Using restorative clinical supervision to boost student retention

Introduction

The role of the professional advocate was first introduced in midwifery in 2017 following reports into failings in maternity services (Rouse, 2019). Professional midwifery advocates (PMAs) were trained to give restorative clinical supervision (RCS) to support midwives to deliver high-quality care. The professional advocate role was adopted for nursing towards the end of the third wave of the Covid-19 pandemic, with the introduction of professional nurse advocates (PNAs) forming part of the Covid-19 NHS recovery programme (NHS England, 2023). However, most of the literature on its effectiveness relates to PMAs, as the PNA role is relatively new.

The PNA uses skills such as active listening, advocacy and leadership to facilitate effective RCS for health professionals (Rouse, 2019). The RCS session allows space for open discussion and encourages reflective conversations and open feedback (Pettit and Stephen, 2015). Through this form of clinical supervision and peer support, health professionals are encouraged to identify their own solutions to problems, think critically and develop personal resilience (Power and Thomas, 2018; NHS England, 2017). Butterworth (2022) acknowledges that RCS can be conducted in different ways according to the needs of the organisation and the nurses and midwives it seeks to support.

Advocating for Education and Quality Improvement (A-EQUIP)

A-EQUIP is the model of RCS deployed by PMAs and PNAs. It was developed in response to the supporting mental health and wellbeing aims of the NHS People Plan 2020/21 and the 2019 NHS Long Term Plan, while also focusing on continuing professional development and the clinical leadership response to Covid-19 (NHS England, 2023).

The A-EQUIP model addresses perceived inadequacies in the original supervision model, while incorporating the supportive and developmental aspects of that model that had been shown to offer positive outcomes for individual health professionals and healthcare organisations (Rouse, 2019). A-EQUIP consists of four core components:

• Monitoring, evaluation and quality control (normative);
• Clinical supervision (restorative);
• Personal action for quality improvement and education;
• Education and development (formative) (NHS England, 2023) (Fig 1).

The model encourages nurses to reflect on each component and assist in the provision and delivery of quality improvement initiatives.

Staff retention

Adopting the A-EQUIP model has been found to improve staff retention (Rouse, 2019). Thomas (2022) emphasises that having a sustainable workforce is greatly enhanced if professional advocate support is available.

Van Camp and Chappy (2017) found newly qualified nurses were more likely to leave the profession than nurses who had practised for longer. Stress, anxiety and feeling ill-equipped for the role contributed to newly qualified nurses leaving the profession according to a literature review by Collard et al (2020). Brook et al (2019) highlighted the cost implications of this for healthcare organisations and the importance of considering how to improve retention of early career nurses.

There is a focus on equipping nursing students and work-based learners (WBLs) with the necessary knowledge and practical skills to prepare for qualifying, but Eaves and Payne (2019) say learners’ health and wellbeing should also be prioritised. Collard et al (2020) found personal and professional support during training and in the initial stages of qualifying greatly improves nurse retention. Incorporating supportive mechanisms emphasises the importance of health and wellbeing, and could increase students’ ability to cope with clinical challenges when training, as well as in future practice (Power, 2016).

Mental health and wellbeing

Health professionals are often unaware of the benefits of RCS (Sainsbury and Stacey, 2022) and rarely prioritise their own mental health and wellbeing over caring for patients (Taylor, 2013). This can reduce their ability to provide high-quality patient care (West et al, 2020).

Clinical supervision enhances practitioners’ ability to think and make decisions, reduces the potential of psychological harm and improves the quality of care provided (Wallbank and Hatton, 2011). There is, therefore, a need to raise awareness of RCS and its benefits among student nurses and WBLs, and for employer organisations to provide clear access guidelines and continual reinforcement of the importance of RCS. By prioritising the health and wellbeing of nursing students and WBLs, and encouraging reflective practice, we can equip them with the essential tools to enhance resilience, so they feel supported to manage future challenges.

Anecdotally, many of our students and WBLs have reported that the pandemic has had a detrimental effect on their learning. WBLs especially have reported not feeling valued in the team. Reasons given have included feeling they are without a voice and the lack of priority given to protected learning time.

A survey by Health Education England (HEE) highlighted students’ experiences and concerns during the pandemic and reasons for considering leaving. The main themes identified included: struggling academically, feeling overwhelmed and stressed by the challenging environment, and doubting their clinical ability (HEE, nd).

PNAs address these concerns by promoting a sense of belonging and highlighting the positive contribution of student nurses and WBLs to the team and patient care (West et al, 2020). There is a need for people to feel valued in the workplace and the PNA delivering RCS support will undoubtedly assist with this.

