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C O N C E P T A N A L Y S I S

The nature of advocacy vs. paternalism in nursing:

clarifying the ‘thin line’

Meg Zomorodi & Barbara Jo Foley

Accepted for publication 6 March 2009

Correspondence to: M. Zomorodi:

e-mail: [email protected]

Meg Zomorodi BSN PhD RN

Clinical Assistant Professor

School of Nursing, University of North

Carolina, Chapel Hill, North Carolina, USA

Barbara Jo Foley PhD RN FAAN

Clinical Professor

School of Nursing, University of North

Carolina, Chapel Hill, North Carolina, USA

Z O M O R O D I MZ O M O R O D I M . & F O L E Y B . J& F O L E Y B . J . (2 0 0 92 0 0 9 ) The nature of advocacy vs. paternalism in

nursing: clarifying the ‘thin line’. Journal of Advanced Nursing 65(8), 1746–1752.

doi: 10.1111/j.1365-2648.2009.05023.x

Abstract Title. The nature of advocacy vs. paternalism in nursing: clarifying the ‘thin line’.

Aim. This paper is an exploration of the concepts of advocacy and paternalism in

nursing and discusses the thin line between the two.

Background. Nurses are involved in care more than any other healthcare profes-

sionals and they play a central role in advocating for patients and families. It is

difficult to obtain a clear definition of advocacy, yet the concepts of advocacy and

paternalism must be compared, contrasted, and discussed extensively. In many

situations, only a thin line distinguishes advocacy from paternalism.

Data sources. A literature search was conducted using PubMed and CINAHL

databases (2000–2008) as well as a library catalogue for texts.

Discussion. Four case stories were described in order to discuss the ‘thin line’

between advocacy and paternalism and develop communication strategies to elim-

inate ambiguity. Weighing the ethical principles of beneficence and autonomy helps

to clarify advocacy and paternalism and provides an avenue for discussion among

nurses practicing in a variety of settings.

Implications for nursing. Advocacy and paternalism should be discussed at inter-

disciplinary rounds, and taken into consideration when making patient care deci-

sions. It is difficult to clarify advocacy vs. paternalism, but strategies such as

knowing the patient, clarifying information, and educating all involved are initial

steps in distinguishing advocacy from paternalism.

Conclusion. Truly ‘knowing’ patients, their life experiences, values, beliefs and

wishes can help clarify the ‘thin line’ and gain a grasp of these difficult to distinguish

theoretical concepts.

Keywords: advocacy, beneficence, clinical decision-making, concept analysis,

ethics, nursing, paternalism

Introduction

Nurses spend more time with patients than any other health-

care professionals and they play a central role in the care of

them and their families. Despite this central role, they are often

inadequately prepared to advocate for patients or address

concerns about advocacy and medical paternalism (Breier-

Mackie 2001). Traditionally, clinical decision-making has

1746 � 2009 The Authors. Journal compilation � 2009 Blackwell Publishing Ltd

J A N JOURNAL OF ADVANCED NURSING

been the role of the physician, yet interventions associated with

their decisions (pain control, postoperative care and symptom

management) fall largely on nurses. Further, patients and

families are often excluded from decision-making. Nurses have

an obligation to complete the orders of physicians, and this

sometimes results in distress for nurses who may question the

orders. For example, critical care nurses cite moral distress

when faced with situations in which they think that medically

futile care is being provided (Taylor 1995, Brown 2003, Elpern

et al. 2005). There is no evidence that physicians are more

qualified in ethical decision-making than nurses, and there is no

reason for physicians to have a monopoly over this decision-

making (Goodhall 1997, McCormack 1998, Breier-Mackie

2001). Nurses in every setting across the globe must contribute

effectively to these decisions. To be successful in this new role,

nurses must have an understanding of the thin line between

advocacy and paternalism.

Background

Defining advocacy

Throughout nursing’s history, care has included advocating

for patients. Virginia Henderson described advocacy as

nurses helping ‘people do what they would ordinarily do

for themselves to maintain health, recover from illness, or die

a peaceful death when persons lack the strength, will, or

knowledge to care for themselves’ (Henderson 1961, p. 41).

