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Martin Hogan, Lead Professional Nurse Advocate (PNA) at Central London Community Healthcare NHS Trust, tells us about the PNA training programme and the impact and improvements it can have on both staff and patient safety. He shares his own personal development from taking the programme, how he has used the skills learnt to educate and support his colleagues, and explains why he is championing the PNA to others and has set up a network of PNAs. 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: Restorative clinical supervision. Personal action for quality improvement. Education, development and monitoring. 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 [email protected].

The Learning from Excellence (LfE) team bring you the 4th LfE Community Event. The theme for the event is “Being better, together”, reflecting on their aspiration to grow as individuals, and as part of a community, through focussing on what works. For this event, they are partnering with the Civility Saves Lives (CSL) team, who promote the importance of kindness and civility at work and seek to help us to address the times this is lacking in a thoughtful and compassionate way, through their Calling it out with Compassion programme. The 2021 event is planned to be on-line and will include conversations with people who inspire the work of LfE and CSL. It will be as interactive and will be followed by the release of some longer-form conversations with the conference speakers and the LfE & CSL teams as a podcast series. Closing date for registration: 1st October 2021. Registration

Sierra Leone has one of the highest rates of maternal mortality in the world. The risks are even greater for teenage girls who become pregnant, with up to one in ten dying in childbirth. In this blog, Lucy November, co-founder of 2YoungLives, a mentoring project for pregnant teenagers, describes the risks faced by teenage girls in Sierra Leone and the barriers they face to accessing maternity care. She talks about how 2YoungLives is making pregnancy and birth safer for this vulnerable group through mentoring, building community and equipping young mothers to support themselves and their babies. Aminata* didn’t plan to become pregnant at 15. When her mum died, she was sent to live with her aunty in the country’s capital city, Freetown, and felt from the outset that she was not welcome. Her cousins were attending school but there was no money to send Aminata, and instead she was expected to fetch water for the household every day, often spending four or five hours in the queue. When Patrick, one of the men who ran the pump, asked her to be his girlfriend, saying she could jump the water queue and he would also pay her school fees, she felt that she could finally get back on track. No-one had ever talked to Aminata about sex, contraception or pregnancy, and when she missed her period she was just pleased not to have to bother her aunty for sanitary pads which always made her feel like a burden. She discovered she was pregnant one evening several months later when her aunty noticed her changing body and confronted her, screaming that she had disgraced the family and would have to leave. Her few belongings were thrown into the street and she was on her own again. Patrick had told her he loved her, and she was sure he would be happy, so she climbed the hill to the water pump to tell him the news, only to be told he had already heard and left Freetown earlier in the day with no explanation. Knowing there was nowhere else for her to go, Aminata asked her cousin if she could sleep in his car, where she lay down and cried. The months that followed saw her finding different places to sleep - an empty market stall, a friend’s floor, an abandoned building. She would eat meals here and there in exchange for carrying water, washing pots and occasionally having sex with men she barely knew, who took advantage of her desperation. When she went into labour at eight months, Aminata was anaemic, malnourished and had a sexually transmitted infection. By the time she was taken to the hospital by a neighbour of her aunt’s, her baby was already dead and she was bleeding heavily. The 500ml of blood that she lost would hardly be noticed by a healthy, nourished woman, but for Aminata it was catastrophic. In a culture where blood is donated in an emergency by a relative, Aminata had no options and no money to pay, and died that night with her unborn baby. This is a true story, but it is not a story about just one girl; it describes the experiences of many pregnant girls in Sierra Leone. I lived in Freetown from 2001 to 2004, working with Lifeline Nehemiah Projects with children affected by the 10 year civil war, so was only too aware of the statistics that make Sierra Leone one of the most dangerous places to give birth. I saw the issues the young people we were supporting faced as they started to have their own families. A survey we did in 2015 in Eastern Freetown showed a 1 in 10 incidence of maternal death for girls becoming pregnant under the age of 18—in the UK the figure is 1 in 10,000. There are many reasons for this high death rate. Upstream social determinants such as poverty, gendered social norms, sexual coercion and stigma mean that girls have little agency with their sexual and reproductive lives, and once pregnant they are almost always thrown out of home and struggle to eat regularly or prepare for birth. Disrespectful care at health facilities means that they often do not take up antenatal care and are at very high risk of death from anaemia, bleeding, eclampsia, infections and prolonged labour leading to fistula.[1] I got together with my friend Mangenda Kamara, a gender studies specialist who lives in Freetown, and we looked at what we could do to help these girls. We realised that what they needed was a supportive, consistent adult to make sure they were safe and able to access maternity care as well as having the means to eat well in pregnancy and provide for their babies. We developed 2YoungLives as a simple, scalable, sustainable solution to this intractable issue. It is a mentoring scheme which pairs women known for kindness and compassion with three vulnerable pregnant girls. The project provides the girls with money to start a small business which the mentor supports them to run, allowing them to eat well in pregnancy. As a ‘loving aunty’, the mentor helps the girls to register for antenatal clinic, going with them for check-ups and being a birth partner when the girls go into labour. She provides emotional support, and gathers the girls to eat together, encouraging peer friendships. After birth, the mentor continues to support each girl, not taking over but being available if there are problems with breastfeeding, if she needs a few hours of sleep after a bad night, or if the baby is not well, encouraging timely care-seeking and ensuring the baby gets all immunisations. The mentors also promote postnatal contraception, reducing the risk of a second teenage pregnancy with its associated compounded risks. Since we started with our first team of four mentors in 2017, we have grown steadily to six teams—24 mentors in all—in urban, peri-urban and rural districts. We have seen great success in reducing the risk of maternal and neonatal death. Since 2017, the project has mentored over 200 girls; we have had no maternal deaths and a much-reduced rate of stillbirth and neonatal death. In addition, an education bursary grant from King’s College London in 2021 has allowed many girls to return to school or attend vocational training; some are now fully qualified plumbers and electricians. 2YoungLives is now part of an NIHR-funded Global Health Group, a partnership between King’s College London, the Sierra Leone Ministry of Health and Sanitation, Lifeline Nehemiah Projects (the Sierra Leone-based organisation that runs 2YoungLives), Welbodi Partnership and the University of Sierra Leone, and we are about to double our provision by starting a cluster-randomised feasibility trial in six new sites. There is a high level of buy-in from stakeholders—from local chiefs and women’s leaders to Ministry of Health representatives—as tackling teenage pregnancy, child marriage and maternal mortality are all highly prioritised policy areas in Sierra Leone.[2] 2YoungLives improves patient safety by seeing these young women not simply as ‘patients’ on the isolated occasions when they attend the clinic or come in to give birth, but by addressing the social determinants of maternal health and death. Our mentors provide the most basic of protective factors: a relationship with a caring adult. As a result of our mentors' support, the young women we work with are thriving, not just surviving. You can read more about 2YoungLives and how to support its work on the 2YoungLives website. *not her real name References 1 November L, Sandall J. ‘Just because she’s young, it doesn’t mean she has to die’: exploring the contributing factors to high maternal mortality in adolescents in Eastern Freetown; a qualitative study. Reproductive Health. 21 February 2018 2 Palathingal A. National strategy for the reduction of adolescent pregnancy and child marriage 2018-2022. United Nations Population Fund Sierra Leone. 2018