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

Beneficent Disruptors: A qualitative descriptive... | F1000Research "use strict";function _typeof(t){return(_typeof="function"==typeof Symbol&&"symbol"==typeof Symbol.iterator?function(t){return typeof t}:function(t){return t&&"function"==typeof Symbol&&t.constructor===Symbol&&t!==Symbol.prototype?"symbol":typeof t})(t)}!function(){var t=function(){var t,e,o=[],n=window,r=n;for(;r;){try{if(r.frames.__tcfapiLocator){t=r;break}}catch(t){}if(r===n.top)break;r=r.parent}t||(!function t(){var e=n.document,o=!!n.frames.__tcfapiLocator;if(!o)if(e.body){var r=e.createElement("iframe");r.style.cssText="display:none",r.name="__tcfapiLocator",e.body.appendChild(r)}else setTimeout(t,5);return!o}(),n.__tcfapi=function(){for(var t=arguments.length,n=new Array(t),r=0;r 3&&2===parseInt(n[1],10)&&"boolean"==typeof n[3]&&(e=n[3],"function"==typeof n[2]&&n[2]("set",!0)):"ping"===n[0]?"function"==typeof n[2]&&n[2]({gdprApplies:e,cmpLoaded:!1,cmpStatus:"stub"}):o.push(n)},n.addEventListener("message",(function(t){var e="string"==typeof t.data,o={};if(e)try{o=JSON.parse(t.data)}catch(t){}else o=t.data;var n="object"===_typeof(o)&&null!==o?o.__tcfapiCall:null;n&&window.__tcfapi(n.command,n.version,(function(o,r){var a={__tcfapiReturn:{returnValue:o,success:r,callId:n.callId}};t&&t.source&&t.source.postMessage&&t.source.postMessage(e?JSON.stringify(a):a,"*")}),n.parameter)}),!1))};"undefined"!=typeof module?module.exports=t:t()}(); dataLayer = dataLayer || []; // Standard GTM initialization - Google Consent Mode handles consent automatically (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src= 'https://www.googletagmanager.com/gtm.js?id='+i+dl+ '>m_auth=hzk0Vc3qFsQYhCrIoHz68A>m_preview=env-1>m_cookies_win=x';f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-MWFK8L5J'); ;window.NREUM||(NREUM={});NREUM.init={distributed_tracing:{enabled:true},privacy:{cookies_enabled:true},ajax:{deny_list:["bam.nr-data.net"]}}; ;NREUM.loader_config={accountID:"438030",trustKey:"438030",agentID:"772317073",licenseKey:"97f8f67f26",applicationID:"772317073"} ;NREUM.info={beacon:"bam.nr-data.net",errorBeacon:"bam.nr-data.net",licenseKey:"97f8f67f26",applicationID:"772317073",sa:1} ;/*! For license information please see nr-loader-spa-1.236.0.min.js.LICENSE.txt */ (()=>{"use strict";var e,t,r={5763:(e,t,r)=>{r.d(t,{P_:()=>l,Mt:()=>g,C5:()=>s,DL:()=>v,OP:()=>T,lF:()=>D,Yu:()=>y,Dg:()=>h,CX:()=>c,GE:()=>b,sU:()=>_});var n=r(8632),i=r(9567);const o={beacon:n.ce.beacon,errorBeacon:n.ce.errorBeacon,licenseKey:void 0,applicationID:void 0,sa:void 0,queueTime:void 0,applicationTime:void 0,ttGuid:void 0,user:void 0,account:void 0,product:void 0,extra:void 0,jsAttributes:{},userAttributes:void 0,atts:void 0,transactionName:void 0,tNamePlain:void 0},a={};function s(e){if(!e)throw new Error("All info objects require an agent identifier!");if(!a[e])throw new Error("Info for ".concat(e," was never set"));return a[e]}function c(e,t){if(!e)throw new Error("All info objects require an agent identifier!");a[e]=(0,i.D)(t,o),(0,n.Qy)(e,a[e],"info")}var u=r(7056);const d=()=>{const e={blockSelector:"[data-nr-block]",maskInputOptions:{password:!0}};return{allow_bfcache:!0,privacy:{cookies_enabled:!0},ajax:{deny_list:void 0,enabled:!0,harvestTimeSeconds:10},distributed_tracing:{enabled:void 0,exclude_newrelic_header:void 0,cors_use_newrelic_header:void 0,cors_use_tracecontext_headers:void 0,allowed_origins:void 0},session:{domain:void 0,expiresMs:u.oD,inactiveMs:u.Hb},ssl:void 0,obfuscate:void 0,jserrors:{enabled:!0,harvestTimeSeconds:10},metrics:{enabled:!0},page_action:{enabled:!0,harvestTimeSeconds:30},page_view_event:{enabled:!0},page_view_timing:{enabled:!0,harvestTimeSeconds:30,long_task:!1},session_trace:{enabled:!0,harvestTimeSeconds:10},harvest:{tooManyRequestsDelay:60},session_replay:{enabled:!1,harvestTimeSeconds:60,sampleRate:.1,errorSampleRate:.1,maskTextSelector:"*",maskAllInputs:!0,get blockClass(){return"nr-block"},get ignoreClass(){return"nr-ignore"},get maskTextClass(){return"nr-mask"},get blockSelector(){return e.blockSelector},set blockSelector(t){e.blockSelector+=",".concat(t)},get maskInputOptions(){return e.maskInputOptions},set maskInputOptions(t){e.maskInputOptions={...t,password:!0}}},spa:{enabled:!0,harvestTimeSeconds:10}}},f={};function l(e){if(!e)throw new Error("All configuration objects require an agent identifier!");if(!f[e])throw new Error("Configuration for ".concat(e," was never set"));return f[e]}function h(e,t){if(!e)throw new Error("All configuration objects require an agent identifier!");f[e]=(0,i.D)(t,d()),(0,n.Qy)(e,f[e],"config")}function g(e,t){if(!e)throw new Error("All configuration objects require an agent identifier!");var r=l(e);if(r){for(var n=t.split("."),i=0;i {r.d(t,{D:()=>i});var n=r(50);function i(e,t){try{if(!e||"object"!=typeof e)return(0,n.Z)("Setting a Configurable requires an object as input");if(!t||"object"!=typeof t)return(0,n.Z)("Setting a Configurable requires a model to set its initial properties");const r=Object.create(Object.getPrototypeOf(t),Object.getOwnPropertyDescriptors(t)),o=0===Object.keys(r).length?e:r;for(let a in o)if(void 0!==e[a])try{"object"==typeof e[a]&&"object"==typeof t[a]?r[a]=i(e[a],t[a]):r[a]=e[a]}catch(e){(0,n.Z)("An error occurred while setting a property of a Configurable",e)}return r}catch(e){(0,n.Z)("An error occured while setting a Configurable",e)}}},6818:(e,t,r)=>{r.d(t,{Re:()=>i,gF:()=>o,q4:()=>n});const n="1.236.0",i="PROD",o="CDN"},385:(e,t,r)=>{r.d(t,{FN:()=>a,IF:()=>u,Nk:()=>f,Tt:()=>s,_A:()=>o,il:()=>n,pL:()=>c,v6:()=>i,w1:()=>d});const n="undefined"!=typeof window&&!!window.document,i="undefined"!=typeof WorkerGlobalScope&&("undefined"!=typeof self&&self instanceof WorkerGlobalScope&&self.navigator instanceof WorkerNavigator||"undefined"!=typeof globalThis&&globalThis instanceof WorkerGlobalScope&&globalThis.navigator instanceof WorkerNavigator),o=n?window:"undefined"!=typeof WorkerGlobalScope&&("undefined"!=typeof self&&self instanceof WorkerGlobalScope&&self||"undefined"!=typeof globalThis&&globalThis instanceof WorkerGlobalScope&&globalThis),a=""+o?.location,s=/iPad|iPhone|iPod/.test(navigator.userAgent),c=s&&"undefined"==typeof SharedWorker,u=(()=>{const e=navigator.userAgent.match(/Firefox[/\s](\d+\.\d+)/);return Array.isArray(e)&&e.length>=2?+e[1]:0})(),d=Boolean(n&&window.document.documentMode),f=!!navigator.sendBeacon},1117:(e,t,r)=>{r.d(t,{w:()=>o});var n=r(50);const i={agentIdentifier:"",ee:void 0};class o{constructor(e){try{if("object"!=typeof e)return(0,n.Z)("shared context requires an object as input");this.sharedContext={},Object.assign(this.sharedContext,i),Object.entries(e).forEach((e=>{let[t,r]=e;Object.keys(i).includes(t)&&(this.sharedContext[t]=r)}))}catch(e){(0,n.Z)("An error occured while setting SharedContext",e)}}}},8e3:(e,t,r)=>{r.d(t,{L:()=>d,R:()=>c});var n=r(2177),i=r(1284),o=r(4322),a=r(3325);const s={};function c(e,t){const r={staged:!1,priority:a.p[t]||0};u(e),s[e].get(t)||s[e].set(t,r)}function u(e){e&&(s[e]||(s[e]=new Map))}function d(){let e=arguments.length>0&&void 0!==arguments[0]?arguments[0]:"",t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:"feature";if(u(e),!e||!s[e].get(t))return a(t);s[e].get(t).staged=!0;const r=[...s[e]];function a(t){const r=e?n.ee.get(e):n.ee,a=o.X.handlers;if(r.backlog&&a){var s=r.backlog[t],c=a[t];if(c){for(var u=0;s&&u {let[t,r]=e;return r.staged}))&&(r.sort(((e,t)=>e[1].priority-t[1].priority)),r.forEach((e=>{let[t]=e;a(t)})))}function f(e,t){var r=e[1];(0,i.D)(t[r],(function(t,r){var n=e[0];if(r[0]===n){var i=r[1],o=e[3],a=e[2];i.apply(o,a)}}))}},2177:(e,t,r)=>{r.d(t,{c:()=>f,ee:()=>u});var n=r(8632),i=r(2210),o=r(1284),a=r(5763),s="nr@context";let c=(0,n.fP)();var u;function d(){}function f(e){return(0,i.X)(e,s,l)}function l(){return new d}function h(){u.aborted=!0,u.backlog={}}c.ee?u=c.ee:(u=function e(t,r){var n={},c={},f={},g=!1;try{g=16===r.length&&(0,a.OP)(r).isolatedBacklog}catch(e){}var p={on:b,addEventListener:b,removeEventListener:y,emit:v,get:x,listeners:w,context:m,buffer:A,abort:h,aborted:!1,isBuffering:E,debugId:r,backlog:g?{}:t&&"object"==typeof t.backlog?t.backlog:{}};return p;function m(e){return e&&e instanceof d?e:e?(0,i.X)(e,s,l):l()}function v(e,r,n,i,o){if(!1!==o&&(o=!0),!u.aborted||i){t&&o&&t.emit(e,r,n);for(var a=m(n),s=w(e),d=s.length,f=0;fn,p:()=>i});var n=r(2177).ee.get("handle");function i(e,t,r,i,o){o?(o.buffer([e],i),o.emit(e,t,r)):(n.buffer([e],i),n.emit(e,t,r))}},4322:(e,t,r)=>{r.d(t,{X:()=>o});var n=r(5546);o.on=a;var i=o.handlers={};function o(e,t,r,o){a(o||n.E,i,e,t,r)}function a(e,t,r,i,o){o||(o="feature"),e||(e=n.E);var a=t[o]=t[o]||{};(a[r]=a[r]||[]).push([e,i])}},3239:(e,t,r)=>{r.d(t,{bP:()=>s,iz:()=>c,m$:()=>a});var n=r(385);let i=!1,o=!1;try{const e={get passive(){return i=!0,!1},get signal(){return o=!0,!1}};n._A.addEventListener("test",null,e),n._A.removeEventListener("test",null,e)}catch(e){}function a(e,t){return i||o?{capture:!!e,passive:i,signal:t}:!!e}function s(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2],n=arguments.length>3?arguments[3]:void 0;window.addEventListener(e,t,a(r,n))}function c(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2],n=arguments.length>3?arguments[3]:void 0;document.addEventListener(e,t,a(r,n))}},4402:(e,t,r)=>{r.d(t,{Ht:()=>u,M:()=>c,Rl:()=>a,ky:()=>s});var n=r(385);const i="xxxxxxxx-xxxx-4xxx-yxxx-xxxxxxxxxxxx";function o(e,t){return e?15&e[t]:16*Math.random()|0}function a(){const e=n._A?.crypto||n._A?.msCrypto;let t,r=0;return e&&e.getRandomValues&&(t=e.getRandomValues(new Uint8Array(31))),i.split("").map((e=>"x"===e?o(t,++r).toString(16):"y"===e?(3&o()|8).toString(16):e)).join("")}function s(e){const t=n._A?.crypto||n._A?.msCrypto;let r,i=0;t&&t.getRandomValues&&(r=t.getRandomValues(new Uint8Array(31)));const a=[];for(var s=0;s {r.d(t,{Bq:()=>n,Hb:()=>o,oD:()=>i});const n="NRBA",i=144e5,o=18e5},7894:(e,t,r)=>{function n(){return Math.round(performance.now())}r.d(t,{z:()=>n})},7243:(e,t,r)=>{r.d(t,{e:()=>o});var n=r(385),i={};function o(e){if(e in i)return i[e];if(0===(e||"").indexOf("data:"))return{protocol:"data"};let t;var r=n._A?.location,o={};if(n.il)t=document.createElement("a"),t.href=e;else try{t=new URL(e,r.href)}catch(e){return o}o.port=t.port;var a=t.href.split("://");!o.port&&a[1]&&(o.port=a[1].split("/")[0].split("@").pop().split(":")[1]),o.port&&"0"!==o.port||(o.port="https"===a[0]?"443":"80"),o.hostname=t.hostname||r.hostname,o.pathname=t.pathname,o.protocol=a[0],"/"!==o.pathname.charAt(0)&&(o.pathname="/"+o.pathname);var s=!t.protocol||":"===t.protocol||t.protocol===r.protocol,c=t.hostname===r.hostname&&t.port===r.port;return o.sameOrigin=s&&(!t.hostname||c),"/"===o.pathname&&(i[e]=o),o}},50:(e,t,r)=>{function n(e,t){"function"==typeof console.warn&&(console.warn("New Relic: ".concat(e)),t&&console.warn(t))}r.d(t,{Z:()=>n})},2587:(e,t,r)=>{r.d(t,{N:()=>c,T:()=>u});var n=r(2177),i=r(5546),o=r(8e3),a=r(3325);const s={stn:[a.D.sessionTrace],err:[a.D.jserrors,a.D.metrics],ins:[a.D.pageAction],spa:[a.D.spa],sr:[a.D.sessionReplay,a.D.sessionTrace]};function c(e,t){const r=n.ee.get(t);e&&"object"==typeof e&&(Object.entries(e).forEach((e=>{let[t,n]=e;void 0===u[t]&&(s[t]?s[t].forEach((e=>{n?(0,i.p)("feat-"+t,[],void 0,e,r):(0,i.p)("block-"+t,[],void 0,e,r),(0,i.p)("rumresp-"+t,[Boolean(n)],void 0,e,r)})):n&&(0,i.p)("feat-"+t,[],void 0,void 0,r),u[t]=Boolean(n))})),Object.keys(s).forEach((e=>{void 0===u[e]&&(s[e]?.forEach((t=>(0,i.p)("rumresp-"+e,[!1],void 0,t,r))),u[e]=!1)})),(0,o.L)(t,a.D.pageViewEvent))}const u={}},2210:(e,t,r)=>{r.d(t,{X:()=>i});var n=Object.prototype.hasOwnProperty;function i(e,t,r){if(n.call(e,t))return e[t];var i=r();if(Object.defineProperty&&Object.keys)try{return Object.defineProperty(e,t,{value:i,writable:!0,enumerable:!1}),i}catch(e){}return e[t]=i,i}},1284:(e,t,r)=>{r.d(t,{D:()=>n});const n=(e,t)=>Object.entries(e||{}).map((e=>{let[r,n]=e;return t(r,n)}))},4351:(e,t,r)=>{r.d(t,{P:()=>o});var n=r(2177);const i=()=>{const e=new WeakSet;return(t,r)=>{if("object"==typeof r&&null!==r){if(e.has(r))return;e.add(r)}return r}};function o(e){try{return JSON.stringify(e,i())}catch(e){try{n.ee.emit("internal-error",[e])}catch(e){}}}},3960:(e,t,r)=>{r.d(t,{K:()=>a,b:()=>o});var n=r(3239);function i(){return"undefined"==typeof document||"complete"===document.readyState}function o(e,t){if(i())return e();(0,n.bP)("load",e,t)}function a(e){if(i())return e();(0,n.iz)("DOMContentLoaded",e)}},8632:(e,t,r)=>{r.d(t,{EZ:()=>u,Qy:()=>c,ce:()=>o,fP:()=>a,gG:()=>d,mF:()=>s});var n=r(7894),i=r(385);const o={beacon:"bam.nr-data.net",errorBeacon:"bam.nr-data.net"};function a(){return i._A.NREUM||(i._A.NREUM={}),void 0===i._A.newrelic&&(i._A.newrelic=i._A.NREUM),i._A.NREUM}function s(){let e=a();return e.o||(e.o={ST:i._A.setTimeout,SI:i._A.setImmediate,CT:i._A.clearTimeout,XHR:i._A.XMLHttpRequest,REQ:i._A.Request,EV:i._A.Event,PR:i._A.Promise,MO:i._A.MutationObserver,FETCH:i._A.fetch}),e}function c(e,t,r){let i=a();const o=i.initializedAgents||{},s=o[e]||{};return Object.keys(s).length||(s.initializedAt={ms:(0,n.z)(),date:new Date}),i.initializedAgents={...o,[e]:{...s,[r]:t}},i}function u(e,t){a()[e]=t}function d(){return function(){let e=a();const t=e.info||{};e.info={beacon:o.beacon,errorBeacon:o.errorBeacon,...t}}(),function(){let e=a();const t=e.init||{};e.init={...t}}(),s(),function(){let e=a();const t=e.loader_config||{};e.loader_config={...t}}(),a()}},7956:(e,t,r)=>{r.d(t,{N:()=>i});var n=r(3239);function i(e){let t=arguments.length>1&&void 0!==arguments[1]&&arguments[1],r=arguments.length>2?arguments[2]:void 0,i=arguments.length>3?arguments[3]:void 0;return void(0,n.iz)("visibilitychange",(function(){if(t)return void("hidden"==document.visibilityState&&e());e(document.visibilityState)}),r,i)}},1214:(e,t,r)=>{r.d(t,{em:()=>v,u5:()=>N,QU:()=>S,_L:()=>I,Gm:()=>L,Lg:()=>M,gy:()=>U,BV:()=>Q,Kf:()=>ee});var n=r(2177);const i="nr@original";var o=Object.prototype.hasOwnProperty,a=!1;function s(e,t){return e||(e=n.ee),r.inPlace=function(e,t,n,i,o){n||(n="");var a,s,c,u="-"===n.charAt(0);for(c=0;c 2?n-2:0),o=2;o {r(A[T],e,w),r(E[T],e,w)})),r(l._A,"fetch",y),t.on(y+"end",(function(e,r){var n=this;if(r){var i=r.headers.get("content-length");null!==i&&(n.rxSize=i),t.emit(y+"done",[null,r],n)}else t.emit(y+"done",[e],n)})),t}const O={},j=["pushState","replaceState"];function S(e){const t=function(e){return(e||n.ee).get("history")}(e);return!l.il||O[t.debugId]++||(O[t.debugId]=1,s(t).inPlace(window.history,j,"-")),t}var P=r(3239);const C={},R=["appendChild","insertBefore","replaceChild"];function I(e){const t=function(e){return(e||n.ee).get("jsonp")}(e);if(!l.il||C[t.debugId])return t;C[t.debugId]=!0;var r=s(t),i=/[?&](?:callback|cb)=([^&#]+)/,o=/(.*)\.([^.]+)/,a=/^(\w+)(\.|$)(.*)$/;function c(e,t){var r=e.match(a),n=r[1],i=r[3];return i?c(i,t[n]):t[n]}return r.inPlace(Node.prototype,R,"dom-"),t.on("dom-start",(function(e){!function(e){if(!e||"string"!=typeof e.nodeName||"script"!==e.nodeName.toLowerCase())return;if("function"!=typeof e.addEventListener)return;var n=(a=e.src,s=a.match(i),s?s[1]:null);var a,s;if(!n)return;var u=function(e){var t=e.match(o);if(t&&t.length>=3)return{key:t[2],parent:c(t[1],window)};return{key:e,parent:window}}(n);if("function"!=typeof u.parent[u.key])return;var d={};function f(){t.emit("jsonp-end",[],d),e.removeEventListener("load",f,(0,P.m$)(!1)),e.removeEventListener("error",l,(0,P.m$)(!1))}function l(){t.emit("jsonp-error",[],d),t.emit("jsonp-end",[],d),e.removeEventListener("load",f,(0,P.m$)(!1)),e.removeEventListener("error",l,(0,P.m$)(!1))}r.inPlace(u.parent,[u.key],"cb-",d),e.addEventListener("load",f,(0,P.m$)(!1)),e.addEventListener("error",l,(0,P.m$)(!1)),t.emit("new-jsonp",[e.src],d)}(e[0])})),t}var k=r(5763);const H={};function L(e){const t=function(e){return(e||n.ee).get("mutation")}(e);if(!l.il||H[t.debugId])return t;H[t.debugId]=!0;var r=s(t),i=k.Yu.MO;return i&&(window.MutationObserver=function(e){return this instanceof i?new i(r(e,"fn-")):i.apply(this,arguments)},MutationObserver.prototype=i.prototype),t}const z={};function M(e){const t=function(e){return(e||n.ee).get("promise")}(e);if(z[t.debugId])return t;z[t.debugId]=!0;var r=n.c,o=s(t),a=k.Yu.PR;return a&&function(){function e(r){var n=t.context(),i=o(r,"executor-",n,null,!1);const s=Reflect.construct(a,[i],e);return t.context(s).getCtx=function(){return n},s}l._A.Promise=e,Object.defineProperty(e,"name",{value:"Promise"}),e.toString=function(){return a.toString()},Object.setPrototypeOf(e,a),["all","race"].forEach((function(r){const n=a[r];e[r]=function(e){let i=!1;[...e||[]].forEach((e=>{this.resolve(e).then(a("all"===r),a(!1))}));const o=n.apply(this,arguments);return o;function a(e){return function(){t.emit("propagate",[null,!i],o,!1,!1),i=i||!e}}}})),["resolve","reject"].forEach((function(r){const n=a[r];e[r]=function(e){const r=n.apply(this,arguments);return e!