National Evaluation of the Professional Nurse Advocate Programme in England: SUSTAIN – Supervision, Support, Advocacy for Improvement in Nursing, Mixed Methods study.

EXECUTIVE SUMMARY

INTRODUCTION:

The Professional Nurse Advocate (PNA) programme is a clinical and professional leadership programme delivered by Higher Education Institutions (HEI) which equips nurses with the skills to deliver restorative clinical supervision to colleagues in England. The programme has been gradually rolled out across England during 2021/22 with the aim of ensuring there will be PNAs in place to support colleagues in the following specialties: Critical care, Mental Health (Adult Acute & Children and Young Peoples inpatient settings) Community, Learning Disabilities (Adult), Children and Young People, Safeguarding, Health & Criminal Justice settings (HCJ), and International Nurses. In February 2022, NHSE sought an evaluation of the PNA programme. A research team from Coventry University was commissioned to undertake this work. This Executive Summary Report sets out the methods, activities, findings, and recommendations as requested by commissioners.

BACKGROUND:

Launched towards the end of the third wave of the Covid-19 pandemic, the PNA programme was introduced at the start of a critical point for recovery in the NHS. Whilst the pandemic had added complexity to care delivery and stretched the capacity of the nursing workforce, the PNA programme provided an opportunity to re-build resilience within the profession and promote workforce retention. The A-EQUIP (Advocating for Education and Quality and Improvement) Model with restorative clinical supervision, career conversations is integral to PNA training and starts as soon as their time on the programme begins. The HEI education programme equips PNAs to listen and to understand challenges and demands of fellow colleagues, lead support and deliver quality improvement initiatives in response. Course content focuses first and foremost on restorative supervision practices. Beyond this, the focus is on the four functions of the A-EQUIP Model. These four functions are as follows: Clinical Supervision (Restorative); Monitoring, Evaluation and Quality Control (Normative); Personal Action for Quality Improvement; and Education and Development (Formative).

EVALUATION AIM AND OBJECTIVES:

The evaluation aim was to explore the impact of the Professional Nurse Advocates (PNA) programme on PNAs and wider team, with recommendations for improvements. The following objectives were agreed by commissioners:

1. Create a logic model [programme theory of change] to explain programme implementation activities
2. Rapid review of the PNA literature as this relates to empowerment
3. Evaluate baseline data across organisations participating in the PNA programme
4. Assess factors impacting on the delivery of the PNA programme
5. Describe individual perceptions of PNAs and influencing contextual factors
6. Describe individual perceptions of nurses receiving restorative supervision
7. Assess the usefulness of the model and establish assumptions essential to delivery
8. Evaluate the perceived benefits of restorative supervision, plus enablers and barriers
9. Provide recommendations on how the programme can be effectively embedded, implemented and sustained across a range of contexts.

EVALUATION DESIGN

A mixed methods design was implemented with four work packages. The evaluation was theory driven throughout and we applied the concept of ‘empowerment’ via Laschinger et al, model (2001) and a theory of programme change (Logic Model). Laschinger’s Model enabled the development of study questions, survey design and structured the qualitative phase of the study, including analysis, enabling exploration of structural and psychological empowerment in the workplace and the indicators of positive work feelings (Fig, 1). The Logic Model was used to map the inputs, activities, and outputs of the national programme, with our clearly stated assumptions to guide our questions.

Figure 1: Laschinger’s Empowerment Model (2001)




DATA COLLECTION METHODS

Quantitative and qualitative data were collected via a survey, case studies, semi structured interviews, and a final workshop with commissioners. A Rapid Review of the available literature was used to inform our understanding of the topic and contributed to formation of questions alongside the Laschinger’s empowerment model. A survey was designed to explore the impact on perceptions and levels of empowerment with all PNAs and nurses who have delivered or received restorative clinical supervision. Case study organisations in different settings provided the opportunity to undertake a deep dive of pertinent information at individual sites/areas. Semi- structured interviews (single and joint) were completed with the following staff groups: Higher Education Institute leads for the PNA course (HEI); regional lead PNAs; site lead PNAs; nurses in PNA roles (PNAs); and, nurses who have received restorative clinical supervision (RCS Nurses). We adopted a sampling approach to achieve maximum variation so that we were able to access a wide range of views and perspectives. We included staff working in District General Hospitals, Community trusts, large Acute Trusts and Mental Health Trusts and many speciality areas.

