Restorative clinical supervision (RCS) and the introduction of professional midwife and nurse advocates (PMAs/PNAs) have gained validation and momentum since the process was introduced via the A–Equip (Advocating and Educating for Quality Improvement) model for midwifery supervision and support (NHS England, 2017; 2018).
The RCS model is multifunctional and has been identified has having widespread benefits for both those providing health care and those using services (NHS England, 2017; Hunter et al, 2019; Saab et al, 2021; Whatley et al, 2021).
Background
The delivery of health care is not always high quality, with reports highlighting failings and poor patient experiences and outcomes. The implications of poor quality and unsafe care can be devastating and the consequences have a detrimental impact on multiple stakeholders in many contexts (Kennedy, 2001; Francis, 2013; Kirkup, 2015; Care Quality Commission, 2018; 2019; Ockenden, 2022).
The A-Equip model promotes the RCS model and the professional advocate role (NHS England, 2017). Initially, the model was centred on the midwifery workforce, the service and its users. However, it was later adopted by nursing teams in England (May, 2021), following its perceived widespread benefits and positive impact on wellbeing, quality of care and patient safety, which were identified through national consultation, case studies, evaluation and research (Wallbank and Woods, 2012; NHS England and NHS Improvement, 2021). RCS has the potential to empower staff to learn from adverse incidents and, therefore, the potential to improve the quality of care and its safe delivery proactively rather than reactively following such incidents (NHS, England 2017; Whatley et al, 2021).
The process offers a practical, solution-based one-to-one discussion or facilitated group discussion by a peer to address a specific issue/s or to debrief after an adverse event. The session is conducted in a safe and confidential space, free from judgement and any repercussions, with the aim to provide thinking space and emotional support (NHS England and NHS Improvement, 2021).
The RCS framework includes four key elements of supervision (NHS England, 2017):
- Formative (learning through education and development)
- Normative (taking accountability for one's own practice)
- Restorative (support to contain and restore wellbeing) elements
- Personal action, which encourages continuous growth (action plans and intervention/s) for quality improvements to be adopted in practice.
Psychological safety, as defined by Clark (2020), is a term used to describe the extent to which people feel included and safe to speak up, and enabled to contribute and challenge the status quo. Clark (2020) suggested that individuals should be able to take actions without fear of being embarrassed, feeling marginalised or fearing reprisal.
According to Jones et al (2019), good leadership is a prerequisite for successfully supporting the RCS model and is imperative, if its implementation is to have a sustainable impact. Maintaining psychological safety, as highlighted, is an important factor for optimising professional performance, as well as individual wellbeing.
Applying a SWOT (strengths, weaknesses, opportunities and threats) analysis highlights how implementation of RCS can have a positive impact on the psychological wellbeing of health professionals.
Strengths
Midwifery and nursing are often viewed as complex and stressful occupations. The restorative and supportive functions of RCS have been shown to offer many benefits: this includes the positive impact that use of the model can have on staff wellbeing when it involves working with accredited PMAs/PNAs) (NHS England, 2017; Tyler and Lachanudis, 2020).
Studies have also suggested that RCS has a positive effect on emotional wellbeing, helping to reduce stress levels, anxiety and depression; it may also be a preventive tool for burnout, helping to decrease staff sickness levels and attrition, and increasing job satisfaction (Pettit and Stephen, 2015; Perlo et al, 2017; Whatley et al, 2021). Protected time and flexibility to meet with colleagues is also beneficial. It takes little time to set up a session, and RCS can be available when needed, rather than weeks after an event.
In conversation with the author, an experienced PMA reported identifying referrals, through incidental conversations with colleagues, when visiting work areas covered by her role. She simply asked colleagues if they were OK. Sometimes when receiving a response it was clear from a person's hesitance or body language that they were not OK.
