Abstract
This article explores the role of the professional nurse advocate (PNA) in supporting the nursing workforce through restorative clinical supervision. It outlines the theoretical framework of the A-EQUIP model, which emphasises advocacy, education, quality improvement, and understanding. Initially introduced in midwifery, the PNA role has been expanded to all nursing areas to address issues such as burnout and workforce challenges, particularly those intensified by the COVID-19 pandemic. PNAs provide a safe space for nurses to reflect on their practice, support their wellbeing, and lead quality improvement initiatives. The role is crucial for fostering a positive work environment, enhancing nurse retention, and improving patient care. The training and skills required by PNAs are discussed, along with the benefits and challenges of implementing this role, and its broader impact on the healthcare workforce.
The aim of the professional nurse advocate (PNA) role is to provide support to registered nurses through restorative clinical supervision in the following areas: wellbeing, education and clinical. This is a new role that is designed to be the key enabler of the NHS England Advocating and Educating for Quality Improvement (A-EQUIP) model of professional nursing leadership and clinical supervision (NHS England, 2023).
The role was first introduced in 2016 in midwifery as an employer-led model of supervision enacted by professional midwifery advocates (Capito et al, 2022). Following a successful rollout in midwifery, it was decided that this method of restorative clinical supervision would be rolled out to all areas of nursing practice. This was to provide a clinical model of restorative supervision that allows nurses who are PNA trained to listen to colleagues and understand the challenges experienced by them and to lead in response to these challenges and quality improvement initiatives (Royal College of Nursing (RCN), 2023). However, following the COVID-19 pandemic there was a sense of urgency to ensure this was undertaken. There was a recognition that the NHS workforce needed to recover from the pandemic and a reset was planned through the use of a new model of clinical supervision. In addition to the challenges brought about by the pandemic were the challenges that had arisen from the longstanding workforce issues. The issues in the UK include concerns about working conditions and high vacancy rates. The NHS Confederation (2021) reported that, to support the wellbeing and health of its staff, there was a requirement for NHS staff to have restorative supervision.
In 2021, NHS England commissioned training for the PNA role, which has emerged as an important one in terms of supporting staff in practice (NHS England, 2023). The PNA role enables staff who undertake it to develop a new set of skills and potentially enrich their own practice through an additional responsibility. The role aims to support nurses in their professional and emotional wellbeing, which is critical to maintaining high standards of patient care and fostering a positive work environment. The PNA role is crucial for promoting a positive and supportive work environment, improving nurse retention, and ultimately enhancing the quality of healthcare delivery (RCN, 2023).
Who can undertake the role?
The PNA role is available for any NMC registered nurse working at a patient-facing band 5 role or above who has studied to a bachelor's degree level. NHS England aspires to commit to training at least one in twenty nurses to have the PNA qualification by 2025 (NHS England, 2023: section 2.2). The PNA will have the skills and knowledge to provide restorative supervision, lead quality initiatives and contribute to a positive learning culture. PNAs uphold the NMC (2018) professional standards of practice and behaviour and lead with emotional intelligence to provide a ‘safe space’ for colleagues in which to reflect on their practice and which supports them to feel a sense of belonging, contribution and autonomy (West et al, 2020; NHS England, 2023).
The RCN has conducted an initial evaluation on those who have completed the PNA programmes and found that those who have completed it have experienced improved feelings of empowerment, and those who have accessed the PNA facilitated supervision have reported encouraging experiences (RCN, 2023). PNAs undergo specific training to deliver restorative clinical supervision and support. Their role is crucial in addressing staff burnout, mental health challenges, and retention issues within the NHS. However, given that the PNA is not required to have mental health training, they should not provide psychological interventions. Instead, they should signpost staff to appropriate resources when needed. The PNA can provide emotional support and a safe space for reflection. This model also aligns with the NHS Long Term Plan's focus on workforce wellbeing, quality of care, and leadership (NHS England, 2019).
