Embedding the A-EQUIP model of restorative supervision in a critical care unit by professional nurse advocates

Clinical supervision is a term used to describe a formal process of professional support and learning that enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance patient/client protection and safety of care in complex clinical situations (NHS Employers, 2022). Clinical supervision is not a new concept to nursing. The term clinical supervision has been described as an umbrella term that provides little clarity of its function and purpose (Gonge and Buus, 2011). There have been criticisms of clinical supervision in nursing due to strategies being left to local decision-makers, with no clear overall vision as to how it should be introduced and performed. Wallbank and Hatton (2011) suggested that the effect and purpose of clinical supervision has been unclear, resulting in poorly structured and inconsistent approaches.

Numerous reviews following high-profile failings in NHS care have exposed a lack of a nursing voice and empowerment when concerns are identified (Francis, 2010; Keogh, 2013; Kirkup, 2015; Gosport Independent Panel, 2018; Department of Health and Social Care, 2018). One such action that ensued from the evaluation of failings within midwifery services was that statutory supervision was no longer deemed suitable or fit for practice (Rouse, 2019). In response to the action around statutory supervision, the Advocating for Education and Quality Improvement (A-EQUIP) model was introduced in April 2017 (NHS England, 2017) with professional midwifery advocates (PMA) replacing statutory midwifery supervision.

At the end of the third wave of COVID-19 in 2021, NHS England launched the professional nurse advocate (PNA) training programme. This was identified as a critical point of recovery for both patients and staff (NHS England, 2021). The role of the PNA emerged from the success of PMAs and the positive impact the role has had on staff wellbeing, staff retention, improved patient outcomes and professional resilience (May, 2021). Research from the implementation of the PMA has shown that restorative supervision develops and encourages resilience in staff, leading to personal and professional growth, which in turn contributes to patient safety (Wallbank and Wonnacott, 2015; Macdonald, 2019). There is limited literature relating to the professional nurse advocate role, but the PMA role has been reported to achieve positive outcomes, resulting in safer decision-making and patient care (Wallbank and Hatton, 2011).

Following its successful implementation in midwifery, the A-EQUIP model was adapted for the nursing profession to improve and develop professional nurse clinical leadership and advocacy. The four elements of A-EQUIP, advocating for patients, nurses and healthcare staff, provision of restorative clinical supervision (RCS), personal action for quality improvement and the promotion of education and development for nurses, are relevant for all nurses, student nurses and providers of nursing services (NHS England, 2021).

The unprecedented pressures placed upon staff during the pandemic resulted in strain on the nursing workforce, with negative impacts on personal resilience, and resulting in higher levels of stress and burnout. The role of the PNA was created in response to this (Manzano García and Ayala Calvo, 2022). Prior to the implementation of the PNA role there were no formal mechanisms of clinical supervision in the author's critical care unit. The PNA programme is a level 7 accredited course, which assesses students via a competency portfolio and academic assessment. Recommendations are for one PNA to 20 registered nurses. The training equips the PNA to listen, understand the challenges and demands of colleagues, and to lead, support and deliver quality improvement initiatives (NHS England, 2022). This article discusses the implementation of the PNA role in an 18-bed critical care unit that employs 83 registered nurses. There were no supervisory roles for the newly qualified PNAs in this area due to them being part of the first national 400 registered nurses to take up this position. However, support was given from the senior nursing team within the organisation. The trust is now about to appoint a lead PNA to supervise and support implementation of the role across the organisation.

Pre-implementation

Before implementation of the role and to understand the existing knowledge that staff had around the role, a questionnaire was sent to all staff. Of the relevant 83 staff members, 53 responded (a response rate of 63%).

Results showed most respondents thought restorative supervision would provide elements of psychological support, with 64% feeling the role would have a positive impact on the multidisciplinary team. Seventy-five per cent felt the PNA would advocate for staff. It was positive to note that 70% of staff thought that they could discuss their wellbeing at work. When asked how they were currently feeling at work, the most frequent answers were happy, calm and tired. Staff were also asked to use a colour to express how they were feeling. The three most shared challenges that staff said they were experiencing were being moved to cover other wards, feeling tired and COVID-19. When asked to rate on a scale of 1-10 how they currently felt at work, 71% of respondents rated their feeling as 7 or above (Table 1). This was felt to be a positive base on which to begin education around implementation of the A-EQUIP model.

