Beneficent Disruptors: A qualitative descriptive study of professional advocacy in healthcare

Setting

This research is funded by one large NHS Trust in the UK. An NHS Trust is an organisation which delivers healthcare to a particular geographic region in the UK. This Trust provides services to approx. 1 million people over a wide geographical area, including city, rural and coastal locations and comprises of a range of hospitals and community-based services. It cares for people throughout their life span from maternity and paediatrics through to older adults. The Trust employs 11,600 members of staff, of which 3329 nurses and 323 midwives.

Study purpose

The purpose of this study is to qualitatively describe the experiences of registered PNA’s / PMA’s in one UK NHS Trust. This work will shed light on how NHS England guidance (NHS England, 2017; NHS England, 2023a) is understood and translated into day-to-day practice by those undertaking the role. As this is a relatively new initiative, practice oriented evidence is limited, and this study forms a workstream in a wider funded project evaluating the implementation and impact of PNA / PMA is one Trust. The outcomes will also further national conversations about the role and contribution to the workforce, service provision and patient outcomes.

Study design and data collection

In line with the descriptive purpose of the study, a qualitative research design was chosen in a paradigmatic framework of interpretivism. Interpretivism assumes that concept of reality is subjective, shaped by individual experiences, historical context, and cultural backgrounds. This diversity in perception highlights the complexity of understanding reality as a singular truth, suggesting that multiple realities exist, each valid within its own framework. Consequently, a qualitative descriptive methodology was suitable as we wanted to explore the subjective PNA/PMA perspectives of undertaking this role in their practice context. Following Sandelowski’s (2010) suggestion, it was important to approach this project from a viewpoint which encompassed a naturalistic, comprehensive and realistic understanding of the self-generated experiences of working as a PNA/PMA. Qualitative descriptive methodology is theoretically rooted in naturalism and is set apart from other methodologies such as phenomenology, grounded theory, and case study by more flexible and pragmatic precepts and procedures. Therefore, this type of qualitative descriptive methodology supports the researcher in their quest to develop new understandings of the qualitative data by employing a lens that is directed on the participants’ experiences as opposed to adopting a specific philosophical position (Sandelowski, 2000; Polit & Beck, 2014).

The exploratory qualitative descriptive study design fulfils the central aim to generate a descriptive, subject account of the phenomenon of interest. The emphasis of naturalistic inquiry means that qualitative descriptive studies are not steered by a predetermined theoretical stance on the intended phenomenon. Rather, our intention was to document a detailed, firsthand account of the PNA/PMA role from the PNMA/PMA perspective. This study design enabled the research team to gain access to real world, lived examples from the viewpoint of those working in the role. To do this, we applied the method of semi-structured interviews which are commonly applied to seek individually oriented data.

The study design builds on interpretivist principles prioritised the subjective and intersubjective construction of meaning. Thematic analysis identified themes and their concomitant categories. The inductive approach taken, with its open coding of data, fosters this commitment to understanding the phenomena from the participants’ viewpoints, ensuring that their ascribed meanings guided the analysis. As a data repository, NVivo provided team access to the data for blind coding to check credibility as the coding progresses, and to enhance the capacity for cross-linking data in the wider project.

Recruitment

After securing organisational permission and ethical approval, a Trust based gatekeeper identified potential participants from a register of nurses and midwives who had completed the required PNA / PMA training and made initial contact with them, offering information about the study and an email address for a member of the project team who was available to explain more about the study, should they wish to participate. With their agreement, participants were then sent a copy of the Participant Information Sheet (PIS) and consent form by email. Interview participants were required to sign and return the PIS and consent form prior to being interviewed.