==r&&t.emit("propagate",[e,!0],r,!1,!1),r}})),e.prototype=a.prototype;const n=a.prototype.then;a.prototype.then=function(){var e=this,i=r(e);i.promise=e;for(var a=arguments.length,s=new Array(a),c=0;c e())),t};function m(e,t){i.inPlace(t,["onreadystatechange"],"fn-",E)}function b(){var e=this,t=r.context(e);e.readyState>3&&!t.resolved&&(t.resolved=!0,r.emit("xhr-resolved",[],e)),i.inPlace(e,f,"fn-",E)}if(function(e,t){for(var r in e)t[r]=e[r]}(o,p),p.prototype=o.prototype,i.inPlace(p.prototype,J,"-xhr-",E),r.on("send-xhr-start",(function(e,t){m(e,t),function(e){h.push(e),a&&(y?y.then(A):u?u(A):(w=-w,x.data=w))}(t)})),r.on("open-xhr-start",m),a){var y=c&&c.resolve();if(!u&&!c){var w=1,x=document.createTextNode(w);new a(A).observe(x,{characterData:!0})}}else t.on("fn-end",(function(e){e[0]&&e[0].type===d||A()}));function A(){for(var e=0;e {r.d(t,{t:()=>n});const n=r(3325).D.ajax},6660:(e,t,r)=>{r.d(t,{A:()=>i,t:()=>n});const n=r(3325).D.jserrors,i="nr@seenError"},3081:(e,t,r)=>{r.d(t,{gF:()=>o,mY:()=>i,t9:()=>n,vz:()=>s,xS:()=>a});const n=r(3325).D.metrics,i="sm",o="cm",a="storeSupportabilityMetrics",s="storeEventMetrics"},4649:(e,t,r)=>{r.d(t,{t:()=>n});const n=r(3325).D.pageAction},7633:(e,t,r)=>{r.d(t,{Dz:()=>i,OJ:()=>a,qw:()=>o,t9:()=>n});const n=r(3325).D.pageViewEvent,i="firstbyte",o="domcontent",a="windowload"},9251:(e,t,r)=>{r.d(t,{t:()=>n});const n=r(3325).D.pageViewTiming},3614:(e,t,r)=>{r.d(t,{BST_RESOURCE:()=>i,END:()=>s,FEATURE_NAME:()=>n,FN_END:()=>u,FN_START:()=>c,PUSH_STATE:()=>d,RESOURCE:()=>o,START:()=>a});const n=r(3325).D.sessionTrace,i="bstResource",o="resource",a="-start",s="-end",c="fn"+a,u="fn"+s,d="pushState"},7836:(e,t,r)=>{r.d(t,{BODY:()=>A,CB_END:()=>E,CB_START:()=>u,END:()=>x,FEATURE_NAME:()=>i,FETCH:()=>_,FETCH_BODY:()=>v,FETCH_DONE:()=>m,FETCH_START:()=>p,FN_END:()=>c,FN_START:()=>s,INTERACTION:()=>l,INTERACTION_API:()=>d,INTERACTION_EVENTS:()=>o,JSONP_END:()=>b,JSONP_NODE:()=>g,JS_TIME:()=>T,MAX_TIMER_BUDGET:()=>a,REMAINING:()=>f,SPA_NODE:()=>h,START:()=>w,originalSetTimeout:()=>y});var n=r(5763);const i=r(3325).D.spa,o=["click","submit","keypress","keydown","keyup","change"],a=999,s="fn-start",c="fn-end",u="cb-start",d="api-ixn-",f="remaining",l="interaction",h="spaNode",g="jsonpNode",p="fetch-start",m="fetch-done",v="fetch-body-",b="jsonp-end",y=n.Yu.ST,w="-start",x="-end",A="-body",E="cb"+x,T="jsTime",_="fetch"},5938:(e,t,r)=>{r.d(t,{W:()=>o});var n=r(5763),i=r(2177);class o{constructor(e,t,r){this.agentIdentifier=e,this.aggregator=t,this.ee=i.ee.get(e,(0,n.OP)(this.agentIdentifier).isolatedBacklog),this.featureName=r,this.blocked=!1}}},9144:(e,t,r)=>{r.d(t,{j:()=>m});var n=r(3325),i=r(5763),o=r(5546),a=r(2177),s=r(7894),c=r(8e3),u=r(3960),d=r(385),f=r(50),l=r(3081),h=r(8632);function g(){const e=(0,h.gG)();["setErrorHandler","finished","addToTrace","inlineHit","addRelease","addPageAction","setCurrentRouteName","setPageViewName","setCustomAttribute","interaction","noticeError","setUserId"].forEach((t=>{e[t]=function(){for(var r=arguments.length,n=new Array(r),i=0;i 1?r-1:0),i=1;i {e.exposed&&e.api[t]&&o.push(e.api[t](...n))})),o.length>1?o:o[0]}(t,...n)}}))}var p=r(2587);function m(e){let t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:{},m=arguments.length>2?arguments[2]:void 0,v=arguments.length>3?arguments[3]:void 0,{init:b,info:y,loader_config:w,runtime:x={loaderType:m},exposed:A=!0}=t;const E=(0,h.gG)();y||(b=E.init,y=E.info,w=E.loader_config),(0,i.Dg)(e,b||{}),(0,i.GE)(e,w||{}),(0,i.sU)(e,x),y.jsAttributes??={},d.v6&&(y.jsAttributes.isWorker=!0),(0,i.CX)(e,y),g();const T=function(e,t){t||(0,c.R)(e,"api");const h={};var g=a.ee.get(e),p=g.get("tracer"),m="api-",v=m+"ixn-";function b(t,r,n,o){const a=(0,i.C5)(e);return null===r?delete a.jsAttributes[t]:(0,i.CX)(e,{...a,jsAttributes:{...a.jsAttributes,[t]:r}}),x(m,n,!0,o||null===r?"session":void 0)(t,r)}function y(){}["setErrorHandler","finished","addToTrace","inlineHit","addRelease"].forEach((e=>h[e]=x(m,e,!0,"api"))),h.addPageAction=x(m,"addPageAction",!0,n.D.pageAction),h.setCurrentRouteName=x(m,"routeName",!0,n.D.spa),h.setPageViewName=function(t,r){if("string"==typeof t)return"/"!==t.charAt(0)&&(t="/"+t),(0,i.OP)(e).customTransaction=(r||"http://custom.transaction")+t,x(m,"setPageViewName",!0)()},h.setCustomAttribute=function(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2];if("string"==typeof e){if(["string","number"].includes(typeof t)||null===t)return b(e,t,"setCustomAttribute",r);(0,f.Z)("Failed to execute setCustomAttribute.\nNon-null value must be a string or number type, but a type of was provided."))}else(0,f.Z)("Failed to execute setCustomAttribute.\nName must be a string type, but a type of was provided."))},h.setUserId=function(e){if("string"==typeof e||null===e)return b("enduser.id",e,"setUserId",!0);(0,f.Z)("Failed to execute setUserId.\nNon-null value must be a string type, but a type of was provided."))},h.interaction=function(){return(new y).get()};var w=y.prototype={createTracer:function(e,t){var r={},i=this,a="function"==typeof t;return(0,o.p)(v+"tracer",[(0,s.z)(),e,r],i,n.D.spa,g),function(){if(p.emit((a?"":"no-")+"fn-start",[(0,s.z)(),i,a],r),a)try{return t.apply(this,arguments)}catch(e){throw p.emit("fn-err",[arguments,this,"string"==typeof e?new Error(e):e],r),e}finally{p.emit("fn-end",[(0,s.z)()],r)}}}};function x(e,t,r,i){return function(){return(0,o.p)(l.xS,["API/"+t+"/called"],void 0,n.D.metrics,g),i&&(0,o.p)(e+t,[(0,s.z)(),...arguments],r?null:this,i,g),r?void 0:this}}function A(){r.e(439).then(r.bind(r,7438)).then((t=>{let{setAPI:r}=t;r(e),(0,c.L)(e,"api")})).catch((()=>(0,f.Z)("Downloading runtime APIs failed...")))}return["actionText","setName","setAttribute","save","ignore","onEnd","getContext","end","get"].forEach((e=>{w[e]=x(v,e,void 0,n.D.spa)})),h.noticeError=function(e,t){"string"==typeof e&&(e=new Error(e)),(0,o.p)(l.xS,["API/noticeError/called"],void 0,n.D.metrics,g),(0,o.p)("err",[e,(0,s.z)(),!1,t],void 0,n.D.jserrors,g)},d.il?(0,u.b)((()=>A()),!0):A(),h}(e,v);return(0,h.Qy)(e,T,"api"),(0,h.Qy)(e,A,"exposed"),(0,h.EZ)("activatedFeatures",p.T),T}},3325:(e,t,r)=>{r.d(t,{D:()=>n,p:()=>i});const n={ajax:"ajax",jserrors:"jserrors",metrics:"metrics",pageAction:"page_action",pageViewEvent:"page_view_event",pageViewTiming:"page_view_timing",sessionReplay:"session_replay",sessionTrace:"session_trace",spa:"spa"},i={[n.pageViewEvent]:1,[n.pageViewTiming]:2,[n.metrics]:3,[n.jserrors]:4,[n.ajax]:5,[n.sessionTrace]:6,[n.pageAction]:7,[n.spa]:8,[n.sessionReplay]:9}}},n={};function i(e){var t=n[e];if(void 0!==t)return t.exports;var o=n[e]={exports:{}};return r[e](o,o.exports,i),o.exports}i.m=r,i.d=(e,t)=>{for(var r in t)i.o(t,r)&&!i.o(e,r)&&Object.defineProperty(e,r,{enumerable:!0,get:t[r]})},i.f={},i.e=e=>Promise.all(Object.keys(i.f).reduce(((t,r)=>(i.f[r](e,t),t)),[])),i.u=e=>(({78:"page_action-aggregate",147:"metrics-aggregate",242:"session-manager",317:"jserrors-aggregate",348:"page_view_timing-aggregate",412:"lazy-feature-loader",439:"async-api",538:"recorder",590:"session_replay-aggregate",675:"compressor",733:"session_trace-aggregate",786:"page_view_event-aggregate",873:"spa-aggregate",898:"ajax-aggregate"}[e]||e)+"."+{78:"ac76d497",147:"3dc53903",148:"1a20d5fe",242:"2a64278a",317:"49e41428",348:"bd6de33a",412:"2f55ce66",439:"30bd804e",538:"1b18459f",590:"cf0efb30",675:"ae9f91a8",733:"83105561",786:"06482edd",860:"03a8b7a5",873:"e6b09d52",898:"998ef92b"}[e]+"-1.236.0.min.js"),i.o=(e,t)=>Object.prototype.hasOwnProperty.call(e,t),e={},t="NRBA:",i.l=(r,n,o,a)=>{if(e[r])e[r].push(n);else{var s,c;if(void 0!==o)for(var u=document.getElementsByTagName("script"),d=0;d {s.onerror=s.onload=null,clearTimeout(h);var i=e[r];if(delete e[r],s.parentNode&&s.parentNode.removeChild(s),i&&i.forEach((e=>e(n))),t)return t(n)},h=setTimeout(l.bind(null,void 0,{type:"timeout",target:s}),12e4);s.onerror=l.bind(null,s.onerror),s.onload=l.bind(null,s.onload),c&&document.head.appendChild(s)}},i.r=e=>{"undefined"!=typeof Symbol&&Symbol.toStringTag&&Object.defineProperty(e,Symbol.toStringTag,{value:"Module"}),Object.defineProperty(e,"__esModule",{value:!0})},i.j=364,i.p="https://js-agent.newrelic.com/",(()=>{var e={364:0,953:0};i.f.j=(t,r)=>{var n=i.o(e,t)?e[t]:void 0;if(0!==n)if(n)r.push(n[2]);else{var o=new Promise(((r,i)=>n=e[t]=[r,i]));r.push(n[2]=o);var a=i.p+i.u(t),s=new Error;i.l(a,(r=>{if(i.o(e,t)&&(0!==(n=e[t])&&(e[t]=void 0),n)){var o=r&&("load"===r.type?"missing":r.type),a=r&&r.target&&r.target.src;s.message="Loading chunk "+t+" failed.\n("+o+": "+a+")",s.name="ChunkLoadError",s.type=o,s.request=a,n[1](s)}}),"chunk-"+t,t)}};var t=(t,r)=>{var n,o,[a,s,c]=r,u=0;if(a.some((t=>0!==e[t]))){for(n in s)i.o(s,n)&&(i.m[n]=s[n]);if(c)c(i)}for(t&&t(r);u {i.r(o);var e=i(3325),t=i(5763);const r=Object.values(e.D);function n(e){const n={};return r.forEach((r=>{n[r]=function(e,r){return!1!==(0,t.Mt)(r,"".concat(e,".enabled"))}(r,e)})),n}var a=i(9144);var s=i(5546),c=i(385),u=i(8e3),d=i(5938),f=i(3960),l=i(50);class h extends d.W{constructor(e,t,r){let n=!(arguments.length>3&&void 0!==arguments[3])||arguments[3];super(e,t,r),this.auto=n,this.abortHandler,this.featAggregate,this.onAggregateImported,n&&(0,u.R)(e,r)}importAggregator(){let e=arguments.length>0&&void 0!==arguments[0]?arguments[0]:{};if(this.featAggregate||!this.auto)return;const r=c.il&&!0===(0,t.Mt)(this.agentIdentifier,"privacy.cookies_enabled");let n;this.onAggregateImported=new Promise((e=>{n=e}));const o=async()=>{let t;try{if(r){const{setupAgentSession:e}=await Promise.all([i.e(860),i.e(242)]).then(i.bind(i,3228));t=e(this.agentIdentifier)}}catch(e){(0,l.Z)("A problem occurred when starting up session manager. This page will not start or extend any session.",e)}try{if(!this.shouldImportAgg(this.featureName,t))return void(0,u.L)(this.agentIdentifier,this.featureName);const{lazyFeatureLoader:r}=await i.e(412).then(i.bind(i,8582)),{Aggregate:o}=await r(this.featureName,"aggregate");this.featAggregate=new o(this.agentIdentifier,this.aggregator,e),n(!0)}catch(e){(0,l.Z)("Downloading and initializing ".concat(this.featureName," failed..."),e),this.abortHandler?.(),n(!1)}};c.il?(0,f.b)((()=>o()),!0):o()}shouldImportAgg(r,n){return r!==e.D.sessionReplay||!1!==(0,t.Mt)(this.agentIdentifier,"session_trace.enabled")&&(!!n?.isNew||!!n?.state.sessionReplay)}}var g=i(7633),p=i(7894);class m extends h{static featureName=g.t9;constructor(r,n){let i=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];if(super(r,n,g.t9,i),("undefined"==typeof PerformanceNavigationTiming||c.Tt)&&"undefined"!=typeof PerformanceTiming){const n=(0,t.OP)(r);n[g.Dz]=Math.max(Date.now()-n.offset,0),(0,f.K)((()=>n[g.qw]=Math.max((0,p.z)()-n[g.Dz],0))),(0,f.b)((()=>{const t=(0,p.z)();n[g.OJ]=Math.max(t-n[g.Dz],0),(0,s.p)("timing",["load",t],void 0,e.D.pageViewTiming,this.ee)}))}this.importAggregator()}}var v=i(1117),b=i(1284);class y extends v.w{constructor(e){super(e),this.aggregatedData={}}store(e,t,r,n,i){var o=this.getBucket(e,t,r,i);return o.metrics=function(e,t){t||(t={count:0});return t.count+=1,(0,b.D)(e,(function(e,r){t[e]=w(r,t[e])})),t}(n,o.metrics),o}merge(e,t,r,n,i){var o=this.getBucket(e,t,n,i);if(o.metrics){var a=o.metrics;a.count+=r.count,(0,b.D)(r,(function(e,t){if("count"!==e){var n=a[e],i=r[e];i&&!i.c?a[e]=w(i.t,n):a[e]=function(e,t){if(!t)return e;t.c||(t=x(t.t));return t.min=Math.min(e.min,t.min),t.max=Math.max(e.max,t.max),t.t+=e.t,t.sos+=e.sos,t.c+=e.c,t}(i,a[e])}}))}else o.metrics=r}storeMetric(e,t,r,n){var i=this.getBucket(e,t,r);return i.stats=w(n,i.stats),i}getBucket(e,t,r,n){this.aggregatedData[e]||(this.aggregatedData[e]={});var i=this.aggregatedData[e][t];return i||(i=this.aggregatedData[e][t]={params:r||{}},n&&(i.custom=n)),i}get(e,t){return t?this.aggregatedData[e]&&this.aggregatedData[e][t]:this.aggregatedData[e]}take(e){for(var t={},r="",n=!1,i=0;i t.max&&(t.max=e),e 2&&void 0!==arguments[2])||arguments[2];super(e,r,j.t,n),c.il&&((0,t.OP)(e).initHidden=Boolean("hidden"===document.visibilityState),(0,N.N)((()=>(0,s.p)("docHidden",[(0,p.z)()],void 0,j.t,this.ee)),!0),(0,O.bP)("pagehide",(()=>(0,s.p)("winPagehide",[(0,p.z)()],void 0,j.t,this.ee))),this.importAggregator())}}var P=i(3081);class C extends h{static featureName=P.t9;constructor(e,t){let r=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];super(e,t,P.t9,r),this.importAggregator()}}var R,I=i(2210),k=i(1214),H=i(2177),L={};try{R=localStorage.getItem("__nr_flags").split(","),console&&"function"==typeof console.log&&(L.console=!0,-1!==R.indexOf("dev")&&(L.dev=!0),-1!==R.indexOf("nr_dev")&&(L.nrDev=!0))}catch(e){}function z(e){try{L.console&&z(e)}catch(e){}}L.nrDev&&H.ee.on("internal-error",(function(e){z(e.stack)})),L.dev&&H.ee.on("fn-err",(function(e,t,r){z(r.stack)})),L.dev&&(z("NR AGENT IN DEVELOPMENT MODE"),z("flags: "+(0,b.D)(L,(function(e,t){return e})).join(", ")));var M=i(6660);class B extends h{static featureName=M.t;constructor(r,n){let i=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];super(r,n,M.t,i),this.skipNext=0;try{this.removeOnAbort=new AbortController}catch(e){}const o=this;o.ee.on("fn-start",(function(e,t,r){o.abortHandler&&(o.skipNext+=1)})),o.ee.on("fn-err",(function(t,r,n){o.abortHandler&&!n[M.A]&&((0,I.X)(n,M.A,(function(){return!0})),this.thrown=!0,(0,s.p)("err",[n,(0,p.z)()],void 0,e.D.jserrors,o.ee))})),o.ee.on("fn-end",(function(){o.abortHandler&&!this.thrown&&o.skipNext>0&&(o.skipNext-=1)})),o.ee.on("internal-error",(function(t){(0,s.p)("ierr",[t,(0,p.z)(),!0],void 0,e.D.jserrors,o.ee)})),this.origOnerror=c._A.onerror,c._A.onerror=this.onerrorHandler.bind(this),c._A.addEventListener("unhandledrejection",(t=>{const r=function(e){let t="Unhandled Promise Rejection: ";if(e instanceof Error)try{return e.message=t+e.message,e}catch(t){return e}if(void 0===e)return new Error(t);try{return new Error(t+(0,D.P)(e))}catch(e){return new Error(t)}}(t.reason);(0,s.p)("err",[r,(0,p.z)(),!1,{unhandledPromiseRejection:1}],void 0,e.D.jserrors,this.ee)}),(0,O.m$)(!1,this.removeOnAbort?.signal)),(0,k.gy)(this.ee),(0,k.BV)(this.ee),(0,k.em)(this.ee),(0,t.OP)(r).xhrWrappable&&(0,k.Kf)(this.ee),this.abortHandler=this.#e,this.importAggregator()}#e(){this.removeOnAbort?.abort(),this.abortHandler=void 0}onerrorHandler(t,r,n,i,o){"function"==typeof this.origOnerror&&this.origOnerror(...arguments);try{this.skipNext?this.skipNext-=1:(0,s.p)("err",[o||new F(t,r,n),(0,p.z)()],void 0,e.D.jserrors,this.ee)}catch(t){try{(0,s.p)("ierr",[t,(0,p.z)(),!0],void 0,e.D.jserrors,this.ee)}catch(e){}}return!1}}function F(e,t,r){this.message=e||"Uncaught error with no additional information",this.sourceURL=t,this.line=r}let U=1;const q="nr@id";function G(e){const t=typeof e;return!e||"object"!==t&&"function"!==t?-1:e===c._A?0:(0,I.X)(e,q,(function(){return U++}))}function V(e){if("string"==typeof e&&e.length)return e.length;if("object"==typeof e){if("undefined"!=typeof ArrayBuffer&&e instanceof ArrayBuffer&&e.byteLength)return e.byteLength;if("undefined"!=typeof Blob&&e instanceof Blob&&e.size)return e.size;if(!("undefined"!=typeof FormData&&e instanceof FormData))try{return(0,D.P)(e).length}catch(e){return}}}var X=i(7243);class W{constructor(e){this.agentIdentifier=e,this.generateTracePayload=this.generateTracePayload.bind(this),this.shouldGenerateTrace=this.shouldGenerateTrace.bind(this)}generateTracePayload(e){if(!this.shouldGenerateTrace(e))return null;var r=(0,t.DL)(this.agentIdentifier);if(!r)return null;var n=(r.accountID||"").toString()||null,i=(r.agentID||"").toString()||null,o=(r.trustKey||"").toString()||null;if(!n||!i)return null;var a=(0,_.M)(),s=(0,_.Ht)(),c=Date.now(),u={spanId:a,traceId:s,timestamp:c};return(e.sameOrigin||this.isAllowedOrigin(e)&&this.useTraceContextHeadersForCors())&&(u.traceContextParentHeader=this.generateTraceContextParentHeader(a,s),u.traceContextStateHeader=this.generateTraceContextStateHeader(a,c,n,i,o)),(e.sameOrigin&&!this.excludeNewrelicHeader()||!e.sameOrigin&&this.isAllowedOrigin(e)&&this.useNewrelicHeaderForCors())&&(u.newrelicHeader=this.generateTraceHeader(a,s,c,n,i,o)),u}generateTraceContextParentHeader(e,t){return"00-"+t+"-"+e+"-01"}generateTraceContextStateHeader(e,t,r,n,i){return i+"@nr=0-1-"+r+"-"+n+"-"+e+"----"+t}generateTraceHeader(e,t,r,n,i,o){if(!