The findings and recommendations from this mixed methodology study in one large UK NHS Trust will provide new and contextually meaningful ways of viewing, developing, and implementing multi-level strategies underpinning PNA/PMA. Working in close alignment with the Trust senior leadership team, the current PNA’s/ PMA’s and nurses and midwives who do and do not use professional advocacy extends and maximises the reach and relevance of this research. The combination of qualitative and quantitative data in this study allows for a comprehensive exploration of the underlying issues, concerns, opportunities, and potential gains associated with engaging in professional advocacy for nurses and midwives across diverse health services and specialities and in different locations including acute and community directorates. Therefore, this design and aims deliberately speaks to the agenda set by the funding Trust. The rationale for the selected methods will firstly present an explanation of how the PNA/PMA service is currently being implemented, secondly describe the experience of using the service might/might not be, and finally, generate co-developed, sustainable strategies for PNA/PMA in a single NHS Trust.
This project is timely and necessary as the PMA and PNA role has now shifted from the rhetoric of guidance to the reality of practice. Since the inception of PMA following changes to the supervisory requirements in midwifery and the launch of PNA in 2021, the PMA/PNA role has signalled the ‘start of a critical point of recovery: for patients, for services and for our workforce’ [30]. However, to date, there is limited experiential evidence of PMA/PNA both in terms of the role, the delivery, and the impact. Although clinical supervision in nursing was first formally proposed in the late 1980’s, the general lack of evidence for securing a systematic and fully embedded approach to professionally orientated support remains notable in the literature [34, 35]. Following the success of the PMA roll out and to address this gap, PNA training (a level 7 accredited programme) highlights restorative supervision as part of the A-EQUIP model, adapted from the original PMA training [4].
This project seeks to identify and demonstrate the ways in which PNA/PMA is understood, performed, and recognised. In doing so, the data will be used to guide each of the four distinct, yet related workstreams. There is a need to move on from the initial wave of literature and evidence which announced the arrival of professional advocacy for midwives [2, 36, 37, 38, 39] and nurses [4, 40, 41]. Publications have gone on to describe the accepted A-EUQIP model for providing advocacy, with connections to coaching, mentoring and restorative supervision [42, 43]. The lens of personal reflection is also widely used to present ‘in-action’ narratives [44, 47]. In addition, there are some comparisons between previous supervisory models and A-EQUIP [45, 46]. Hence, the evidence base for PNA/PMA is developing, with further examples including a professional midwifery advocate quality improvement project [48], along with projects exploring PNA and wellbeing [49,51].
However, the current available literature leans toward narrative observations rather than uncovering the processes involved in sustainably rolling out professional advocacy in the wider workforce. Consequently, the experiences and implications of PNA/PMA using the combined elements of the A-EQUIP model remains relatively uncharted. The protocol for this project is therefore situated in an agenda of discovery about what works in PNA/PMA. The point of difference is that this design incorporates both PNA’s and PMA’s and aims to address the gap in understanding the day-to-day, practice-based experience from a variety of perspectives. This much needed project will provide insights for implementation and strategic planning derived from how professional advocacy contextually occurs from the ground up.
The contextual orientation of this study is important. A key strength of this study is the co-operation and collaboration between the funding Trust and the research team. This inter-organisational partnership has ensured that research aims, and design are directed toward gaining practice-based insights which can inform contextually relevant routine practice to develop and maintain staff support in ways that make sense to the staff in the Trust. This approach to ‘real-life’ research allows staff voices to be heard and translated into favourable action, and as a result overtly shape their PNA/PMA. This is a unique opportunity to untangle individual, disciplinary, service-level, and structural components that contribute to the sustainable implementation and development of PNA/PMA in a single Trust, for which few other data sets are available or equipped to address.
Although, there are some limitations of this study to acknowledge. Firstly, the data collection, findings and recommendations are confined to one UK NHS Trust. Therefore, whilst transferable insights might be gained, there is no intention to seek or claim generalisability. Secondly, the data collection in the 4 workstreams is founded on the volunteering of information and good-will. Hence, participation and response rates cannot be guaranteed and all advertising about the research is bound by the ethical and policy procedures of the HEI and the Trust. Lastly, the Trust is a large and complex organisation, so time, planning and authorisation are needed to ensure that communications about the research reach all areas and as many staff as possible.
Dissemination:
The dissemination strategy is designed to get the findings to those people, services, and organisations, so that they can use the outcomes in a timely way. To maximise the benefit and ensure consistent visibility, the progress, and findings for each workstream will be written up, shared, and then collated into one final report and presented across various practice and academic structures. In Workstream 4, we will ask Trust based colleagues about how to best disseminate our findings in their practice environment, this continued attention to place, people and context will help us to understand what works (or not) and construct meaningful and nuanced knowledge exchange products. Therefore, our plan is to produce targeted outputs that are in the relevant format to meet the needs of a variety of audiences. These outputs will be tailored for decision makers, policy influencers, managers, clinical staff, students, and academic colleagues, and those who are connected to initiating, delivering, and engaging with professional advocacy.
Locally, the final report will be presented to the Trust, along with a plain language summary and an informatic outlining key outcomes. We will also provide those who have participated with a summary of the overall findings which acknowledges and respects the contribution they have made. To maintain and promote our partnership approach, members of the core team will work alongside the Trust to disseminate the findings and recommendations across various groups in the organisation, for example nurses, midwives, allied health professionals and clinical leaders. We will also liaise with communication teams, IT, and other support services to ensure that we inclusively reach our intended audiences and creatively and collaboratively overcome any barriers for sharing. As such, this protocol embeds practice-based research as a series of people-centred activities, where together, we can learn and develop new ideas and ways of doing things.
Nationally, the report will be anonymised and released across various stakeholders, for example: the Nursing and Midwifery Council, The Royal college of Midwives and the combined NHSEI / HEE national body. The findings will be presented at various conferences, such as the Royal College of Nursing and the Royal College of Midwifery annual conferences. Each stage of the project will be adapted for publication across both professional and academic literatures. We will ensure that the outcomes are translated for publication across various other outlets, including the RCNi journals, the British Journal of Nursing and the British Journal of Midwifery, and the International Journal for Advancing Practice. The findings will also be streamlined for circulation around university organisations that deliver training for the professional advocacy role. To amplify the key findings, recommendations, and implications for practice, we will develop content for social media platforms/groups using appropriate hashtags to maximise promotion of the findings. In addition, we will work with stakeholders to develop the findings so that they can be made transferable across wider health professions, for example allied health professionals, comprised of fourteen professional groups, including paramedics, occupational therapy, and physiotherapy. We will also adapt the findings to make useful across the differing health care sectors.
Whilst the intention for this project is to present a model for sustainably embedding professional advocacy for nurses and midwives in one large Trust using local evidence, we are mindful of the potential for the transferable implications for the wider NHS workforce. Of particular interest is how engagement with Professional Nurse or Midwifery Advocacy may contribute to staff wellbeing and improved retention. The developed model will inform nuanced and workable strategies for how professional advocacy is understood, delivered, and received, so that practice patterns can be adjusted to support professional advocacy within specific clinical settings. The overriding advantage of this research is that it is informed by the people who are likely to use the outcomes in their day-to-day practice. Hence, it will raise awareness of professional advocacy and how research evidence can be transparently used in the practice setting.