things might involve policies or rules that are hard 
that speaking out for the voiceless in society, for the vulnerable in to break and can lead to unfair treatment of our cli-
the community, and for those who have no voice or have their voices ents, for instance, deposit before treatment 
not heard is important as a nurse. (PN19, 41-y ear-o ld female).
I spoke for the boy because his parents were igno- Non- institutional advocacy context
rant of the other treatment options available. As an This was given as examples of times when nurses needed to speak 
advocate for health, I made them aware of the other up for a person or group in the nurses everyday lives, not just in 
options to choose from a hospital. The nurses did this when they noticed social injustice, 
(PN13, 43- year-o ld female). such as the unjust treatment of individuals in society. Participants 
also spoke out to protect the vulnerable and to empower the dis-
advantaged and less privileged. A participant recounted the non- 
4.1.3  |  Negotiating for clients institutional advocacy context of a mental health client:
Participants mentioned some situations that made them act on This man (a psychiatric patient) was tied to a tree, 
behalf of their clients by reaching a compromise while avoiding and all activities of his daily living were carried out 
arguments. Most of the participants reported that negotiating is under this tree… We felt it was inhumane. We went 
something they do daily, which involves bargaining with those in to the pastor to advocate for him, and he (the pas-
power, pleading on behalf of the client, and standing in for the tor) released the client to be sent for treatment after 
vulnerable. a long argument concerning the patient's human 
rights 
There was one patient here; after discharge, I had to (PN20, 33- year-o ld male).
negotiate…pleaded on his behalf before the adminis-
tration allowed him to go home 
(PN23, 51- year- old male). 4.2.2  |  Role influence
Role influence emerged as the intervening condition that aided or 
4.2  |  Data analysis for context thwarted the nurses' ability to perform their roles as health advo-
cates. Under the role influence, two dimensions emerged: positive 
Context is a combination of all the circumstances that constitute a intervening conditions called facilitators and negative intervening 
situation and includes one's reasons for one's interactions (Corbin & conditions called barriers.
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LAARI and DUMA     |  7
Negative conditions “barriers” for her care. Enquiry from the client has always been 
These are the conditions that prevented some nurses from fulfill- one thing I consider very important prior to client care 
ing the role of HA. Among these were three barriers, including: (1) (PN11, 41- year-o ld male).
intrapersonal barriers related to the nurses' innate traits that pre-
vented them from performing the HA role; (2) interpersonal bar- Observing, listening, and questioning emerged under role enquiry.
riers resulting from poor relationships between the client and the 
professionals, such as poor clientele traits and persecution from Observing the client
colleges; and (3) structural barriers such as organisation and man- This is the nurse's ability to watch the client during care to help as-
agement issues, including red tape, poor educational preparation, certain issues that require advocacy. The nurses' observational skills 
professional alienation, and victimisation from the authorities (Laari allowed them to assess not only the clients' unmet needs but also the 
& Duma, 2023b). A participant reported that: immediate and remote environments of the clients.
Clients themselves are part of it. I have stood up for We are always observant of the patient's reactions to 
clients several times, but at the end of the day, some issues, and mostly it gives us clues and information for 
of them behaved in a way that made it difficult for me some action to be taken 
to advocate for them in the future (PN24, 33-y ear- old male).
(PN16, 31-y ear- old female).
Listening to the client
Positive conditions “facilitators” This involves the accuracy of the nurse in receiving verbal and non-
These conditions emerged as ones that aided nurses in their HA roles. verbal information from the client during communication. Listening 
These facilitators included: (1) clientele influence, which relates to keenly assisted the nurses in identifying their clients' situational 
the readiness and openness of the client to receive assistance from needs and advocating for them.
the nurse; (2) the intrinsic influence of the nurse, where the nurse 
is self- motivated and driven by empathy and compassion to speak I try to have a keen interest in what they tell me, so 
out for the client; (3) professional influence, where the nurse sees I listen keenly all the time I communicate with my 
advocacy as a professional obligation that links with years of experi- clients 
ence and the educational background of the nurse; and (4) cultural (PN13, 43- year-o ld female).
influence relating to the nurse's religious background, where they 
perform advocacy as a religious obligation (Laari & Duma, 2021). Questioning the client
The ability of the nurse to make relevant inquiries that would reveal 
For me, I see it as a religious obligation; yes, to speak the issues of the client that would require the nurse to speak up for. 
up for someone and help them get what they couldn't This, according to the participants, was done by interviewing clients 
get on their own is a privilege for me as a religious for information and conferring with other professionals to get the 
person information necessary for clients' care. The nurses reported that 
(PN20, 33- year- old male). questioning serves many functions during client care in healthcare 
facilities.
