The Advocating for Education and QUality ImProvement model and professional midwife advocate role were introduced by an abortion care provider
An abortion care and contraception provider implemented both the role of the professional nurse/midwife advocate and the Advocating for Education and QUality ImProvement model. The aim was to create a culture of reflection and support for staff members. As a result of the implementation, nurses and midwives have reported an increase in job satisfaction and in feeling supported.
Citation: Ash GL, Pollock J (2023) Clinical supervision led by professional midwife advocates. Nursing Times [online]; 119: 12.
Authors: Grace Louisa Ash is practice development and advocacy midwife; Jane Pollock is clinical excellence lead for education; both at MSI Reproductive Choices UK.
- This article has been double-blind peer reviewed
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In 2017, in response to the removal of statutory supervision from the Nursing and Midwifery Order 2001, a new model for nursing and midwifery supervision was introduced in England, titled Advocating for Education and QUality ImProvement (A-EQUIP) (Capito et al, 2022). There have been many different models of statutory supervision since the one set out in the Midwives Act 1902, the most recent of which appeared in the Nursing and Midwifery Order 2001. However, this model was removed by the Parliamentary and Health Service Ombudsman in response to Kirkup’s (2015) report. As a result, the role and title of supervisor of midwives was no longer statutory; it was replaced with the new role and title of professional nurse advocate (PNA) or professional midwife advocate (PMA) (elearning for healthcare, nd).
The new A-EQUIP model for supervision allows employers to lead their own implementation, but provides a guidance framework that encourages building a workforce with a culture of strong professional and personal resilience. The evidence for A-EQUIP derives from Proctor’s (1987) three-function model of clinical supervision and Hawkins and Sohet’s (2012) adaptation of that model.
Proctor’s original model provides a base from which colleagues can be coached through three main functions:
- The restorative function – this highlights the need to support employees and their wellbeing to enable them to build resilience in practice;
- The normative function – this encourages employees to reflect on the quality-control aspects of their role and outline their own definition of their professional identity;
- The formative function – this allows employees to seek their own learning opportunities and develop their practice in the interest of improved patient care, quality and safety (Proctor, 1987).
Additionally, Hawkins and Sohet’s (2012) development of the A-EQUIP model added a fourth function: personal action for quality improvement.
The four functions mean that the supervision model has the overall aims of:
- Enhancing care quality;
- Creating a culture of continuous improvement.
These, in turn, support staff preparedness for appraisal and revalidation.
Addressing the need
MSI Reproductive Choices UK is an abortion care and contraception provider with nine main treatment centres across England. In April 2022, our clinical education team began to implement the A-EQUIP model and the roles of the PMA and PNA. Before this, although health professionals were able to access clinical supervision, engagement was low at 5% (Fig 1). The initial vision, therefore, was to embed restorative clinical supervision into the professional culture. We hoped this would provide staff members with a psychologically safe space to:
- Reflect on their practice;
- Obtain support around their own career development.
We also aimed to improve the service for our staff and service users through the model’s quality improvement function.
As a team, we had long recognised the need for an additional layer of support for staff that differentiated from the standard appraisal system. Our team’s nurses and midwives provide consultations, along with medical and surgical treatment, to clients who are accessing abortion care and contraception services. The team, therefore, performs safeguarding assessments for all clients.
We often face complex safeguarding scenarios and challenging circumstances and, as had also been recognised by Kerelo (2020), it became clear that team members’ determination to remain clinically resilient to their intense work was sometimes affecting their own mental health. This was first exacerbated by the Covid-19 pandemic. Furthermore, 2022 saw the overturning of the historic US Supreme Court-appointed right to access abortion (Roe versus Wade, 410 US 113 (1973)), which increased media attention on abortion care (Howard and Geetanjali, 2022). This meant that our team members were facing increased stigma towards both their profession and the service provided. We recognised that they required the ability to access restorative supervision of excellent quality to support their wellbeing.
The benefits of clinical supervision have long been recognised. Hawkins and Sohet (2012) highlighted that providing staff with the opportunity to regularly step back and reflect on their own practice encouraged them to seek new options, solve problems and learn from difficult situations. Additionally, a study by Sheena et al (2015) identified that support strategies, such as reactive supervision, following traumatic events can reduce midwives’ “significant symptoms” of distress in practice.
In April 2021, a year before we implemented the A-EQUIP model, the average length of service for a health professional in our organisation was 2.8 years, and the most common reason given for leaving was to seek better job opportunities. The following year, the Nursing and Midwifery Council (2022) reported that the number of professionals leaving its register each year was slowly increasing, and that reasons for this included increased working pressures and feeling unsupported or unappreciated.
Implementing the project
At the start of the implementation, both members of the clinical education team completed the level-7 training that was necessary to become a PMA and PNA, respectively, and began to run the service. Delivered by several universities, the PMA/PNA course comprises 10 weeks of lectures and a formative assessment to prepare registrants to become a professional advocate. For the remainder of the article, the term PMA will be used to refer to both roles.