Key aspects of the PNA role are:
Support and advocacy for nurses: PNAs help nurses process their experiences, reflect on their practice, and address challenges such as stress, burnout, or moral distress. They provide a safe space for nurses to discuss concerns and work towards solutions
Restorative supervision: a core element of the PNA role is offering restorative clinical supervision, which helps nurses reflect on their practice in a non-judgmental, supportive setting. This is vital for mental wellbeing and maintaining resilience in a demanding profession (Mann et al, 2020)
Promoting reflective practice: PNAs encourage reflective practice, enabling nurses to learn from their experiences, celebrate successes, and identify areas for growth. This process contributes to continuous professional development and better patient care (Gibbs, 1988)
Advocacy for quality care: PNAs advocate for high standards in nursing care by addressing systemic issues that may affect patient outcomes, such as staffing levels, resources, and working conditions (NHS England, 2023)
Improving patient experience: by supporting the nursing workforce and ensuring their wellbeing, PNAs contribute to better patient care, as a well-supported nursing team is more engaged, motivated, and effective (RCN, 2023)
Educational role: PNAs also facilitate training and development opportunities for nurses, ensuring that they have access to the latest evidence-based practices and encouraging lifelong learning.
Theoretical model used: A-EQUIP
The role is grounded in the principles of the A-EQUIP (Advocating for Education and Quality Improvement) model, originally developed for midwives, and adapted for nurses (NHS England, 2023; 2025). The A-EQUIP model has four key functions:
Restorative supervision – helping nurses reflect on their practice, reducing burnout, and improving emotional resilience
Personal action for quality improvement – enabling nurses to identify and lead quality improvement initiatives
Education and development – facilitating continuous professional development and career progression
Advocacy – supporting nurses in their workplace challenges, whether related to patient care, professional development, or work-life balance.
The PNA programme, specifically its A-EQUIP model, is an innovative initiative designed to support nurses in their professional development and wellbeing. The A-EQUIP model is broken down as follows:
Advocating for education (A): PNAs act as facilitators, helping nurses identify educational opportunities for professional growth. Continuous education is essential in nursing to keep up with rapidly advancing medical practices, technologies, and evidence-based care. PNAs ensure that nurses are encouraged and supported in their learning journey
Educating and developing (E): PNAs provide direct support in skill-building, clinical decision-making, and resilience training. They may offer one-on-one mentoring or group workshops to address skills gaps and promote professional development
Quality improvement (Q): PNAs support the continuous quality improvement process. They work with nurses to identify areas in need of improvement, collect and analyse data, and implement changes that benefit both the patient and the care team
Understanding (U): PNAs promote self-reflection and personal awareness among nurses. They provide safe spaces where nurses can express their challenges and emotions, helping them process experiences healthily
Improvement (I): PNAs encourage a culture of self-improvement, inspiring nurses to continually assess their practice and strive for excellence
Professional role (P): PNAs champion the professional role of nurses. They support their peers in advancing through career progression and achieving professional goals.
Implementation of the A-EQUIP model in practice
In practical terms, the model is implemented through training, integration into settings, reflective supervision and quality improvement initiatives. PNAs are trained through specific educational programmes. These programmes involve advanced training in coaching, leadership, reflective practice, and quality improvement methods (Flack and Abdulhohdi, 2023). Following training, PNAs are introduced into hospitals, community health services, and other care settings to provide ongoing support (Smythe et al, 2023). Reflective supervision is a key part of the A-EQUIP model, involving regular one-on-one or group sessions where nurses can discuss their experiences and challenges (NHS Employers, 2024). PNAs are also involved in leading or supporting quality improvement projects within their clinical areas (NHS Employers, 2022).