4.3  |  Data analysis for process I do ask my patients questions, sometimes in the form 
of interviews or during personal interaction. By ask-
The action/interaction strategies with regard to role performance ing them some relevant questions, I get to know and 
were role enquiry and role dimensions. understand them better, and understanding them 
helps me in my care for them 
(PN01, 33- year-o ld male).
4.3.1  |  Role enquiry
Role inquiry is when a nurse gathers information about a client or 4.3.2  |  Role dimensions
does a biopsychosocial assessment of a client to figure out if the cli-
ent needs the nurse to play a HA role. It is an important step for the These are dimensions of HA that nurses perform. Proactive HA and 
nurse to take in order to find out what the client's unmet needs are. reactive HA emerged as subdimensions. A participant noted that:
So, I started talking to her. I asked her if she had any I believe in the rights of customers, whether they ask 
information about her health, concerning her status, for help or not… we have demanded an unqualified 
and she gave us information that was very necessary apology for a lot of our clients here when they were 
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8  |    LAARI and DUMA
abused by other professionals without the client's Training reforms
knowledge… but in some cases the clients requested Participants mentioned that incorporating necessary changes in the 
for us to intervene professional education process will enable students to be exposed 
(PN04, 37- year-o ld female). to HA while they are in school. The nurses believe that changes that 
are important in training reform are to incorporate HA into the train-
Proactive health advocacy ing curriculum, have curriculum innovations, and encourage lifelong 
A situation during HA role performance where the nurse monitors, learning concepts during the training (Laari & Duma, 2023a).
controls, or performs an action based on his or her independent bi-
opsychosocial nursing assessment of the client without a demand If they (authorities) could add health advocacy to the 
from the client. The nurses saw this as a preventive process in the cli- curriculum at the nursing training school… it would 
ent's care where they championed clients' rights when patients were help a lot to get the trained nurse to acquire the nec-
abused and not treated well. They initiate and do not wait until clients essary knowledge and the attitude to work on the 
complain to them because some clients will never request help. health advocacy role for clients 
(PN23, 51- year- old male).
Sometimes issues pushed us to the point where we 
spoke language that sounded like threats to man- Practice reforms
agement before things were done. If the most basic These are the changes that are needed in the professional culture to 
things are not there and all you are telling me is to facilitate the performance of HA. As reported by the participants, 
manage, manage with what?… I value the lives under continuous professional education, interprofessional collaboration, 
my care, so I usually don't wait for clients to complain and empowering nurses with advocacy skills to change negative pro-
or request fessional socialisation are needed within the practice, as mentioned 
(PN13, 43- year- old female). by the participants (Laari & Duma, 2023a).
Reactive health advocacy There should be a clear pathway so that we will know 
This is a response to a request from the client for the nurse to per- the right place to go when something is happening. 
form the HA role. The nurses spoke out to facilitate access to care or But for now, we don't know whom to go to for what, 
to provide the requested service in the form of leading and teaching and it makes the performance of the health advocacy 
the client. The participants saw this as a curative process in the cli- role cumbersome 
ent's care. (PN13, 43- year- old female).
We felt she was not treated right concerning her Practitioner reforms
bills, so when she came and laid the complaints, we These are the changes an individual nurse or group of nurses re-
responded and followed up with the right offices to quires to facilitate and promote the performance of the HA role. 
make sure that all her needs regarding her healthcare Participants reported the need for attitudinal change among pro-
were met fessionals, enhancement of professional solidarity, empowerment of 
(PN03, 36- year-o ld female). professional assertiveness, and professional approachability (Laari & 
Duma, 2023a). A participant reported how unity and professional 
solidarity can reform the practitioner.
4.4  |  Consequence
Our colleagues with experience in health advocacy who 
The findings of this study showed that the consequence of the know what to do should mentor the young nurses and 
nurses action- interaction in relation to role performance was role coach them to grow up. Uniting will make our role great. 
reforms. This category consisted of training, practice, practitioner, (PN01, 33-y ear-o ld male).
and policy reforms.