Participants

The inclusion criteria for recruitment comprised of all registered PNA’s and PMA’s, with no exclusion criteria. Information and invitations were provided through informal meetings, email exchanges and practice-based networking by the project co-ordinator. In total 14 agreed to participate (8 PNA and 6 PMA). Following ARU ethical approval (ETH2223-2520) and gatekeeper permission, the project co-ordinator liaised with the participants and project team to share the participant information sheet, answer any questions, seek consent, and organise interview dates and times. Written informed consent was obtained prior to the interviews though an informed consent form, and reconfirmed verbally at the completion of the interviews with reference to the data withdrawal procedure in the participant information form. The interviews took place over a 6-week period, online via MS Teams, and recorded with verbatim transcription. The primary work base for the participants covered 2 acute hospitals (N = 4/n = 8) and those working in community services (n = 2) and included NHS grade bands 5 (n = 1), 6 (n = 1), 7 (n = 10) and 8 (n = 2).

Data collection

To understand the PNA/PMA experience of implementing the role in practice, semi-structured interviews using open ended questions were conducted with PNA’s/PMAs across the organisational locations. Questions were developed from the wider literature review, key national policy documents and analysis of local organisational scoping review. The questions centred on participant experiences of being a PNA/PMA, including what they hoped to achieve. Examples included how professional advocacy may/may not have resulted in QiP, retention and wellbeing, barriers to implementing the role, and their thoughts as to how the role could be best utilised in relation to QiP, retention and wellbeing. Descriptive demographic questions were asked to identify the band of the interviewee, current position, length of service and area of practice. To ensure consistency, one experienced qualitative interviewer conducted all interviews. In preparation, two pilot interviews pre-tested the interview schedule and recording technology. The interviews were anticipated to last for 1 hour to allow for detailed conversation, instigated by the prompts. The interview transcription redacted all biographical/identifiable details. Following the study protocol and interview guide, semi-structured interviews were conducted via MS Teams.

The function of the interviews was to reveal how the PNA / PMA role was enacted (or not) in everyday practice. The participants shared a range of experiences which included positive recollections as well as frustrations and concerns. Therefore, the interview conversation required sensitive and ethically minded handling as the interview experience can be troublesome (Brinkmann and Kvale, 2018). Although, talking through thoughts and events may also be a helpful and heartening experience as opportunities may arise for alternative insights are gained about everyday situations (Engward et al., 2024). Following data collection, a Trust based member of the project team remained in contact with the participants to keep them updated about our findings and the wider project.

With permission from each participant, the MS Teams audio and video recording facility was used and generated an audio verbatim transcription. The recording and transcript were downloaded and stored onto a secure, password protected system. After checking the transcripts for accuracy, the video recordings were deleted. To ensure anonymity, the data set did not include any identifying information (e.g., name, role, work location).

The interview schedule ( Table 1) was developed and piloted with the Trust based project co-ordinator (Goldspink et al., 2025) to ensure relevance and intelligibility. The 14 interviews gathered approximately 25 hours of transcribed data.

Data analysis

The data were analysed ( Figure 1) using a thematic analysis approach to search for themes and patterns in the focus group data (Sandelowski, 2010). Following cleaning of the raw data to remove all identifying content and checking with the audio recording for accuracy, two independent analysts (HE and SG) read the data sets several times to familiarise themselves with the data and uploaded the transcripts to NVivo to generate and assign initial codes to units of meaning. Open coding (fracturing of the data and grouping/categorising) was performed, which led to axial coding (restructuring the data in different ways to build themes across the data set). The two analysts who generated and assigned initial codes were members of the academic project team, this was deliberate to ensure that they did not have preconceived biases about the PNA/PMA role. A total of 14 interview data sets were separately analysed to develop initial codes. Then two original analysts performed thematic analysis by searching, reviewing, defining and naming themes to construct and finalise the themes. Next, the detected themes and concomitant data extracts (quotes) were examined by two analysts (AT and NvV) to establish the extent to which the themes portrayed the data in terms of transparency, accuracy and coherence and meaning in relation to our study purpose.

Figure 1. Data analysis process.

Figure 2. Conceptual diagram of the professional advocate as a beneficent disruptor.