("function"==typeof c._A?.btoa))return null;var a={v:[0,1],d:{ty:"Browser",ac:n,ap:i,id:e,tr:t,ti:r}};return o&&n!==o&&(a.d.tk=o),btoa((0,D.P)(a))}shouldGenerateTrace(e){return this.isDtEnabled()&&this.isAllowedOrigin(e)}isAllowedOrigin(e){var r=!1,n={};if((0,t.Mt)(this.agentIdentifier,"distributed_tracing")&&(n=(0,t.P_)(this.agentIdentifier).distributed_tracing),e.sameOrigin)r=!0;else if(n.allowed_origins instanceof Array)for(var i=0;i 2&&void 0!==arguments[2])||arguments[2];super(r,n,Z.t,i),(0,t.OP)(r).xhrWrappable&&(this.dt=new W(r),this.handler=(e,t,r,n)=>(0,s.p)(e,t,r,n,this.ee),(0,k.u5)(this.ee),(0,k.Kf)(this.ee),function(r,n,i,o){function a(e){var t=this;t.totalCbs=0,t.called=0,t.cbTime=0,t.end=E,t.ended=!1,t.xhrGuids={},t.lastSize=null,t.loadCaptureCalled=!1,t.params=this.params||{},t.metrics=this.metrics||{},e.addEventListener("load",(function(r){_(t,e)}),(0,O.m$)(!1)),c.IF||e.addEventListener("progress",(function(e){t.lastSize=e.loaded}),(0,O.m$)(!1))}function s(e){this.params={method:e[0]},T(this,e[1]),this.metrics={}}function u(e,n){var i=(0,t.DL)(r);i.xpid&&this.sameOrigin&&n.setRequestHeader("X-NewRelic-ID",i.xpid);var a=o.generateTracePayload(this.parsedOrigin);if(a){var s=!1;a.newrelicHeader&&(n.setRequestHeader("newrelic",a.newrelicHeader),s=!0),a.traceContextParentHeader&&(n.setRequestHeader("traceparent",a.traceContextParentHeader),a.traceContextStateHeader&&n.setRequestHeader("tracestate",a.traceContextStateHeader),s=!0),s&&(this.dt=a)}}function d(e,t){var r=this.metrics,i=e[0],o=this;if(r&&i){var a=V(i);a&&(r.txSize=a)}this.startTime=(0,p.z)(),this.listener=function(e){try{"abort"!==e.type||o.loadCaptureCalled||(o.params.aborted=!0),("load"!==e.type||o.called===o.totalCbs&&(o.onloadCalled||"function"!=typeof t.onload)&&"function"==typeof o.end)&&o.end(t)}catch(e){try{n.emit("internal-error",[e])}catch(e){}}};for(var s=0;s 1?e[1]=i:e.push(i)}else e[0]&&e[0].headers&&s(e[0].headers,n)&&(this.dt=n);function s(e,t){var r=!1;return t.newrelicHeader&&(e.set("newrelic",t.newrelicHeader),r=!0),t.traceContextParentHeader&&(e.set("traceparent",t.traceContextParentHeader),t.traceContextStateHeader&&e.set("tracestate",t.traceContextStateHeader),r=!0),r}}function x(e,t){this.params={},this.metrics={},this.startTime=(0,p.z)(),this.dt=t,e.length>=1&&(this.target=e[0]),e.length>=2&&(this.opts=e[1]);var r,n=this.opts||{},i=this.target;"string"==typeof i?r=i:"object"==typeof i&&i instanceof Y?r=i.url:c._A?.URL&&"object"==typeof i&&i instanceof URL&&(r=i.href),T(this,r);var o=(""+(i&&i instanceof Y&&i.method||n.method||"GET")).toUpperCase();this.params.method=o,this.txSize=V(n.body)||0}function A(t,r){var n;this.endTime=(0,p.z)(),this.params||(this.params={}),this.params.status=r?r.status:0,"string"==typeof this.rxSize&&this.rxSize.length>0&&(n=+this.rxSize);var o={txSize:this.txSize,rxSize:n,duration:(0,p.z)()-this.startTime};i("xhr",[this.params,o,this.startTime,this.endTime,"fetch"],this,e.D.ajax)}function E(t){var r=this.params,n=this.metrics;if(!this.ended){this.ended=!0;for(var o=0;o 2&&void 0!==arguments[2])||arguments[2];super(e,t,we.t,r),this.importAggregator()}}new class{constructor(e){let t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:(0,_.ky)(16);c._A?(this.agentIdentifier=t,this.sharedAggregator=new y({agentIdentifier:this.agentIdentifier}),this.features={},this.desiredFeatures=new Set(e.features||[]),this.desiredFeatures.add(m),Object.assign(this,(0,a.j)(this.agentIdentifier,e,e.loaderType||"agent")),this.start()):(0,l.Z)("Failed to initial the agent. Could not determine the runtime environment.")}get config(){return{info:(0,t.C5)(this.agentIdentifier),init:(0,t.P_)(this.agentIdentifier),loader_config:(0,t.DL)(this.agentIdentifier),runtime:(0,t.OP)(this.agentIdentifier)}}start(){const t="features";try{const r=n(this.agentIdentifier),i=[...this.desiredFeatures];i.sort(((t,r)=>e.p[t.featureName]-e.p[r.featureName])),i.forEach((t=>{if(r[t.featureName]||t.featureName===e.D.pageViewEvent){const n=function(t){switch(t){case e.D.ajax:return[e.D.jserrors];case e.D.sessionTrace:return[e.D.ajax,e.D.pageViewEvent];case e.D.sessionReplay:return[e.D.sessionTrace];case e.D.pageViewTiming:return[e.D.pageViewEvent];default:return[]}}(t.featureName);n.every((e=>r[e]))||(0,l.Z)("".concat(t.featureName," is enabled but one or more dependent features has been disabled (").concat((0,D.P)(n),"). This may cause unintended consequences or missing data...")),this.features[t.featureName]=new t(this.agentIdentifier,this.sharedAggregator)}})),(0,T.Qy)(this.agentIdentifier,this.features,t)}catch(e){(0,l.Z)("Failed to initialize all enabled instrument classes (agent aborted) -",e);for(const e in this.features)this.features[e].abortHandler?.();const r=(0,T.fP)();return delete r.initializedAgents[this.agentIdentifier]?.api,delete r.initializedAgents[this.agentIdentifier]?.[t],delete this.sharedAggregator,r.ee?.abort(),delete r.ee?.get(this.agentIdentifier),!1}}}({features:[J,m,S,class extends h{static featureName=oe;constructor(t,r){if(super(t,r,oe,!(arguments.length>2&&void 0!==arguments[2])||arguments[2]),!c.il)return;const n=this.ee;let i;(0,k.QU)(n),this.eventsEE=(0,k.em)(n),this.eventsEE.on(se,(function(e,t){this.bstStart=(0,p.z)()})),this.eventsEE.on(ae,(function(t,r){(0,s.p)("bst",[t[0],r,this.bstStart,(0,p.z)()],void 0,e.D.sessionTrace,n)})),n.on(ce+ne,(function(e){this.time=(0,p.z)(),this.startPath=location.pathname+location.hash})),n.on(ce+ie,(function(t){(0,s.p)("bstHist",[location.pathname+location.hash,this.startPath,this.time],void 0,e.D.sessionTrace,n)}));try{i=new PerformanceObserver((t=>{const r=t.getEntries();(0,s.p)(te,[r],void 0,e.D.sessionTrace,n)})),i.observe({type:re,buffered:!0})}catch(e){}this.importAggregator({resourceObserver:i})}},C,xe,B,class extends h{static featureName=de;constructor(e,r){if(super(e,r,de,!(arguments.length>2&&void 0!==arguments[2])||arguments[2]),!c.il)return;if(!(0,t.OP)(e).xhrWrappable)return;try{this.removeOnAbort=new AbortController}catch(e){}let n,i=0;const o=this.ee.get("tracer"),a=(0,k._L)(this.ee),s=(0,k.Lg)(this.ee),u=(0,k.BV)(this.ee),d=(0,k.Kf)(this.ee),f=this.ee.get("events"),l=(0,k.u5)(this.ee),h=(0,k.QU)(this.ee),g=(0,k.Gm)(this.ee);function m(e,t){h.emit("newURL",[""+window.location,t])}function v(){i++,n=window.location.hash,this[ve]=(0,p.z)()}function b(){i--,window.location.hash!==n&&m(0,!0);var e=(0,p.z)();this[pe]=~~this[pe]+e-this[ve],this[ye]=e}function y(e,t){e.on(t,(function(){this[t]=(0,p.z)()}))}this.ee.on(ve,v),s.on(be,v),a.on(be,v),this.ee.on(ye,b),s.on(ge,b),a.on(ge,b),this.ee.buffer([ve,ye,"xhr-resolved"],this.featureName),f.buffer([ve],this.featureName),u.buffer(["setTimeout"+le,"clearTimeout"+fe,ve],this.featureName),d.buffer([ve,"new-xhr","send-xhr"+fe],this.featureName),l.buffer([me+fe,me+"-done",me+he+fe,me+he+le],this.featureName),h.buffer(["newURL"],this.featureName),g.buffer([ve],this.featureName),s.buffer(["propagate",be,ge,"executor-err","resolve"+fe],this.featureName),o.buffer([ve,"no-"+ve],this.featureName),a.buffer(["new-jsonp","cb-start","jsonp-error","jsonp-end"],this.featureName),y(l,me+fe),y(l,me+"-done"),y(a,"new-jsonp"),y(a,"jsonp-end"),y(a,"cb-start"),h.on("pushState-end",m),h.on("replaceState-end",m),window.addEventListener("hashchange",m,(0,O.m$)(!0,this.removeOnAbort?.signal)),window.addEventListener("load",m,(0,O.m$)(!0,this.removeOnAbort?.signal)),window.addEventListener("popstate",(function(){m(0,i>1)}),(0,O.m$)(!0,this.removeOnAbort?.signal)),this.abortHandler=this.#e,this.importAggregator()}#e(){this.removeOnAbort?.abort(),this.abortHandler=void 0}}],loaderType:"spa"})})(),window.NRBA=o})(); window.jQuery || document.write(' ') CKEDITOR_BASEPATH='https://f1000research.com/js/vendor/ckeditor/' window.reactTheme = 'research'; window.MathJax = { CommonHTML: { linebreaks: { automatic: true } }, 'HTML-CSS': { linebreaks: { automatic: true } }, SVG: { linebreaks: { automatic: true } }, AuthorInit: function() { MathJax.Hub.Register.MessageHook('End Process', function () { let timeout = false; // holder for timeout id const delay = 250; // delay after event is "complete" to run callback const reflowMath = function() { const dispFormulas = document.querySelectorAll('.disp-formula.panel'); if (!dispFormulas) { return; } for (const dispFormula of dispFormulas) { const child = dispFormula.querySelector('.MathJax_Preview').nextSibling.firstChild; const isMultiline = MathJax.Hub.getAllJax(dispFormula)[0].root.isMultiline; if (dispFormula.offsetWidth < child.offsetWidth || isMultiline) { MathJax.Hub.Queue(['Rerender', MathJax.Hub, dispFormula]); } } }; window.addEventListener('resize', function() { clearTimeout(timeout); // clear the timeout timeout = setTimeout(reflowMath, delay); // start timing for event "completion" }); }); }, }; if (window.location.hash == '#_=_'){ window.location = window.location.href.split('#')[0] } !function(f,b,e,v,n,t,s){if(f.fbq)return;n=f.fbq=function() {n.callMethod? n.callMethod.apply(n,arguments):n.queue.push(arguments)} ;if(!f._fbq)f._fbq=n; n.push=n;n.loaded=!0;n.version='2.0';n.queue=[];t=b.createElement(e);t.async=!0; t.src=v;s=b.getElementsByTagName(e)[0];s.parentNode.insertBefore(t,s)}(window, document,'script','https://connect.facebook.net/en_US/fbevents.js'); fbq('init', '1641728616063202'); fbq('track', "PixelInitialized", {}); (function(h,o,t,j,a,r){ h.hj=h.hj||function(){(h.hj.q=h.hj.q||[]).push(arguments)}; h._hjSettings={hjid:2318163,hjsv:6}; a=o.getElementsByTagName('head')[0]; r=o.createElement('script');r.async=1; r.src=t+h._hjSettings.hjid+j+h._hjSettings.hjsv; a.appendChild(r); })(window,document,'https://static.hotjar.com/c/hotjar-','.js?sv='); search file_upload Submit your research search menu close search Browse Gateways & Collections How to Publish Submit your Research My Submissions Article Guidelines Article Guidelines (New Versions) Open Data, Software and Code Guidelines Open Data and Accessible Source Materials Guidelines (HSS) Open Data, Software and Code Guidelines (PSE) Prepublication Checks Production Process Posters and Slides Guidelines Document Guidelines Article Processing Charges Peer Review Finding Article Reviewers About How it Works For Reviewers Our Advisors Policies Glossary FAQs For Developers Newsroom Contact My Research Submissions Content and Tracking Alerts My Details Sign In file_upload Submit your research { "@context": "https://schema.org", "@type": "ScholarlyArticle", "mainEntityOfPage": { "@type": "WebPage", "@id": "https://f1000research.com/articles/14-674" }, "headline": "Beneficent Disruptors: A qualitative descriptive study of professional advocacy in healthcare", "datePublished": "2025-07-07T17:27:50", "dateModified": "2025-07-07T17:27:50", "author": [ { "@type": "Person", "name": "Sally Goldspink" }, { "@type": "Person", "name": "Nieky van Veggel" }, { "@type": "Person", "name": "Hilary Engward" }, { "@type": "Person", "name": "Naim Abdulmohdi" }, { "@type": "Person", "name": "Andrea Tuckwell" }, { "@type": "Person", "name": "Marie Alexander" } ], "publisher": { "@type": "Organization", "name": "F1000Research", "logo": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 480, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 1200, "width": 150 }, "description": " Background In England, the Professional Nurse Advocate (PNA) and Professional Midwifery Advocate (PMA) role places nurses and midwives at the centre of workforce retention and transformation. The PNA/PMA role blends professional leadership and clinical supervision through the A-EQUIP model, which is grounded in directing change and steering service development. The overarching impetus for the PNA/PMA role is to improve care quality whilst developing and sustaining cultures of professional wellbeing and nurse/midwife retention. To date, however, little is known about what the impact the PNA/PMA role has on the day-to-day practice of nurses and midwives, nor if it improves quality in practice, professional wellbeing, and retention. This study examines the impact of the PNA/PMA role on nurse/midwife involvement in quality improvement, wellbeing, and retention within one public sector healthcare NHS Trust in England. Methods During 2022, fourteen semi-structured interviews were conducted with PNA’s and PMA’s who had completed their training and are included on the NHS Trust PNA/PMA register. The interviews were transcribed verbatim and analysed through qualitative descriptive analysis. Findings The analysis detected 5 themes and 10 subthemes: (1) Transforming in Tandem (a) Role of Advocacy, (b) Restorative Focus, (2) Creating Safe Spaces, (c) Emotional Support, (d) Interpersonal Relationships, (3) Challenging the Status Quo (e) Counteracting Blame Culture, (f ) Empowering Change (4) Empowerment and Development (g) Building Resilience, (5) Types of Advocacy (h) Educational and Emotional Advocacy (i) Coaching and Conversations. Conclusions The findings suggests that the most effective aspects of the PNA and PMA roles are those that directly empower individuals and create a supportive, reflective environment. However, while building resilience is vital, it is equally important to recognise its limits and ensure that healthcare professionals are not pushed to the point where their resilience becomes a barrier to their well-being and the overall improvement of their work environment. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-674/v1", "name": "Beneficent Disruptors: A qualitative descriptive study of professional..." } } ] } Home Browse Beneficent Disruptors: A qualitative descriptive study of professional... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Goldspink S, van Veggel N, Engward H et al. Beneficent Disruptors: A qualitative descriptive study of professional advocacy in healthcare [version 1; peer review: 1 approved] . F1000Research 2025, 14 :674 ( https://doi.org/10.12688/f1000research.166551.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Beneficent Disruptors: A qualitative descriptive study of professional advocacy in healthcare [version 1; peer review: 1 approved] Sally Goldspink 1 , Nieky van Veggel https://orcid.org/0000-0001-6738-6989 1 , Hilary Engward https://orcid.org/0000-0002-5419-7131 2 , Naim Abdulmohdi 1 , Andrea Tuckwell 1,3 , Marie Alexander 3 Sally Goldspink 1 , Nieky van Veggel https://orcid.org/0000-0001-6738-6989 1 , [...] Hilary Engward https://orcid.org/0000-0002-5419-7131 2 , Naim Abdulmohdi 1 , Andrea Tuckwell 1,3 , Marie Alexander 3 PUBLISHED 07 Jul 2025 Author details Author details 1 Faculty of Health, Medicine and Social Care, Anglia Ruskin University, Cambridge, England, UK 2 Veterand and Families Institute for Military Social Research, Anglia Ruskin University, Chelmsford, England, UK 3 East Suffolk and North Essex NHS Foundation Trust, Colchester, England, UK Sally Goldspink Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Nieky van Veggel Roles: Data Curation, Formal Analysis, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Hilary Engward Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Naim Abdulmohdi Roles: Formal Analysis, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Andrea Tuckwell Roles: Formal Analysis, Investigation, Methodology Marie Alexander Roles: Funding Acquisition, Project Administration, Supervision OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background In England, the Professional Nurse Advocate (PNA) and Professional Midwifery Advocate (PMA) role places nurses and midwives at the centre of workforce retention and transformation. The PNA/PMA role blends professional leadership and clinical supervision through the A-EQUIP model, which is grounded in directing change and steering service development. The overarching impetus for the PNA/PMA role is to improve care quality whilst developing and sustaining cultures of professional wellbeing and nurse/midwife retention. To date, however, little is known about what the impact the PNA/PMA role has on the day-to-day practice of nurses and midwives, nor if it improves quality in practice, professional wellbeing, and retention. This study examines the impact of the PNA/PMA role on nurse/midwife involvement in quality improvement, wellbeing, and retention within one public sector healthcare NHS Trust in England. Methods During 2022, fourteen semi-structured interviews were conducted with PNA’s and PMA’s who had completed their training and are included on the NHS Trust PNA/PMA register. The interviews were transcribed verbatim and analysed through qualitative descriptive analysis. Findings The analysis detected 5 themes and 10 subthemes: (1) Transforming in Tandem (a) Role of Advocacy, (b) Restorative Focus, (2) Creating Safe Spaces, (c) Emotional Support, (d) Interpersonal Relationships, (3) Challenging the Status Quo (e) Counteracting Blame Culture, (f ) Empowering Change (4) Empowerment and Development (g) Building Resilience, (5) Types of Advocacy (h) Educational and Emotional Advocacy (i) Coaching and Conversations. Conclusions The findings suggests that the most effective aspects of the PNA and PMA roles are those that directly empower individuals and create a supportive, reflective environment. However, while building resilience is vital, it is equally important to recognise its limits and ensure that healthcare professionals are not pushed to the point where their resilience becomes a barrier to their well-being and the overall improvement of their work environment. READ ALL READ LESS Keywords Professional Nurse Advocate, PNA, Professional Midwife Advocate, PMA, Advocacy, Service development Corresponding Author(s) Nieky van Veggel ( [email protected] ) Close Corresponding author: Nieky van Veggel Competing interests: AT and MA are employed by the East Suffolk and North Essex NHS Foundation Trust who funded the work. Grant information: The Professional Advocacy Project is funded by East Suffolk and North Essex NHS Foundation Trust, Trust Offices, Colchester Hospital, Turner Road, Colchester, Essex, CO4 5JL under project number 418278. