Cent Eur J Nurs Midw 2026, 17(3):2507-2517 | DOI: 10.15452/cejnm.2026.17.0018

An examination of the relationship between midwives’ and nurses’ patient advocacy and submissive behavior: a cross-sectional study

Şerife Kelle Dikbaş, İrem Erkal, Asiye Aslı Esmer, Kübra Helvacı
Midwifery Department, Faculty of Health Sciences, Üsküdar University, Istanbul, Turkey

Aim: The objective of this study was to examine the relationship between patient advocacy and submissive behaviors among midwives and nurses.

Design: A cross-sectional, descriptive study was conducted.

Methods: The study population consisted of midwives and nurses working in Turkey. The study was completed with 430 midwives and nurses who were actively working between April and June 2025, volunteered to participate in the study, and had at least a bachelor’s degree. Research data were collected using a personal information form, the Patient Advocacy Scale for Nurses, and the Submissive Behavior Scale. The data were analyzed using the SPSS Statistics 26 software package.

Results: Midwives and nurses had high mean patient advocacy scores (162.11 ± 20.31) and low mean submissive behavior scores (29.72 ± 9.79). A negative and significant relationship was found between the mean scores on the advocacy and submissive behavior scales.

Conclusion: Midwives and nurses with high advocacy scores exhibit low submissive behaviors.

Keywords: advocacy, midwifery, nursing advocacy, patient advocacy, submissive behavior

Received: November 21, 2025; Revised: April 25, 2026; Accepted: August 6, 2026; Published: September 6, 2026  Show citation

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Kelle Dikbaş Ş, Erkal İ, Esmer AA, Helvacı K. An examination of the relationship between midwives’ and nurses’ patient advocacy and submissive behavior: a cross-sectional study. Central European Journal of Nursing and Midwifery. 2026;17(3):2507-2517. doi: 10.15452/cejnm.2026.17.0018.
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    References

