• Appropriate and mandatory assessment of prescribing should remain as a condition of practice for doctors in the UK: evidence of prescribing competence is highly desirable for new UK doctors, and those entering the UK from overseas.
• The addition of the PSA to the MLA should be considered as a pragmatic suggestion to form a Medical and Prescribing Licensing Assessment (MPLA): this could comprise an additional and separate paper under the umbrella of the MLA. 
• The examination regulations need standardising and publishing: both the PSA and the MLA, when launched (or the MPLA) should publish examination regulations. This will standardise examination delivery between administering institutions and clarify the management of irregularities or appeals. The governance of the PSA should be reviewed to ensure that any examination irregularities are identified and addressed prior to confirming results to candidates.
• The PSA or combined MPLA should be considered as a requirement for medical practice in the UK: this could be a summative assessment as an exit from medical school or an entry requirement for FY1, and should be required for international medical graduates licensing (IMGs) via the PLAB route for entry at FY1 and FY2.
• The GMC should have regulatory oversight: the PSA (or MPLA) should be a national requirement for medical practice. As such, it should be subject to regulatory oversight from the GMC.
• If implemented, the proposed MPLA should be funded in the same way as the MLA: the MPLA should be funded in the same way as the MLA will be funded (by universities). In the case of IMGs, funding would follow the model of the PLAB test (self-funded).

After the first wave of the Covid pandemic, I was redeployed from my Macmillan specialist nurse role in acute oncology to intensive care. Up to this point, I had never received any form of supervision. Emotionally, I bottled up the feelings I would have from breaking bad news or a prognosis to a patient and other harrowing conversations. There was no space or time for that in a busy role.

However, being redeployed to intensive care I found people did sit me down and we'd openly talk about our feelings, which I found crucial as a form of preventative mental health first aid.

Being redeployed from acute oncology to intensive care, I had gone from one highly emotive and distressing role into a role that felt like a war zone. Burnout was high, morale very low and the ability to cope depleted among staff and myself.

However, patient care never faulted despite the tsunami of chaos that surrounded us. After the second wave of the pandemic, I decided to continue to champion the voice of my nursing profession and join the Royal College of Nursing (RCN) as the Senior Officer for Surrey. This was a phenomenal opportunity to develop my leadership skills within a local and regional-wide role.

During my time at the RCN, I learnt a great deal and supporting RCN members from every speciality and organisation you could think of. We all had experienced similar distress – moral injury. I had always been an advocate for the mental health of my patients and colleagues.

But in all honesty, as a general nurse and a former Macmillan specialist nurse, the culture has never been to look after oneself as a nurse.

In 2021, my career took me on to working within mental health and education. I supported nurses from every band – newly qualified nurses up to senior management – through either teaching and running educational programmes or supporting people undertaking higher education. At this point, I decided to take the Professional Nurse Advocate (PNA) course at Kingston University.

The role of the Professional Nurse Advocate

The PNA training programme was brought into nursing from midwifery following the pandemic in response to improving the critical state in which the nursing profession found itself in – with hospitals short staffed, staff with ongoing sustained moral injury, and burnout at an all-time high.

The PNA training programme uses the four elements of the Advocating for Education and Quality Improvement (A-Equip) model:

1. Restorative clinical supervision.
2. Personal action for quality improvement.
3. Education, development and monitoring.
4. Advocating for the patient, the nurse and healthcare staff.

The programme is MSC level 7 module upskilling Nursing and Midwifery Council (NMC) registrants. The module aims to educate aspirant nurses on quality improvement, restorative supervision, health and wellbeing, leadership, mental health first aid, and education and implementing cultural change.

Applying the training

As part of the PNA training, I needed to practice my skills and the newly qualified nurses on my preceptorship programme allowed me to offer them support. After just one restorative clinical supervision session, the importance of providing this space more regularly than once a month to my preceptees was evident. I put on weekly drop-in clinics for all newly qualified staff allowing them to drop in and talk about how they were. After 10 months of this I had become known as a “rock” or a “lifeline” – someone external who wasn’t a line manager, someone experienced who could advise and support during the most vulnerable time, the first 18 months, in a nurses’ career.

I extended these sessions not just to our new nurses but to anyone NMC registered within my post-graduate portfolio. There was resistance at first, a lack of understanding of the importance of these sessions, but after a session, irrespective of what band people were on, they understood it.