To examine the feelings of staff in further detail, a professional quality-of-life scale (ProQOL) scale was distributed to all 83 staff members (Stamm, 2010), with a response rate of 68%. The scale considers compassion, satisfaction, burnout, and secondary traumatic stress.

Compassion in this context is described as the pleasure staff gain from being able to perform the caring aspect of their work well. Higher scores in this category demonstrate higher satisfaction in relation to being an effective caregiver. The results demonstrated that staff had a good deal of professional satisfaction, with ‘medium’ scoring 79% for the compassion satisfaction score on the ProQOL scale (Table 2).

Burnout is associated with negative feelings, such as hopelessness and difficulty in working effectively within a person's job role, and is often associated with a high workload (Stamm, 2010). Results demonstrated that most staff surveyed (57%) were at low risk of burnout, with 40% at medium risk of burnout (Table 2).

Joinson (1992) suggested that secondary traumatic stress is a component of compassion fatigue – the latter was first described as a unique form of burnout that affects individuals in care-giving roles (Joinson, 1992).

Experiencing other people's traumatic events during the course of clinical work can result in secondary traumatic stress, with staff reporting difficulty sleeping and/or replaying images of the event repeatedly. Results indicate that the staff surveyed were at low risk of secondary traumatic stress.

Following the survey results, a poster and charter were developed in order to share information and expectations with the nursing team. The charter has been adapted to be used at a regional level and the poster won a trust innovation award.

Further developments included the introduction of a structured crib sheet to support the trained PNAs, who expressed concerns and anxiety around delivery of the initial RCS session.

Implementation

Initially, sessions were offered at pre-arranged dates and times; however, staff were often unable to attend due to clinical activities and demanding workloads. It became apparent that creative and flexible ways of offering RCS would need to be considered to facilitate staff attendance.

The PNAs were able to hold regular sessions with nursing students during practice placements. Supernumerary status provided protected time for students to be released from clinical activity and provided opportunities for newly qualified PNAs to facilitate group sessions. This allowed the PNAs to gain experience and confidence in the delivery of RCS sessions, while trying to overcome challenges to release registered nurses from clinical duties for RCS sessions. An example of how a typical RCS session is conducted is provided in Box 1.

Box 1.A typical professional nurse advocate restorative clinical supervision sessionProfessional nurse advocate (PNA) restorative clinical supervision (RCS) sessions are held in a quiet room to provide staff with a safe space. The PNA will introduce the group session and describe the role of the PNA. This is followed by the establishment of ground rules and a safe space agreement. The group will make their own rules but, typically, these will include that sessions would involve confidentiality, respect and non-judgmental listening, with the aim of bringing focus and clarity to the themes discussed. Accepting each other's views, and aiming for the staff/student nurse to leave the session feeling better than they did when it began, was another aim.If required, as the PNA, the author would lead a grounding exercise to help the students/nurses to focus on the ‘here and now’. Following this, all members ‘check in’ − each person has around two minutes to share their feelings, with the focus being on feelings/emotions and not events. This allows the PNA to identify shared emotions and gain a focus for the reflective discussion.During the reflective discussion each member is given more time to discuss their feelings. Positive reframing is used if required, alongside members of the group offering suggestions to help a person move forward. Individual strengths are recognised, and unhelpful personal expectations are challenged. The group will then be guided to respond to themes using action plans or quality improvement initiatives, if appropriate. The session concludes with a ‘check out’ of how the nurse/students feel after sharing their feelings.

The A-EQUIP model is to be used for all nurses, nursing students and providers of nursing services (NHS England, 2021). The students gave positive quantitative feedback, highlighting some of the many benefits of RCS. One student said:

‘Really enjoyed the session, I feel supported and comforted, thank you.’

It was evident from the feedback that students often encounter similar challenges during clinical practice placements:

‘Good to talk to others going through the same things.’

A flexible range of delivery methods are offered to improve accessibility for registered nurses to attend sessions.

Although some of the PNA sessions are predetermined, several sessions take place on a one-to-one unplanned basis. Such sessions are usually at the request of a staff member who has encountered a demanding situation at work, or who is feeling upset or anxious and is having difficulty processing emotions.

Group sessions are offered following a critical incident, with staff who have been involved invited to attend. Group-based sessions are held within the trust wellbeing centre at a pre-arranged date/time that is convenient to all staff members involved. Quantitative evaluation would suggest that staff have found group sessions helpful. One nurse commented:

‘Really good to get things off my chest.’