Curtin (1979), Gadow (1980), and Kohnke (1982) were the

earliest authors to define nursing advocacy from the perspec-

tive of patient care. Curtin noted that the purpose of nursing

advocacy is to ensure the welfare of other human beings,

which she calls human advocacy. According to Gadow

(1980), nurses should help individuals to clarify their values

when making decisions and to reach decisions that uphold

their reaffirmed values. Both Gadow (1980) and Curtin

(1979) believe that professionals cannot decide what is in the

best interests of a patient unless they have underlying

knowledge of the patient and have established sufficient trust

with the patient to understand that individual’s values.

Kohnke (1982) defines the role of the advocating nurse as

informing and supporting a patient in decision-making.

Defining paternalism

Paternalism is derived from the Latin word for father and has

been defined as the ‘intentional overriding of one person’s

known preferences or actions by another person, where that

person justifies the action with the goal of benefiting or

avoiding harm to the person whose will is overwritten’

(Johnstone 1999, p. 232). Thus, paternalism in nursing

occurs when a patient’s preferences, decisions, or actions are

denied out of concern for the patient’s well-being (Breier-

Mackie 2001).

Early literature on this concept identified two types of

paternalism: (1) harm paternalism; and (2) benefit paternal-

ism (Johnstone 1999). Harm paternalism’s hallmark is the

ethical principle of maleficence, which is designed to prevent

the individual from self-harm. That is, the healthcare

provider intervenes to prevent the patient from inflicting

self-harm. Benefit paternalism uses the ethical principal of

beneficence, by which a ‘good’ is performed that would not

otherwise have occurred. Beauchamp and Childress (2001)

divide paternalism into two forms: weak and strong pater-

nalism. Weak paternalism is the inability of the individual to

make an autonomous decision due to a compromised state.

Strong paternalism, in contrast, involves interventions that

are anticipated to benefit the individual, despite the fact that

their refusal of the intervention is informed, voluntary and

autonomous (Beauchamp & Childress 2001).

Autonomy and beneficence in advocacy and medical

paternalism

Autonomy is the unhindered and independent ability to

think, decide and act on a decision, without fear of retaliation

(Rubin 1998). In health care, autonomy is often defined as

self-determination of rights, such as the right to accept or

refuse treatment (Beauchamp & Childress 2001). The oppo-

site of autonomy is heteronomy, or decision-making on the

basis of another rather than the individual (Rubin 1998). The

principle of beneficence declares that one must ‘above all, do

good’ and demands that one act for the benefit of others

(Johnstone 1999, p. 90). At first glance, the ethical principles

of beneficence and autonomy appear to help clarify the

concepts of advocacy and paternalism, but the distinction

between the two concepts is in fact quite difficult. While the

principles may be clear, the act of beneficence or autonomy

can be a component of both advocacy and paternalism. It is

important for nurses to understand this distinction in order to

clarify the thin line between advocacy and paternalism. The

purpose of this paper is to explore the concepts of advocacy

and paternalism in nursing and discuss the thin line between

the two concepts.

Data sources

In order to explore the concepts of advocacy and paternalism,

a literature search was conducted using PubMed and

CINAHL databases as well as a library catalogue for texts.

JAN: CONCEPT ANALYSIS The ‘thin line’

� 2009 The Authors. Journal compilation � 2009 Blackwell Publishing Ltd 1747

The search range was restricted to the years 2000–2008 to

ensure currency of material. The ancestry method was used

by hand-searching the references and bibliographies of the

retrieved articles.

Discussion

The thin line

Advocacy and paternalism often blend when a patient cannot

communicate. Patients who are silenced by neurological status

or intimidation are at risk for getting lost in the ‘thin line’

between these concepts. In addition, individuals who do not

receive sufficient information to make an informed decision are

subject to medical paternalism. In this case, it is important for

the nurse to really know the needs, desires, and wants of the

individual in order to fully advocate for them.

In the literature, medical paternalism is usually portrayed as

negative and unjustified. This is largely due to the fact that the

definition of paternalism always involves the choices or actions

of one person being overridden by another without true consent

(Johnstone 1999). It is difficult to justify paternalism since this

denies the autonomy of the individual, but in cases when the

individual’s cognitive status is compromised, it could be argued

that paternalism is ethical, such as in the example of a confused

patient with diabetes or a suicidal individual. Some argue that

medical paternalism can only be justified when beneficence is

applied or when autonomy or personal rights are not violated

(Bassford 1982). Since the role of the nurse is often an intimate

and personal one, it could be argued that that role is to weigh

ethical principles, such as beneficence and autonomy, in order

to determine where advocacy ends and paternalism begins.