The findings are offered in a manner which conveys the story of the phenomenon along with describing the interpreted meanings which illuminated the participants subjective and collective experiences. Throughout the analytic process the project team reflexively questioned their observations, vocabulary and decision-making to heighten their awareness of potential bias and opening discussion to safeguard data derived codes and themes.

Trustworthiness

To enrich the trustworthiness of this project, attention was consistently toward to the quality and rigour of each stage of the research process (Nowell et al., 2017). The key areas of transparency, credibility, intelligibility, dependability, confirmability, auditability, and reflexivity formed an appraisal framework. As a team, we established actions to enhance credibility and auditability that established agreed strategies for activity recording and data organisation and analysis, (for instance, during the coding process, the memo function of NVivo was used to demonstrate what we noticed and how this influenced our decision-making). Following the interviews, the interviewer’s field notes were logged alongside the recording and transcript. To develop high levels of transferability, intelligibility and authenticity we deliberately returned to the transcripts on several occasions to build rich, thick explanations drawn directly from the raw interview data. Although transferability is a contested area (Drisko, 2024), we worked with the intention to offer the type and level of detail necessary for readers to compare the outcomes of this study with their situation, and to complement this, we have included verbatim narratives to display the links derived from raw data and the findings.

User involvement

There is no patient/public involvement in this project as the project focuses on the experience of staff caregivers.

The context and purpose of PA actions

PAs offer support in varied contexts, primarily through clinical supervision and career-focused discussions. In clinical supervision, PAs assist individuals in reflecting on incidents, particularly when clinical skills have been challenged. As outlined by two participants:

Career discussions are also facilitated, often using tools such as coaching cards to help individuals clarify their goals. One participant explained,

A primary concern for PAs is restorative support, focusing on the supervisee’s emotional wellbeing and personal growth. A participant puts it as

This pastoral element is essential, aiming to provide an empathetic, supportive presence:

In addition to skill development, PAs work to reduce supervisee loneliness or isolation by actively listening and addressing their concerns. One participant shared,

Contextual actions in support

PAs engage supervisees in reflective questions to deepen their understanding of practice and enhance problem-solving abilities:

These questions are designed to deconstruct challenges and reduce catastrophising. As one participant noted,

These interactions help reframe perspectives, encouraging supervisees to view challenges in a more balanced way. A PA may prompt further exploration: “How can we process what you’re feeling? Is there an additional service you might need?”

This reflective process often results in collaborative action plans, for example, by linking continuing professional development (CPD) directly to clinical practice: “Making CPD really real and linked to practice.” However, this integration is not solely about skill enhancement; rather, it aims to foster transformation at both individual and service levels: “So it’s about developing the individual and the service, together, at the same time.” This approach acknowledges individuals as catalysts for change, where their personal growth contributes to a healthier, more resilient service. One participant observed, “The PMA can facilitate that discussion, offering restorative supervision for the service… the service needs ways of managing stress together.” Another added, “People who develop themselves can develop their teams; this isn’t just about individuals for me; it’s about how, as individuals, we can make a difference.”

The role of advocacy in PA work is seen as distinct from traditional clinical supervision, emphasising a non-blaming, supportive culture. A strong commitment to challenging a culture of blame is central to this role, ensuring that the support provided fosters growth without judgement.

Beneficent disruptors

The primary purpose of advocacy is to create a safe space that supports colleagues in making meaningful changes to their practice and within their practice environments. Advocates work quietly and persistently, using their professional and organisational knowledge to empower others to harness their own potential to improve practice. In doing so, they serve as understated disruptors to the traditionally passive status quo.

Advocates accomplish this through three key avenues:

Advocacy creates a space where individuals can openly discuss themselves within the context of their specific practice environment:

This safe space acknowledges that care work is inherently emotional. Advocates provide an outlet for practitioners to process their feelings in a way that supports their mental and emotional wellbeing:

Advocacy emphasises relationships and interactions within the workplace, recognising the role of interpersonal dynamics in emotional and professional wellbeing:

For effective support, advocates provide a separate space away from the immediate practice area. This allows nurses and midwives to process their experiences and emotions outside the demands of their roles:

Advocacy thus provides a safe, intentional space for reflection and emotional processing, separate from the work environment.