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Goldspink S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Goldspink S, van Veggel N, Engward H et al. Beneficent Disruptors: A qualitative descriptive study of professional advocacy in healthcare [version 1; peer review: 1 approved] . F1000Research 2025, 14 :674 ( https://doi.org/10.12688/f1000research.166551.1 ) First published: 07 Jul 2025, 14 :674 ( https://doi.org/10.12688/f1000research.166551.1 ) Latest published: 07 Jul 2025, 14 :674 ( https://doi.org/10.12688/f1000research.166551.1 ) Introduction The concept of professional advocacy in relation to the nursing/midwifery professions stems from supervision in midwifery, with the roll out to the nursing profession coming as a direct response to the COVID-19 pandemic ( Ariss et al., 2017 ). Initially, professional advocacy used the Advocating for Education and Quality and Improvement (A-EQUIP) model. The function of A-EQUIP was expected to: ‘Support a continuous improvement process that builds personal and professional resilience, enhances quality of care, and supports preparedness for appraisal and professional revalidation. The aim of using the A-EQUIP model is that through staff empowerment and development, action to improve quality of care becomes an intrinsic part of everyone’s job, every day in all parts of the system’ [ NHS England, 2017 , p. 11]. With the roll out to nursing, a fourth function of the model was added: personal action and quality in practice improvement ( Whatley, Stephens, and Sterry, 2021 ). From this, the PNA/PMA role has four distinct elements, firstly to advocate for the patient, fellow midwives/nurses, and healthcare staff. Secondly, to provide clinical supervision using a restorative approach. Thirdly, enable midwives/nurses to undertake personal action for quality improvement and finally, to promote the education and development of midwives/nurses. The purpose of the PMA/PNA role is strategically linked to the to the National Health Service (NHS) Long Term Plan ( NHS England, 2019 ), NHS People Plan 2020/21 (NHS England, 2020), and to the NHS Workforce Plan ( NHS England, 2023b ) as the central tenets surround retention through building positive and proactive workforce cultures. By raising the profile of continuing professional development and further integration with organisational local governance, the intension of the PNA/PMA role is to support practitioners to develop themselves and the services that they work in. Despite ambitious intentions for the professional advocacy role in nursing and midwifery, to date, an initial rapid literature review suggested little was known about the efficacy of PNA/PMA, how the role was implemented at a local level and, the potential impact (or not) on professional wellbeing and retention. The current study focussing on how PNA’s/PMA’s describe their experience of the role is part of a larger project seeking to contribute to a wider workforce conversation by examining what is happening in one Trust from a staff-based perspective. In the UK, there are approximately 50,000 nursing and midwifery vacancies ( Palmer and Rolewicz, 2022 ). The NHS Staff Survey ( NHS Staff Survey, 2020 ) suggests this is likely to increase, with 49% of respondents reporting having experienced work-related stress that had impacted their health, and 40% experienced stress and burnout ( NHS Staff Survey, 2020 ; Kinman, Teoh and Harris, 2020 ; The King’s Fund, 2023 ). As such, there is a need to understand and support professional wellbeing in the work environment ( Department of Health and Social Care [DHSC], (2022) ), alongside the need to retain nurses and midwives ( Holmes, 2022 ) and develop services ( NHS England & NHS Innovation, 2021 ). One means of doing so is via the introduction of Professional Nurse and Midwifery Advocacy. To date, however, there is little extant literature about the implementation and impact of the PNA/PMA role. This is probably because the role is new and while evidence is emerging there is a disciplinary focus and attention given to those who have engaged with professional advocacy. In addition, the evidence points to specific issues such as empowerment ( Lees-Deutsch et al., 2023 ), burnout ( Miles, 2023 ) and critical care ( Wade, 2023 ) rather than the overarching issues of what PNA/PMA looks like in routine practice and how it is understood by those who do and do not engage with it. The origin of role stems from clinical supervision in midwifery. Clinical supervision has a long established and well documented association with midwifery practice ( DHSC, 2022 ; UKCC, 2001 ), often as a response to failing standards in patient safety and care ( Flynn, 2012 ; Care Quality Commission, 2013 ; Francis, 2013 ; Kirkup, 2015 ; Ockenden, 2022 ). Despite its presence in guidelines, there is little consensus as to how supervision occurs in different healthcare contexts ( Jones, 2022 ), nor how this might link to retention and professional wellbeing. This is important because the operational guidance for implementing the PNA/PMA is via the A-EQUIP model which concentrates on the barriers and opportunities in care giving, combined with individual professional development and wider contributions to understanding and improving service delivery. The A-EQUIP model is based on leading change and driving improvement ( Proctor, 1987 ; Whatley, Stephens and Sterry, 2021 ; NHS England & NHS Innovation, 2021 ). However, this model and subsequent adaptations have received little empirical attention, particularly in terms of overall practice-based impact from the integration of the four A-EQUIP elements of A dvocating and E ducating for QU ality I m P rovement and supervision. As such, the PNA/PMA role needs to be considered alongside the A-EQUIP model to determine how the model is applied (or not) in practice. This new understanding can inform the delivery of PNA/PMA at the local and the national level. A further problem, as evidenced in the literature, is that there is little consensus about what professional advocacy is. Advocacy for patients is a familiar concept in nursing and midwifery. In this sense, advocacy refers speaking or acting on behalf of another person/patient. The [ Royal College of Nursing, 2023 , p. 17] suggests that advocacy is to ‘ ensure that people, particularly those who are most vulnerable in society, can have their voice heard on issues that are important to them, defend and safeguard their rights, and have their views and wishes genuinely considered when decisions are being made about their lives ’. However, Scott and Scott (2021) argue that advocacy for the patient has been under-examined, and indeed, advocacy remains undefined in professional regulatory guidance; the term ‘advocate’ is mentioned on a single occasion in the Standards of Proficiency for Registered Nurses ( NMC, 2018 ) and not in the Standards Framework for Nursing and Midwifery Education ( NMC, 2018 ). Where advocacy is mentioned in the literature, it does so as an overarching term for complex issues relating to the wider moral responsibilities of the profession. For example, Choi (2015) identified the attributes of an effective nurse advocate comprise of proficiency, flexibility, empathy, self-directedness, motivation, accountability, commitment, and resilience. Understandings of advocacy, so far, are geared toward the interaction between the professional and the patient ( Smith and Mee, 2017 ; Abbasinia, Ahmadi, and Kazemnejad, 2020 ), and this change in focus toward the professional is likely to require further definition and acceptance to become fully assimilated and applied in routine practice. However, patient care remains at the heart of professional advocacy ( Whatley, Stephen and Sterry, 2021 ). This project joins the conversation about the different notions of professional advocacy from a practice-based perspective. To ensure that this project was contextually meaningful and useful, the purpose, aims and design were securely aligned and agreed with the Trust requirements. Therefore, the project included understandings into the possible impact (or not) of the PNA / PMA role in relation to the A-EQUIP model for service improvement, retention, and professional wellbeing. Importantly, it explored how PNA/PMAs themselves understand and implement the role, and how the PNA/PMA role was perceived and used by nurses and midwives as well as developing an understanding of what stops nurses and midwives from engaging with PNA/PMA. Overall, this project sought to explain the how the PNA/PMA is described, experienced, and implemented, with the view to offering sustainable strategies to develop PNA/PMA in the Trust. Context The transition to professional advocacy (PA) is a vehicle for deploying the four elements of the Advocating for Education and Quality Improvement (A-EQUIP) model ( NHSE, 2017 ), which evolved in response to a monumental change in the regulation of Midwifery practice ( NHSE, 2017 ; Ariss et al., 2017 ). A new model of midwifery supervision in the UK was recommended following the publication of ‘Midwifery supervision and regulation: recommendations for change’ ( PHSO, 2013 ) and ‘Midwifery regulation in the United Kingdom’ ( Baird et al., 2015 ). Central to this change was that Midwifery supervision and regulation should be separated. The policy paper ‘Proposals for changing the system of midwifery supervision in the UK’ ( Department of Health and Social Care, 2016 ) reframed the process of midwifery supervision following legislative changes removing statutory supervision in March 2017 when the Professional Midwifery Advocate (PMA) role replaced the Supervisor of Midwives (SOM) in England. The value of the non-regulatory elements of supervision were acknowledged, and a task force produced a new model of supervision and oversaw the transition from a statutory requirement to an employer-led, PMA system (Department of Health, 2016; NHS England, 2017 ). The employer-led design of the A-EQUIP model offers healthcare organisations flexibility to implement the model according to their workforce needs and adapt it to address the specific challenges faced by their staff ( Dunkley-Bent, 2017 ). There is a risk that employer-led models allow for inconsistencies in the implementation of PMA across Trusts ( Ariss et al., 2017 ; Capito et al., 2022 ). However, similar criticism has been levelled at previous models of supervision and advocacy, through the suggestion that Trusts have not allocated enough time to supervision (Health and Social Care Act 2008) and supervision has been undervalued and under resourced ( Henshaw, Clark and Long, 2011 ). The A-EQUIP model is underpinned by the seminal works of Douglas and Ginty (2001) , Hawkins and Shohet (2012) , Proctor (1986) and Wallbank (2007) . According to Capito et al., (2022) the A-EQUIP model also uses principles from Solihull Approach ( Douglas and Ginty, 2001 ) (reciprocity, containment, behaviour management). Initially, the ‘A-EQUIP’ model of midwifery supervision incorporated three core features: 1. Restorative clinical supervision 2. Quality improvement 3. Education and development The operation guidance for implementing the model stated ‘The deployment of the model supports a continuous improvement process that builds personal and professional resilience, enhances quality of care, and supports preparedness for appraisal and professional revalidation. The aim of using the A-EQUIP model is that through staff empowerment and development, action to improve quality of care becomes an intrinsic part of everyone’s job, every day in all parts of the system.’ ( NHSE, 2017 , p. 11). Thus, the introduction of the A-EQUIP model signalled a major shift in midwifery by focussing on staff wellbeing and resilience to encourage positive staff cultures ( Sterry, 2018 ), while also enabling and empowering midwives through meaningful engagement with education and quality improvement in the practice setting. To support the recovery from the COVID-19 pandemic, NHS England and NHS Improvement introduced Professional Nurse Advocate (PNA) training across England in March 2021. Nearing the backend of the third major wave of COVID-19, the timing of the launch emphasised the ‘start of a critical point of recovery: for patients, for services and for our workforce’ ( NHS England/NHS Improvement, 2021 ). Although clinical supervision in nursing was first formally proposed in the late 1980’s, Sawbridge and Hewison (2013) argued that there was a general lack of evidence for securing a systematic and fully embedded approach to professionally oriented support. Following the success of the PMA roll-out and to address this gap, PNA training (an EHEA/EQF Level 7 professionally accredited programme of professional development) highlights restorative supervision alongside the other three functions of the current Advocating for Education and Quality and Improvement (A-Equip) model adapted from the original PMA training ( Whatley et al., 2021 ; Smythe et al., 2023 ): 1. Clinical supervision (Restorative) 2. Monitoring, evaluation, and quality control (Normative) 3. Personal action for quality improvement 4. Education and development (Formative) The overall aim of the training is to develop professional advocate skills to facilitate restorative supervision for their colleagues and teams, in nursing and midwifery and beyond into the multi-disciplinary team, leading to higher levels of staff wellbeing and retention, together with better patient outcomes. The training also equips professional advocates to proactively understand the clinical challenges and service demands faced by colleagues, with the mandate to instigate, support and deliver quality improvement initiatives ( NHS England/NHS Improvement, 2021 ; Whatley et al., 2021 ). We conducted a rapid literature review between July 2022 – November 2022 because there was a more in-depth, national review underway, funded by NHS England, which was subsequently published by Lees-Deutsch et al., (2023) . To avoid duplication, we focussed on gathering a current overview ( Table 1 ) of what literature and evidence is focussed on. We then used this information to situate our study. Table 1. Rapid literature review inclusion and exclusion criteria. Criteria Inclusion PMA / PNA focus, UK-based, primarily practice based Exclusion Patient advocacy, advocacy for the profession, advocacy for the community, policy advocacy, not UK, primarily theory based