Over recent years, one has witnessed increasing levels of stress and associated absences, alongside rising numbers of errors and complaints, within district nursing. The King’s Fund (2020) and The Queen’s Nursing Institute (QNI) (2022) concur, noting that high levels of stress and burnout impact negatively on staff wellbeing in district nursing and, in turn, on the safety and quality of care being provided to patients. Several significant reports have highlighted safety failings across healthcare, necessitating the need for action and for greater support, development and supervision of healthcare professionals (Francis, 2013; The King’s Fund, 2015).
A new model of supervision—Advocating and Educating for Quality Improvement (A-EQUIP)—was introduced into midwifery in 2017. Alongside this came Professional Midwifery Advocates (PMAs), whose role is to lead in supporting midwives and driving implementation of A-EQUIP (Dunkley-Bent, 2017). The success of these measures have led to a move to roll-out professional advocates into nursing, with professional nurse advocate (PNA) training, which commenced in 2021 (Griffiths, 2022). The potential impact and role of PNAs in relation to reducing burnout and improving wellbeing and quality of care in district nursing will be considered in this article.
Burnout and role of professional nurse advocates (PNAs) in district nursing
Within the past decade in district nursing, the author has seen increasing complexity of care and workload, with associated high levels of stress and burnout. The QNI (2022) suggested this is a widespread issue, significantly impacting the care needed for patients in the community. During the COVID-19 pandemic, the workload and stressors for community nurses significantly increased, further risking burnout (QNI, 2022). The King’s Fund (2020) agreed, detailing a widening gap between the demand for, and capacity of, district nurses. This gap negatively impacts their wellbeing, with community teams feeling ‘broken’ and ‘exhausted’. Nurses feel pressure to continuously develop knowledge and skills to meet the more complex needs and provide high quality care. Such pressure can ultimately lead to stress and burnout (Kerelo, 2020; Nash, 2021). Kinman et al (2020) noted that 30—40% of nurses and midwives have symptoms of burnout linked to workload, lack of support, lack of control, lack of training opportunities, incivility and bullying.
Kerelo (2020) discussed evidence connecting poor staff wellbeing to impaired standards of care. Although Kerelo (2020) specifically looked at midwives, many nursing sources support this by detailing reduced performance, increased absence/sickness, poor recruitment and retention, alongside more complaints and errors, with nurses who are stressed being unable to think clearly when making clinical decisions (Rouse, 2019; Mahachi, 2020; Dall’Ora and Saville, 2021; Nash 2021; QNI, 2022). Foster (2021) further suggested a direct link between nurses’ wellbeing and the quality of care provided.
Kakemam et al (2021) conducted a cross-sectional survey of over 1000 nurses, which included Maslach Burnout Inventory alongside nurses’ own perceptions and found significant positive correlation between burnout, increased adverse events and reduced quality of care. This study was restricted to Iranian nurses and used a convenience sample. However, these findings are supported by Perez-Francisco et al (2020) whose integrative review suggested that the links between high workload/burnout and reduced patient safety and quality of care is a global phenomenon.
Kinman et al (2020) also identified studies showing nurses feeling engaged and satisfied in their work, suggesting positive wellbeing can be achieved given the right support and circumstances, with the need for supportive cultures where staff feel valued (NHS People Plan, 2020; The King’s Fund, 2020). This encourages learning, development, autonomy and accountability where individuals feel more content and in control. Overall, they have better wellbeing and burnout becomes less likely. This, in turn, promotes productivity and quality improvement. Engaging and motivating staff is essential for quality improvement; staff wellbeing is at the heart of innovation (Mahachi, 2020).
NHS England (2017) and Rouse (2019) suggest A-EQUIP can be an effective model to facilitate wellbeing of staff, which improves retention, reduces absences, stress and burnout. It enables development of staff who have resilience in today’s workforce and can improve quality of care and can advance in the profession. A-EQUIP, as detailed by NHS England (2017), Rouse (2019), NHS England and NHS Improvement (2021), has formative, normative, restorative and quality improvement elements.
Elements of the Advocating and Educating for Quality Improvement (A-EQUIP) model
The A-EQUIP model has four distinct functions, these are:
- Formative: involves considering education and development to increase knowledge and skills
- Normative: focuses on managing, monitoring and evaluating quality and supporting individuals to be competent and effective in the clinical role, whilst considering consequences of errors and promoting accountability and effectiveness
- Restorative: focuses on emotional support, listening, development of resilience and supporting wellbeing through restorative clinical supervision conversations
- Personal action for quality improvement: the final element, which highlights the importance of continually improving quality and encouraging everyone to be involved in quality improvement and assurance (NHS England, 2017; Rouse, 2019; NHS England and NHS Improvement, 2021) (Figure 1).
