Supervision, Support and Advocacy for Improvement in Nursing: A study to understand the impact that PNAs have on patient outcomes and patient experience, through quality improvement projects they lead.

Lees-Deutsch, Liz, Kneafsey, Rosie, Palmer, Shea ORCID: https://orcid.org/0000-0002-5190-3264 and Wilde, Laura 2025. Supervision, Support and Advocacy for Improvement in Nursing: A study to understand the impact that PNAs have on patient outcomes and patient experience, through quality improvement projects they lead. [Project Report]. Coventry University Press. Available at: https://doi.org/10.18552/CHC/2025/0005

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Abstract

EXECUTIVE SUMMARY INTRODUCTION The Professional Nurse Advocate (PNA) programme is a clinical and professional leadership initiative that prepares nurses in England to provide restorative clinical supervision (RCS) to their colleagues. The national PNA Programme was devised and commissioned by NHS England in 2021 and since that time Higher Education Institutions (HEIs) have been delivering PNA courses across the country (NHSE, 2021). On becoming a qualified PNA, nurses have worked in different ways within their organisations to implement the various elements of the role. During 2022-23, Coventry University was commissioned to evaluate the roll out of the national PNA programme. This highlighted positive impacts on nurse morale through RCS and career conversations. However, it also identified areas needing further development, particularly in quantifying improvements in patient care derived from Quality Improvement (QI) work. In May 2024, NHS England commissioned Coventry University to evaluate the impact of PNAs on patient outcomes and experience through QI projects. This report presents the resultant methods, findings, and recommendations. BACKGROUND Quality Improvement (QI) is essential in NHS leadership roles, with ward leaders and clinical staff crucial in identifying and addressing care issues. The NHS employs a range of resources and methods to ensure continuous quality improvements, plus support is often typically provided via in-house training. The PNA role is structured via the Advocating and Educating for Quality Improvement (AEQUIP) model which includes RCS, quality control, personal action for improvement, and education. In 2023, the Royal College of Nursing's educational standards for PNA programmes further defined the 'personal action for quality improvement' function. Standard 3 emphasises the PNA's role in fostering continual care development and innovation, making QI integral to practice. It includes supporting staff through continuous improvement processes, applying nursing research to innovate and improve practice, and using quality improvement methodologies to enhance care and services systematically. It is on this element that the evaluation focuses. EVALUATION DESIGN AND APPROACH This evaluation explored the extent to which successive cohorts of PNA’s have been able to impact patient outcomes and experience through the implementation of QI work. Our primary research question asked: what is the impact of QI work led by PNAs on patient outcomes and experience? The evaluation was delivered using mixed-methods design comprising four work streams: • Workstream 1: Rapid Review and Expert PNA Group • Workstream 2: National Survey • Workstream 3: Case Studies • Workstream 4: Conference; Workshop; and Case Examples Laschinger's (2001) Theory of Organisational Empowerment, which expands on Kanter's (1993) theory, was utilised to shape the study questions (interviews, survey, and co-creation workshop) and to direct the interpretation and synthesis of qualitative data. This model identifies three constructs of empowerment within an organisation: Structural Empowerment, Psychological Empowerment, and Positive Work Feelings. Several of the survey questions were also informed by Michie et al.’s (2011) Capability, Opportunity, Motivational and Behaviour framework (COM-B). This evaluation gained research ethics approval via Coventry University (Ref: P174616). Workstream Activities and Data Collection Rapid Scoping Review - A systemised rapid review process, aligned with Preferred Reporting Items for Systematic Reviews (PRISMA, 2021), was used to guide data collection and reporting. This aimed to inform the research team's knowledge and reporting, contribute to the work of PNAs, and shape the study questions. The main review question was: What is the scope and nature of quality improvements completed by PNAs? National PNA Survey - An electronic cross-sectional survey was developed and distributed via JISC Online Surveys to trained PNAs through NHS England's email list between January and March 2025. The survey covered demographics, nursing experience, QI training and support, QI delivery, impact on patient care, and PNA roles related to QI. The survey aimed to evaluate PNA participation and leadership in relation to QI programmes. Organisational Case Studies - Organisations