PMA: Professional Midwife Advocate, PNA: Professional Nurse Advocate. Table 2. Interview schedule. Question Purpose How did you start in your PMA/PNA role? General context How would you describe what you do as a professional advocate? Comparing ‘in practice’ to the national model What works/doesn’t work in professional advocacy (and why) – can you give examples? Explaining what factors make professional advocacy efficient and effective (or not) In what ways have you seen professional advocacy help? Talk me through examples in terms of what you did and what the nurse/midwife did and how this impacted on practice. Identifying the impact of professional advocacy What impact does your role as a professional advocate have on you? What support do you receive as a PNA/PMA or would like to receive? Exploring the needs of PMA’s/PNA’s and those who engage with advocacy What are the options for you to develop as PNA/PMA, do these meet your needs or would you like something else? CPD (Continuing Professional Development) What are the opportunities and barriers for professional advocacy in the Trust? ‘In practice’ appraisal If you were mentoring a new PMA /PNA, what advice would you give and why? Finding ways to optimise the organisational structures for PMA & PNA PMA: Professional Midwife Advocate, PNA: Professional Nurse Advocate. The data bases searched included: CINAHL Plus, Medline, Psychology and Behavioural Sciences Collection and Google Scholar. The search and selection strategy identified 21 resources ranging from commentary to primary research and a thematic analysis generated three key findings. Firstly, the literature and evidence has focused on announcing the arrival of professional advocacy for midwives ( Ariss et al., 2017 ; Dunkley-Bent, 2017 ; Martin, Stephens and Dennis, 2018 ; Purdy and Read, 2019 ; Kerelo, 2020 ) and nurses ( May, 2021 ; Capito et al., 2022 ; Pearce, 2022 ; Flack and Abdulmohdi, 2023 ; Smythe et al., 2023 ). Many publications describe the accepted A-EQUIP model for providing advocacy, with connections to coaching and mentoring skills ( Thomas, 2022 ; Wells, 2022 ). The lens of personal reflection is widely used to present ‘in-action’ narratives ( Darling, 2021 ). There are some comparisons between previous supervisory models an A-EQUIP ( Wain, Britt and Divall, 2018 ; Macdonald, 2019 ). Secondly, there is limited implementation information on how professional advocacy occurs from a service perspective and attention is given to aspects of the A-EQUIP model. In other words, there is a lack of service level strategies to make professional advocacy happen are unclear. Sterry (2018) has evaluated a professional midwifery advocate quality improvement project, however attention is mostly given to the individual experience ( Devereux, 2022 ; Kont, 2022 ), rather than the processes required to roll professional advocacy out to the workforce. Similarly, Griffiths (2022) focussed using restorative supervision to help nurses during the COVID-19 pandemic. Thirdly, practice-based evaluation is missing from the evidence, both in terms of the methods for evaluation and the outcomes of evaluation. There is some commentary about the barriers and enablers to implementation for professional midwifery advocacy ( Rouse, 2019 ). Where evaluation is present, the work is mostly framed in the educational context rather than the practice setting ( Muscat, Morgan and Hammond, 2021 ). In the disciplines of nursing and midwifery, the literature and evidence base for professional advocacy is evolving, however practice-based inquiry relating to implementation is limited. The need to enquire further into the understanding and application of professional advocacy from a multi stake-holder perspective is apparent. Therefore, this study is necessary and timely to inform develop strategic, evidence-led decision-making aligned to the requirements of the NHS Trust and the workforce. Methods 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. Table 3. Professional advocacy is multidimensional. Dimension Examples from data Educational Identify gaps in their knowledge What are you interested in? Teaching clinical skills Allowing emotions Focus on people’s emotions and how they’re feeling Understanding emotions, how they dealt with them, rather than the incident itself What did you feel at the time? What could help you? Looking at different ways of managing things Linking support to pastoral care Understand that feelings are normal, valid, and temporary, that things will move on Linking small changes made to CPD Linking ideas to CPD to practice Linking CPD to practice Revalidation Personal development Exploring what happened via reflection Reflecting on how you can change Thinking how to change negative to action Career conversations Assist with application for a new job Talking about stress Talking about what to do next Coaching conversations Using coaching cards Priorities game Bringing people together Action reviews Debriefing Talk about how they’re feeling, not what happened and what can be learnt? CPD: Continuing Professional Development. 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. Findings The role of Professional Advocates (PAs) is centred on empowering individuals in clinical roles to identify and develop solutions within their own contexts. Significantly, PAs are not providing solutions for them; instead, they focus on creating an environment where supervisees can reflect on their practice and learn to handle challenges independently. By anchoring discussions in the supervisee’s real-world context, PAs help reduce catastrophising and encourage constructive problem-solving. This approach creates a subtle yet transformative process, where both the individual and the service evolve together. Importantly, participants described PA actions as active, framed as care, and directed towards supporting the overall wellbeing of others. 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: “Clinical supervision tends to be around incidents that have happened and what they could have done differently,” and “I’ll do a couple of drug rounds with them, and if I’m happy with their practice, then I’m happy for them to carry on.” Career discussions are also facilitated, often using tools such as coaching cards to help individuals clarify their goals. One participant explained, “I have a pack of barefoot coaching cards… and they pick two or three cards, and then we sit down and discuss why they picked each one. Things sort of develop from that.” A primary concern for PAs is restorative support, focusing on the supervisee’s emotional wellbeing and personal growth. A participant puts it as “I think the role of the PNA works because it focuses more on people’s emotions and how they’re feeling… the PNA is more about things that have happened, how it made them feel, their emotions, and how they handled it emotionally.” This pastoral element is essential, aiming to provide an empathetic, supportive presence: “Pastoral is paramount,” and “It’s also that pastoral side of support as well.” In addition to skill development, PAs work to reduce supervisee loneliness or isolation by actively listening and addressing their concerns. One participant shared, “My concern for them means that they’re actually being listened to, and something is happening rather than just being told to go back to being on their own.” Contextual actions in support PAs engage supervisees in reflective questions to deepen their understanding of practice and enhance problem-solving abilities: • “What did you do?” • “Why did you do it?” • “Why do you think that was the right thing to do?” • “Let’s look at it from another angle.” These questions are designed to deconstruct challenges and reduce catastrophising. As one participant noted, “It [the problem] sort of comes back and forth, then it becomes a big mole, and then you feel a bit better because you’ve let it off a little.” 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: • Interpersonal safe space: Providing a secure environment for nurses and midwives to talk openly about their experiences, focusing on them as individuals and addressing both emotional and professional aspects of their roles. • No-blame support: Offering a supportive space that transcends mere task completion, aiming to build trust and a constructive perspective on practice issues. • Collaborative problem-solving: Helping individuals to work through challenges by fostering solutions from within, rather than imposing them from above. Advocacy creates a space where individuals can openly discuss themselves within the context of their specific practice environment: “Just allowing her space to say all the what-ifs and helping her explore her thoughts through that.” “That what they say isn’t gonna get shot down. They are gonna be more willing to share ideas and be really invested in what they’re doing.” “So, it’s about finding someone with whom you can have those difficult conversations.” “I’m here to talk about practice.” 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: “It’s about people actually having that space and time to think through their thoughts and work through things themselves.” “What emotions are you feeling, and how do we process those emotions, and what can we do about those emotions?” “There was one member of staff who couldn’t really explain why she felt the way she did, but she was completely overwhelmed.” “It’s more about things that have happened and how it made them feel emotionally… rather than the actual incident itself.” Advocacy emphasises relationships and interactions within the workplace, recognising the role of interpersonal dynamics in emotional and professional wellbeing: “And then we ended up having some sessions about it, which opened a cascade of issues because it was about workload.” “It’s more about work relationships and things that people tend to be upset about.” “Taking very much from a person’s perspective and where they’re at and addressing their needs.” “How do you meet the needs of a person? That’s deep listening… to give them tools to go back stronger, to be able to carry on that job.” 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: “Every single one of those nurses couldn’t tell you how they were feeling at that moment, they just can’t because they are too wrapped up in the task of caring. But at the end of their shift, or in between, there’s someone to talk to and kind of vent, verbalise it, process it, and see if anything could be done.” “When it’s my team coming to me with their distress, I struggle more with that because I have more affinity with them… Although I know them, I’m able to take a step back from what they’re telling me, because it doesn’t affect me in the same way.” 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: “I just kept trying to encourage her to think about how she could handle things going forward. Like, what would you like to see change from this situation?” “To point you in a different direction.” “To stop some of the firefighting.” This future-oriented stance emphasises the belief that individuals can make positive changes within their practice: “It’s to support them in understanding if something has happened in their own practice, how they approach things, analyse their own way of working, and look back to guide them in understanding if any changes can be made. I’m not here to tell you what to do.” “I’m here to support you, to help you get your head around anything that’s happened and process things that have happened. I’m here to talk about practice.” In this approach lies a quiet yet powerful notion of using conversation to challenge the organisational culture: “Nurses talk, don’t we? We talk and talk… you get a group of nurses together, and you just talk about anything and everything. You put the world to rights, but let’s make those conversations productive. Let’s now do something about it and make it productive.” 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: “It’s about trying to take away that guilty feeling… actually, let them see that if they weren’t looking after two women at the same time, trying to provide intrapartum care, or they had a postnatal woman as well because they can’t move the postnatal woman upstairs, then something is gonna get missed. And that’s not their fault.” This deliberate focus on organisational factors aims to counteract the perception of individual blame: “I don’t want it to look like we’re attributing blame, but sometimes people do feel that way, even if it’s under the surface. No one goes into work to cause an issue or harm, but sometimes, when the external pressures are so much, things do happen.” 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: “Looking at it slightly differently… not just moaning about things, but thinking about how you could, how you can change it, how you can reflect on it, make it better. You reflect on it, but you sit and think about it a bit, and they’ll see things that were really OK, or things that you could have done differently.” “People moan, or let off their worries, or talk about things to colleagues, who are also dealing with a lot, and it comes back and forth, and then it becomes a big mole. You feel a bit better because you’ve let it off a little bit, but nothing actually changes.” 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: “They think that, well, that’s the service or quality improvement midwives’ job, that’s a specialist job, and I’m not in that specialist job. So, I don’t have a role to play in that, but you can. You absolutely can. And if you’re seeing something that’s really frustrating you? Absolutely. Get involved in those conversations.” “I’m actually there to help you develop and you’ll be more self-aware which improves your practice and improve your care, and you’ll be able to pass this on to other people that have been in the same situation and be able to support your peers better.” “But less you ask them, empower them to find their own solutions, they don’t know it’s a good idea. They don’t”. 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. “I’ll talk to you about the, you know, inch wide mile deep theory, of just picking one small thing, but delving down and really picking out what could be changed and what could be improved.” “Having these little ideas that sometimes people will just poo poo. But actually, if they’ve got that support to help them follow through, can make huge differences.” To empower the individual: “It might be the little things at work, but you just need to talk through the possibilities.” “She said, I really struggle with my hand over because the folders with the patient’s details and all the notes there are in such a mess, like a proper mess. Nothing’s in the same place, she said, you know, I’ve got some ideas where we could really sort of do that. And I went brilliant. Go and speak to you award manager and talk this through”. “Figure out which one you think is best, and then have someone encourage you to make the change.” “It’s like maybe picking just one small thing and being able to actually, you know, make a difference. It might only seem a small thing, but the deeper you delve into it, the more change you could improve. And again, with that you’re changing patient care.” “Before we can improve services, we need to improve staff wellbeing and resilience.” 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: “It’s empowering people to sort things out in ways that make sense as a nurse.” “It’s empowering and building each other up. It’s nurses building nurses, which I think I think it could be amazing.” “Sometimes, people don’t know how capable they are because they have had experiences like her and have been put down, for whatever reason. For me PMA is about building people up, helping them to see that they are good at what they do, offering development to make them even better, but it comes from a place of helping, of sharing, of developing as midwives, together.” “I’m actually there to help you develop and you’ll be more self-aware which improves will improve your practice and improve your care and you’ll be able to pass this on to other people that have been in the same situation and be able to support your peers better.” Therefore, a connection is made between empowering the individual, empowering the professional and developing services: “To create a culture where they’re able to be honest about what isn’t working for them as well.” “The bit the I feel strongly about is the development bit, you know the idea that you can develop yourself but also you can develop the service that you work in.” “PMA could facilitate that discussion, kind of restorative supervision for the service, because the service is stressed, but the service needs to find a way of managing that stress together.” 