Looking forward

The advocates adopted a proactive approach, focusing on future solutions, redirecting strategies, and minimising reactive problem-solving:

This future-oriented stance emphasises the belief that individuals can make positive changes within their practice:

In this approach lies a quiet yet powerful notion of using conversation to challenge the organisational culture:

One way of making conversations productive is by unpacking organisational factors that present challenges to the everyday practice of nurses and midwives. Advocacy subtly challenges the context in which practice occurs, focusing on understanding what external factors contribute to these challenges, rather than blaming individuals:

This deliberate focus on organisational factors aims to counteract the perception of individual blame:

Through this focus on systemic factors, advocates challenge blame culture, helping individuals recognise they can still make meaningful changes that improve patient care. This approach empowers nurses and midwives to reject a passive acceptance of the status quo and take active steps towards improvement. To address blame culture, advocates actively work to disrupt the idea that nurses and midwives lack the agency to effect change. They do so, in part, by challenging habitual, unproductive moaning:

By gently challenging these behaviours, advocates introduce a quiet disruption to traditional, passive approaches in the practice environment, empowering staff to believe in their ability to create change.

Empowering for change

Supporting the idea that small changes in practice can lead to significant differences empowers change and positively impacts individuals, the profession, and the service:

Important is recognising that small changes in practice benefit everyone. This was described as the ‘inch wide mile deep’ theory. The inch wide, mile deep theory made sense because, from intuitive practice of knowing that small change can have big impact.

To empower the individual:

Empowering the individual alone is not enough. Instead, individuals must support and empower one another, fostering collective growth and strengthening the entire profession simultaneously.

Empowering the profession

The realisation of empowerment in the context of advocacy is through the shared understanding that enhancing skills, building confidence, and recognising capabilities leads to improved practice, better care, and enhanced peer support through collective development:

Therefore, a connection is made between empowering the individual, empowering the professional and developing services:

Building collective resilience

Resilience, both individual and collective, is viewed as underpinning a stronger workforce. However, while resilience is viewed as necessary, especially in high-stress environments like those experienced during COVID-19, there is also a risk of overemphasising resilience to the point where individuals feel they must cope alone. Therefore, the goal of the PA’s is to equip staff with the tools and support needed to manage challenges effectively without feeling overwhelmed or isolated:

But there is a sense that being too resilient is counteractive:

While the participants acknowledge that resilience is necessary, especially in high stress environments, they also indicate that overemphasising resilience is counterproductive, leaving individuals detached from the available support. Rather, the intention of the PA’s is to galvanise staff to effectively manage work-based challenges without feeling overwhelmed or isolated.

Types of advocacy

The data presented professional advocacy as multidimensional to address different needs.

What PNAs/PMAs are not doing

Advocacy is different from clinical supervision. The participants framed clinical supervision as focussing on rectifying actions that are wrong:

Advocacy was explained to be ‘completely the opposite’.

Therefore, unlike previous conceptualisations of clinical supervision, which is often associated with correcting mistakes, PA asserts the need for a more accepting and collegiate atmosphere to examine practice issues and foster professional autonomy.

Characteristics of being an advocate

Empathy, listening, and helping individuals find their own solutions are indicated as essential to the PA role. Value is observed in providing support in the background, using everyday interactions to provide guidance, and encouraging professional intuition to challenge the status quo. Courage and initiative at different professional levels is aligned with making the best decisions for patients while taking care of themselves:

Understanding differences between grade bands

Providing support through everyday interactions and encouraging professional intuition are prominent features of the PA role. By empowering staff in their patient-centred decision-making while taking care of themselves, promotes a culture of courage and initiative across different professional levels.