with exemplary QI work from the PNA Programme were purposively sampled, spanning community, mental health, and acute sectors. Semi-structured interviews with key participants explored the nature of QI work by PNAs in their organisations. PNA Conference and Co-creation - Entitled "Inspire, Innovate and Impact", the Conference was held at Coventry University on November 13, 2024, to showcase PNA QI work and promote learning on its positive impacts. A co-creation workshop was held where delegates shared experiences and strategies for sustaining QI work. Further activities supported gathering QI case examples, with contributions from conference delegates and other invited participants. FINDINGS Rapid Scoping Review: • A limited number of relevant papers were retrieved, describing the PNA role (Smythe et al. 2023; Pearce 2023a, 2023b), the role of RCS in the PNA model (Scanlan and Hart 2024; Hart and Scanlan 2024), and reflections on being a PNA (Brookes, 2022). • Sharman et al. (2025) evaluated the implementation PNA programme in a mental health and learning disability NHS trust, finding that only 18% of RCS sessions resulted in identifying a QI project. However, one of the identified signposting areas from RCS was to the continuous quality improvement team. 41% of sessions addressed stress and wellbeing, providing psychological safety for staff to discuss issues. They concluded that PNA training increases confidence to undertake QI, however further CPD was identified as needed as new insights develop regarding the role. • Within the Professional Midwifery Advocate (PMA) literature, Horler (2020) implemented a QI project to increase home birth rates, using various tools and culminating in an audit, new service proposal, guideline review, and training development. Sterry (2019) introduced the A-EQUIP model to support practice change for PMAs. • The review highlighted gaps in reporting and quantifying QI projects arising from PNA work and informed potential questions for the expert involvement group and survey. National PNA Survey: • There were 105 survey responses. Most respondents (72%) had QI experience before becoming PNAs, and nearly all (92%) were currently engaged in QI work. PNA training was moderately rated as equipping nurses for QI, with 51% receiving additional training. • PNAs felt ‘somewhat confident’ in leading QI work and ‘somewhat supported’ in practice. The perceived impact of QI work was rated higher on patient care outcomes (‘high impact’) than on patient experience (‘moderate impact’), and patients were only reportedly involved ‘to a small extent’. • Over half (54%) reported improvements in patient care outcomes or experience, with only 5% stating no improvement. • Three main areas of QI work positively impacting patient care or outcomes were identified: interventions and treatment processes; workforce and staff wellbeing issues, and focused clinical projects tailored to specific clinical contexts. Case Study Interviews: Eight participants provided case study interviews (October 2024 to December 2024). Four key themes were identified during the thematic analysis of narrative data, namely; Identifying QI projects and lack of preparedness; Implementing QI projects, related support and collaboration; Monitoring, reporting and disseminating QI work; and the Impact, reach and sustainability of QI work. Theme 1. Identifying QI projects and lack of preparedness: PNAs identified potential QI work through RCS sessions, staff feedback, care observations, patient feedback and complaints. Whilst some staff felt unprepared for QI, others felt empowered by the PNA role and emphasised the importance of utilising this to empower others to take forward their own ideas and projects. Theme 2. Implementing QI work, related support and collaboration: The importance of support, teamwork, and collaboration in relation to QI was emphasised. Time was a major barrier and being released from the clinical duty if this was needed to develop QI work. It was stressed that these barriers needed resolution to successfully implement QI projects. Theme 3. Monitoring, reporting and disseminating QI work: There was a clear need for robust data collection to demonstrate the impact of QI initiatives. Participants discussed the methods used to gather data (local level), the challenges of measuring outputs/successes (system level), and the value of qualitative feedback as well as its limitations in providing concrete evidence of impact. Theme 4. Impact, reach and sustainability of QI work: Respondents emphasised the ability of QI to significantly impact both staff wellbeing and patient outcomes. Where successes had been garnered via QI projects, efforts were made to share these within and beyond their organisation. Designing QI projects focused directly on patient outcomes was considered particularly challenging. As such, QI projects focused on staff wellbeing could indirectly improve patient outcomes, by creating supportive environments for staff, leading to better