Our initial aims of introducing the PMA role were to:
- Build a culture of open and honest communication;
- Develop a strong sense of professional identity among staff;
- Support staff members who were experiencing difficulties;
- Raise awareness of quality improvement to ameliorate staff and client experiences;
- Improve staff retention and satisfaction.
When implementing the A-EQUIP model into the organisation, we began by addressing the largest need, which was the restorative element of clinical supervision. We felt this would be a good launch, as it would allow staff members to directly communicate with their PMA before exploring the other elements of the model. The organisation’s director of nursing, midwifery and quality wrote a comprehensive policy, which stated that all staff members were entitled to one hour’s protected supervision time per year. This was a fantastic support and ensured employees felt there was an investment in their mental and emotional wellbeing.
Some of the main stakeholders in MSI Reproductive Choices UK’s centres were the clinical matrons, who line-managed team members. To build support and drive for the A-EQUIP model, we needed to ensure the matrons were well informed and involved in its implementation. To address this, we delivered a pitch to:
- Explain the project’s aims and objectives;
- Clarify their involvement;
- Provide an opportunity to respond to questions and concerns.
The main aim of assuring line-managers’ engagement was to ensure they would allow staff members to access the sessions in their working hours. Love et al (2017) highlighted the difficulty of this, as their study showed that busy working environments and time constraints meant clinicians were often unable to attend clinical supervision sessions during their working hours; furthermore, there appeared to be a culture in which staff felt it was unreasonable to take time out from their work to reflect. These findings support those of Wallbank and Woods (2012), who observed that supervision sessions in working hours presented teams with the additional stress of further reducing their already-compromised staffing levels. Fortunately, our management teams were extremely supportive of the project and remained heavily involved throughout the implementation phase.
The clinical supervision sessions were offered both face-to-face and via Microsoft Teams. Offering them virtually made it easier for staff members who were working remotely and met the needs of those who simply preferred to access them in this way.
To allow staff members to book supervision sessions, we used our learning management system (LMS) to create the sessions as events. This approach meant staff could easily see the available sessions and have time allocated by their line manager. A key benefit of managing the appointments in this way was that we could report on the number of employees attending supervision, as well as the number continuing to access the service beyond their allotted one hour per year.
We also used the LMS to host a bespoke e-learning module outlining the A-EQUIP model and the remit of the PMA role, so staff members were aware of who they could contact. This short, one-off, mandatory module was created by the PMA team for all nurses and midwives in the organisation and was completed by >80% of them in the first year.
To further promote the new role and supervision sessions, we created posters and materials, such as screensavers, that would help to increase awareness across the organisation.
Reviewing the service
We reviewed the project one year after its launch, assessing both its successes and the challenges faced throughout implementation. This was extremely insightful, as it allowed us to:
- Reassess the model we used;
- Use the information to create our own methods of quality assurance to ensure the project’s sustainability.
The main barriers were categorised as follows:
- Initial lack of engagement;
- Number of PMAs;
- Cancelled sessions.
Initial lack of engagement
For many staff, this was their first exposure to this form of supervision and, because the new model encouraged a non-direct coaching approach, it was very different from the one-to-one appraisals they were accustomed to. Initially, some staff reported finding the sessions frustrating, because the role of the PMA was not to provide answers, but simply to support and empower them to find the outcomes for themselves. This finding supported that of Taylor (2013), whose study identified that health professionals approached clinical supervision with a sense of caution; they often found sessions “scary” and “unsettling” due to their open-ended format, which was different from the support they had previously encountered.
In response to this, we adapted the initial communication booking email that employees received, so that it provided a descriptive account of what clinical supervision sessions consisted of and gave examples of questions that might be asked.
Some staff also reported that they initially found it daunting to fully confide in the PMA during clinical supervision, due to previous negative experiences in other roles or concerns about confidentiality. This finding is supported by Power (2006), who identified that these barriers hinder health professionals attempting to participate in reflective supervision. To address this, we ensured a formal contracting process was undertaken at the start of each session so staff were aware of the confidentiality statement surrounding supervision. This was a standardised contract written by the PMA team, which was revisited and signed by the PMA and supervisee at the start of each session.
“Reactive supervision following traumatic events can reduce midwives’ ‘significant symptoms’ of distress”
Number of PMAs
At the start of the implementation, there was one full-time PNA and one part-time PMA, with a shared caseload of approximately 120 staff members. Initially, the PMA ran three one-hour sessions per day, with one-hour breaks between each to encourage self-reflection and promote personal wellbeing.
In total, there were 6-8 sessions available per week – this meant >400 sessions per year could be accessed by staff members for single and repeat sessions.