The nature of advocacy in nursing

Advocacy is central to nursing care, but it is difficult to obtain

a clear definition of the term. Qualitative studies of nursing

advocacy have identified honouring autonomy, assisting with

advance directives, standing up for others, controlling pain

and other symptoms, facilitating communication, accessing

services, interpreting the system, and finding solutions as

aspects of advocacy (Curtin 1979, Gadow 1980, Cartwright

et al. 1997, Danis et al. 1999, Foley et al. 2002, Johnson

2004, Valente 2004). The nursing literature classifies advo-

cacy in three ways: (1) advocacy motivated by a patient’s

right to information and self-determination; (2) advocacy as a

right to personal safety; and (3) advocacy as a philosophical

principle in nursing (Vaartio & Leino-Kilpi 2005). However,

when the concept of advocacy is explored through theoretical

and ethical examples, it is not as easy to define.

Most definitions of advocacy focus on the nurse com-

pleting the desired wishes or needs of the patient. Using

Henderson’s definition of advocacy, it could be argued that

to truly advocate for patients, the nurse must know the

patient on an individual basis and perform the activities

that the individual desires or values. If the nurse does not

know the individual’s desires or values, the nurse responds

according to their personal beliefs on the matter. According

to Curtin (1979), human advocacy is the basis of the nurse-

patient relationship. The nurse expresses advocacy by creating

an environment that is open and supportive to decision-

making. To do this, nurses must possess a sustained and

intimate knowledge of the person as a distinct human being

(Curtin 1979, Mallik 1997). Gadow (1980) takes a similar

perspective on advocacy, which she calls existential advocacy,

and thus begins the ‘thin line’ where advocacy and pater-

nalism blend.

When patients are able to communicate their wishes and

possess autonomy, Curtin and Gadow’s definition of advo-

cacy are clear. However, when patients are ‘silent’ or unable

to communicate they are unable to practise autonomy, and

thus the thin line between advocacy and paternalism may be

crossed. Nurses may not know the individual needs of

patients and may not have family members who can act as

surrogates for them. In this situation, nurses may act in what

they think is the best interests of the patient, which

unwittingly can move advocacy into medical paternalism.

According to Kohnke’s definition of advocacy, the nurse

supplies the patient with the information needed to make an

informed decision, but the nurse has the right to choose

whether to advocate by disclosing the most current and

correct information. The nurse must decide whether to

‘support’ the patient when the nurse feels that the patient

has made the right decision (advocacy) and must refrain from

‘rescuing’ the patient when the nurse considers that the

patient has not made the correct decision (paternalism)

(Kohnke 1982). Although Kohnke does not directly state this,

it may be suggested that ‘supporting’ the individual rather

than ‘rescuing’ the individual is the difference between

advocacy and medical paternalism. When nurses ‘rescue’

individuals by guiding their decision-making, they are deny-

ing the individuals’ autonomy and promoting heteronomy.

However, this distinction may not be entirely clear, and to

decipher the difference between advocacy and paternalism,

nurses must be aware of when they are ‘supporting’ or

‘rescuing’ the patient. To do this, they should examine the

nature of paternalism in nursing, as well as the nature of

advocacy, and apply the principles of autonomy and benef-

icence to both concepts as they are reflected in both advocacy

and paternalism.

M. Zomorodi and B.J. Foley

1748 � 2009 The Authors. Journal compilation � 2009 Blackwell Publishing Ltd

The nature of paternalism in nursing

Unlike advocacy, paternalism is easier to conceptualize.

Healthcare providers feel an obligation to exhibit beneficence

by ‘doing no harm,’ but at the same time the individual has

the right to make an autonomous decision (Cody 2003).

Again, the ability of the patient to communicate is a key

element in distinguishing advocacy and paternalism.

For example, a confused individual with hypoglycemia

refuses medical care but is brought to the hospital by the

Emergency Medical Service (EMS) anyway. According to

Henderson’s definition of advocacy, it could be argued that

EMS is advocating for the patient by helping them to

maintain health and recover from illness when the patient

lacks the knowledge to care for themself. Using Beauchamp

and Childress’ definition of weak paternalism, the patient is

in a compromised state and cannot make an autonomous

decision, thus requiring a paternalistic approach. Using this

example, it is difficult to distinguish where advocacy ends and

paternalism begins.

