The role of professional nurse advocates in primary care
Challenges and pressures in our working environment can have a negative impact on our personal resilience, but Professional Nurse Advocates can help to tackle these issues, and lead and support nurses to improve care and meet the changing needs of patients
Increasing patient need and an ageing population are having an impact on the role of nurses in primary care. Dementia and mental health issues are increasing, resulting in the need for nurses to be responsive to the needs of patients, their carers, and families.
Other long term conditions are also rising, and a recent NHS white paper1 highlights that one in three patients admitted to hospital as an emergency has five or more long-term health conditions. This increased workload and complexity of care highlights the importance of collaborative working within the community. This is necessary to help patients manage their conditions, promote healthy behaviours, and to improve outcomes and related quality of life. Integrated and collaborative working will ensure that clinicians not only focus on single long-term conditions but also lifestyle, prevention of ill health and education to empower patients to self-manage their long-term conditions. Ensuring the wellbeing of team members and a compassionate working culture are essential to teams being equipped to meet these challenges.
Nurses are having to develop their skills to meet these increasingly complex presentations, to promote healthy lifestyles and ensure patients have the knowledge to understand and manage their conditions including managing their mental health and overall wellbeing.
General practice nursing is an exciting and rewarding job yet, like many other NHS workers, we have faced an incredibly challenging year and an increased workload. This has contributed to nurses becoming more at risk of burn out and stress. The King’s Fund Courage of compassion paper2 recognises this and observes it is critical that the underlying causes of stress, ill health and poor wellbeing in staff are tackled. Challenges and pressures in our working environment can have a negative impact on our personal resilience. The King’s Fund suggests interventions such as resilience training and mindfulness should be implemented into practice to enable nurses to be better able to manage the stressors that can influence their own emotional health and wellbeing.2
One of the strategies to tackle these issues is the role of the Professional Nurse Advocate (PNA). There are currently PNA -training courses available for nurses across England. National funding is available to train up to 5,000 nurses across different nursing specialties. There is an aim that for every 20 nurses, one PNA will be available, leading and supporting nurses to improve care and to meet the changing needs of patients.
WHAT IS A PRACTICE NURSE ADVOCATE?
The Professional Nurse Advocate (PNA) programme is a Level 7 accredited course, which assesses participants through a competency portfolio, academic assessment, and a presentation. The course enables nurses to facilitate restorative clinical supervision (RCS) among nursing colleagues. PNAs lead and support nurses in practice. They advocate and encourage nursing teams to lead on quality improvement, which in turn improves patient's care. The A-EQUIP Model has been successful amongst midwives and through supporting the emotional health of nurses, has been shown to reduce staff burnout and stress.
The course helps nurses develop an understanding of the PNA role and an understanding of the A-EQUIP model, which has four components:
- Monitoring, evaluation, and quality control
- Clinical supervision (restorative)
- Personal action for quality improvement
- Education and development (formative).
MONITORING, EVALUATION, AND QUALITY CONTROL
This element focuses on promoting professional accountability and encouraging nurses to reflect on challenges or incidences in practice. The benefit of this is that it prepares nurses for revalidation and it helps them identify their learning needs. It is important for nurses to develop in their roles; PNAs can highlight development opportunities within the local area and support nurses to enhance their learning, ultimately improving patient care. Nurses are encouraged to share best practice and through group and individual restorative clinical supervision, can share ideas for audit and development of policies. This aims to build a culture of providing high standards of patient care and to motivate staff to develop within their roles. Practitioners who are exposed to RCS have been shown to be better able to develop positive coping strategies and less likely to be off sick.3
RESTORATIVE CLINICAL SUPERVISION
RCS encourages reflective conversations and builds personal resilience; this can be done one-to one or in a group environment. The restorative part of the session focuses on personal emotions and pilot studies show that RCS improves the emotional wellbeing of staff, along with improvement of mental health.4 Clinical supervision is a safe space where colleagues can explore and make sense of the emotional demands that can come with the nursing role.5 Findings from the Restorative Supervision Program review found that the use of RCS reduced staff burnout by 43% and stress by 62%.3 Increased levels of stress can affect a person’s ability to think clearly and make decisions in practice. Group RCS can reduce isolation in teams and increases opportunities for learning.6
The PNA course provides the tools to become more self-aware, and the skills to be able to listen, support and challenge individuals to improve their ability to cope and manage in stressful situations, promoting an emotionally intelligent style of leadership.7 RCS is not a judgement of a nurse’s practice or intended as an appraisal, it is a safe space for nurses to reflect and share experiences and feelings.