FINDINGS

Survey An electronic survey was distributed by NHS England between August and December 2022, via email to three constituent groups: Nurses who received RCS (known as RCS Nurses); PNAs; and Trust PNA Leads. There were 302 responses to the survey (RCS Nurses n=73, PNAs n=214, Trust Leads n=15). Most respondents worked in adult nursing, were female and mainly identified as ‘white’. RCS Nurse respondents were more ethnically diverse than PNAs and Trust Leads. Trust Leads and PNAs tended to be qualified for longer and were more likely to have been educated in the UK than RCS Nurses.

Of the 214 PNA respondents, 175 (81.8%) had delivered RCS and 39 (18.2%) had yet to do so.
Overall, RCS was rated very positively in terms of enhancing structural empowerment, psychological empowerment, and positive work feelings. These items were all rated at a median of ‘moderately agree’ by all three groups, illustrating strong beliefs in the effectiveness of RCS in having a positive impact on these aspects. All groups provided a median rating of ‘strongly agree’ to the statement “I believe that restorative supervision is effective”, illustrating strong support for the effectiveness of RCS. The ability of RCS to improve the support available to nurses at work and nurse confidence was rated as a median of ‘strongly agree’ by all three groups.

Open text comments highlighted the importance of adequate time provision to undertake the role and to secure staff release for RCS. A safe private space, in a calm area to create a relaxed environment for the planned RCS session was overwhelmingly identified as a pre-requisite factor in which to discuss confidential matters. Most RCS Nurses were fundamentally satisfied with their experience of RCS which left them feeling positive and looking forward to continuing the process. One example of this relates to being challenged:

‘…matters related to work are opened up, that could either hinder [] or push me to improve, but they do push me to improve the way I approach work’.

It seemed there was a growing appreciation of the benefits of RCS. RCS was described as a reflective process that legitimises the time and the necessity for nurses to understand and process difficult experiences in their roles. This could only be done with the support and underpinning of a trusting relationship. Participating in RCS was described as a positive and constructive experience by many RCS nurses which had boosted their self-confidence, leaving them restored and reinvigorated.

Case Studies were conducted with eight sites, spanning Healthcare and HEI settings across England to provide in-depth, contextually based information regarding the implementation of the professional nurse advocate programme. For most HEIs, the PNA training module was established at great speed in the context of the covid-19 pandemic, aided through experienced teaching staff, amidst a great sense of urgency. The case studies revealed that a personal commitment to implement the PNA programme was important but in the early waves, a lack of communication hampered initial strategic efforts. For example, nurses undertaking the course in the early days often self-selected and returned to organisations without a strategic lead in place to then implement the programme. In later waves, this became less common. Learning was facilitated online using Microsoft team or zoom, via a level 7 (Masters) module, requiring attendance one day per week over approximately 10 weeks. However, it was noted that there was little parity regarding module content or assessment strategy across the many HEIs delivering the programme in the initial stages. This created some frustrations and barriers to access for training amongst some PNAs due to inadequate entry credentials at the appropriate level to enable this study at level 7. This was rectified in later course iterations.