Policy reforms
Participants mentioned the regulatory bodies, such as the Nursing 
4.4.1  |  Role reforms and Midwifery Council of Ghana, the Ministry of Health, the Health 
Training Institutions, and the implementing bodies, including the 
These are the changes and strategies needed to reform in the right Ghana Health Services and the Christian Health Association of 
direction for better accomplishment. The people who took part said Ghana, as key stakeholders. These bodies were thought of by par-
that role reforms were ways to recheck and fix things that needed to ticipants as bodies that should provide reformed policies that are 
be changed. Training, practice, practitioner, and policy reforms were necessary for the policy reforms and provide a supervisory role for 
the four areas that required reform. the reforms to be successful (Laari & Duma, 2023a).
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LAARI and DUMA     |  9
Nurses who work as health advocates need clear the value of nursing assessment is poorly recognised, and there is 
policies and rules to guide and protect them. Those a lack of clarity regarding the importance of nursing assessments 
in charge up there should restructure (reform) our (Ceesay, 2018; Laging et al., 2018).
policies. Biopsychosocial assessment should be encouraged from the 
(PN01, 33- year- old male). undergraduate level on to instil a culture of role inquiry in future 
nurses, as it will aid in the development of skills to provide holistic 
and person-c entred care. It should be encouraged because partial 
4.5  |  Assumptions of the theory and incorrect performance of patient assessment promotes less 
critical thinking and could lead to poor clinical decisions (Alamri & 
The HARP theory assumes that the HA role of the nurse will facili- Almazan, 2018).
tate healthcare equity in underdeveloped and developing countries. The current findings identified role enquiry to supports previ-
Nurses are the frontline staff in healthcare, and if they are equipped ous literature where listening, observing, and questioning were 
with the necessary knowledge and skills to protect the vulnerable seen as important in nursing care assessment, as stated by Merisier 
and empower the disadvantaged and less privileged, health for all et al. (2018) and Phillips et al. (2017). Haley et al. (2017) also, re-
would be a reality. It is assumed that providing proper knowledge to ported on the significance of active listening as an integral part of 
nurses today, either through in-s ervice or formal education in HA, nursing when they identified that active listening was significantly 
is an investment that would bring huge dividends in the future for associated with empathy. Similarly, the current study reveals that lis-
society. tening, observing, and questioning are important in nursing role per-
formance. Without keen listening and attentive observation, subtle 
issues and changes in the client's condition can go unnoticed.
5  |  DISCUSSION As averred by Rossiter et al. (2017), nurses play an age- old role 
in reacting to clients' unmet needs or responding to clients' needs. 
The aim of this study was to identify and explain how nurses per- However, because proactive HA appears to be lacking in the current 
form their HA role in underserved populations. The HARP theory findings, it is past time for nurses to perceive and act as proactive 
describes how nurses perform their HA role in underserved popula- professionals. Proactive advocacy allows the nurse to initiate and 
tions. Varied categories of nurses were interviewed across Ghana perform the HA role without a request from the client, which facili-
in three strategic locations. Nurses of various ages, varied experi- tates the preventive roles of nurses. The current findings show that 
ences, and vast ranges of practical experiences were sampled, which more nurses perform reactive advocacy than proactive advocacy, 
gives this theory densified data (Dearholt & Dang, 2012; Markey suggesting one of two things. Either these nurses had insufficient 
et al., 2018). knowledge to advocate or they were unassertive to initiate the HA 
This HARP theory is different from role theory by Turner (2001), role performance process. A question that requires an answer in a 
and social theory and social structure by Merton and Merton (1968). further study is: What promotes proactive activity among nurses 
The HARP theory uncovers and describes nurses' practices in under- during professional duties? The seeming lack of assertiveness within 
served populations. The current findings reveal most nurses see HA the nursing profession is reported by Vaupot and Železnik (2018), 
as a professional obligation and perform this role with keen interest. who believe low levels of assertiveness among nurses towards their 
Though some professional nurses only reacted to their clients' needs clients and other professionals are evident. Further education of the 
and were not proactive enough to assess and initiate the HA role for nurse might be necessary to increase and improve knowledge to 
their clients, their responses confirm the assertions by ANA and ICN promote assertiveness as the current findings, although not conclu-
that nurses top the list of professionals who speak for their clients sive, reveal that nurses with further education and important years 
(ANA, 2010; ICN, 2010). of experience in nursing practice are assertive and inclined to advo-
Few people who did assessments did so with little to do with cate for their clients.