What PNA/PMAs need to develop

There is consensus that PNA role is important, despite its intangible nature. Emphasis is placed on mentoring and skill development to support staff in the workplace. Although, confidence is more evident in providing informal support and debriefing but is there is less comfort with formal PA activities, such structured RCS.

There is a consensus on the importance of the PA role, yet there is a difference in how comfortable the participants are with engaging with distinct types of PA activities. Of not is the discrepancy between what is perceived as informal and formal activity.

Summary

PAs are creating safe spaces for practitioners to discuss experiences and emotions, fostering mental and emotional wellbeing. They underline the importance of positive interpersonal relationships and reflection away from immediate practice demands. By adopting a proactive approach, PA’s encourage future solutions and robust problem-solving to challenge organisational culture and blame. In their view, empowering individuals through small changes leads to significant improvements in practice, care, and peer support. Therefore, the PAs are focusing on support rather than judgment, using empathy, listening, and guidance to help individuals find their own solutions and build individual and collective resilience. They are working to shift the expectation (either real or perceived) that staff are expected to cope alone. However, the attention given to support others may have left little room for the PAs to consider what they need to develop.

Empowering through advocacy

This project underscores the transformative power of advocacy when it prioritises empowerment and reflection in the context of routine practice (Lucas, 2023). PNAs and PMAs, acting as beneficent disruptors, catalyse meaningful changes in practice by creating environments that are safe, supportive, and which promote the insightful use of professional knowledge. These environments enable nurses and midwives to process their professional and emotional challenges without fear of judgment, thus fostering resilience (Barratt, 2018) and capacity for self-improvement. The emphasis of advocacy on reflective practice aligns with the aim of the A-EQUIP model (NHS England, 2023a) of embedding quality improvement and education into daily routines, creating a culture where personal development becomes integral to professional practice.

The participants’ narratives revealed that advocacy is most effective when it focuses on collaborative problem-solving and challenges systemic barriers to improvement. This aligns with existing literature, which suggests that empowering individuals within their own context strengthens their ability to contribute to collective service enhancements. Notably, the study highlights advocacy’s ability to address the relational and emotional dynamics of clinical practice. This interpersonal dimension of advocacy is crucial, given that workplace relationships significantly influence staff satisfaction and retention. Engeström’s (1987) Cultural-Historical Activity Theory (CHAT) is a useful lens to illuminate the significance of collective activity systems, where the interactions between what people do, think can inform and transform practices (Qureshi, 2021). By recognising this interconnectedness, advocacy can effectively address both individual and systemic issues, cultivating a more collaborative and supportive work environment.

Building resilience and its boundaries

The role of advocacy in building resilience emerged as a central theme in the study, reflecting the pressing need for healthcare professionals to withstand the pressures of increasingly demanding environments (Unjai et al., 2024). Participants recognised the value of equipping individuals with coping mechanisms and tools to manage stress and challenges effectively. This emphasis on resilience is consistent with NHS workforce strategies, which identify resilience as a key factor in improving retention and reducing burnout (NHS England, 2020).

However, the findings also caution against overemphasis on resilience as a singular solution to systemic issues. This point corresponds with Traynor (2025) who argues that current views of resilience contribute to the burden of caring by oversimplifying solutions and detracting attention from underlying systemic problems such as high workload, ineffective structures and staff retention. The participants expressed concerns that the excessive focus on individual resilience might inadvertently perpetuate a culture of endurance rather than addressing the root causes of stress and burnout. This echoes wider critiques of resilience discourse, which argue that it can shift responsibility from organisations to individuals, neglecting the structural factors that contribute to staff dissatisfaction (Kim and Chang, 2022). Therefore, while resilience-building remains a cornerstone of the PNA/PMA role, it must be complemented by efforts to tackle systemic barriers and ensure sustainable improvements in the working environment.