PERSONAL ACTION FOR QUALITY IMPROVEMENT
The Personal Action for Quality Improvement element of the course focuses on the need for continuous development and recognises that quality improvement is part of the nursing role. All nurses are responsible for implementing change and improving the care that patients receive; however, nurses do not always see themselves as leaders. A PNA will encourage conversations around improvement in service in practice; nurses have a good understanding of the issues in practice so are best placed to lead change. Engaging in improvement of care will in turn improve outcomes for patients. When staff feeling listened to and treated with respect, it has a positive effect on the working environment.8
EDUCATION AND DEVELOPMENT
This element of the model encourages nurses to be an advocate for the people they support, in line with the NMC Code.9 PNAs focus on the development of knowledge and skills through education to inform appraisal, revalidation and leadership development. Guided reflection is used to support nurses to identify learning needs and encourages them to develop professionally. This could be making nurses aware of local training available to them or encouraging them to undertake an academic course. PNAs can offer support with revalidation, giving nurses a safe space to share experiences and discuss learning and development opportunities.
A REFLECTIVE EXPERIENCE
I have recently undertaken training to become a professional nurse advocate. As part of the training, I have had the opportunity to undertake RCS. During a one-to-one session on individual restorative clinical supervision, the issue I shared was the stress I was experiencing managing the dual role of practice nurse and a lecturer. I was feeling that I was not good enough at either job so may need to prioritise one over the other.
The facilitator asked if I had heard about imposter syndrome. I had, but I had not linked it to my concerns until that point. The facilitator used the Solihull approach using containment that involves supporting an individual to process their anxieties and provide time to think.10 This approach holds the individual in their thoughts allowing for reflection. In my case, I was able to be more in tune with my feelings and identify what was causing my anxiety at work.
Imposter syndrome is common in nurses, particularly newly qualified nurses and nurses who transition into education roles. Imposter syndrome is destructive and linked to burnout and stress.12 I recognised through this time and space to reflect that my anxiety might be due to the feeling of not being good enough. Imposter syndrome feeds off critical self-talk and self-doubt.13 A session about the importance of self-compassion resonated with me and I began to see the importance of positive self-talk. While self-compassion might be seen as self-indulgent to some, the use of self-compassion is the foundation of compassionate care, and can benefit both nurses and patients.14 I can see the benefits of highlighting this to my nursing colleagues and students during RCS. To care for others, it is important to care for one's self.
During the current working climate, it is important that nurses can process and make sense of the challenges that they face. Having someone recognise the feelings of being overwhelmed during an RCS can often be the first time the nurse can acknowledge and contain their emotions and begin to make sense of them. The PNA course equips nurses with the skills of using open questions and affirmations to help individual’s to process feelings. Containment does not mean that the facilitator takes on the emotions of the participant; it is about helping the participant step back to recognise and to start to manage these feelings. Acknowledging feelings and taking the needed step back can help restore the participant, allowing them to think more clearly. The process can allow the individual to identify learning and developmental needs.15
CONCLUSION
I have given an example of the benefits of the PNA role; I plan to use the methods I have learnt to help fellow nurses and colleagues to also benefit from RCS. The process addresses the emotional needs of staff, which in turn has shown to improve personal resilience. Personal resilience improves when an individual feels supported and listened to. Improving communication between staff through regular RCS will play a key role in improving care outcomes for patients. A sense of belonging among teams, and a shared understanding of the challenges staff face improves staff morale and motivation. Staff are able to build constructive relationships within the working team, which improves the workplace environment.
If staff are more motivated at work, they are more likely to develop and work at their best. As the King’s Fund3 points out, health and social care leaders need to lead with compassion, and compassionate leadership promotes effective team working. Nurses having access to a PNA within their organisation will ensure that they feel connected and valued. If staff are supported effectively, they will thrive and develop in their roles.
My experience is that the role of the PNA is a welcome and essential initiative for primary and community nursing teams. It is imperative, following the challenges of the past 18 months,16 that we retain staff and encourage nurses to reflect and practise self-care to build personal resilience. Doing so will bring teams together, promote compassionate leadership and enhance patient care.
- Adapted from a blog first published by The Queen’s Nursing Institute, available at https://www.qni.org.uk/the-role-of-professional-nurse-advocates-in-primary-care/
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