    1. Abbasinia, M., Ahmadi, F., & Kazemnejad, A. (2020). Patient advocacy in nursing: a concept analysis. Nursing Ethics, 27(1), 141-151. https://doi.org/10.1177/0969733019832950 Go to original source... Go to PubMed...
    2. Alanezi, F. Z. (2022). Nurses' attitude towards patient advocacy in a single tertiary care hospital. Nursing Open, 9(6), 2602-2607. https://doi.org/10.1002/nop2.958 Go to original source... Go to PubMed...
    3. Boynukisa, C., & Akin, B. (2022). Hemşirelik öğrencilerinin hasta savunuculuğu konusundaki düşünceleri [Nursing students' perspectives on patient advocacy]. In 6. Uluslararasi 24. Ulusal Halk Sağliği Kongresi (pp. 667-668). Halk Sağliği Uzmanlari Derneği.
    4. Cerit, B., & Evler, E. S. (2020). Hemşirelerde boyun eğici davranişlarin mesleki benlik saygisina etkisi [Impact of submissive behavior on professional self-esteem in nurses]. Kirikkale Üniversitesi Tip Fakültesi Dergisi, 22(3), 314-321. https://doi.org/10.24938/kutfd.759133 Go to original source...
    5. Dadzie, G., Aziato, L., & Aikins, A. G. (2017). "We are the best to stand in for patients": a qualitative study on nurses' advocacy characteristics in Ghana. BMC Nursing, 16(1), 61. https://doi.org/10.1186/s12912-017-0259-6 Go to original source... Go to PubMed...
    6. Dağlar, G., Bilgiç, D., & Kaya, S. (2020). Ebelik öğrencilerinin klinik uygulamalarda karşilaştiklari şiddet ve boyun eğici davranişlar arasindaki ilişki [The relationship between violence experienced by midwifery students in clinical practice and their submissive behaviors]. Sivas Cumhuriyet Üniversitesi Sağlik Bilimleri Enstitüsü Dergisi, 5(3), 187-199.
    7. Dönmez, A., Yeyğel, Ç., & Kilinç, D. (2022). Sağlik hizmet uygulamalarinda etik karar verme süreci [The ethical decision-making process in healthcare practice]. İZTÜ Tip ve Sağlik Bilimleri Dergis, 1(2), 65-74.
    8. Engward, H., Goldspink, S., Abdulmohdi, N., & Alexander, M. (2023). Understanding professional advocacy: a mixed method approach to explore professional nurse advocacy and professional midwifery advocacy in one NHS trust [Preprint]. Research Square. https://doi.org/10.21203/rs.3.rs-3740297/v1 Go to original source...
    9. Gerber, L. (2018). Understanding the nurse's role as a patient advocate. Nursing, 48(4), 55-58. https://doi.org/10.1097/01.NURSE.0000531007.02224.65 Go to original source... Go to PubMed...
    10. Gilbert, P., & Allan, S. (1994). Assertiveness, submissive behaviour and social comparison. British Journal of Clinical Psychology, 33(3), 295-306. https://doi.org/10.1111/j.2044-8260.1994.tb01125.x Go to original source... Go to PubMed...
    11. Gong, W., Tang, J., Chen, Y., & Ma, J. (2024). Collaborative communication: a qualitative study of roles and emphases of health care providers in obstetrics and gynecology. Journal of Multidisciplinary Healthcare, 17, 1913-1922. https://doi.org/10.2147/JMDH.S457056 Go to original source... Go to PubMed...
    12. Hemşirelik Fakülteleri Dekanlar Konseyi. (2022). Hemşirelik ulusal çekirdek eğitim programi (HUÇEP-2022) [Nursing national core education program (HUÇEP-2022)]. Hemşirelik Eğitimi Derneği.
    13. International Confederation of Midwives. (2022, November 3). History of midwifery: the role of advocacy in midwifery. https://internationalmidwives.org/history-of-midwifery-the-role-of-advocacy-in-midwifery/
    14. International Council of Nurses. (2021, October 20). The ICN code of ethics for nurses (Revised 2021). https://www.icn.ch/resources/publications-and-reports/icn-code-ethics-nurses
    15. Josse-Eklund, A., Jossebo, M., Sandin-Bojö, A. K., Wilde-Larsson, B., & Petzäll, K. (2014). Swedish nurses' perceptions of influencers on patient advocacy: a phenomenographic study. Nursing Ethics, 21(6), 673-683. https://doi.org/10.1177/0969733013515488 Go to original source... Go to PubMed...
    16. Kolawole, I. O. (2017). Nurses' perception and patients' validation of nurses' advocacy roles in promotion of surgical patients' safety and rights in three hospitals, Ibadan, Nigeria. West African Journal of Nursing, 28(1).
    17. Kurt, D., & Gurdogan, E. P. (2023). Professional autonomy and patient advocacy in nurses. Collegian, 30(2), 327-334. https://doi.org/10.1016/j.colegn.2022.09.015 Go to original source...