An invitation for RCS can be offered immediately following an event to talk things through. It can be delivered to teams, to small groups and as one-to-one sessions, depending on context (Tyler and Lachanudis, 2020). All contacts take place in a safe and confidential environment, giving individuals the space and time to express what is concerning them. Participants are listened to within a context of mutual respect, with the PMA is able to offer an alternative perspective and to suggest an action plan, with the opportunity for the nurse to reflect on the conversation following the session (Sterry, 2018; Whatley et al, 2021).
It is important to stress that RCS is not counselling. From a management and leadership perspective, it provides staff with support; it is a tool that facilitates a confidential, proactive interest in staff wellbeing and enables them to speak about their concerns without fear of reprisal (NHS England, 2017; Sterry 2018).
A report for The Health Foundation (Jones, 2019) suggested that a supportive, collaborative and inclusive workplace culture, which RCS promotes, enables meaningful learning to take place by helping to create a safer, happier work environment. Similarly, Wallbank (2016) suggested that an organisation that promotes a strong sense of attachment and support is more likely to have a resilient, engaged workforce that is loyal and willing to stay in the organisation.
RCS therefore supports staff, helping to make them feel valued and psychologically safe in raising concerns; it offers them support and enables them to try new approaches to solving problems (Jones, 2019). The more an individual feels psychologically safe and supported in the workplace (Edmondson, 2019; West, 2021), the more likely it is that communication will improve at all levels of an organisation. This contributes to the delivery of safer care and better performance, which in turn has an impact on better outcomes and experiences for both staff and patients.
Weaknesses
Clark (2020) suggested that the presence of fear within an organisation is a sign of poor leadership, with the result that psychological safety cannot be easily achieved.
For RCS to be integral to good staff management and leadership and to be used effectively, it is vital that it has the support and investment of senior management. Although the model has been embraced by midwives, its adoption by nurses has been much slower, despite evidence of its value (Whatley et al, 2021). It will therefore take some time to train potential advocates and for support to build up among peers in NHS organisations, which has been the experience of the author locally.
There is a presumption that time to deliver RCS will be easily available. But it is important to explore whether registered nurses will be willing and able to commit time to be involved in and engage with RCS, while facing unrelenting work pressures, or whether this is an activity that, without being given management priority and investment, professionals will end up delivering voluntarily outside work hours.
Wallbank (2013) pointed out that employers have a duty of care, so a professional reaction is always required following any given incident. However, the emotional impact on any individuals affected by a situation is seldom considered and depends on individual managers and their leadership style. Clark (2020) concluded that attitudes may also differ due to perceived generational traits. In essence, this means that some managers are more supportive than others.
Traditionally, investigatory measures within healthcare organisations have often been met with suspicion by staff and can be perceived as punitive exercises, essentially looking for someone to blame, rather than learning from an event and preventing recurrence (Maxton et al, 2021). Midwives and nurses constitute the largest health professional group within the NHS, providing direct care to patients (Rolewicz and Palmer, 2020) which meant that, due to the scope of their roles, they will be associated directly or indirectly with incidents.
Despite having many implementation challenges, RCS is being positively embraced and is gaining momentum and support within the NHS not only in terms of volunteers becoming accredited PMAs/PNAs, but also with regard to those seeking RCS because they need help. It is therefore paramount that the perceived strengths of RCS continue to be promoted positively, to show that the strengths outweigh any perceived weaknesses. The adoption of RCS offers the opportunity for change and should be viewed as a positive step (Whatley et al, 2021).
Opportunities
RCS is a continuous improvement process that develops and builds on personal and professional resilience (NHS England, 2017), and is now being adopted by the nursing workforce. The model could be widely adopted throughout NHS organisations by all professional and non-professional groups.