Beauchamp and Childress’ definition of strong paternalism

is much more difficult to defend and is open to considerable

ethical debate. For example, an individual who is well-

educated about their terminal disease trajectory develops

pneumonia and chooses to not have the infection treated

because they view treating the pneumonia as simply prolonging

the dying process. The nurse believes that the individual should

be treated because after the pneumonia clears, the individual

will return to their baseline illness. In this situation, the

individual is knowledgeable about their decision and the

consequences associated with it. The nurse, on the other hand,

thinks that ethically they must intervene on the patient’s behalf,

in order to justify the ethical principle of beneficence.

Additionally, the principle of beneficence can be a compo-

nent of both advocacy and medical paternalism. In advocacy,

acts of beneficence include care, compassion, empathy, sym-

pathy, kindness, mercy, love, and charity, but there are some

limits to it. Beneficence can be limited by moral considerations

and it is this limit that causes the ‘thin line’ to develop and cross

over to paternalism. For example, we are not obliged to follow

the principle of beneficence when doing so could result in our

own moral distress or injury. Beauchamp and Childress suggest

that there are five conditions that determine when the principle

of beneficence must be upheld:

(1) the patient is at risk of significant loss of, or damage to, life or

health or some other major interest (a violation of spiritual/religious

beliefs included); (2) the nurse’s action is needed to prevent this loss

or damage; (3) the nurse’s action has a high probability of preventing

it; (4) the nurse’s action would not present significant risks, costs, or

burden to themselves; and (5) the benefits that the patient can expect

to gain outweigh any harm, costs, or burdens that the nurse is likely

to incur (Beauchamp & Childress 2001, p. 266).

If these five conditions are not met, then the principle of

beneficence can be overturned. This principle is often

questioned when healthcare providers believe that it is their

moral right to uphold life.

In the case of an individual refusing medical treatment,

healthcare professionals often feel a moral obligation to treat

that individual for their own good. Healthcare professionals

may attack the patient’s competence because it seems incom-

prehensible that any competent person would deny life-

sustaining treatment. In this example, they are acting on a

moral principle to protect the individual from harm or illness.

Problems arise between the concepts of advocacy and pater-

nalism when the individual meets the five conditions of

beneficence, yet healthcare providers consider that they ‘know

best’ and it is in the patient’s best interest for them to intervene.

Case examples of the ‘thin line’

The cases presented below illustrate the thin line between

advocacy and paternalism. The first case has been reported in

several media sources, while the other three are from our

personal experiences and are used to highlight the thin line

between advocacy and paternalism.

Case 1

One of the most recent, well-known illustrations of the ‘thin

line’ was the case of Abraham Cherrix, a 15-year old male

diagnosed with Hodgkin’s lymphoma. Traditional chemo-

therapy did not achieve remission, and Abraham’s physicians

recommended high dose chemotherapy, radiation and a stem

cell transplant. With these treatments, they could predict only

a 50% chance of survival. The Cherrix family carefully

researched their options and decided their best one was to

pursue a natural remedy in Mexico. This decision resulted in

a national legal battle between the hospital, the Department

of Social Services, and the Cherrix family.

In the Juvenile and Domestic Court, Abraham’s parents

faced charges of neglect, loss of custody of their son, and

orders to submit to the physician’s recommended treatment.

They appealed and were cleared of all charges of medical

neglect. The higher court judge also allowed Abraham to

pursue alternative treatment, but with monitoring by a

board-certified oncologist. This case represents a particularly

tough ‘thin line’, because the patient’s age also made it a legal

issue (Simpson 2008).

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� 2009 The Authors. Journal compilation � 2009 Blackwell Publishing Ltd 1749

Case 2

A group from a large major medical centre in the United States

of America (USA) travelled to Africa on a medical mission trip.

The physicians in the African hospital were pleased to have the

advanced education and technical skills available. The African

patients were screened and challenging cases were treated. The

US nurses found that African patients spent considerably less

time in the intensive care unit than patients in the US. They also

found that in the African hospital care was paid for upfront by

patients and family members. The US nurses were concerned

about the lack of communication among patients, families and

physicians, as well as the financial repercussions of patient care

postoperatively. The nurses in the African hospital explained

that physicians always made these decisions and that the family

‘just goes along with it’. They raised the question of where the

appropriate place was for them to intervene on behalf of

patients and families.