Although this was manageable, to ensure sustainability it was evident that more PMAs were needed in the team. Since April 2022, an additional 12 staff members have been trained as PMAs. This ensures the team can evenly share the workload of the supervision sessions, as well as focusing on the other functions of the A-EQUIP model.
Approximately 3-4 months after the project’s implementation, we observed an increase in the number of staff members cancelling or not attending booked sessions. We investigated this and learned that the main reason was a lack of staffing cover to allow them to attend. We felt it was positive that they wanted to attend the sessions, however, and explored ways we could resolve the issue.
The initial supervision sessions that were uploaded to the LMS were during the working day; therefore, we rescheduled these to the start and end of the day to enable staff members to attend before and after completing their clinic lists.
In addition, during supervision sessions, the PMAs encouraged supervisees to contact them directly to book future sessions, rather than using the LMS. This was to ensure that both the supervisor and supervisee could allocate time and avoid the supervisor having wasted time slots. We were still able to add the sessions to the LMS in retrospect, meaning reporting was not compromised. As the trust between the supervisor and supervisee increased, so did the level of communication; supervisors, therefore, began to contact supervisees about their upcoming scheduled sessions to confirm whether they were still able to attend.
Implementing the clinical supervision policy also had a very positive impact on increasing the level of engagement and reducing the number of booked sessions that were cancelled or not attended. The policy mandated that all nurses and midwives access at least one session per year, providing them with protected time to access supervision.
“Some staff members initially found it daunting to fully confide in the professional midwife advocate during clinical supervision”
Outcomes and feedback
Throughout the implementation phase we discussed different methods of quality assurance, and this remains an ongoing process. We conducted two surveys of supervisees, one week and then six months after their supervision. The aim was to understand the effect of the supervision on their wellbeing, as well as to gather information regarding retention. To avoid supervisees feeling pressured to complete a survey that would be shared directly with their supervisor, we created a non-mandated, anonymous feedback form. This resulted in a 62% completion rate.
The surveys revealed that, six months after their supervision session:
- 88% of supervisees reported an increased ability to take control of internal work issues;
- 90% of supervisees reported an improvement in job satisfaction;
- 77% of supervisees went on to have conversations with their line manager about their personal development;
- More than 10 supervisees had completed their revalidation with their supervisor.
The feedback provided on the survey also revealed what staff members most valued about the sessions:
“It was a safe space to discuss any issues I had.”
“I really appreciated the session and feel I have a plan in place until the next session/whenever I need to contact my PMA/PNA again.”
“Incredible experience to reflect.”
“Very useful and supportive session. [I] felt able to communicate effectively, and listened to and appreciated for my input.”
By December 2022, we had achieved our target of supervising 98% of all nurses and midwives. Since then, supervision attendance has constantly remained at ≥85%, including for new starters (Fig 1).
Although staff retention as a direct result of clinical supervision is difficult to assess, one year after implementing the project we observed an:
- Increase of 1% of employees remaining with the organisation;
- Increase in average length of service to 2.9 years.
In addition to these improvements, in 2022 our service was a finalist in multiple categories at the Nursing Times Workforce Awards, including Best Employer for Staff Recognition and Engagement.
We are currently planning to evolve the project by implementing the remaining functions of the A-EQUIP model. Earlier this year, we launched a quality improvement ‘Dragon’s Den’ as part of an internal leadership programme. This aims to support and encourage staff members to submit ideas to improve the service. They present their ideas to a panel of clinical leads, who review them and then decide which to implement. This has seen great success and engagement, and staff members have reported feeling the organisation is invested in them and cares about their practice.
We predict the future guidance for A-EQUIP will expand into providing supervision for all health professionals. We, therefore, plan to continue to grow our team of PMAs and PNAs and enable access to clinical supervision for all other clinical roles within the organisation, including doctors, anaesthetists, nursing associates and healthcare assistants. This would make provision equitable across the service and offer support to all the organisation’s health professionals.
Finally, we have created an internal support network for the organisation’s PMAs and PNAs. In July 2023, we delivered a conference that brought them together from across the country to share learning and experiences as well as provide support to each other. We plan to make this an annual event.
Implementing the A-EQUIP model and the role of the PMA/PNA had a positive effect on nurses’ and midwives’ wellbeing within the first year. The key areas of improvement have been supervisees’ engagement, ability to take control over internal issues, and feelings of being supported. We aim to continue and evolve the project to create a sustainable support network for the organisation’s health professionals.
- Restorative supervision has a positive effect on staff wellbeing and retention, as well as patient care
- The Advocating for Education and QUality ImProvement model for clinical supervision provides a framework for a culture of professional and personal resilience
- An abortion care provider implemented the model, as well as the professional midwife advocate role
- Initial barriers to engagement with clinical supervision were a lack of time and trust
- Implementing the model improved staff wellbeing and the ability to take control of internal issues
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