Counteracting blame culture

One of the most striking findings was the potential of PNAs and PMAs to challenge and counteract blame culture within healthcare settings (Hawkins, Jeong and Smith, 2019). According to Stone (2020), an error-free healthcare environment is impossible to achieve, and when mistakes happen, the support provided is often insufficient and intolerant. By creating a non-judgemental and supportive environment, advocacy helps individuals explore workplace behaviour and improve patient care without fear of reprimand. This fosters a learning-oriented approach to incidents, enabling practitioners to focus on improvement rather than defensiveness or speculation. Buhlmann, Ewns and Rashidi’s (2022) qualitative study reiterates how workplace incidents can leave professionals feeling emotionally and physically distressed. The accessibility of organisational and peer support is vital to wellbeing, maintaining professional duties and service development, for both individual and staff groups. Such an approach corresponds with the broader objectives of the A-EQUIP model, which seeks to embed a culture of continuous improvement and accountability without assigning blame.

The study participants identified advocacy’s role in shifting perspectives, encouraging practitioners to view challenges as opportunities for growth. This non-punitive perspective is particularly valuable in high-stakes healthcare environments, where errors can have significant consequences. By reframing the narrative around incidents, PA’s contribute to a culture where practitioners feel less isolated and more supported to innovate and improve their own practice, the practice of others and the services they work in.

Limitations and opportunities in advocacy

While the study highlighted the significant contributions of advocacy, it also revealed limitations in the implementation of the PA role. At a national level, the NHS Workforce Plan (2023) identified clinical supervision as necessary for nurturing professional development and safeguarding patient care. However, in their local context, the participants described challenges in balancing their advocacy responsibilities with clinical workloads, suggesting that insufficient time for advocacy undermines its potential impact. This finding aligns with earlier critiques of employer-led models of supervision, which caution against the risks of under-resourcing, misunderstandings linked to the purpose and inconsistent implementation across trusts (Sterry, 2018; Masamha et al., 2022).

Moreover, the findings suggest that advocacy’s transformative potential is not fully realised without clear organisational support and integration. This observation corresponds with Rothwell et al.’s (2021) international rapid evidence review which associated successful supervision with individual factors such as protected time and supervisor and supervisee trust. In contrast, barriers were related to broader systemic issues, such as a lack of organisational backing. Hence, professional advocacy cannot effectively operate in isolation; it must be integrated within broader organisational goals, policies, and support systems. Greater alignment is needed between the emphasis on advocacy as a vehicle for systemic change and the organisational commitment required to recognise and prioritise the PA role as fundamental to workforce development and service improvement.

Implications for practice and policy

This study offers several implications for the future development of the PA role. First, it highlights the importance of embedding advocacy within organisational structures and policy to ensure consistent support and visibility. Second, it underscores the need for ongoing training and professional development to equip PA’s with the skills and confidence required to navigate complex interpersonal and systemic challenges. Finally, it calls for greater attention to the interplay between individual and organisational resilience, advocating for a holistic approach that addresses both personal and systemic factors.

Strengths and limitations

Having one experienced researcher complete all the interviews secured constancy in data collection, which can improve the dependability of the findings. Including participants from a range of service areas and with various level of PNA / PMA role experience allowed varied perspectives to be heard. The use of semi-structured, qualitative interviews offered the opportunity for deeper inquiry by enhancing the conversational flow to sensitively seek detailed examples and explanations of participants’ practice-based experiences, opinions, and insights. The ability to manoeuvre around the flexible interview schedule, resulted in the combination of vivid, subtle and insight-led data as the researcher modified the interview questions in response to the participants’ replies.

The small sample size (fourteen participants), in one Trust provides a snapshot of a single context. The nature of qualitative research means that the findings are characteristically subjective and are developed via the researchers’ interpretation of what the participants’ have said. Therefore, no claims of generalisability could or should be inferred. The participant data presents useful (and contextually sensitive) insights of what it is like to be a PMA / PNA and what the role currently looks like in their practice. The outcomes of this study need to be cautiously considered, with an understanding of the parameters of qualitative research.