Dunkley-Bent (2017) indicated that the four elements can be accessed separately, depending on the specific needs of the individual or team. However, Nash (2021), disagrees and stresses that the elements are all interrelated and each element may require involvement of other elements.
In terms of implementing A-EQUIP in practice, NHS England and NHS Improvement (2021) stress the importance of using PNAs, whose role centres on leadership and advocacy, guiding and supporting staff with the use of A-EQUIP. The vision is for trained PNAs to listen to challenges faced by nurses and to use A-EQUIP to support and guide staff in developing resilience and facilitating continuous improvement and high-quality care, and also assisting individuals to achieve revalidation preparedness (NHS England, 2017; Rouse, 2019).
PNAs need to be emotionally intelligent practitioners with open-mindedness and self-awareness, in order to be able to aid staff with reflective practice and development. They must also be skilled in facilitating feedback on themes to enable quality improvement, learning and education (NHS England and NHS Improvement, 2021; Whatley et al, 2021). PNAs are in a position to be able to encourage learning and positive behaviours and to motivate individuals and teams to promote change, all of which lead to improved care and outcomes for patients (Nash, 2021). Using A-EQUIP, PNAs can facilitate time to talk and reflect (restorative clinical supervision). They can guide and support staff with making their own decisions/choices based on consideration of issues identified, which can then lead to changes in care delivery (normative). PNAs encourage individuals/teams to take actions for safe and consistent high-quality care (personal action for quality improvement). PNAs also guide staff with accessing support with professional development, gaining knowledge and skills, and preparing for appraisals and revalidation (formative). Kerelo (2020) suggested all of these measures will reduce the chance of burnout by dealing with factors that can cause stress, include feeling a lack of control, feeling a lack of knowledge and skills, feeling unprepared, unable to cope with high workload and feeling unable to provide adequate levels of care. Through supporting individuals to identify and discuss their issues, giving them ownership and empowering them to take actions, stress and burnout can be reduced. The King’s Fund (2020) supported this by discussing autonomy as a significant need, with individuals being able to have a voice, able to influence their work and able to be involved in change, having increased job satisfaction, control, engagement and accomplishment, while reducing stress, burnout and absenteeism.
QNI (2022) indicated that, in terms of supporting district nurses (DNs) in practice, one of the most important actions for PNAs is to implement restorative clinical supervision, with DNs today, needing more than ever, to be able to process the experiences and challenges they face. PNAs can facilitate nurses to acknowledge and talk about how they feel, to process these feelings and to then be able to step back and let them think more clearly. This will then facilitate the identification of learning and development needs, as well as the consideration of how these needs may be met in order to move on to quality improvement and prepare for appraisals and revalidation (Nash, 2021). The King’s Fund (2020) added that supervision conversations can aid identification and removal of obstacles, leading to development and improvement. These conversations can assist in finding ways to adapt and cope with complex situations, and also the ways in which individuals react to their work and environment. This, in turn, will improve wellbeing, reduce stress and burnout and enable nurses to function more effectively, as well as help them make appropriate decisions and improve patient care (Griffiths, 2022). This is evidenced by Wallbank and Hatton (2011), who found statistically significant reductions in stress and burnout through implementation of regular restorative clinical supervision over a 6-month period. Although the study was small-scale, using just 22 participants, it appears to have validity through using recognised quantifiable quality of life and stress measurement tools, and recording baseline measures pre-intervention, with the same measurements then taken post-intervention.
