Professional midwifery advocates: delivering restorative clinical supervision

Introduction

On 28 April 2017, the Advocating for Education and Quality ImProvement (A-EQUIP) model of midwifery supervision was introduced in England (Dunkley-Bent, 2017) in response to the removal of statutory supervision from the Nursing and Midwifery Order 2001. In the UK, there had been a version of midwifery supervision in place since the Midwives Act in 1902 and, over the years, the model of supervision had undergone many revisions. The most recent version of midwifery supervision was described in Statutory Instrument 2002 No. 253, of the Nursing and Midwifery Order 2001. The Nursing and Midwifery Council (NMC) set out the rules that governed the practice of supervision of midwives in the former Midwives’ Rules and Standards (NMC, 2012).

After the publication of reports by the Parliamentary and Health Service Ombudsman (PHSO) in 2013 and the King’s Fund (nd), the NMC accepted the recommendations that midwifery supervision and regulation should be separated, with the NMC solely being in control of the regulation of midwives (Purdy and Read, 2019). On 31 March 2017, the statutory supervision of midwives was removed from statute as well as the Midwives Rules and Standards.

In 2016, the Department of Health tasked all four countries in the UK with establishing a time-limited taskforce to ensure processes of good clinical governance and support for professional practice were put in place for the midwifery profession. In England, the taskforce consisted of stakeholders including women who used maternity services, midwives, academics, midwifery and nurse leaders and managers, commissioners, the Royal College of Midwives and Birthrights.

A new model of employer-led midwifery supervision – A-EQUIP (Fig 1) – emerged from the consultation (NHS England, 2017). It provides a framework that supports a culture of improvement, with the aim of building personal and professional resilience, thereby enhancing care quality and supporting preparedness for appraisal and revalidation. The evidence base derives from Proctor’s (1987) three-function model of clinical supervision, and Hawkins and Shohet’s (2012) adaptation of that model. The model also has a fourth function – personal action for quality improvement – and highlights the importance of continuous improvement.

A professional midwifery advocate (PMA) is a practitioner who uses the A-EQUIP model and takes on the associated leadership required. The model and PMA role are employer led, so it is the responsibility of the NHS provider to decide how these are implemented. The need to use the model is contained in the NHS Standard Contract as a means of supporting the midwifery workforce (NHS England, 2018a).

PMAs are qualified midwives who have undertaken further recognised training provided by a higher education institute (NHS England, 2017). Once trained, PMAs can take on a range of duties as part of their substantive midwifery role (Box 1), set out in the A-EQUIP operational guidance.

The evidence base for restorative clinical supervision

Restorative clinical supervision (RCS) is one part of the A-EQUIP model, which is also associated with wellbeing benefits, team working and staff retention (Box 2). RCS offers midwives a safe space to reflect on the experiences they wish to discuss so they can source their own solutions, individually or in groups (Macdonald, 2019).

The RCS model in A-EQUIP promotes and uses the principles of the Solihull Approach (Douglas and Ginty, 2001), which involves concepts of reciprocity, containment and behaviour management to allow professionals to process emotions, focusing on their interactions with others and maintaining professional boundaries. The sessions can be formal and rostered or done on an ad-hoc basis and tailored to the needs of the practitioners. The benefits of RCS can be embraced by health professionals at any level, including students (Tyler and Lachanudis, 2020; Power and Thomas, 2018).

The supportive culture that RCS facilitates is designed to promote a positive staff culture, the impact of which will be demonstrated through high-quality, safe midwifery care (Whatley et al, 2021). Research has suggested that the benefits of this positively affect emotional wellbeing, reducing levels of stress and anxiety (Wallbank and Woods, 2012).

How RCS is taught

Anecdotal evidence suggests that RCS is a new skill for most midwives and seems to cause most concern during PMA training programmes. There is a lack of understanding of what RCS is and how it can be used to support staff. The principles seem straightforward, but it is often not clear how they work until practitioners experience RCS for themselves.

Initially, student PMAs were learning RCS face to face but, due to the Covid-19 pandemic, academic institutions moved to the use of virtual platforms. Teaching RCS is based on the A-EQUIP model, which includes practical experience as well as building wider relationships with peers outside of their workplace. PMA students may be asked to develop ‘powerful questions’ to have in their PMA toolkit should the session be slow to start, but they should not be afraid of silence.

The importance of confidentiality and a safe space – not breaching safeguarding or the NMC’s (2018) Code – is reiterated, alongside feedback and evaluation. Skills are practised on a one-to-one basis and in groups before students are encouraged to support a PMA. How PMAs learn clinical supervision skills during their training programme is set out in Box 3.

Delivering RCS in maternity settings

RCS is an essential part of the PMA role. Since the introduction of the A-EQUIP model, PMA teams in employer-led models have developed innovative ways of delivering RCS to midwives. Many teams use a combination of individual and group sessions – available as pre-arranged or ‘drop in’ sessions in the style of a ‘coffee morning catch-up’. Some include PMA walkabout sessions to make sure the offer is available throughout the working week. The main thing is that PMAs have the time to support the delivery method they choose.

As the interpretation of the A-EQUIP model varies, there is variation in the RCS offer; this, inevitably, leads to variation in effectiveness and outcome.

Benefits of RCS

The Covid-19 pandemic has shone a spotlight on health professionals’ wellbeing, and bespoke mental health support is required now more than ever (Kinman et al, 2020; NHS Confederation, 2020; West et al, 2020). PMAs have reported via regional support networks that providing rostered RCS sessions is more challenging, but they have become innovative and creative about how the restorative function can be experienced in the workplace.

One PMA reported that, “at the height of the pandemic, I called myself the ‘hello midwife’ and tried to directly and meaningfully ask as many staff as possible ‘how are you?’. The feedback I received was how unusual it was to be asked that question by someone who had the time and interest to genuinely listen.” The PMA continued, “I consider that the work of the PMA is finding the ‘extraordinary in the ordinary’ and I am continually amazed at the impact listening well can have” (private communication to Capito, 2021).

Another said: “When I deliver RCS, I know from the interactions I have and the feedback I receive that it is essential at these really challenging times. I have heard that it supports midwives to recover from some of the experiences they have had over the past 18 months and has helped them to adapt to the rapidly changing environment they work in. It is valued and valuable, and I have more of my colleagues requesting it every day” (private communication to Keegan, 2021).

In 2021, NHS England funded 160 PMA training places in England, with the potential of a further 100 training places for 2022. PMAs have also received a psychological training boost in recognition that, to provide compassionate leadership, they require self-care and acknowledgement of the psychological “wear and tear” they have experienced (Smith, 2021). The A-EQUIP model has the potential to support midwives with their wellbeing and, given the challenges of the Covid-19 pandemic, it is important that the PMA role is promoted and utilised.