patient care. PNA Conference and Co-Creation Workshop The Conference was extremely well attended by 90 delegates, mostly PNAs. At the Conference the Co-Creation Workshop enabled the development of a set of Principles for PNAs, translated into a Toolkit, aimed at helping PNAs to engage in QI; in particular for nurses with minimal nursing experience, or PNAs new to the role of QI work. Additionally, the Toolkit provides nine characteristics of good QI work and a set of ‘top tips’ for PNAs initiating QI work have been developed. The toolkit sets out the following principles to support the development of QI work: 1. ACCESS: the QI team (or support person) to facilitate further QI training, tools and ongoing support as needed, before commencing any work. 2. EXPLORE: the problem (s) to envisage how this could be improved and decided whether or not, to progress with QI work. 3. UNDERSTAND: the complexity of the problem through discussing the impact this is having in your area and barriers it potentially creates – it might be more than one problem. 4. CONTACT: your Lead PNA to enable identification of other PNAs or ward-based nurses with experience of undertaking QI work, for transitional support. 5. NEGOTIATE: Establish if/how other PNAs have negotiated the time to undertake QI work (see Tool 3). 6. COLLABORATE: Consider ways to buddy with other PNAs to build your confidence of QI work and enhance your practice. For example, join a PNA network/forum to create inspiration, creativity and support for QI work. 7. COMMUNICATE: your QI plans to the Lead PNA and upwards to senior leadership/corporate nursing team/the education/practice development team to facilitate awareness of QI work. 8. ALIGN: your QI work to the organisational nursing priorities, to achieve organisational buy in. This will connect your QI work and enable greater traction. 9. DOCUMENT: your QI project ready to receive feedback, disseminate or to celebrate success using existing organisational mechanisms, such as team meetings and Newsletters. CONCLUSION Three core elements were identified from the qualitative findings namely, the need for further QI training; to develop confidence in QI and the ambiguity of the PNA role in relation to leadership of QI. Adequate time to conduct QI work within the PNA role was identified as an issue throughout. PNAs report that their QI activities enhance patient outcomes and experiences, with case examples showing benefits for both staff and patients. Improved data capture could lead to more routinely reported patient benefits. While PNAs use QI methodologies, strengthening training within the PNA programme could aid their transition and support QI efforts. PNAs value the professional growth from QI involvement, but greater organisational commitment is needed to fully realise the benefits of the PNA role in clinical settings. RECOMMENDATIONS Eight recommendations were derived from the evaluation: Provider organisations for the education of PNAs to 1. Enhance the QI element of PNA training: Provider organisations for the education of PNAs should review the QI training as part of the PNA programmes to improve the confidence, skills and capacity of PNAs to undertake QI work. 2. Clarify responsibilities for QI work: Expand upon current education guidance/policy (RCN, 2023) regarding the PNA responsibilities in relation to delivering and supporting QI work to ensure the expectations and deliverables are clear. Provider organisations for the employment of PNAs to 3. Recognise the time required for QI work to be realised: Acknowledge QI work within PNA roles to ensure there is adequate time. 4. Foster a supportive culture for QI work: Encourage empowerment and leadership among PNAs to facilitate QI projects through communities of practice (e.g., Shared decision-making councils). PNA’s to 5. Promote the involvement of patients in QI work: Establish ways of routinely involving patients to represent their voice in addressing issues which required improvement. 6. Improve the quality of data reporting at organisational level: Encourage the development of methods across organisations for data reporting (quantitative and qualitative) to better demonstrate impact from work PNA Leads regional and system level to 7. Enhance communication and engagement regarding QI work: Promote communications regarding the sharing and dissemination of QI work to highlight successful projects and innovative practices. 8. Ensure sustainability and greater reach of QI projects: Clear mechanisms should be developed to support continuous improvement and the reach across organisations of successful QI work.

Item Type:	Monograph (Project Report)
Date Type:	Publication
Status:	Published
Schools:	Schools > Healthcare Sciences
Subjects:	R Medicine > RT Nursing
Publisher:	Coventry University Press
ISBN:	97818460013201
Date of First Compliant Deposit:	16 June 2025
Last Modified:	17 Jul 2025 14:30
URI:	https://orca.cardiff.ac.uk/id/eprint/179081

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