Although the literature generally focuses on one-to-one supervision, Griffiths (2022) and Dunkley-Bent (2017) suggested group restorative supervision sessions are also useful. These facilitate team members to share and listen to feelings and experiences, to process their own needs, as well as those of their team members and their patients, and to support each other and make collaborative and appropriate decisions in complex situations (Rouse, 2019). This can create a more positive work environment and deepen team members’ appreciation and respect for each other. This will enable individuals to feel valued, which, in turn, will improve wellbeing and team dynamics, and reduce stress, emotional exhaustion and burnout, thus improving job satisfaction and retention, quality of care and patient satisfaction (Aiken et al, 2012; Dunkley-Bent, 2017; Dall’Ora and Saville, 2021). A cross-sectional questionnaire study by Wallbank (2013) also found a significant reduction in stress and burnout of individuals who had attended group restorative supervision sessions. This study reviewed 174 questionnaires; unfortunately, there is no indication of the number of participants that this sample was drawn from. However, some confidence can be taken as it is peer-reviewed and widely referenced. The study focuses on community-based staff and suggests that group sessions can be of use where organisations do not have capacity for one-to-one sessions. It is therefore of particular relevance to community nursing directorates where teams may only have one PNA. Barker (2017) suggested that, if a particular issue is affecting a team, it may be beneficial to have a group supervision session with that topic on the agenda. However, predominantly there should be no set agenda. The PNA’s role is important to facilitate group sessions with an appropriate, positive and supportive environment (Mahachi, 2020).
Although, as suggested by Foster (2021), the launch of A-EQUIP and the PNA programme could mark the turning point for recovery of the NHS, barriers to its implementation will still exist. Kinman et al (2020) found that a reluctance to disclose mental health issues and stigma of ‘not coping’ will prevent individuals accessing support. There may also be confusion of the term ‘clinical restorative supervision’ with ‘clinical supervision’, which traditionally is a management down strategy for dealing with concerns (Rouse, 2019). Other barriers include ensuring protected time, suitable space for sessions, guilt felt at taking time away from clinical practice, limited availability of PNAs, lack of understanding of A-EQUIP and the PNA role. In addition, staffmay feel there is a conflict of interest if their manager is also their PNA. Another concern, expressed by Rouse (2019), is that if selected PNAs do not have an appropriate leadership style and are not able to empower individuals, they will be less effective in the role, as only by empowering will they enable learning, development and resilience. PNAs must also be able to acknowledge that they may not always have the skills and answers, and should be able to appropriately signpost to available resources such as freedom to speak up to guardians, wellbeing teams, learning and development teams (Ripley, 2020).
Much of the literature when discussing PNAs, including Foster (2021), has focused predominantly on implementation of restorative supervision. There is a concern that focus in practice may be predominantly on restorative clinical supervision and miss out on other elements of A-EQUIP and their importance; this is something that needs to be considered in practice by PNAs.
While completing this work, many other areas of relevance to the PNA role have been noted, which were not explored, but should be explored by the PNA in the future, such as ‘compassion fatigue’ (Kinman et al, 2020), the dangers of ‘presenteeism’ (The King’s Fund, 2020), use of ‘appreciative enquiry’ to move quality forwards (Griffiths, 2022) and dealing with incivility and bullying in the workplace (Bar-David, 2018). In terms of district nursing, the ‘lone working’ nature could potentially also be impacting on nurse’s stress and wellbeing and may be something to consider further in future studies.
Conclusion
Burnout in district nursing is a significant problem, which affects quality of patient care. Although limited research is yet available into the impact of the role of PNAs, indications are that PNAs can make a difference to staff wellbeing and reduce burnout, by supporting staff and using the A-EQUIP model of supervision. One element of this model is using restorative clinical supervision sessions, which can facilitate staff to be able to take a step back, to identify, acknowledge and process issues (restorative), to consider ways to manage these, to identify learning needs and opportunities for development (formative), and to consider how this can promote changes to benefit patient care (individual action for quality improvement).
While still early in one’s PNA journey, understanding of the role, its implementation and benefits to district nursing can be seen. Ways to take the role forward in practice are evident, as is the importance of the PNA in terms of promoting staff wellbeing and reducing burnout. This, in turn, improves attendance, retention, innovation and quality of patient care. Although barriers can be seen, these are hopefully not insurmountable and a positive future exists for PNAs in nursing. Only a few aspects of the role have been considered and many more have been identified that should be explored further.
Key points
- Significant increases in complexity of patients in the community setting, alongside staff shortages and high workloads, are affecting staff wellbeing and consequently quality of patient care.
- Professional nurse advocates (PNAs) could have an important role in supporting healthcare staff to improve their wellbeing and thus reduce staff absences and increase staff retention and levels of care.
- Barriers do exist and further work is needed to implement the introduction of PNAs, and enable them to be effective in practice.
CPD reflective questions
- What stressors do you feel most affect the wellbeing of staff in your area?
- Do you feel some elements of the Advocating and Educating for Quality Improvement (A-EQUIP) model may be more useful than others for use in supporting you in your own practice? If so, why?
- Can you think of an example of when restorative supervision was used or would have been useful in practice?