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: “It’s all about building resilience and therefore a stronger workforce. So that’s the end goal.” “It is interesting because when I when I’ve done some group sessions and I’ve done a little bit of what resilience is and afterwards I sit there thinking, gosh, I’m talking to the converted. Why am I even saying this? They’ve just survived working through COVID, you know, I mean, the ward I work on is quite busy, It’s quite stressful working with high dependency patients. It’s intense. So, I think if you’re surviving in that environment, you’ve got that resilience going to a fine art, but I do also of course see when staff are struggling and perhaps you know there are ways to build up that resilience.” “It is about not taking everything quite so hard. In a way thinking well, yeah that was difficult, but I managed.” “I think what they’re hoping for is a better resilience and therefore retention of staff because they feel they can, they’ve got better coping mechanisms, they’ve got the tools and the skill set to be able to, you know that that resilience is much more prevalent and they won’t feel like next time they’ve got a handle, you know, handle a situation like that, that they’re not, that there is out of their control. It’s all about building resilience and therefore a stronger workforce. So that’s the end goal.” But there is a sense that being too resilient is counteractive: “Historically, as nurses, it’s that get on with it and cope, you know with that’s what we’ve done on our lives, isn’t it? When you think about the troubles and NHS and the way wards are staffed, and you just are expected to go on with it, and put up with it, and resilience, which is this big buzzword. Just noise, isn’t it? You know, it’s all about being resilient, and that was a big part of our training for the PNA role is, you know, helping people to be resilient. But people are too resilient. Sometimes I think in that you know; you can go too far the other way. And, actually, I can cope by myself, I have to do this. That’s what’s expected of me, and I think that is where we’re at really with a lot of stuff.” 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: “If you say clinical supervision to a nurse, it immediately gives a negative feeling, cause supervision is linked to doing something wrong. It’s like, what have I done wrong?” “If somebody’s made a mistake or done something wrong, people will be put under clinical supervision. So, it’s the terminology is negative.” Advocacy was explained to be ‘completely the opposite’. “I’m not there as a higher grade than you or say this is what you should have done and tell you off.” “I’m not there to sign a bit of papers as you’re fit to practice. I’m not there to judge your practice. I’m not your gatekeeper.” “Knowing that I am going to be there and I’m not gonna judge them, I’m not going to make them feel stupid.” “I’m not a counsellor, I’m here to support you, to help you get your head round anything that’s happened and process things that have happened.” 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: “When you do the PMA, your training, very specific skills, you know empathy and the listening, counselling kind of advisory capacity but also getting them to find the answers within themselves as well, which is a whole different level.” “Then say, I’ll catch up with you after you know where I am. If you need me, best of luck and hopefully from that they’d then feel like ohh OK yeah, that did work, you know? Or it didn’t work, and you go back to the drawing board, and they try again.” “I feel guilty that I’m like, well, I haven’t done any PMA. But then my friend who sits next to me, she says you do PMA, all Yes, all the time and all your conversations. I’m like, I don’t. I don’t think I do, but she, she says I do that kind of thing.” “It’s about making people realise that you might not be doing what you call a PNA session, but actually your conversations with staff. You’re using those skills all the time.” “But I feel that the impromptu stuff and people seeing me, I get more discussion with people that way rather than people responding to an email.” “Whereas now as a band seven I not only have the experience, but I’m around people where I can see that actually you can use your initiative and your common sense, and you can go doesn’t exactly fit policy. But do you know what? It’s the best thing for the patient and I think we can justify that we can really use that. I don’t think anyone, if we were to explain our situation, would stop us from doing this. It’s the right thing to do, but I think it’s about empowering everyone to feel that way. That’s what I want PNA’s to do for people, empower them to question and do the best for the patients while taking care of themselves too.” Understanding differences between grade bands “I think it’s about courage for me. As a band 5, I didn’t go outside the guidelines. I followed policy and procedure even though I didn’t want to all the time because I didn’t necessarily agree with it. I was so scared of retribution and consequence. Whereas now as a band seven I not only have the experience, but I’m around people where I can see that actually you can use your initiative and your common sense, and you can go doesn’t exactly fit policy. But do you know what? It’s the best thing for the patient and I think we can justify that we can really use that. I don’t think anyone, if we were to explain our situation, would stop us from doing this. It’s the right thing to do, but I think it’s about empowering everyone to feel that way. That’s what I want PNA’s to do for people, empower them to question and do the best for the patients while taking care of themselves too.” 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. “I wouldn’t say I focused on my own development as much as I should, considering it’s the crux of you know, it is it is the main crux of a PNA.” “I’m not sure, probably because it’s not tangible.” “To develop skills, get a skill set to sustain them in the workplace as well, and a lot of it could come from mentoring.” “I’ve done a lot of support. I’ve done a lot of chats. We do some sort of debriefing and that kind of thing, but I’ve not done really very much structured RCS, so I don’t feel particularly confident in that. But if anyone wants to come and talk to me about anything, I feel quite happy to deal with those things. So, I think that makes me a little bit nervous to think someone says, oh, can you run an RCS session?” 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. Discussion The findings of this project illuminate the nuanced role of Professional Nurse Advocates (PNAs) and Professional Midwifery Advocates (PMAs) in transforming both individual practice and the wider healthcare environment, as well as in benefitting the PA themselves ( Walker et al., 2025 ). The discussion seeks to situate these findings within the broader context of workforce wellbeing, retention, and quality improvement, as well as the potential and limitations of the A-EQUIP model. 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. Conclusion This project highlights the significant and divers potential of PA in healthcare. These roles are pivotal in fostering a supportive and empowering environment for healthcare professionals. Through the implementation of the A-EQUIP model, PA’s significantly contribute to professional wellbeing, workforce retention, and service improvement. The findings highlight the transformative power of advocacy, with PA’s acting as “beneficent disruptors” by challenging traditional hierarchical structures by promoting a culture of reflective and resilient practice. PA is characterised by creating safe interpersonal spaces, enabling emotional support, and empowering individuals and teams to pursue incremental but impactful changes. Therefore, PA not only enhances individual practice but also drive collective service transformation, addressing systemic challenges and counteracting blame culture. However, the findings also caution against over-reliance on resilience as a cure-all, advocating for a balanced approach that prioritises both individual and organisational wellbeing. The insights gained offer valuable strategies for refining the implementation of the PA role, ensuring their sustained impact on healthcare delivery. Therefore, the introduction PA holds great promise in addressing critical workforce challenges, fostering innovation, and enhancing the quality of care. Continued exploration and refinement of this role will be essential to align it with the evolving needs of a dynamic healthcare system. Ethical considerations This project was approved by the Anglia Ruskin University Faculty of Health, Medicine and Social Care Research Ethics Panel on 4 September 2023 under reference ETH2223-2520. Participants were informed about the study aims and procedures, and they were asked to sign informed consent for participation in the study before each interview. All participant data were treated as confidential. 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. Reporting guidelines The completed SRQR checklist for this paper can be found at: SRQR checklist for ‘Beneficent Disruptors: A qualitative descriptive study of professional advocacy in healthcare’. http://doi.org/10.25411/aru.28987271 . ( Goldspink et al., 2025 ) Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Data availability Due to the fact that open posting of data on a repository was not included in the study information sheet at the time the interviews were done, the underlying dataset has restricted access. Following IRB process, data access will be granted once users have consented to the data sharing agreement and have provided written plans and justification, inclusing IRB approval from their own institution, for what is proposed with the data. Data access may be obtained by submitting a request to the authors via email through the Anglia Ruskin University ARRO repository (the contact email address is available in the repository record. The relevant repository record and procedure for data access requests can be found here: http://doi.org/10.25411/aru.28847294 . ( Goldspink et al., 2025 ). Data access requests will be reviewed by the authors and key collaborators as named on the repository. Acknowledgements The authors would like to thank the ESNEFT team for help with distribution of information, and the participants who took part in this study. References Abbasinia M, Ahmadi F, Kazemnejad A: Patient advocacy in nursing: A concept analysis. Nurs. Ethics. 2020; 27 (1): 141–151. PubMed Abstract | Publisher Full Text Ariss S, Earley V, Jokhi R, et al. : Final Evaluation Report: Pilot for New Model of Midwifery Supervision.2017. Reference Source Baird B, Murray R, Seale B, et al. : Midwifery regulation in the United Kingdon. [Commissioned Report]. The King’s Fund. 2015; p. 32. Reference Source Barratt C: Developing resilience: the role of nurses, healthcare teams and organisations. Nurs. Stand. 2018; 33 : 43–49. PubMed Abstract | Publisher Full Text Brinkmann S, Kvale S: Doing interviews. SAGE Publications Ltd; 2018. Publisher Full Text Buhlmann M, Ewens B, Rashidi A: Moving on after critical incidents in health care: a qualitative study of the perspectives and experiences of second victims. J. Adv. Nurs. 2022; 78 : 2960–2972. PubMed Abstract | Publisher Full Text | Free Full Text Capito C, et al. : Professional midwifery advocates: delivering restorative clinical supervision. Nurs. Times. 2022; 118 (2): 26–28. Care Quality Commission: Women’s experiences of maternity care have improved, but further progress is needed—Care Quality Commission.2013. Retrieved 1 May 2025. Reference Source Choi PP: Patient advocacy: the role of the nurse. Nurs. Stand. 2015; 29 (41): 52–58. PubMed Abstract | Publisher Full Text Darling K: Learning from the past and building a better future through the lens of a professional midwifery advocate; healing wounds from a decade of midwifery. MIDIRS Midwifery Digest. 2021; 31 (1): 1–13. Department of Health and Social Care: Proposals for changing the system of midwifery supervision in the UK. Her Majesty’s Government; 2016. Reference Source Department of Health and Social Care [DHSC]: Policy paper, 50,000 Nurses programme: delivery update.2022. Reference Source Devereux E: Professional nurse advocates having ‘phenomenal’ impact on staff wellbeing. Nursing Times online. 2022. Douglas H, Ginty M: The Solihull Approach: changes in health visiting practice. Community Pract. 2001; 74 (6): 222–224. Drisko JW: Transferability and Generalization in Qualitative Research. Res. Soc. Work. Pract. 2024; 35 : 102–110. Publisher Full Text Dunkley-Bent J: Introducing A-EQUIP: the new model of midwifery supervision. Blog post for NHS England. 2017; 25 : 278–279. Publisher Full Text Reference Source Engeström Y: Learning by Expanding: An Activity-Theoretical Approach to Developmental Research. Cambridge: Cambridge University Press; 1987. Engward H, Goldspink S, Abdulmohdi N, et al. : Understanding Professional Advocacy: A protocol for a mixed method project to explore professional nurse advocacy and professional midwifery advocacy in one NHS trust. SocArXiv. 2024. Publisher Full Text Flack L, Abdulmohdi N: Designing and delivering a professional nurse advocate training module. Nurs. Times. 2023; 119 (11). Flynn M: Winterbourne View Hospital: a serious case review. South Gloucestershire Safeguarding Adults Board. 2012. Reference Source Francis R: Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Stationery Office. 2013. Reference Source Goldspink S, Van Veggel N, Engward H, et al. : Dataset accompanying Beneficent Disruptors: A qualitative descriptive study of professional advocacy in healthcare. Dataset. Anglia Ruskin Research Online (ARRO). 2025. Publisher Full Text Griffiths K: Using restorative supervision to help nurses during the Covid-19 pandemic. Nurs. Times. 2022; 118 (3): 33–36. Hawkins N, Jeong S, Smith T: New graduate registered nurses’ exposure to negative workplace behaviour in the acute care setting: an integrative review. Int. J. Nurs. Stud. 2019; 93 : 41–54. PubMed Abstract | Publisher Full Text Hawkins P, Shohet R: Supervision in the Helping Professions. Maidenhead: McGraw-Hill Education; 4th ed. 2012. Henshaw L, Clark D, Long M: Supervision in Practice. London: Sage Publications; 2011. Holmes J: The NHS nursing workforce – have the floodgates opened? | The King’s Fund. The King’s Fund: Leadership and Worksforce. 2022. Reference Source Jones S: Is clinical supervision for nurses difficult to access? Nurs. Manag. 2022; 29 (6): 12–13. Publisher Full Text Reference Source Kerelo S: What is a professional midwifery advocate? Br. J. Midwifery. 2020; 28 (4): 220–221. Publisher Full Text Kim EY, Chang SO: Exploring nurse perceptions and experiences of resilience: a meta-synthesis study. BMC Nurs. 2022; 21 : 26. PubMed Abstract | Publisher Full Text | Free Full Text Kinman G, Teoh K, Harris A: The mental health and wellbeing of nurses and midwives in the United Kingdom. Soc. Occup. Med. 2020. Reference Source Kirkup B: The Report of the Morecambe Bay Investigation.2015. Reference Source Kont I: The Importance of Implementing Role of Professional Nurse Advocator (PNA) and Use of A-EQUIP Model in Clinical Area Post COVID-19 Pandemic. Int. J. Nurs. Health Care Res. 2022; 5 : 1318. Lees-Deutsch L, et al. : National Evaluation of the Professional Nurse Advocate Programme in England: SUSTAIN – Supervision, Support, Advocacy for Improvement in Nursing.2023. Reference Source Lucas B: Using reflection in nursing practice to enhance patient care. Nurs. Stand. 2023; 38 (6): 44–49. Publisher Full Text Macdonald B: Restorative clinical supervision: a reflection. Br. J. Midwifery. 