According to the report, The Courage of Compassion: Supporting Nurses and Midwives to Deliver High-Quality Care (West et al, 2020), the NHS healthcare workforce has been struggling to cope for many years, under pressure from many internal and external forces. Capacity has continued to outweigh capability (Wallbank, 2016), coupled with issues of staff stress, absenteeism, high turnover and intentions to quit, and the large number of nursing and midwifery vacancies throughout the service (West et al, 2020). The benefits of RCS and the PMA/PNA role must be supported to overcome, what Wallbank (2016) described as, the ‘erosion of resilience’ and ‘professional vulnerability. A psychologically safe workforce is ‘an engaged workforce, capable of great things’ (Edmondson 2019:41). Furthermore, the impact of the global pandemic has not, as yet, been fully realised (World Health Organization, 2020).
What the pandemic may have done is to magnify the value and contribution of midwives and nurses, and the challenges they face daily across the healthcare sector (Woodford et al, 2020). There has also been growing recognition of the importance of ensuring the positive health and wellbeing of our valuable NHS workforce during the pandemic (NHS England, 2021). West et al (2020) suggested that, to effectively address the historical problems of nurses and midwives, it is essential to focus on three core needs – autonomy, belonging and contribution – which echo the fundamentals of psychological safety as described by Clark (2020) and form the cornerstones of the RCS model (Wallbank, 2016). There are many opportunities in the context of RCS to build on.
Threats
Blame may be often associated with adverse event investigations, despite the main goal of such inquiries being to enable learning and prevent a recurrence (Maxton et al, 2021).
Maxton et al (2021) suggested that governance can often be seen as unsupportive and accusatory. Furthermore, it can often be weaponised to instil fear and suspicion among the workforce. This is far removed from its underlying functions of monitoring, risk management and learning about workforce issues (Chambers et al, 2004) and doing things for the right reasons. The health and wellbeing of midwives and nurses is essential to ensure they can provide good quality care and follow safe practice guidelines, assisted by good leadership and appropriate processes. Poor understanding of quality systems, poor governance and poor leadership pose the risk of causing more stress and distrust in the workplace.
The time necessary to carry out and receive RCS can also be identified as a potential threat, as well as a weakness of the process. There is also a risk that, due to current operational pressures, support for the model could be deprioritised, despite evidence suggesting that, over the longer term, RCS enhances patient care. It is therefore fundamental for all stakeholders, facilitators and recipients of RCS to ensure this does not happen, and that the use of RCS continues to grow and is successful.
Conclusion
Midwives and nurses have complex and stressful roles. The use of the RCS model, supported by the PMA/PNA roles, has been found to significantly reduce stress and occupational burnout, as well sustain job satisfaction and improve staff retention, while maintaining compassion, improving working relationships and good team dynamics (NHS England, 2017).
RCS can proactively help staff to manage their work and workplace pressures more effectively, and has been shown to increase job satisfaction (Pettit and Stephen, 2015; Wallbank, 2016). It may also be instrumental in retaining staff and supporting them after the COVID-19 pandemic and the ever-changing complex landscape of the NHS.
Such valuable resources must be protected and supported. It is only then that the service can continue to strive to provide good quality and safe care, while supporting a competent, resilient and psychologically safe midwifery and nursing workforce that is fit for service. There are also potential weaknesses and threats for professionals that could hinder implementation and best use of this model. Despite this, the potential strengths and opportunities would seem to outweigh the weaknesses and threats underlying the RCS model. For the benefit of both health professionals and the delivery of care to patients, the RCS model surely is worth a closer look and evaluation.
KEY POINTS
- The restorative clinical supervision (RCS) model empowers professional midwives and nurses to learn and support each other in practice
- The model's framework supports four key elements of supervision:
- – Formative (learning through education and development)
- – Normative (taking accountability for one's own practice)
- – Restorative (support to contain and restore wellbeing)
- – Personal action, which encourages continuous growth (action plans and intervention/s) for quality improvements to be adopted in practice
- RCS is not counselling, it is proactive peer support
- RCS can be delivered on a one-to-one basis or through a group session
- RCS usually lasts for approximately one hour