Consideration is given to how the Professional Midwifery Advocate (PMA) role can serve as a catalyst for change and help drive improvement within maternity services as it promotes the development of a positive learning culture and compassionate care. The significance of advocating for education and quality improvement (A-EQUIP) and potential that the PMA role has to contribute to the transformation of maternity services is emphasised.
The A-EQUIP model incorporates the four functions presented in Figure 1 which provide the framework for the PMA role. These are normative, formative, restorative and personal action for quality improvement. An overview of these four functions is provided in Table 1.
Figure 1. A-EQUIP model
Table 1. An overview of the four functions of the A-EQUIP model (adapted and developed from Proctor, 1986; NHS England, 2017)
| Formative | Involves providing opportunities for increasing knowledge and skill development, and links with education and development |
| Normative | Focuses on monitoring, evaluation and the quality control aspects of professional practice. Midwives are supported to develop their ability and effectiveness in their role while encouraging personal and professional autonomy and accountability, as well as cultivating the motivation to produce change |
| Restorative | Concerned with supporting the emotional needs of staff and creating thinking space which provides opportunity for clinicians to mentally and physically slow down using a process of discussion, reflection, supportive challenge and honest feedback (Pettit and Stephen, 2015). The use of Restorative Clinical Supervision restores individual thinking capacity enabling practitioners to consider different perspectives and ways to move forward to create positive change within a safe environment |
| Personal action for quality improvement (QI) | Emphasis is placed on continuous improvement and encouraging individuals to proactively seek opportunities for meaningful change. The use of QI tools and techniques enable practitioners to implement changes in a systematic and principled way to improve care and workplace culture |
Based on one of the most commonly used clinical supervision frameworks (Proctor, 1986) with the addition of the fourth function, ‘personal action for quality improvement,’ (NHS England, 2017) A-EQUIP should be used as a tool for optimising personal and professional accountability, facilitating professional development, supporting staff wellbeing, and contributing to a learning and compassionate care culture.
This approach enables opportunities for reflection and professional development following which midwives can be encouraged and supported to take action to improve care provision through the use of quality improvement. Quality improvement refers to the systematic use of methods and tools to continuously try to improve care quality and outcomes for those we provide care for. It is a combination of a ‘change’ (improvement) and ‘method’ (an approach with appropriate tools), while paying attention to the context within which the improvement takes place in order to achieve better outcomes (Alderwick et al, 2017).
While definitions of clinical supervision may vary, it is commonly agreed that Restorative Clinical Supervision facilitated by the PMA should incorporate the following principles:
- A reflective component
- Support from a skilled facilitator (the PMA)
- Have a focus on clinical practice (which may include team dynamics, communication, personal coping strategies) and improving care
- Support professional development.
The development of skills in both quality improvement and restorative clinical supervision are an integral part of the training required for the PMA role. This ensures that PMAs in training are encouraged and supported to develop their skills in quality improvement as well as be equipped with supportive skills in clinical supervision.
Why there is a need for A-EQUIP and the PMA role
The last decade has shown that a significant proportion of absence due to ill health within the NHS is stress-related. While reports of stress and burnout in midwifery are not new (Sandall, 1997; Ball et al, 2002; Mollart et al, 2009), midwives find themselves increasingly under pressure to deliver safe, high quality, personalised care while managing limited resources. Work factors associated with stress and occupational burnout include perceived loss of job control, lack of teamwork and feeling unsafe. Organisational factors such as shift work, heavy workload, bullying, poor quality support and staff shortages have been well documented (Kirkham, 2018) and all contribute to a culture where blame and fear can thrive. Midwives have reported experiencing considerable stress within the workplace and may experience post-traumatic stress symptomatology at clinical levels (Sheen et al, 2015; 2016).
The NHS Staff Survey (2021) has shone a light on the recent experiences of midwives and other health practitioners with 44% of staff having reported feeling unwell as a result of workplace stress in the past 12 months. This measure has seen a marked increase this year with overall figures showing a steady increase since 2016. The impact of the COVID-19 pandemic has highlighted staff health and wellbeing (Bailey and West, 2020), and it is likely that staff shortages and the wider influence of the pandemic on family and social support structures have increased the pressures faced by many within clinical practice.
Compassion in practice, the national strategy for nurses, midwives and care staff (NHS England, 2014) emphasises the necessity of inclusivity and ensuring that the voices of clinicians and those that use our services are heard, with opportunities for all to be involved with quality improvement (West et al, 2017). Sadly, many aspects of our working life can threaten opportunities for quality improvement and compassionate care. Poor teamwork, defensive practice, fear of blame, and an over-emphasis on technical mastery as well as the desensitisation and detachment that may result from unprocessed emotions (Sabo, 2006) can all detrimentally impact midwives ability to provide compassionate care.
There is an urgent need to move from a blame culture to a culture of authentic reflection, learning and improvement through systematic and methodical methods with a collective vision to improve our working culture and care for women and their families. High quality, safe healthcare provision is dependent on teamwork and effective multidisciplinary working. Teams work best when all members feel safe, have a voice and feel able to contribute effectively. The importance of all NHS staff having clear objectives, shared values, a willingness to learn from past mistakes and engage with improvement initiatives are considered vital in creating a culture of safety and learning within the NHS (Francis, 2013; Kirkup, 2015; West et al 2015; Ockenden, 2020).
Through the functions of A-EQUIP, PMAs can contribute to the transformation of maternity services and help promote a compassionate culture, multidisciplinary team working and opportunities for learning that are integral to safe, personalised care provision as set out in the Maternity Transformation Programme (NHS England, ND), NHS Patient Safety Strategy (NHS England, 2020; 2021a), the NHS Long Term Plan (NHS England, 2019), Healthcare Safety Investigation Branch ([HSIB], 2021) and the Ockenden (2020) review.
Sustained meaningful improvement is only possible when practitioners operate in a workplace that nurtures civility and kindness. Recognising the importance of individuals' day-to-day behaviours in relation to safety is increasingly recognised (West et al, 2017; NHS England, 2020). The detrimental impact incivility has on patient safety has been well documented (Civility Saves Lives, 2021). Compassionate leadership and the promotion of positive working relationships are vital ingredients in the creation of an open, safe, learning culture where teams work and learn together to improve care (West et al, 2017; Ockenden, 2020; HSIB, 2021)
The PMA is in a unique position to facilitate opportunities for staff support and reflection during challenging situations which encourages insight and may enhance personal and professional autonomy. The creation of a scheduled safe thinking space through the use of Restorative Clinical Supervision enables staff to proactively seek solutions to the problems they face and opportunities for further development and learning (West et al, 2020).
Ideally placed to create and offer opportunities for staff support during change and in challenging situations, PMAs are able to encourage a learning rather than blame culture with opportunity for quality improvement and the promotion of collaborative relationships which enhance teamworking (NHS England, 2019; 2020). In addition, PMAs are able to role model the positive values and behaviours that are fundamental to the core principles underpinning the NHS Patient Safety Strategy and are necessary for an open culture of learning and civility to flourish. Through this, the capabilities of the midwifery workforce are strengthened, benefiting women and their families through safe, high quality care provision.
Table 2. Examples of how the Professional Midwifery Advocate can contribute to quality improvement and a compassionate learning culture
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