2019; 27 (4): 258–264. Publisher Full Text Martin T, Stephens L, Dennis T: Introduction and background to the role of professional midwifery advocate. MIDIRS Midwifery Digest. 2018; 28 (2): 161–163. Masamha R, Alfred L, Harris R, et al. : ‘Barriers to overcoming the barriers’: A scoping review exploring 30 years of clinical supervision literature. J. Adv. Nurs. 2022 Sep; 78 (9): 2678–2692. Epub 2022 May 16. PubMed Abstract | Publisher Full Text | Free Full Text May R: I am pleased to announce the roll-out of the professional nurse advocate programme. Nurs. Times. 2021; 117 (4): 12. Miles B: A review of the potential impact of professional nurse advocates in reducing stress and burnout in district nursing. Br. J. Community Nurs. 2023 2; 28 (3): 132–136. PubMed Abstract | Publisher Full Text Muscat H, Morgan L, Hammond K: Staff burnout: how a nurse advocate course can help. Learn. Disabil. Pract. 2021; 24 (4): 13–14. Publisher Full Text NHS England: NHS Long Term Plan. NHS England; 2019; 136. Reference Source NHS England: We are the NHS: People Plan 2020/21 - action for us all. 2020. Reference Source NHS England: A-EQUIP: A Model of Clinical Midwifery Supervision.2017; 102. Reference Source NHS England: Professional nurse advocate A-EQUIP model: a model of clinical supervision for nurses. Version 2.2023a. NHS England » Professional nurse advocate A-EQUIP model: a model of clinical supervision for nurses NHS England: NHS Long Term Workforce Plan.2023b. Reference Source NHS England & NHS Innovation: PAR799: Professional Nurse Advocate A-EQUIP model: A model of clinical supervision for nurses.2021; 2021 . Reference Source NHS Staff Survey Coordination Centre: NHS staff survey results - key findings by occupational groups.2020. Reference Source Nowell LS, Norris JM, White DE, et al. : Thematic analysis: Striving to meet the trustworthiness criteria. Int. J. Qual. Methods. 2017; 16 (1): 1609406917733847. Publisher Full Text Nursing and Midwifery Council: Future nurse: Standards of proficiency for registered nurses. NMC; 2018. Reference Source Ockenden D: Findings, conclusions and essential actions from the independent review of maternity services and the Shrewsbury and Telford Hospital NHS Trust.2022. Reference Source Palmer W, Rolewicz L: The long goodbye? Exploring rates of staff leaving the NHS and social care.2022. Reference Source Pearce L: Professional nurse advocates: what they do and why they’re needed. Nursing Standard Online.2022. Parliamentary and Health Service Ombudsman [PHSO]: Midwifery supervision and regulation: recommendations for change. London: The Stationery Office; 2013. 9780102987324. Polit DF, Beck CT: Essentials of nursing research: Appraising evidence for nursing practice. Philadelphia: Wolters Kluwer; 8th ed. 2014. Proctor B: Supervision: A Co-operative Exercise in Accountability. Marken M, Payne M, editors. Enabling and Ensuring. Leicester: National Youth Bureau and the Council for Education and Training in Youth and Community Work; 1986. Proctor B: Supervision: A co-operative exercise in accountability. Marken M, Payne M, editors. Enabling and ensuring. Supervision in practice. Leicester: National Youth Bureau and Council for Education and Training in Community Work; 1987. Purdy S, Read J: Employer-led models of midwifery supervision.Marshall J, editor. Myles Professional Studies for Midwifery Education and Practice: Concepts and Challenges. London: Elsevier; 2019; pp 159–174. Qureshi SP: Cultural Historical Activity Theory for Studying Practice-Based Learning and Change in Medical Education. Adv. Med. Educ. Pract. 2021; 12 (12): 923–935. PubMed Abstract | Publisher Full Text | Free Full Text Royal College of Nursing [RCN]: Three Steps to Positive Practice. London: RCN; 2023. Reference Source Rothwell C, Kehoe A, Farook SF, et al. : Enablers and barriers to effective clinical supervision in the workplace: a rapid evidence review. BMJ Open. 2021; 11 (9): e052929. PubMed Abstract | Publisher Full Text | Free Full Text Rouse S: The role of the PMA and barriers to the successful implementation of restorative clinical supervision. Br. J. Midwifery. 2019; 27 (6): 381–386. Publisher Full Text Sandelowski M: Focus on research methods: Combining qualitative and quantitative sampling, data collection, and analysis techniques in mixed-method studies. Res. Nurs. Health. 2000; 23 (3): 246–255. Publisher Full Text Sandelowski M: What’s in a name? Qualitative description revisited. Res. Nurs. Health. 2010; 33 : 77–84. PubMed Abstract | Publisher Full Text Sawbridge Y, Hewison A: Thinking about the emotional labour of nursing – supporting nurses to care. J. Health Organ. Manag. 2013; 27 (1): 127–133. Publisher Full Text Scott SM, Scott PA: Nursing, advocacy and public policy. Nurs. Ethics. 2021; 28 (5): 723–733. Publisher Full Text Smith L, Mee S: Patient advocacy: breaking down barriers and challenging decisions. Nurs. Times. 2017; 113 (1): 54–56. Smythe A, Flatt C, Mahachi L, et al. : Introduction of the professional nurse advocate role using a quality implementation framework. Br. J. Nurs. 2023; 32 (8): 378–383. PubMed Abstract | Publisher Full Text Sterry M: How can Professional Midwifery Advocates use Restorative Clinical Supervision to Positively Influence Staff Cultures in Midwifery? MIDIRS Midwifery Digest. 2018; 28 (2): 157–160. Stone M: Second victim support: Nurses’ perspectives of organizational support after an adverse event. J. Nurs. Adm. 2020; 50 (10): 521–525. Publisher Full Text The King’s Fund: Improving NHS Culture.2023. (Accessed: 3 April 2025). Reference Source Thomas C: Coaching and mentoring skills: a complement to the professional midwifery advocate role. Br. J. Midwifery. 2022; 30 (5): 290–296. Publisher Full Text Traynor M: Nursing, Covid and the end of Resilience: A Critical Approach. Abingdon: Routledge; 2025. United Kingdom Central Council for Nursing, Midwifery and Health Visiting [UKCC]: UKCC position statement on the covert administration of medicines, disguising medicine in food and drink. London: UKCC; 2001. Unjai S, Forster EM, Mitchell AE, et al. : Interventions to promote resilience and passion for work in health settings: A mixed-methods systematic review. Int. J. Nurs. Stud. Adv. 2024; 7 : 100242. PubMed Abstract | Publisher Full Text | Free Full Text Wade R: Embedding the A-EQUIP model of restorative supervision in a critical care unit by professional nurse advocates. BMJ. 2023; 32 (15): 744–747. Publisher Full Text Wain A, Britt S, Divall B: Development of the bridging programme for the development of the professional midwifery advocate to support quality improvement.2018; 28 : 285. Walker W, Smythe A, Lees-Deutch L, et al. : The personal and professional impacts of becoming and being a professional nurse advocate. Br. J. Nurs. 2025; 34 (6): 336–344. PubMed Abstract | Publisher Full Text Wallbank S: Restorative Supervision.2007. Reference Source Wells A: Professional nurse and midwifery advocates. Care to Share. 2022 Winter 2022; 14: 15. Whatley V, Stephens L, Sterry M: Professional Advocates: Investing in practitioners to achieve excellence in service delivery. BMJ Blog: Evidence-based nursing. 2021. 6 June 2021. Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 07 Jul 2025 ADD YOUR COMMENT Comment Author details Author details 1 Faculty of Health, Medicine and Social Care, Anglia Ruskin University, Cambridge, England, UK 2 Veterand and Families Institute for Military Social Research, Anglia Ruskin University, Chelmsford, England, UK 3 East Suffolk and North Essex NHS Foundation Trust, Colchester, England, UK Sally Goldspink Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Nieky van Veggel Roles: Data Curation, Formal Analysis, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Hilary Engward Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Naim Abdulmohdi Roles: Formal Analysis, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Andrea Tuckwell Roles: Formal Analysis, Investigation, Methodology Marie Alexander Roles: Funding Acquisition, Project Administration, Supervision Competing interests AT and MA are employed by the East Suffolk and North Essex NHS Foundation Trust who funded the work. Grant information The Professional Advocacy Project is funded by East Suffolk and North Essex NHS Foundation Trust, Trust Offices, Colchester Hospital, Turner Road, Colchester, Essex, CO4 5JL under project number 418278. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (1) version 1 Published: 07 Jul 2025, 14:674 https://doi.org/10.12688/f1000research.166551.1 Copyright © 2025 Goldspink S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Goldspink S, van Veggel N, Engward H et al. Beneficent Disruptors: A qualitative descriptive study of professional advocacy in healthcare [version 1; peer review: 1 approved] . F1000Research 2025, 14 :674 ( https://doi.org/10.12688/f1000research.166551.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 07 Jul 2025 Views 0 Cite How to cite this report: Francis E. Reviewer Report For: Beneficent Disruptors: A qualitative descriptive study of professional advocacy in healthcare [version 1; peer review: 1 approved] . F1000Research 2025, 14 :674 ( https://doi.org/10.5256/f1000research.183553.r398982 ) The direct URL for this report is: https://f1000research.com/articles/14-674/v1#referee-response-398982 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 08 Sep 2025 Elaine Francis , Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, England, UK Approved VIEWS 0 https://doi.org/10.5256/f1000research.183553.r398982 Peer Review Report Overview and Summary The article contributes valuable first-hand narratives from 14 staff members working in Professional Nurse Advocate (PNA) and Professional Midwife Advocate (PMA) roles within a single NHS Trust. It explores the implementation of ... Continue reading READ ALL Peer Review Report Overview and Summary The article contributes valuable first-hand narratives from 14 staff members working in Professional Nurse Advocate (PNA) and Professional Midwife Advocate (PMA) roles within a single NHS Trust. It explores the implementation of Professional Advocacy (PA) roles and their impact on day-to-day practice, professional wellbeing, staff retention, and quality improvement. The authors argue convincingly that PAs act as “beneficent disruptors,” challenging traditional hierarchical structures by empowering individuals, promoting reflective practice, and fostering resilience. The study employs a qualitative, interpretive naturalistic design with semi-structured interviews, offering rich, descriptive data supported by direct participant quotes. The inclusion of Figure 2, a conceptual infographic, effectively illustrates the multidimensional nature of the PA role. The authors appropriately acknowledge the limited generalisability due to the small, single-Trust sample. Overall Impression This is a well-conducted and timely study that fills a gap in the PA literature by focusing on practice-based inquiry and implementation. Its main strength lies in the robust qualitative methodology, the clarity of participant voices, and the novel conceptual framing of the PA as a beneficent disruptor. However, some areas would benefit from deeper discussion and clarification to enhance the article’s rigor and applicability. Detailed Comments 1. Introduction Strength: The article clearly situates the PA role within existing literature, highlighting gaps around implementation and impact on wellbeing and retention. Suggestion: The rationale for combining PMA and PNA roles could be elaborated more thoroughly, given possible differences in professional culture, purpose, and implementation between nursing and midwifery advocacy roles. This would help clarify the scope and applicability of findings. 2. Methods Strength: The use of semi-structured interviews and interpretive naturalistic design aligns well with the study aims. Researcher reflexivity and neutrality are well-addressed, enhancing trustworthiness. Suggestion (Minor): A brief acknowledgment of the subjective nature of recall bias in interview data would strengthen the methodological transparency, especially regarding how those receiving PA support may perceive its effects. 3. Results and Analysis Strength: Presentation of participant quotes is balanced and helps ground findings in lived experience. The conceptual diagram (Figure 2) is a highlight and adds visual clarity to complex ideas. Suggestion (Minor): The article touches on PAs’ potential to challenge blame culture, but would benefit from expanded discussion on collaborative problem-solving aspects of the role, such as restorative group supervision or team-based approaches – or the absence of these. Integrating relevant literature here could deepen understanding of interpersonal and group dynamics in PA practice. 4. Discussion and Conclusion Strength: The discussion accurately reflects the findings and appropriately cautions against over-reliance on PAs as a sole solution for wellbeing, emphasising organisational responsibility. Suggestion: Consider expanding on organisational implications and future research directions, especially regarding development and training of PAs and how organisations can better support these roles structurally. Conclusion Overall, this article presents rigorous and insightful research that meaningfully advances understanding of Professional Advocacy roles within NHS settings. Its strengths in methodology and conceptual framing are clear, though addressing the points raised would strengthen its contribution further. The article is suitable for publication. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Not applicable Are all the source data underlying the results available to ensure full reproducibility? No source data required Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Restorative Clinical Supervision in care for the elderly health care settings; impact of 'frailty' on discharge decision making; use of acceptance and commitment therapy in group carer support I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Francis E. Reviewer Report For: Beneficent Disruptors: A qualitative descriptive study of professional advocacy in healthcare [version 1; peer review: 1 approved] . F1000Research 2025, 14 :674 ( https://doi.org/10.5256/f1000research.183553.r398982 ) The direct URL for this report is: https://f1000research.com/articles/14-674/v1#referee-response-398982 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 07 Jul 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 07 Jul 25 read Elaine Francis , Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Francis E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 08 Sep 2025 | for Version 1 Elaine Francis , Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, England, UK 0 Views copyright © 2025 Francis E. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Peer Review Report Overview and Summary The article contributes valuable first-hand narratives from 14 staff members working in Professional Nurse Advocate (PNA) and Professional Midwife Advocate (PMA) roles within a single NHS Trust. It explores the implementation of Professional Advocacy (PA) roles and their impact on day-to-day practice, professional wellbeing, staff retention, and quality improvement. The authors argue convincingly that PAs act as “beneficent disruptors,” challenging traditional hierarchical structures by empowering individuals, promoting reflective practice, and fostering resilience. The study employs a qualitative, interpretive naturalistic design with semi-structured interviews, offering rich, descriptive data supported by direct participant quotes. The inclusion of Figure 2, a conceptual infographic, effectively illustrates the multidimensional nature of the PA role. The authors appropriately acknowledge the limited generalisability due to the small, single-Trust sample. Overall Impression This is a well-conducted and timely study that fills a gap in the PA literature by focusing on practice-based inquiry and implementation. Its main strength lies in the robust qualitative methodology, the clarity of participant voices, and the novel conceptual framing of the PA as a beneficent disruptor. However, some areas would benefit from deeper discussion and clarification to enhance the article’s rigor and applicability. Detailed Comments 1. Introduction Strength: The article clearly situates the PA role within existing literature, highlighting gaps around implementation and impact on wellbeing and retention. Suggestion: The rationale for combining PMA and PNA roles could be elaborated more thoroughly, given possible differences in professional culture, purpose, and implementation between nursing and midwifery advocacy roles. This would help clarify the scope and applicability of findings. 