Outcomes of the A-EQUIP model
The A-EQUIP model is pivotal in providing emotional support, promoting wellbeing, fostering personal and professional development, and improving the quality of care in nursing. PNAs act as both mentors and advocates, ensuring that nurses have the tools and resources they need to thrive in their roles while maintaining their health and wellbeing (NHS England, 2023). The outcomes have been:
Improved nurse wellbeing: one of the most significant outcomes of the A-EQUIP model has been its impact on nurse wellbeing. Reflective practice and supervision have provided a structured outlet for emotional support, reducing burnout rates by providing a structured way to reflect on work-related stress and challenges (Scanlan and Hart, 2024) and improving job satisfaction. PNAs help nurses feel valued and listened to, creating a supportive environment that fosters both personal and professional growth
Retention and workforce stability: retention of nursing staff is a critical issue in health care. By supporting nurses through emotional challenges and helping them achieve their career goals, the A-EQUIP model has been shown to improve retention rates. Hospitals and healthcare providers that have implemented the model report fewer staff shortages and a more stable workforce, as nurses feel better supported in their roles (Jennison and Walker, 2023)
Enhanced patient care: through its focus on continuous quality improvement, the A-EQUIP model has had a direct impact on patient care. Nurses are better equipped to implement evidence-based practices, identify and address care delivery issues, and provide safer, more effective care (Scanlan and Hart, 2024). Teams that engage with PNAs also report improved collaboration and communication, which enhances the overall patient experience
Leadership development: the model encourages nurses to take on leadership roles and contribute to decision-making processes in their teams. This is part of a plan to grow a pool of nurse leaders who are better prepared to drive innovation and advocate for improvements in care (NHS England, 2021)
Positive organisational culture: the introduction of PNAs has contributed to a shift in organisational culture, fostering a more open and supportive atmosphere. Nurses are encouraged to discuss challenges, share ideas, and take an active role in improving care delivery, leading to a more engaged and motivated workforce (NHS Employers, 2022).
Successfully overcoming the challenges of implementing the A-EQUIP model requires a combination of organisational support, clear role definition, adequate resources, and ongoing professional development for PNAs. By fostering a culture of reflection, continuous improvement, and wellbeing, healthcare organisations can create a more resilient nursing workforce and improve patient outcomes.
Key challenges in implementation and strategies to address these
Addressing workload and time constraints
PNAs often struggle to balance their advocacy and support roles with their clinical duties, especially in busy healthcare environments. The heavy workload can limit the time they have to dedicate to reflective practice, mentorship, and quality improvement projects.
Strategies
Protected time for PNAs: ensure that PNAs are given protected time away from their clinical duties to carry out their advocacy work. This means scheduling time where they are solely focused on A-EQUIP responsibilities, such as leading reflective sessions or working on quality improvement initiatives (Beckwith, 2022)
Workforce planning: incorporate the PNA role into workforce planning to ensure adequate staffing levels that allow PNAs to fully perform their functions without overwhelming clinical teams (Bridger, 2025)
Clear role definition: clearly define the scope of the PNA's role within the team to prevent overloading them with additional clinical responsibilities. This ensures that PNAs are focused on their core duties of supporting staff wellbeing and quality improvement (Intensive Care Society, 2024).
Securing organisational buy-in
Gaining widespread support for the A-EQUIP model across all levels of the organisation can be difficult, especially when staff are unaware of the benefits or when senior management does not fully endorse the model.
Strategies
Leadership engagement: involve senior leadership from the outset by demonstrating the value of the A-EQUIP model in improving workforce wellbeing, retention, and patient outcomes. Present data from pilot programmes or other successful implementations to gain their support
Awareness and communication campaigns: develop communication strategies to raise awareness of the PNA role among nursing staff and management. Use presentations, workshops, and internal communications to explain the benefits of the A-EQUIP model and how it aligns with organisational goals
Pilot programmes: start with pilot programmes in selected departments or wards to demonstrate the positive impact of PNAs. Once the results are visible, it will be easier to scale the model across the organisation.
Integrating the PNA role into the culture
In some organisations, nurses may be unfamiliar with reflective practice or hesitant to engage in the A-EQUIP model due to time pressures or cultural resistance to change.
Strategies
Cultural change initiatives: embed the PNA role into the organisation's culture by promoting a shift toward reflective practice and continuous learning. Encourage an open environment where discussing challenges, seeking support, and self-improvement are normalised (Adegboye et al, 2023)
Mentorship and role models: leverage experienced PNAs as mentors to guide new PNAs and nursing staff in embracing the A-EQUIP model. Role modelling positive engagement with the PNA can foster buy-in from nurses who may initially be resistant (Wade, 2023)
Regular feedback loops: establish ongoing feedback mechanisms to allow nurses to share their experiences with PNAs. Actively seek feedback on the PNA's impact and make necessary adjustments to ensure their support aligns with the needs of the staff (Adegboye et al, 2023).