Stress and burnout

Nash (2021) acknowledged that many absences within the NHS are stress related. The restorative component of RCS has been found to reduce staff burnout, stress and absence rates, as well as improving job satisfaction and the patient experience (NHS England, 2023). A review of RCS for health visitors found that RCS reduced burnout by 43% and stress by 62% (Wallbank and Woods, 2012). As well as RCS promising similar benefits for students and WBLs, it could improve the assessment and supervisory abilities of registered nurses, with Thurgate (2018) recognising that effective practice supervision and assessment is key to successful completion of nurse training. This highlights the need to establish how RCS can best be used to support students and WBLs, as well as supervisors and assessors, to further enhance the benefits of RCS.

Resilience

RCS has also been found to aid resilience, helping health professionals cope with challenging or distressing situations (Crowther et al, 2016). Thomas (2022) highlighted that resilience can also help people build competence and confidence, which is an essential part of preparing to become a newly qualified registered professional. Using RCS to build resilience may benefit students and WBLs even more than registered nurses, although the evidence is inconsistent as to whether age, experience or years in practice contribute towards an individual’s ability to be resilient (Hart et al, 2014).

Traynor (2018) argued that resilience for nurses can be over-emphasised in an attempt to mitigate more systemic problems with health services. Maben and Bridges (2020) discussed how this can lead to a sense of failure, whereby nurses blame themselves for being unable to apply their training to manage the challenges encountered in practice, potentially heightening stress levels further. Rather than explicitly emphasising the need for nurses to be resilient, encouraging reflection within the professional framework of RCS could enhance resilience in a way that is more beneficial for individuals and their development.

RCS encourages health professionals to slow down and process experiences through reflective discussion (NHS England, 2017). Thomas (2022) recognised the importance of reflection and said that students should be encouraged to engage in self-reflection and evaluation. This should include reflecting on what they have done well, as well as gaps in their knowledge and aspects of their practice requiring improvement and development (Thomas, 2022). The Nursing and Midwifery Council (2018) requires registrants to “gather and reflect on feedback from a variety of sources, using it to improve practice and performance”. A culture of reflection is essential to effectively incorporate this into practice.

Challenges

Wallbank (2010) found that regular RCS sessions can have notable benefits for health professionals, such as an increase in compassion satisfaction, which is the pleasure derived from performing work duties. This is supported by Murashiki et al (2021) who found that follow-up RCS sessions were particularly beneficial. However, literature relating to PMAs suggests the low ratio of qualified PMAs to midwives may prevent this (Rouse, 2019). This will also be the case in the early stages of implementing the PNA role into adult services and it will require significant investment of time and energy for organisations to establish and embrace the initiative fully.

It has been acknowledged that PMAs can find it difficult to achieve protected time to conduct RCS, because they are often confined to their substantive role (Rouse, 2019). However, an education practitioner who combines being a PNA with their substantive role could be well placed to reach out to students and WBLs, which could potentially increase uptake and the accessibility of the service.

The PMA not being the supervisee’s line manager has been acknowledged as key to providing successful and effective RCS (Macdonald, 2019). This removes any conflict of interest and allows them to focus on their own goals for learning and development
Since an education practitioner does not line manage students or WBLs, combining their role with that of a PNA would allow the development of a positive therapeutic relationship outside of the student’s or WBL’s immediate practice area.

Trusts may argue that WBLs should be the primary focus for RCS as WBLs are employed by them. Equally, it could be argued that responsibility for providing RCS for students lies with the higher education institutions. However, if a trust makes RCS available and accessible to students, this would demonstrate its commitment to the health and wellbeing of its staff and show it is a supportive and desirable place in which to train and work. This could improve retention of nursing students once they qualify.

Recommendations

Our initial goal and recommendation is to implement RCS in the student and WBL population. However, it will also be important to consider the need and benefits of RCS for practice supervisors and assessors. Setting up focus groups for those who are supporting nursing students and WBLs to discuss the challenges in practice could help enhance the overall experience of the students and WBLs, and establish a supportive network for students and WBLs as well as supervisors and assessors. Focusing on getting it right for specific populations – in this case students and WBLs – should help make the overall goal of providing the PNA service to the wider nursing workforce much more achievable. Providing one-to-one and group supervisory sessions to meet individual needs and preferences, along with feedback from each RCS session, will help in further developing and improving this service provision. A summary of recommendations is included in Box 1.

Conclusion

Although the literature on PNAs is limited, evidence around clinical supervision suggests potential benefits of the PNA role and RCS for health professionals, patients and organisations as a whole. Setting up a pilot focus group of students and WBLs could be a catalyst for testing and refining the PNA strategy to implement and maximise the potential of the role, while delivering positive and sustainable benefits for the future NHS workforce.