The public health nursing workforce in England is facing significant workforce challenges, including recruitment, retention and increased workload and demand. For health visitors and school nurses, the impact of the increased health and social care needs of families further adds to the workforce challenges.
The professional nurse advocate (PNA) Advocating and Educating for QUality ImProvement (A-EQUIP) professional nurse leadership programme, developed by NHS England (2023), offers an opportunity to enhance workforce wellbeing, resilience and retention. The PNA model builds upon the principles of restorative clinical supervision (RCS), enabling practitioner-focused reflective discussion on quality improvement, monitoring and evaluation of practice, professional development and leadership.
Early evaluation indicates that PNA-facilitated RCS increases awareness about the importance of staff wellbeing, and engagement in RCS-supported nurse retention.
It is important that commissioners and providers work together to champion the implementation of the model within public health nursing teams and embrace the benefits of the model to support staff wellbeing.
Implementing the PNA A-EQUIP model across the public health nursing and midwifery workforce offers an invaluable opportunity to support staff wellbeing.
Workforce challenges
As an Office for Health Improvement and Disparities (OHID) regional programme manager leading on early years children and families, I am acutely aware of the workforce challenges faced by the public health nursing workforce. This includes health visitors (HVs) and school nurses (SNs) who deliver the Healthy Child Programme (HCP) in England. The workforce challenges are multi-faceted and include recruitment, retention and the workload impact presented by the increased health, wellbeing and safeguarding needs of families. NHS Digital figures (2022) showed a potential 37% reduction in HV numbers since 2015, and a recent survey found that 48% of HVs intend to leave the profession in the next 5 years (Institute of Health Visiting, 2023), making supporting staff wellbeing a pressing priority.
A chance for reflective discussion
The PNA A-EQUIP model offers an invaluable opportunity to help support the development of public health nurses as it prioritises time to engage in PNA-led RCS sessions as a one-to-one or group activity. The PNA model adds value to RCS, as it is practitioner-focused, enabling reflective discussion on quality improvement, professional leadership, monitoring and evaluation of practice and personal and professional development.
The PNA A-EQUIP model (NHS England, 2023) is a nationally funded clinical professional nurse leadership programme that includes RCS. The PNA model was developed in 2020, building on the positive evaluation of the professional midwifery advocate (PMA) model (NHS England, 2016). The NHS standard contract now requires provider organisations to offer clinical supervision facilitated by trained professional nurse advocates (PNAs). The leadership development programme for PNAs is underpinned by Level 7 study.
The A-EQUIP model has four elements, which build on Proctor's model of Clinical supervision (Proctor, 1986); these are:
- Monitoring, evaluation and quality control (normative)
- Education and development (formative)
- Restorative clinical supervision (restorative)
- Personal action for quality improvement (quality improvement). See Figure 1.
Public health nursing teams are well-placed to implement the PNA model. Over the past four decades, there has been periodic focus on RCS; earlier work by Wallbank (2016) showed the positive impact of RCS on staff wellbeing and resilience when applied within HV and SN teams. RCS has been found to support a sense of belongingness, which is closely correlated with staff wellbeing.
I strongly believe that the renewed focus, contractual requirements, and the additional elements offered within the PNA model have real potential to enhance HV, SN and public health nurse wellbeing.
Benefits of the model
The implementation of the PNA model is more than the sum of its parts. As well as focusing on wellbeing, the model clarifies the purpose of RCS and the benefits afforded through the inter-relationship of the four elements of the model. For example, the focus on quality improvement and the associated increase in practitioner autonomy have the potential to increase practitioner job satisfaction and, in turn, contribute to improvements in workforce wellbeing and retention.
Research and evaluations have also shown the potential for PNA-led RCS to improve wellbeing. Outcomes from the implementation of the PMA programme show improved staff wellbeing and retention, alongside quality improvements that enhance care (Whatley, 2022). The first national evaluation of the PNA A-EQUIP model also found that engaging in PNA-facilitated RCS increased awareness about the importance of staff wellbeing and that active engagement in timely supervision supported nurse retention. The national evaluation considered that, as the PNA model becomes embedded and staff increasingly engage in quality improvement initiatives and RCS, this will improve patient and staff wellbeing (Adegboye et al, 2023).
Given the current workforce challenges, it is important that commissioners and providers discuss and work together to champion the implementation of the PNA model, including prioritising protected time for RCS. One option would be to include this as a 2024-2025 HCP service development improvement priority. Focusing on the public health nursing workforce who deliver the HCP, I would encourage HCP providers, including those not subject to an NHS standard contract, to discuss implementation approaches with their regional PNA leads and to secure access to NHS England-funded PNA training.
Implementing the PNA model within the public health nursing workforce provides a tangible opportunity to increase practitioner wellbeing, and the sense of team and organisational belongingness. This will make a positive contribution and help to ameliorate the current workforce challenges and, at the same time, increase the public health practitioner focus on service development and quality improvement.