2. Methods Strength: The use of semi-structured interviews and interpretive naturalistic design aligns well with the study aims. Researcher reflexivity and neutrality are well-addressed, enhancing trustworthiness. Suggestion (Minor): A brief acknowledgment of the subjective nature of recall bias in interview data would strengthen the methodological transparency, especially regarding how those receiving PA support may perceive its effects. 3. Results and Analysis Strength: Presentation of participant quotes is balanced and helps ground findings in lived experience. The conceptual diagram (Figure 2) is a highlight and adds visual clarity to complex ideas. Suggestion (Minor): The article touches on PAs’ potential to challenge blame culture, but would benefit from expanded discussion on collaborative problem-solving aspects of the role, such as restorative group supervision or team-based approaches – or the absence of these. Integrating relevant literature here could deepen understanding of interpersonal and group dynamics in PA practice. 4. Discussion and Conclusion Strength: The discussion accurately reflects the findings and appropriately cautions against over-reliance on PAs as a sole solution for wellbeing, emphasising organisational responsibility. Suggestion: Consider expanding on organisational implications and future research directions, especially regarding development and training of PAs and how organisations can better support these roles structurally. Conclusion Overall, this article presents rigorous and insightful research that meaningfully advances understanding of Professional Advocacy roles within NHS settings. Its strengths in methodology and conceptual framing are clear, though addressing the points raised would strengthen its contribution further. The article is suitable for publication. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Not applicable Are all the source data underlying the results available to ensure full reproducibility? No source data required Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Restorative Clinical Supervision in care for the elderly health care settings; impact of 'frailty' on discharge decision making; use of acceptance and commitment therapy in group carer support I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Francis E. Peer Review Report For: Beneficent Disruptors: A qualitative descriptive study of professional advocacy in healthcare [version 1; peer review: 1 approved] . F1000Research 2025, 14 :674 ( https://doi.org/10.5256/f1000research.183553.r398982) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-674/v1#referee-response-398982 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). You work at the same institute as any of the authors. You hope/expect to benefit (e.g. favour or employment) as a result of your submission. You are an Editor for the journal in which the article is published. Examples of 'Financial Competing Interests' You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements. You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors. You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on. Stay Updated Sign up for content alerts and receive a weekly or monthly email with all newly published articles Register with F1000Research Already registered? Sign in Not now, thanks close PLEASE NOTE If you are an AUTHOR of this article, please check that you signed in with the account associated with this article otherwise we cannot automatically identify your role as an author and your comment will be labelled as a “User Comment”. If you are a REVIEWER of this article, please check that you have signed in with the account associated with this article and then go to your account to submit your report, please do not post your review here. If you do not have access to your original account, please contact us . All commenters must hold a formal affiliation as per our Policies . The information that you give us will be displayed next to your comment. User comments must be in English, comprehensible and relevant to the article under discussion. We reserve the right to remove any comments that we consider to be inappropriate, offensive or otherwise in breach of the User Comment Terms and Conditions . Commenters must not use a comment for personal attacks. When criticisms of the article are based on unpublished data, the data should be made available. I accept the User Comment Terms and Conditions Please confirm that you accept the User Comment Terms and Conditions. Affiliation ✕ refresh Please enter your institution. Note: To add your institution or organisation, start typing the name and then select the correct name from the list. Where applicable, the name will appear in both the original language and in English. Do not paste in the name. If the name does not appear in the drop-down list, we will display the information you have entered. ✕ refresh Country/Region * USA UK Canada China France Germany Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Federated States of Micronesia Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo (Serbia and Montenegro) Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Minor Outlying Islands of the United States Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Is South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Gambia The Netherlands Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu UK USA Uganda Ukraine United Arab Emirates United States Virgin Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Wallis and Futuna West Bank and Gaza Strip Western Sahara Yemen Zambia Zimbabwe Please select your country/region. You must enter a comment. Competing Interests Please disclose any competing interests that might be construed to influence your judgment of the article's or peer review report's validity or importance. Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). You work at the same institute as any of the authors. You hope/expect to benefit (e.g. favour or employment) as a result of your submission. You are an Editor for the journal in which the article is published. Examples of 'Financial Competing Interests' You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements. You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors. You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on. Please state your competing interests The comment has been saved. An error has occurred. Please try again. Cancel Post var lTitle = "Beneficent Disruptors: A qualitative descriptive...".replace("'", ''); var linkedInUrl = "http://www.linkedin.com/shareArticle?url=https://f1000research.com/articles/14-674/v1" + "&title=" + encodeURIComponent(lTitle) + "&summary=" + encodeURIComponent('Read the article by '); var deliciousUrl = "https://del.icio.us/post?url=https://f1000research.com/articles/14-674/v1&title=" + encodeURIComponent(lTitle); var redditUrl = "http://reddit.com/submit?url=https://f1000research.com/articles/14-674/v1" + "&title=" + encodeURIComponent(lTitle); linkedInUrl += encodeURIComponent('Goldspink S et al.'); var offsetTop = /chrome/i.test( navigator.userAgent ) ? 4 : -10; var addthis_config = { ui_offset_top: offsetTop, services_compact : "facebook,twitter,www.linkedin.com,www.mendeley.com,reddit.com", services_expanded : "facebook,twitter,www.linkedin.com,www.mendeley.com,reddit.com", services_custom : [ { name: "LinkedIn", url: linkedInUrl, icon:"/img/icon/at_linkedin.svg" }, { name: "Mendeley", url: "http://www.mendeley.com/import/?url=https://f1000research.com/articles/14-674/v1/mendeley", icon:"/img/icon/at_mendeley.svg" }, { name: "Reddit", url: redditUrl, icon:"/img/icon/at_reddit.svg" }, ] }; var addthis_share = { url: "https://f1000research.com/articles/14-674", templates : { twitter : "Beneficent Disruptors: A qualitative descriptive study of professional.... Goldspink S et al., published by " + "@F1000Research" + ", https://f1000research.com/articles/14-674/v1" } }; if (typeof(addthis) != "undefined"){ addthis.addEventListener('addthis.ready', checkCount); addthis.addEventListener('addthis.menu.share', checkCount); } $(".f1r-shares-twitter").attr("href", "https://twitter.com/intent/tweet?text=" + addthis_share.templates.twitter); $(".f1r-shares-facebook").attr("href", "https://www.facebook.com/sharer/sharer.php?u=" + addthis_share.url); $(".f1r-shares-linkedin").attr("href", addthis_config.services_custom[0].url); $(".f1r-shares-reddit").attr("href", addthis_config.services_custom[2].url); $(".f1r-shares-mendelay").attr("href", addthis_config.services_custom[1].url); function checkCount(){ setTimeout(function(){ $(".addthis_button_expanded").each(function(){ var count = $(this).text(); if (count !== "" && count != "0") $(this).removeClass("is-hidden"); else $(this).addClass("is-hidden"); }); }, 1000); } close How to cite this report {{reportCitation}} Cancel Copy Citation Details $(function(){R.ui.buttonDropdowns('.dropdown-for-downloads');}); $(function(){R.ui.toolbarDropdowns('.toolbar-dropdown-for-downloads');}); $.get("/articles/acj/166551/183553") new F1000.Clipboard(); new F1000.ThesaurusTermsDisplay("articles", "article", "183553"); $(document).ready(function() { $( "#frame1" ).on('load', function() { var mydiv = $(this).contents().find("div"); var h = mydiv.height(); console.log(h) }); var tooltipLivingFigure = jQuery(".interactive-living-figure-label .icon-more-info"), titleLivingFigure = tooltipLivingFigure.attr("title"); tooltipLivingFigure.simpletip({ fixed: true, position: ["-115", "30"], baseClass: 'small-tooltip', content:titleLivingFigure + " " }); tooltipLivingFigure.removeAttr("title"); $("body").on("click", ".cite-living-figure", function(e) { e.preventDefault(); var ref = $(this).attr("data-ref"); $(this).closest(".living-figure-list-container").find("#" + ref).fadeIn(200); }); $("body").on("click", ".close-cite-living-figure", function(e) { e.preventDefault(); $(this).closest(".popup-window-wrapper").fadeOut(200); }); $(document).on("mouseup", function(e) { var metricsContainer = $(".article-metrics-popover-wrapper"); if (!metricsContainer.is(e.target) && metricsContainer.has(e.target).length === 0) { $(".article-metrics-close-button").click(); } }); var articleId = $('#articleId').val(); if($("#main-article-count-box").attachArticleMetrics) { $("#main-article-count-box").attachArticleMetrics(articleId, { articleMetricsView: true }); } }); var figshareWidget = $(".new_figshare_widget"); if (figshareWidget.length > 0) { window.figshare.load("f1000", function(Widget) { // Select a tag/tags defined in your page. In this tag we will place the widget. _.map(figshareWidget, function(el){ var widget = new Widget({ articleId: $(el).attr("figshare_articleId") //height:300 // this is the height of the viewer part. [Default: 550] }); widget.initialize(); // initialize the widget widget.mount(el); // mount it in a tag that's on your page // this will save the widget on the global scope for later use from // your JS scripts. This line is optional. //window.widget = widget; }); }); } close Error Close Add Reset F1000.MICROSERVICES.AFFILIATION = ''; $(document).ready(function () { $('.js-affiliations-form').each((index, form) => { new AffiliationForm({ formId: form.id, institutionErrorSelector: '.comment-enter-institution', departmentErrorSelector: '.comment-enter-department', placeSelector: '.js-add-comment-place', stateSelector: '.js-add-comment-state', zipCodeSelector: '.js-add-comment-zipcode', countrySelector: '.js-add-comment-country', countryErrorSelector: '.comment-enter-country', }); }); }); $(document).ready(function () { var reportIds = { "398982": 14, "398983": 0, "398980": 0, "398981": 0, "398979": 0, "398988": 0, "398986": 0, "398987": 0, "398984": 0, "398985": 0, "412574": 0, "412575": 0, "412582": 0, "409894": 0, "412583": 0, "409895": 0, "412580": 0, "409892": 0, "412581": 0, "409893": 0, "412578": 0, "412579": 0, "409891": 0, "412576": 0, "412577": 0, "409900": 0, "409898": 0, "409899": 0, "409896": 0, "409897": 0, "403926": 0, "403927": 0, "403924": 0, "403925": 0, "407263": 0, "403932": 0, "403933": 0, "403930": 0, "403931": 0, "403928": 0, "403929": 0, "407270": 0, "407271": 0, "407268": 0, "407269": 0, "407266": 0, "407267": 0, "407264": 0, "407265": 0, "407272": 0, }; $(".referee-response-container,.js-referee-report").each(function(index, el) { var reportId = $(el).attr("data-reportid"), reportCount = reportIds[reportId] || 0; $(el).find(".comments-count-container,.js-referee-report-views").html(reportCount); }); var uuidInput = $("#article_uuid"), oldUUId = uuidInput.val(), newUUId = "1e6becdc-a720-4037-88ec-ff65109f75b6"; uuidInput.val(newUUId); $("a[href*='article_uuid=']").each(function(index, el) { var newHref = $(el).attr("href").replace(oldUUId, newUUId); $(el).attr("href", newHref); }); }); An innovative open access publishing platform offering rapid publication and open peer review, whilst supporting data deposition and sharing. Browse Gateways Collections How it Works Contact For Developers Cookie Notice Privacy Notice RSS Submit Your Research Follow us © 2012-2026 F1000 Research Ltd. ISSN 2046-1402 | Legal | Partner of Research4Life • CrossRef • ORCID • FAIRSharing R.templateTests.simpleTemplate = R.template(' $text $text $text $text $text '); R.templateTests.runTests(); var F1000platform = new F1000.Platform({ name: "f1000research", displayName: "F1000Research", hostName: "f1000research.com", id: "1", editorialEmail: "[email protected]", infoEmail: "[email protected]", usePmcStats: true }); $(function(){R.ui.dropdowns('.dropdown-for-authors, .dropdown-for-about, .dropdown-for-myresearch');}); // $(function(){R.ui.dropdowns('.dropdown-for-referees');}); $(document).ready(function () { if ($(".cookie-warning").is(":visible")) { $(".sticky").css("margin-bottom", "35px"); $(".devices").addClass("devices-and-cookie-warning"); } $(".cookie-warning .close-button").click(function (e) { $(".devices").removeClass("devices-and-cookie-warning"); $(".sticky").css("margin-bottom", "0"); }); $("#tweeter-feed .tweet-message").each(function (i, message) { var self = $(message); self.html(linkify(self.html())); }); $(".partner").on("mouseenter mouseleave", function() { $(this).find(".gray-scale, .colour").toggleClass("is-hidden"); }); }); Sign In Remember me Forgotten your password? Sign In Cancel Email or password not correct. Please try again Please wait... $(function(){ // Note: All the setup needs to run against a name attribute and *not* the id due the clonish // nature of facebox... $("a[id=googleSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("GOOGLE"); $("form[id=oAuthForm]").submit(); }); $("a[id=facebookSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("FACEBOOK"); $("form[id=oAuthForm]").submit(); }); $("a[id=orcidSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("ORCID"); $("form[id=oAuthForm]").submit(); }); }); If you've forgotten your password, please enter your email address below and we'll send you instructions on how to reset your password. The email address should be the one you originally registered with F1000. Email address not valid, please try again You registered with F1000 via Google, so we cannot reset your password. To sign in, please click here . If you still need help with your Google account password, please click here . You registered with F1000 via Facebook, so we cannot reset your password. To sign in, please click here . If you still need help with your Facebook account password, please click here . Code not correct, please try again Reset password Cancel Email us for further assistance. Server error, please try again. If your email address is registered with us, we will email you instructions to reset your password. If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance. Please wait... Register $(document).ready(function () { signIn.createSignInAsRow($("#sign-in-form-gfb-popup")); $(".target-field").each(function () { var uris = $(this).val().split("/"); if (uris.pop() === "login") { $(this).val(uris.toString().replace(",","/")); } }); });