A general appreciation was reflected that the PNA programme has opened opportunities for nurses at any stage of their career to engage in further study and to combine this with experience, which served to make nurses feel valued and empowered in their roles. For the most part QI activities focused on delivering the restorative aspect of the PNA role. We asked participants about their understanding of RCS delivery outputs regarding the frequency and types of sessions offered. Some participants described the workforce returns and counting activities, but at the same time, not being sure what counted as RCS. Respondents in the case studies identified key aspects which enabled more effective joint working to achieve programme role out. For example: they operated a planned and strategic roll out with careful selection of nurses to complete the PNA training; existing forums were used to drive the progress of the PNA work; the PNA role was linked with others in similar domains (e.g., practice educators, speak up guardians, psychological first aiders); PNAs were given adequate time to functionalise this aspect of their role; a wider interpretation of the PNA role was adopted and linked with existing clinical supervision mechanisms; PNAs were enabled through CPD and this was facilitated through Personal Development Plans; PNAs were supported to do their role through wellbeing mechanisms; PNA leads were linked effectively to support via the NHS England PNA office.

All these elements enabled PNS leads to celebrate achievements and generated a sense of sustainability – that this is not a project – it is here to stay.

Interview data were collected from 63 individuals, with 59 individual interviews and 4, two-person interviews. This included Regional PNA leads (6), Trust PNA leads (13), PNAs (32) and RCS Nurses (7) and HEI Leads (5). Individuals were recruited from a range of specialties (such as, the criminal justice system, primary care, and the ambulance service), from a range of ages (25-62 years), males (N = 3) and females (N = 60) and those who completed PNA training via different course providers ranging from the first cohort to complete the course to the most recent cohort (in total N = 18 different course providers).

It was evident that when the PNA programme was implemented, clinical supervision was seen as a new thing for nursing - the idea of nurse-to-nurse support was valued but had not really been experienced before for many respondents. Clear differences were identified between clinical supervision and restorative supervision. Nurses who had experienced RCS wanted the process to be ‘normalized’ and more mainstream as there were still some concerns about the negative connotations associated with ‘supervision.’ Follow up after initial RCS was seen as important, but there were barriers to this occurring. Time and being freed from the duty were the chief issues. Nurses who had completed the PNA course praised the content and experience of the studying for this qualification. Online learning was the core approach due to covid restrictions, and whilst many benefits were identified (e.g. no travel) some respondents’ felt more practical experience and assessment of their skills was needed. However, there were challenges in implementing what had been promoted during the programme within the workplace context. This was largely related to short staffing, and a lack of space and time to undertake RCS.

Most PNA respondents were very clear on the benefits of RCS in restoring, supporting and enabling nurses, and in some cases enabling nurses to stay in the profession. Feeling valued, supported and listened to, were the over-riding perspectives. There appeared to be confusion about data collection and RCS as many respondents did not report their data to a lead PNA. The process of receiving restorative clinical supervision and careers conversations required more clarity to understand if, when and how progress was being made throughout the process. For example, some nurses indicated their first-time experiences of RCS were surrounded with uncertainty, especially if they were asked to attend supervision, with little explanation beforehand. This left some nurses describing their ‘offloading of issues’ rather than being active participants in a process leading towards greater resilience. We have suggested that this is an area for further research.

CONCLUSION:

The support of experienced nurses (PNAs) in practice helps nurses feel valued and empowered; in some cases, RCS and career conversations are enabling nurses, who might otherwise leave the profession, to stay. The programme has opened opportunities for nurses to engage in further study and development following the programme. These factors are important in the context of a global workforce retention crisis. The A-EQUIP model can be accomplished through good Nursing leadership at site level to assist the implementation of the model, with PNAs supporting this role-out. The intention to implement requires a solid commitment and not contingent on the perfect conditions. The prerequisite conditions must be considered and well-thought-out during implementation to include time for RCS and PNAs to carry out the role; private space to conduct the RCS sessions and good communication regarding the plans to involve the key people. Finally, despite some of the issues identified, the creation of a ‘PNA movement’ through the development of the national programme, has created much needed support for nurses and is the transformative element of nurse empowerment and greater satisfaction at work.