Another nurse valued the opportunity to talk confidentially:

‘Good to have opportunity to talk in a safe space.’

A significant part of the A-EQUIP model is to consider opportunities for quality improvement initiatives. Anecdotally, staff have felt empowered to be able to influence future practice. Another notable benefit following PNA sessions is the potential to retain staff who would have otherwise left the clinical environment or the organisation. For example, two staff members who had intended to leave, remained in their roles following sessions with the PNA.

Regular weekly drop-in sessions were scheduled; however, staff did not attend. Some of the challenges cited in relation to non-attendance were clinical pressures, demanding workloads and staff did not want to travel into work during time away from clinical practice. Following this, group feedback sessions were offered after mandatory training sessions that staff were required to attend. Such an approach has proved popular with a significant increase in attendance. Qualitative feedback, once again, highlights the potential benefits of a well-run PNA session. One nurse said:

‘I have learned coping mechanisms that I will use in my future practice.’

Sessions seems to be particularly well received in the post-COVID-19 phase, where staff are managing complex clinical situations with competing demands in terms of clinical priorities. One nurse commented:

‘Sessions are very important in this current climate.’

Other themes emerged around thoughts and feelings, emphasising the need to conduct PNA sessions in a safe and confidential space. Nurses commented as follows:

‘Really helpful session. I could discuss my problems and feelings and was responded to empathetically.’

‘Taught me to express my feelings and thoughts and that it's OK to do that.’

‘Prioritise self-care in my work.’

A significant number of staff from one clinical area within critical care were successful at interview for junior sister/junior charge nurse posts. A PNA session was held for this staff group to discuss their successes and challenges. To deliver the session a flexible approach was offered so that some staff could attend in person and others via Teams, which resulted in all invited members attending. This blended approach did not negatively impact the session and PNAs felt that they would be comfortable in offering this hybrid approach in the future.

Staff who are absent from work with a stress-related issue are offered a PNA session when they return to work.

At the time of writing, 36 sessions have been provided to 73 members of staff. There have been several quality improvement initiatives, career conversations alongside staff referrals to their GP/occupational health staff. The PNAs intend to re-audit using the same questionnaires one-year post-implementation.

It is important to acknowledge that the PNA also requires supervision. Bi-monthly group sessions are offered alongside one-to-one peer PNA support. There is also a national community of practice groups that provide support for critical care PNAs to share practice and ideas (see https://future.nhs.uk).

Discussion

It can be daunting to implement the role of the PNA into any area of clinical practice. It is worthwhile taking time to plan a bespoke approach before implementation. Communication is essential to inform staff about the PNA role and what to expect from RCS. The use of the author's trust's PNA charter supports understanding and defines the expectations of all those involved. Sharing practice and ideas with fellow PNAs is beneficial for support and improvements to practice.

A crib sheet can be useful, particularly when new to the role to keep a structure to sessions. Within this NHS Trust staff are fortunate to have support from senior nurses/directors of nursing for the project. The author recommends readers should speak to senior staff to understand their vision of the PNA role for their organisation and how they can be part of it.

The NHS is under unprecedented pressure in the current climate and, despite best planning, implementation of the role may not go as planned, but persistence and flexibility can result in staff attending sessions. PNAs in the author's trust find the sessions very rewarding and get real satisfaction from the PNA role. This keeps staff motivation going and encourages them to find new ways to organise sessions.

KEY POINTS

• The role of the professional nurse advocate (PNA) has emerged as a response to exceptional challenges and pressures following the COVID-19 pandemic
• PNAs are trained to use the A-EQUIP model to facilitate restorative clinical supervision, promote education, advocate for patients and staff, and enable nurses to take personal action for quality improvement
• It can be daunting to implement the role into a clinical area. There are forums sharing good practice to guide and support PNAs in their role and to share advice and information with other PNAs
• Although it can be challenging, with persistence and flexibility, nurses can begin to embed the PNA role in their clinical area

CPD reflective questions

• What are the benefits of restorative clinical supervision (RCS) and what could RCS sessions bring to your clinical area?
• What are the challenges associated with the professional nurse advocate (PNA) role?
• How could you share and celebrate quality improvement initiatives that ensue from RCS?
• How could you evaluate and demonstrate the impact of the PNA role?