In these stories, it is unclear whether advocacy or pater-

nalism is occurring. In the first case, it could be argued that

the physicians were advocating for the best outcome for Mr

Cherrix, and that the family was not making an unbiased and

informed decision. This same argument could be used in Case

2, where healthcare was often left in the hands of physicians,

despite the expense (ethical and financial) to patients. On the

other hand, these may be examples of paternalism, since

physicians were making the decisions completely, without

input from patient or family.

What nurses must do to clarify the ‘thin line’

Ideally, the patient, family and health care team act as

partners in the treatment process. Decision-making is a

shared event, with the final decision resting with the patient

or designated surrogate. Unfortunately, in today’s world, this

is not always the case. Historically, physicians have been in a

position of authority, and therefore have been seen as in the

best position to determine whether treatment goals could or

could not be accomplished and whether treatments were

viable or futile (Breier-Mackie 2001). The following case

depicts the ‘healthcare provider knows best’ mentality that is

at the heart of the debate about advocacy and paternalism.

Case 3

A nurse cared for a newborn baby with severe heart defects.

The parents had to decide whether or not the baby would

have surgery. Since they had no previous knowledge of the

condition or its seriousness, they had to trust what they were

told by healthcare providers to help them make the agonizing

decision of whether or not to operate. The cardiac surgeon

presented surgery as representing the difference between life

and death, and therefore the only option. There was no

mention of any alternatives, e.g. wait and see, heart trans-

plant, etc. The most frustrating thing for this nurse was that

the parents were not told what the likely long-term outcome

would be for either the patient or family (a lifetime of acute

and chronic illness). The rationale for this was that limited

information is best as parents are seldom able to fully

understand the anatomy of the normal heart, much less what

is happening with an abnormal heart. The nurse suffered

moral distress as she considered that the surgeon described a

falsely optimistic view of life after surgery, and the parents

did not receive all the information they needed to make the

best decision for their baby and the family.

The role of the nurse as advocate is to educate the patient and

family about their care so that they can make informed

decisions. In addition, nurses are responsible for making sure

that the voice of the patient is heard once decisions have been

made (Taylor 1995, Breier-Mackie 2001). When healthcare

providers replace the patient’s self-determination with their

own personal judgment, autonomy is removed. One strategy

that nurses can use to respond to this kind of ethical dilemma is

to ‘clarify the thin line’. This can be accomplished by assessing

the patient’s and family’s knowledge of the situation. After

assessment, nurses can clarify concepts, and answer questions

about care. This is consistent with Kohnke’s definition of

advocacy. However, if the physician withholds knowledge, this

puts the nurse in an awkward position. How much additional

information will help the parents make an informed decision?

If there is no clarification beyond the physician’s explanation,

this is probably a case of medical paternalism. Even if

information is withheld out of concern for the patient’s well-

being, it is hard to make a case that the individual’s autonomy is

being respected. Paternalism also occurs when healthcare

providers simplify the interventions being used in an intensive

care setting. This is done because of fear of overwhelming the

patient or family, and because of an assumption that the family

cannot handle the high technology and intensive interventions

in the intensive care unit (ICU). For example, healthcare

providers may not disclose all of the signs indicating poor

outcome, such as poor laboratory test result or vital signs, but

will only tell the patient or family what they want them to

understand. Healthcare professionals then make decisions

based on their own underlying experience and knowledge of

the situation. As a result, the patient and family do not have the

ability to make an informed decision, and autonomy is

displaced. The nurse must not forget that medical and technical

competence do not replace knowing a patient’s personal life

experiences or values (Taylor 1995).

In this situation, the nurse can clarify the thin line by

educating the family about decision-making alternatives, as

M. Zomorodi and B.J. Foley

1750 � 2009 The Authors. Journal compilation � 2009 Blackwell Publishing Ltd

well as the consequences of each decision in terms that they

will understand. The nurse should have the patient or family

explain their understanding of the situation in their own

words, and use those same words to clarify concepts and

answer questions regarding care. The patient and family

should feel confident that they can make a decision based on

their own goals and views of success, rather than the goals or

values of practitioners. The nurse must serve as a facilitator in

this process, and clarify information in order to separate the

concepts of paternalism and advocacy. The following case

depicts advocacy.

