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Conflict at work: how professional advocates help staff cope with challenging situations

An approach borrowed from midwifery can improve care quality and nurses’ working lives

A nurse explains how she is enabling colleagues to reflect on unconscious bias and raising awareness of diversity issues

The murder of George Floyd in the United States in May reignited the Black Lives Matter movement and conversations about systemic racism, cultural difference, and diversity and inclusion in the NHS.

The health service has a diverse workforce, particularly on the front line. But a diverse workforce does not necessarily mean an inclusive workforce; data from the NHS Workforce Race Equality Standard show that staff from black and minority ethnic (BME) backgrounds report the poorest workplace experiences in the NHS.

If we are to address systemic racism in the health service and

...

A nurse explains how she is enabling colleagues to reflect on unconscious bias and raising awareness of diversity issues

Staff tutorial groups can be valuable forums for exploring challenging situations. Picture: iStock

The murder of George Floyd in the United States in May reignited the Black Lives Matter movement and conversations about systemic racism, cultural difference, and diversity and inclusion in the NHS.

The health service has a diverse workforce, particularly on the front line. But a diverse workforce does not necessarily mean an inclusive workforce; data from the NHS Workforce Race Equality Standard show that staff from black and minority ethnic (BME) backgrounds report the poorest workplace experiences in the NHS.

If we are to address systemic racism in the health service and move towards cultural inclusion and understanding and valuing our differences, it is imperative we challenge the mindsets of people and organisations.

Professional advocacy in nursing

I have worked as a nurse in the NHS for 18 years. Alongside my current role as an endoscopy governance sister, I am a professional advocate, which is a role new to nursing.

Professional advocates are health professionals who have completed the A-EQUIP (advocating for education and quality improvement) course, designed to meet the NHS A-EQUIP model of clinical supervision that has its origins in midwifery.

‘The aim is to help staff build personal and professional resilience and positive relationships, which can enhance care and help reduce stress and burn out’

In 2013, a review of midwifery supervision and regulation by the Parliamentary and Health Service Ombudsman recommended the supervision and regulation of midwives be separated.

This followed an investigation into serious care failings at Furness General Hospital in Cumbria, part of University Hospitals of Morecambe Bay NHS Foundation Trust, where the deaths of at least 19 mothers and babies were linked to poor quality maternity care between 2004 and 2012.

A 2015 report of the investigation at the trust found a ‘lethal mix’ of failings, including midwifery supervision failing to identify poor midwifery practice. In March 2017, the role of supervisor of midwives was replaced with professional midwifery advocates.

Staff’s challenging experiences in the NHS

My interest in professional advocacy was prompted by informal discussions with staff about their well-being and the challenging situations they face in the health service. After exploring the A-EQUIP model, I decided to do this as an elective for my master’s degree in leadership, qualifying as a professional advocate in October 2019.

By using the model to empower and develop staff, improving quality of care becomes an integral part of everyone’s job, every day.

The four functions of the A-EQUIP model

  • Clinical supervision
  • Personal action for quality improvement
  • Education and development
  • Monitoring, evaluation and quality control

In-house tutorials for staff from all backgrounds and groups

Over the past couple of years, the professional advocacy role has been adopted by the nursing profession, but as the role is new to nursing, there is no tried and tested framework for delivery.

Our service delivery structure has therefore been modified from midwifery. It includes in-house, class-based tutorials, where concepts of neurobiology, neuroscience, psychology, sociology, anthropology and philosophy are explored in groups of around 20 staff from all backgrounds and staff groups.

The sessions are interactive, with staff raising examples of challenging situations they have faced at work.

The ability of staff to discuss challenging issues in a reflective environment benefits patient care as well as the healthcare workforce Picture: iStock

Reflection bias, conscious and unconscious

My role as a professional advocate is to listen, and share tools and techniques to help staff understand their own behaviours and emotions and the impact these have on others. This encourages staff to think about their own bias – conscious or unconscious – and open their minds to the views of others.

The aim is to help staff build personal and professional resilience and positive relationships, which can enhance care quality and help reduce stress and burn out among staff.

Restorative clinical supervision

To support the emotional needs of staff, we also deliver restorative clinical supervision. The hour-long sessions, which can be either one-to-one or in groups of no more than eight, provide time out and an opportunity to reflect away from the clinical area.

Staff are encouraged to discuss challenging events and explore techniques for resolving difficult situations. Having open discussions about how to deal with these experiences can help staff build trusting relationships with their line managers.

If a member of staff requires additional support that cannot be met by a professional advocate, they are directed to and encouraged to access additional support from other services.

The role of restorative clinical supervision

Sessions can be one-to-one or in small groups

Restorative clinical supervision has been shown to:

  • Improve the immediate well-being of staff
  • Help staff feel valued because their employer as invested in them
  • Influence a significant reduction in stress and burn out
  • Enhance compassion and job satisfaction of staff
  • Increase staff retention
  • Improve working relationships and team dynamics
  • Help staff to manage work-life balance
  • Increase enjoyment and satisfaction at work

Source: Department of Health and Health Education England

A safe space for honest discussion of front-line issues

Although I am now in a leadership position, I have been a front-line nurse for many years and understand the challenges of the practice environment. I work alongside staff, encouraging them to talk openly and honestly in a safe space. Feedback from those who have attended the sessions shows they feel empowered to approach me for support.

‘Professional advocacy should no longer be restricted to midwifery but be adopted by all healthcare staff, and there are many talented people in the NHS who could take on this role’

You cannot have conversations about inclusion and diversity without reflection and questioning. Changing mindsets requires work from everybody, including middle and senior management, to ensure all staff feel valued and included.

Mechanisms and strategies to combat implicit bias

Implicit bias needs to be addressed through mandatory education, along with initiatives such as blind peer-reviewing of job applications and including staff network champions on interviews panels or in employee relation processes, providing advocacy for Black, Asian and minority ethnic (BAME) staff in disciplinary meetings.

With a better understanding of implicit bias, workplace culture can start to shift, eliminating fears and anxieties about differences and encouraging growth, innovation, and health and well-being in teams.

The professional advocate role is ideally placed to supplement already established staff support networks and services. I have delivered sessions at matron’s meetings, and to the trust’s BAME network and executive board, using the same tools and techniques to raise awareness of well-being, diversity and inclusion.

The whole healthcare workforce would benefit from professional advocacy

The NHS needs to invest in the emotional well-being of its workforce. Professional advocacy should no longer be restricted to midwifery but be adopted by all healthcare staff, and there are many talented people in the NHS who could take on this role.

The cost of any initial investment in the role would likely be off-set by a reduction in staff sickness rates, which are around 2.3% points higher in the NHS than in the rest of the economy, with around one in 11 staff leaving every year.

Harnessing the skills, attributes, creativity and knowledge of the entire workforce has huge value for staff, patients and the NHS. But this cannot be achieved without learning – we don’t know what we don’t know.

Professional advocates have an important role to play in educating NHS staff and supporting them to navigate the everyday challenges of their working lives. Not only will this improve the overall health and well-being of staff, reducing sickness absence rates and improving retention, it will help staff achieve their full potential and get the most out of their careers.


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