Ensuring adequate resources
Implementing and sustaining the A-EQUIP model requires resources for training, staffing, and ongoing support. In resource-limited settings, there may be challenges in funding PNA training or allocating additional staff.
Strategies
Secure funding for training: seek funding opportunities from educational institutions, government programmes, or healthcare bodies that offer support for professional development in nursing. Present a strong business case that highlights the cost-saving potential of PNAs through improved staff retention and reduced absenteeism
Phased rollout: consider a phased approach to implementation, starting with a smaller number of PNAs and gradually expanding as resources become available. This allows the organisation to manage costs and adjust the model based on initial feedback
Leverage external partnerships: collaborate with academic institutions or external organisations that can offer support in the form of training programmes, mentorship, or research opportunities to strengthen the PNA role.
Ongoing support and professional development
PNAs need continuous development and support to carry out their roles effectively. Without adequate training or professional growth opportunities, PNAs may struggle to keep up with their responsibilities.
Strategies
Continuous education and development: provide ongoing professional development opportunities for PNAs to enhance their leadership, coaching, and quality improvement skills. This could involve regular workshops, advanced training programmes, or peer support networks
Peer networks and collaboration: establish a network of PNAs within and across healthcare organisations to foster peer support and knowledge sharing. This can include regular meetings, workshops, or online platforms where PNAs can share challenges, best practices, and innovative solutions
Regular supervision and support for PNAs: ensure that PNAs themselves receive regular reflective supervision from senior leadership or mentors. This will help them manage their workload and emotional wellbeing, allowing them to remain effective in their support of others.
Monitoring and evaluating impact
Measuring the impact of the A-EQUIP model can be complex, particularly when trying to link nurse wellbeing and quality improvement activities to patient outcomes.
Strategies
Set clear metrics for success: establish clear and measurable goals for the PNA programme, such as reduced nurse absenteeism, improved staff satisfaction, higher retention rates, and quality of care improvements. Collect baseline data before implementation and track changes over time Regular reviews and adjustments: conduct regular reviews of the PNA programme's effectiveness, using staff feedback and outcome metrics. Be flexible and willing to adjust the model based on what's working and where there are challenges
Share success stories: highlight positive case studies and success stories where PNAs have made a difference. Sharing these examples can reinforce the value of the programme and encourage further engagement from staff and leadership.
Conclusion
The A-EQUIP model, through the role of the PNA, is making a tangible difference in the wellbeing of nurses and the quality of patient care. By providing emotional and professional support, promoting reflective practice, and driving quality improvement, PNAs are fostering a healthier, more resilient workforce. PNAs play a vital role in improving nurse wellbeing, promoting professional growth, and ultimately enhancing patient care within the NHS. The A-EQUIP model underpins a culture of support, learning, and continuous improvement in nursing, with PNAs acting as key drivers of this positive change. It is a holistic approach designed to support the workforce and, ultimately, improve patient outcomes.
KEY POINTS
The professional nurse advocate (PNA) has a major role to play in supporting the nursing workforce through restorative clinical supervision
The theoretical model used by PNAs, the A-EQUIP model, focuses on advocacy, education, quality improvement, and understanding
The PNA role, initially introduced in midwifery, has been expanded to all nursing areas to address challenges such as burnout and workforce issues exacerbated by the COVID-19 pandemic
PNAs provide a safe space for nurses to reflect on their practice, support nurses' wellbeing, and lead quality improvement initiatives
The role is crucial for promoting a positive work environment, improving nurse retention, and enhancing patient care
CPD reflective questions
In what ways can restorative clinical supervision provided by professional nurse advocates (PNAs) improve patient care and outcomes in your workplace?
Reflect on a time when you experienced burnout or stress. How might the support of a PNA have changed that experience?
How can the principles of the A-EQUIP model be applied to address current challenges in your nursing practice?
What strategies can PNAs use to foster a positive and supportive work environment for their colleagues?