Case 4

A 79-year old woman was admitted to hospital with a urinary

tract infection. She quickly developed sepsis, had great diffi-

culty breathing, was nursed on a ventilator, and transferred to

the ICU. After being intubated for 10 days, she remained in a

coma, and the physician told her children that she needed to

have a tracheotomy. The children knew that their mother had

been lonely since their father died, and knew both orally and

through the woman’s living will that she did not want any

heroic measures if she had a terminal disease. They saw a tra-

cheotomy as moving their mother to a state where she could be

kept alive, but with decreasing hope that she would have the

independent life she had had prior to this illness. However, they

weighed the facts that she did not come into the hospital with a

terminal illness and that no one had told them she was currently

in a terminal state. Even though they were fully informed of the

slim odds of someone in this condition living independently

again, they chose the tracheotomy, due to the fact that the

urinary tract infection was not a terminal illness. As for clari-

fying the ‘thin line’, this family was informed of the percentage

of patients who fully recover from a similar situation, and then

made the decision they believed their mother would make. Had

they not been fully informed, this would have been a case of

medical paternalism.

Implications for nursing

As technological advances are made in the healthcare system

and patient acuity increases, nurses must be aware of the

distinctions between advocacy and paternalism and assess

where the ‘thin line’ begins and ends. Communication

strategies are key during this process. Asking open- ended

questions, using terms that the family prefers, educating in

small amounts, and taking time to answer questions have

been identified in the advocacy literature as useful strategies

(Taylor 1995, Erlen & Sereika 1997, Altun & Ersoy 2003,

Johnson 2004). In addition, nurses should have open discus-

sion with physicians, other nursing staff, and ethics commit-

tees to continue to raise awareness and resolve conflicts.

Advocacy and paternalism must be discussed at interdisci-

plinary rounds, and consciously taken into consideration

when making patient decisions. It is a nurse’s responsibility to

ensure that discussions take place and to develop communi-

cation strategies to eliminate ambiguity.

Conclusion

It is important for nurses constantly to examine the distinction

between the concepts of advocacy and paternalism, and discuss

them on an ongoing basis, since in many situations only a thin

What is already known about this topic

• Advocacy and paternalism in nursing are difficult to define and no clear delineation between the two con-

cepts exists.

• There are several definitions of advocacy and paternal- ism, and in some instances it is not clear whether

advocacy or paternalism is being upheld.

• There is need for more research on the concepts of advocacy and paternalism in nursing.

What this paper adds

• Nurses can participate in the debate about the distinc- tion between advocacy and paternalism if they have a

better understanding of these two concepts and the thin

line that exists between them.

• Weighing the ethical principles of beneficence and autonomy can help to clarify advocacy and paternalism

and provide avenues for discussion among nurses

practising in a variety of settings.

• Strategies such as knowing the patient, clarifying information, and educating all involved in the decision-

making process help to ensure that advocacy occurs.

Implications for practice and/or policy

• A holistic approach needs to be taken to assess a patient’s and family’s wishes, desires and needs in order

to effectively advocate for the patient, thus clarifying

the ‘thin line’.

• Communication between the family, patient and healthcare team is imperative if we are to clarify the

thin line between advocacy and paternalism.

• Further research is needed on nurses’ views of advocacy and paternalism as well as the development of strategies

to assist them in identifying and responding to these two

concepts.

JAN: CONCEPT ANALYSIS The ‘thin line’

� 2009 The Authors. Journal compilation � 2009 Blackwell Publishing Ltd 1751

line can distinguish these two concepts. Truly ‘knowing’

patients, their life experiences, values, beliefs, and wishes can

help distinguish this line in order to care for patients ethically

rather than violating their basic rights because we think we

know best. Initiating discussions about ethical principles,

identifying evidence based practice, encouraging interdisci-

plinary communication, educating the patient, and developing

leadership skills should be at the foundation of all nursing

programs and nursing employers. Nursing has a strong voice

when united and silence is not an option.

Funding statement

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

Conflicts of interest

No conflict of interest has been declared by the authors.

Author contributions

MZ & BJF were responsible for the study conception and

design. MZ & BJF performed the data collection. MZ & BJF

performed the data analysis. MZ & BJF were responsible for

the drafting of the manuscript. MZ & BJF made critical

revisions to the paper for important intellectual content. BJF

supervised the study.

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The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the

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