The feedback I received was overwhelming; for example, “if it wasn’t for you, I don’t think I would stay in my current role” or “I wouldn’t be able to have got through this situation”.

I quickly understood the role of the PNA was bigger than I had imaged.

Next steps

As the only PNA in the trust at that current time, I felt alone and unsure of what I should or could do next. Taking a leap of faith, I set up a Twitter page to connect and learn from others, while at the same time sharing ideas I had tried. This over time grew and the network it has built has been invaluable to me, the staff I support and, of course, our patients. The network now has over 3,500 followers. This has led to me setting up an informal gathering from people from all over the UK – a 'parliament of PNAs'. This is a learning, sharing and caring space to borrow brilliance from one another, to unify support and drive good practice forward for the benefit of our nursing staff and patients.

My personal experience as a PNA in mental health (at the time) showed me that you cannot provide effective care to your patient without having received effective support from the healthcare profession. This wasn’t a new concept to me over the 20 years of my career, but after the PNA programme I felt more confident to act on this, through promotion, role modelling, compassionately challenging culture where this was lacking and educating others on how to do this.

As a general nurse learning about mental health, I kept hearing the phrase: "parity of esteem" – no mental health without physical health and vice versa.

Although I had always advocated this for my patients, I hadn’t for myself. I felt after completing the PNA course I was a better nurse.

I had more skills in my arsenal to provide the most effective care – leadership skills and interpersonal skills, and assessment and implementing cultural change that was sustainable. I didn’t understand to its entirety quality improvement, nor what measures for success meant. But I had them without even realising. I supported 110 newly qualified nurses over a 10-month period with only one person leaving within that timeframe. In comparison, in the previous year more than 10 newly qualified nurses had left within that time. The difference is that they now had a dedicated PNA who used bespoke initiatives to provide support.

These nurses provide care to hundreds of patients each year. With clearer, less burnout out minds they were able to not only cope but, more importantly, thrive.

I have since moved to a community trust as the lead PNA co-producing its implementation to the entire nursing workforce. Creating initiatives such as PNAs, providing support for the patient safety team or to nurses undergoing investigations, Datix and learning from serious incidents. 

Conclusions

The role of the PNA is ever growing and in my mind applies to everything we do, particularly patient safety. 

The more support our workforce has through supervision, career development and quality improvement the better able they are to provide effective care. The PNAs have expertise in providing this support, not just when things are going wrong or when your battery is on 25%, but when things are going well also.

It is critical that all organisations invest in growing this role and allowing PNAs protected time to deliver at first recovery and then restoration to our nursing workforce in order to support and improve staff retention given the state in which our profession has found itself in over the last two years. I have joined shared governance groups which are chaired by our patients, carers and relatives and the loudest take away message is our patients want and need us to be well and healthy in order for us to look after them.

This is a more than a training module, it has been life changing for me and many of the nurses I know who have undertaken the PNA training and it impacts and improves both staff and patient safety.

Further information

• NHS England: Information on the Professional Nurse Advocate
• Twitter @advocacy_forum
•  To join the ‘Parliament of PNAs’, email m.hogan2@nhs.net.

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• View the competency-based PPMC curriculum
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1. Ensure learning from patient safety data and good practice.
2. Develop and use a common language to describe all elements of quality improvement science and human factors with respect to patient safety.
3. Ensure robust evaluation of education and training for patient safety .
4. Engage patients, family members, carers and the public in the design and delivery of education and training for patient safety.
5. Supporting the duty of candour is vital and there must be high quality educational training packages available.
6. The learning environment must support all learners and staff to raise and respond to concerns about patient safety.
7. The content of mandatory training for patient safety needs to be coherent across the NHS.
8. All NHS leaders need patient safety training so they can have the knowledge and tools to drive change and improvement.
9. Education and training must support the delivery of more integrated ‘joined-up’ care.
10. Ensure increased opportunities for inter-professional learning .
11. Principles of human factors and professionalism must be embedded across education and training
12. Ensure staff have the skills to identify and manage potential risks.

This has led to the implementation of many education, training and development schemes that promote safe clinical practice across all health and care services. This guide highlights many of the key areas where progress has been made, while offering a roadmap to what still needs to be achieved. Most importantly, it illustrates how all NHS stakeholders – including you – can get involved to help adopt and promote a safety-first culture whichever care sector you work within.