The role of Professional Nurse Advocates in Primary Care

Increasing patient need and an ageing population are major factors impacting the role of nurses in primary care.

More people are living with long-term health conditions (LTCs), with the NHS White Paper (NHSE 2021) highlighting that one in three patients admitted to hospital as an emergency has five or more. Dementia and mental health issues are also increasing, and services must be responsive to the needs of patients, their carers, and families.

The increased workload and complexity of care highlights the importance of collaborative working within the community, helping patients manage their conditions, promote healthy behaviours, and improve outcomes and quality of life. Integrated and collaborative working ensures that clinicians focus not only on single long-term conditions but also lifestyle, prevention of ill health and education to empower patients to self-manage.

Nurses are having to develop their skills to meet these increasingly complex presentations, promote generic healthy lifestyles and ensure patients have the knowledge to understand and manage their conditions, including managing their mental health and overall well-being.

A compassionate working culture, ensuring the well-being of all team members is essential to meeting these challenges.

Supporting Staff Wellbeing

General practice nursing is an exciting and rewarding job, yet we have faced an incredibly challenging year and an increased workload. This has contributed to nurses becoming more at risk of burnout and stress. The courage of compassion document by the King’s Fund (West et al., 2020) recognises this and observes it is critical that the underlying causes of stress, ill health and poor wellbeing in staff are tackled. Pressures in our working environment can have a negative impact on our personal resilience. The King’s Fund (2020) suggest interventions such as resilience training and mindfulness should be implemented to enable nurses to better manage the stressors that can influence their own emotional health and wellbeing.

One of the strategies to tackle these issues is the role of the Professional Nurse Advocate (PNA). There are PNA training courses available for nurses across England.

What is it?

The Professional Nurse Advocate 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) amongst 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 care. 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).

The A-EQUIP Model has been shown to reduce staff burnout and stress.

Restorative Clinical Supervision

Clinical supervision is a safe space where colleagues can explore and make sense of the emotional demands that can come with the nursing role (NHS Education for Scotland, 2018). 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. Pilot studies show that RCS improves the emotional well-being of staff, along with improvements in mental health (Wallbank and Hatton, 2011).

Increased levels of stress can affect a person’s ability to think clearly and make decisions in practice. Findings from the Restorative Supervision Programme Review (Royal College of Nursing, 2021) found that the use of RCS reduced stress by 62% and staff burnout by 43%. The course provides the tools for staff 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 (Proctor, 1988).

A Reflective Experience

I have recently undertaken training to become a professional nurse advocate myself. As part of the training, I had the opportunity to undertake RCS. During a one-to-one session, the issue I shared was the stress I was experiencing managing the dual role of practice nurse and lecturer. I felt that I was not good enough at either job, so needed 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 (2004), using containment that involves supporting an individual to process their anxieties and provide time to think. This approach holds the individual in their thoughts, allowing for reflection. In my case, I was able to become 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 that transition into education (John, 2019). Imposter syndrome is destructive and linked to burnout and stress (Whitman and Shanine, 2012). 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 (Gadsby, 2020).

A session about the importance of self-compassion resonated with me and I began to see the importance of positive self-talk. Whilst self-compassion might be seen as selfish to some, the use of self-compassion is the foundation of compassionate care. Mills (2014) argues that self-care benefits both nurses and patients. 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 oneself.

In 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 individuals 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 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 (Wallbank, 2007).

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 too. 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 amongst teams and a shared understanding of the challenges staff face will improve staff morale and motivation. Staff can build constructive relationships within the working team, which improves the workplace environment.

Conclusion

If staff are more motivated at work, they are more likely to develop and work at their best. The courage of compassion document (King’s Fund, 2020) highlights the need for health and social care leaders to lead with compassion; compassionate leadership promotes effective team working. Nurses who have access to a PNA in their organisation will 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 that we retain staff and encourage nurses to reflect and practice self-care to build personal resilience. Doing so will bring teams together, promote compassionate leadership and enhance patient care.

Useful links

https://www.england.nhs.uk/nursingmidwifery/delivering-the-nhs-ltp/professional-nurse-advocate/

https://www.kingsfund.org.uk/publications/courage-compassion-supporting-nurses-midwives

PNA Webpage – https://www.england.nhs.uk/nursingmidwifery/delivering-the-nhs-ltp/professional-nurse-advocate/

PNA Animation – https://youtu.be/KsfBu7xeRgE (Can also be found on the Main Page of the PNA Webpage)

E-Learning Modules (A-EQUIP Model and Professional Clinical Nursing Leadership) – https://www.e-lfh.org.uk/programmes/professional-clinical-nursing-leadership/

National Implementation Guide – https://www.england.nhs.uk/publication/professional-nurse-advocate-a-equip-model-a-model-of-clinical-supervision-for-nurses/

Monthly Webinars – Updates and Registration is accessed via the PNA Webpage under ‘Latest news, events and updates’ to register via NHS Events – https://www.england.nhs.uk/nursingmidwifery/delivering-the-nhs-ltp/professional-nurse-advocate/latest-news-and-updates/

Donna Brookes, Queen’s Nurse