    18. Negarandeh, R., & Dehghan Nayeri, N. (2012). Patient advocacy practice among Iranian nurses. Indian Journal of Medical Ethics, 9(3), 190-195. https://doi.org/10.20529/ijme.2012.063 Go to original source... Go to PubMed...
    19. Negarandeh, R., Oskouie, F., Ahmadi, F., Nikravesh, M., & Hallberg, I. R. (2006). Patient advocacy: barriers and facilitators. BMC Nursing, 5(1), 3. https://doi.org/10.1186/1472-6955-5-3 Go to original source...
    20. Omar, F. A. A., Eltarhuni, A., Elamrony, R. M. G., & Kutran, H. (2023). Nurses' awareness of patient privacy and confidentiality in Benghazi Medical Centre (BMC): a cross-sectional study. Libyan Journal of Dentistry, 7(1), 22-30. https://doi.org/10.37376/ljd.v7i1.4076 Go to original source...
    21. Özdemir, M. H., Can, İ. O., Ergönen, A. T., Hilal, A., Önder, M., & Meral, D. (2009). Midwives and nurses' awareness of patients' rights. Midwifery, 25(6), 756-765. https://doi.org/10.1016/j.midw.2008.01.010 Go to original source... Go to PubMed...
    22. Panda, S., Dash, M., John, J., Rath, K., Debata, A., Swain, D., Mohanty, K., & Eustace-Cook, J. (2021). Challenges faced by student nurses and midwives in clinical learning environment - a systematic review and meta-synthesis. Nurse Education Today, 101, 104875. https://doi.org/10.1016/j.nedt.2021.104875 Go to original source... Go to PubMed...
    23. Park, S. Y. (2024). Patient advocacy in nursing: an integrative literature review. Korean Journal of Health & Nursing, 1(1), 13-23. https://doi.org/10.12972/kjhn.2024.01.01.02 Go to original source...
    24. Pazarcikci, F., & Dilmen, B. (2019). Hemşirelik eğitimine yeni başlayan öğrencilerin meslek seçimini etkileyen faktörler ile boyun eğici davranişlari arasindaki ilişkinin incelenmesi [Examining the correlation between factors affecting the choice of profession of freshmen in nursing education and their submissive behaviour]. Süleyman Demirel Üniversitesi Vizyoner Dergisi, 10(25), 599-611. https://doi.org/10.21076/vizyoner.590976 Go to original source...
    25. Sağlik-Der. (2023). Türkiye sağlik raporu 2023 [Turkey Health Report 2023].
    26. Savaşir, I., & Şahin, N. H. (1997). Boyun eğici davranişlar ölçeği [Submissive Behaviour Scale]. In Bilişsel-davranişçi terapilerde değerlendirme: sik kullanilan ölçekler (pp. 100-103).
    27. Şermet, E. (2019). Hemşireler için hasta savunuculuk ölçeğinin geliştirilmesi [Development of the Patient Advocacy Scale for Nurses] [Master's thesis, Marmara Üniversitesi].
    28. Stoddart, R., Simpson, P., & Haire, B. (2020). Medical advocacy in the face of Australian immigration practices: a study of medical professionals defending the health rights of detained refugees and asylum seekers. PLoS ONE, 15(8), e0237776. https://doi.org/10.1371/journal.pone.0237776 Go to original source... Go to PubMed...
    29. Tadie, A., Muche, M., Liknaw, T., & Edmealem, A. (2024). Nurses' attitude towards patient advocacy and its associated factors in East Gojjam Zone public hospitals, Northwest Ethiopia, 2023. BMC Nursing, 23(1), 561. https://doi.org/10.1186/s12912-024-02206-2 Go to original source... Go to PubMed...
    30. Thompson, S. M., Low, L. K., Budé, L., de Vries, R., & Nieuwenhuijze, M. (2021). Evaluating the effect of an educational intervention on student midwife self-efficacy for their role as physiological childbirth advocates. Nurse Education Today, 96, 104628. https://doi.org/10.1016/j.nedt.2020.104628 Go to original source... Go to PubMed...
    31. Türkiye İstatistik Kurumu. (2022). Sağlik personeli sayilarinin illere göre dağilimi, 2002-2022 [Distribution of healthcare personnel by province, 2002-2022]. TÜİK. https://data.tuik.gov.tr/
    32. van der Pijl, M. S. G., Kasperink, M., Hollander, M., Verhoeven, C., Kingma, E., & de Jonge, A. (2021). Client-care provider interaction during labour and birth as experienced by women: respect, communication, confidentiality and autonomy. PLoS ONE, 16(2), e0246697. https://doi.org/10.1371/journal.pone.0246697 Go to original source...
    33. Yükseköğretim Kurulu. (2025). Ebelik ulusal çekirdek eğitim programi (EBE-UÇEP 2025) [Midwifery national core education program (EBE-UÇEP 2025)]. Yükseköğretim Kurulu.

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