their clients' HA needs. Instead, they looked at their clients' anatomy Nurses who identified or got requests from their clients performed 
and physiology to find problems. This resulted in some participants one or more of the following: mediating, speaking out, or negotiating. 
not performing holistic nursing care for their clients, as previously Speaking for clients has always been a role of the nurse. As such, the 
argued by Fusner et al. (2020), that most faculty perceiving assess- current finding confirms the role of nurses as advocates who speak 
ment skills associated with the human anatomical systems as the out when there is a medical omission or when client rights are ignored 
most critical skills taught in nursing assessment courses. Again, a during treatment. This is consistent with Bu and Jezewski (2007) 
previous study by Alamri and Almazan (2018) reported that nurs- findings that nurses safeguard patients' autonomy, act on behalf of 
ing students did not practice assessment in the clinical setting, al- patients, and champion social justice in the provision of health care. 
though they were oriented and educated about assessment in the Some conditions, such as clientele influence, professional influence, 
nursing curriculum. This inability to perform assessments appears cultural influence, and intrinsic influence, promote the performance 
to be linked with workload and red tape issues, as identified in this of the HA role (Laari & Duma, 2021). The presence of these influenc-
current study. Though assessment is a key skill in nursing practice, ers made it easier for the nurse to perform their HA role. Divergently, 
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10  |    LAARI and DUMA
there were barriers, such as the covert nature of advocacy in the with role inquiry, proceeding through role dimensions, role context, 
curriculum, as previously averred by Alamri and Almazan (2018) and and role influence, and terminating at either role performance or role 
Douglas et al. (2018), that prevented nurses from advocating. reforms. As some nurses proactively initiated their professional ob-
The need for key reformations was uncovered, and policymak- ligation to perform the role, others were thwarted from carrying out 
ers are encouraged to use these reformations to enhance clear im- their roles as advocates due to barriers.
plementation strategies in HA (Laari & Duma, 2023a). This included 
training and practice reforms. It, however, appeared as a challenge AUTHOR CONTRIBUTION
as nurses are not involved in most policy development that affects Both LL and SED conceptualised the idea, wrote the proposal, and 
them, as reported by Acheampong et al. (2021) in Ghana, where designed the instruments for data collection. LL collected the data 
nurses are usually overlooked and not acknowledged during health and analysed whiles SED reviewed and made corrections. LL and 
policy development and reviews. The best way to move forward is SED read and approved the manuscript. Both authors contributed 
to ask nursing experts to help make and review policies. This will to this paper.
give experts the knowledge they need to make changes.
ACKNO WLED G E MENTS
The authors wish to acknowledge the support from the College of 
5.1  |  Relevance to clinical practice Health Sciences, University of KwaZulu Natal Scholarship fund for 
supporting data collection.
The current findings reveal most nurses are inclined to react to situa-
tions rather than proactively initiating a biopsychosocial assessment. FUNDING INFORMATION
Nurse educators should prioritise critical thinking during nurses' train- The authors did not receive any funding for this manuscript.
ing to incorporate assertiveness and the ability to initiate within their 
job description without requests from clients. The idea of biopsycho- CONFLIC T OF INTERE S T S TATEMENT
social nursing assessment should be emphasised as a way to encourage Both authors declare no conflict of interest.
nurses to keep learning to improve their skills through in-s ervice train-
ing. Mentoring and coaching should be encouraged in the clinical areas. DATA AVAIL ABILIT Y S TATEMENT
The data that support the findings of this study are available from 
the corresponding author upon reasonable request.
5.2  |  Limitation and recommendations for 
further research ORCID
Luke Laari  https://orcid.org/0000-0001-6450-7335 
This current study described how nurses performed their HA role in 
underserved populations. Due to contextual and cultural differences R E FE R E N C E S
that might affect the behaviours and actions of nurses in developed Acheampong, A. K., Ohene, L. A., Asante, I. N. A., Kyei, J., Dzansi, G., 
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