Professional Advocacy in Focus: A Qualitative Descriptive Study of Nurses and Midwives Perceptions in one UK NHS Trust

Professional Advocacy in Focus: A Qualitative Descriptive Study of Nurses and Midwives Perceptions in one UK NHS Trust | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (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;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Professional Advocacy in Focus: A Qualitative Descriptive Study of Nurses and Midwives Perceptions in one UK NHS Trust Nieky van Veggel, Sally Goldspink, Hilary Engward, Naim Abdulmohdi, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7374915/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This study was conducted within the National Health Service (NHS), the publicly funded healthcare system in the United Kingdom (UK), which provides hospital and community care to a diverse population. The NHS is currently facing significant workforce challenges, including high vacancy rates, staff burnout, and low morale. In response, the Professional Advocacy (PA) role was introduced to support midwives and nurses through structured peer support and restorative clinical supervision and has since been extended to include allied health professionals. While early evidence suggests PA can improve staff wellbeing and retention, there is limited understanding of how the role is perceived and experienced by practitioners. This study aimed to explore nurses’ and midwives’ perceptions of PA, focusing on its implementation, accessibility, and impact within one NHS Trust. Methods A qualitative descriptive design was used, involving online focus groups with nurses and midwives who had varying levels of engagement with PA services. Thirteen focus groups were conducted with fifty-three participants, including those who had accessed PA, those who had not, and those training or registered as professional advocates. Data were transcribed verbatim and analysed thematically using an inductive approach supported by NVivo software. Results Four key themes surfaced during analysis: awareness and understanding of PA, barriers to engagement, perceived benefits, and recommendations for strengthening the service. Participants who had accessed PA described it as a valuable source of emotional and professional support, contributing to improved wellbeing and retention. Barriers included limited awareness, stigma around help-seeking, inconsistent availability, and unclear organisational integration. Participants recommended improving visibility and accessibility, and strengthening the perceived legitimacy of PA by ensuring it is recognised as a credible, well-supported part of the organisation, rather than a peripheral or optional service. Conclusions PA is a promising but underutilised resource within the NHS. While it offers clear benefits for staff wellbeing and retention, its impact is constrained by systemic and cultural barriers. Addressing these challenges through targeted organisational strategies could enhance the integration and effectiveness of PA services. This study contributes to the growing evidence base and offers insights into embedding PA into routine practice to support a more resilient workforce. Professional Advocate Qualitative Descriptive Focus Groups Workforce Nurse Midwife Figures Figure 1 Background Healthcare professionals in the UK face increasing occupational pressures, with rising rates of work-related stress, burnout, and sickness absence ( 1 ). The NHS, the largest employer in England, is currently managing significant workforce shortages, with over 112,000 vacancies reported, undermining the system’s ability to meet escalating service demands ( 2 ). Findings from the 2023 NHS Staff Survey reveal deep-seated dissatisfaction among staff, with only a third reported satisfaction with pay and staffing levels, nearly 30% considered leaving, and almost 20% experienced bullying or harassment ( 3 ). These pressures, exacerbated by the COVID-19 pandemic, have highlighted chronic systemic failings, including insufficient staff, poor infrastructure, and inadequate support environments ( 4 ) There is compelling evidence that poor staff wellbeing negatively impacts patient safety and care quality ( 5 – 7 ). In response, calls have intensified for urgent system-level interventions to support, develop, and retain healthcare professionals ( 8 ). One such intervention is the introduction of the Professional Advocacy (PA) role, an adaptation of the Professional Midwifery Advocate model initially implemented following the removal of statutory supervision in midwifery ( 9 – 11 ). The PA role emerged during the COVID-19 recovery period, designed to support midwives and nurses through structured reflection, peer support, and leadership in quality improvement. Its objectives align with NHS strategic aims to improve retention, foster a positive workplace culture, and embed continuous professional development into clinical practice ( 2 , 12 ). PAs are trained to facilitate reflective discussions, lead service improvements, and foster psychological safety in clinical environments ( 13 – 15 ). Early evaluations suggest that PA enhances resilience, supports staff wellbeing, and contributes to better patient outcomes. For example, Devereaux ( 16 ) highlights the benefits of restorative clinical supervision; Smythe et al. ( 17 ) examine implementation using a quality framework; and Flack and Abdulmohdi ( 18 ) focus on PA training. Context-specific studies explore PA’s role in mitigating stress and supporting care delivery in district nursing ( 19 ) and gerontology settings ( 20 ). Despite a growing body of evidence supporting PA, limited attention has been paid to how the role is understood and experienced by practitioners more broadly. In particular, little is known about how PA services are perceived by both users and non-users within single provider settings, and how these perceptions influence service implementation. This study addresses that gap by exploring the experiences and views of nurses and midwives within one large NHS Trust in England. It asks what an effective PA service looks like in practice and aims to identify both the perceived and tangible opportunities and barriers to its integration, while examining how its purpose and function are understood across clinical roles. Methods Study design We utilised a exploratory qualitative descriptive design ( 21 ) to align with the study's descriptive aim. The intention of this design is to comprehensively summarise participants' subjective understandings, opinions, and experiences ( 22 ). Embedded in naturalistic inquiry, qualitative descriptive studies often use focus groups to gather information because the interactive group setting offers a space where participants' attitudes, beliefs, and experiences may be revealed ( 23 ). The facilitated conversation fosters idea-sharing and deeper insights, and the flexible format allows the exploration of new topics as they arise. By bringing together nurses and midwives from diverse clinical backgrounds and experiences in PA, the purpose of the focus groups was to shed light on a range of perspectives and uncover common themes. Setting and recruitment This project took part in a large NHS Trust in the UK, a public sector organisation responsible for delivering healthcare services, including hospitals and community health services. Serving roughly one million residents across diverse settings that include urban, countryside, and seaside regions, this NHS Trust operates an extensive network of inpatient and community-based facilities. It offers comprehensive care covering all stages of life, from neonatal and paediatric care to geriatric services. The Trust workforce comprises of 11,600 individuals, including approximately 3,300 nurses and 320 midwives. Online focus groups using MS Teams were conducted between May and June 2024. We were cognisant of the opportunities and challenges of conducting online data collection ( 24 ) and paid careful attention to the format of the meetings to ensure the focus group conversations were ethically constructed and facilitated, with particular attention to the psychological comfort and confidentiality of both participants and facilitators ( 25 ). Online contact was chosen due to the participants’ wide geographical distribution and varied working patterns within the NHS Trust, making in-person meetings difficult to organise. Our decision was further supported by the ability to eliminate travel requirements and to schedule meetings at times and in formats that suited the participants’ availability ( 26 ). Data Collection and Analysis Thirteen focus groups were conducted, each lasting one hour and comprising 3–6 participants. A member of the research team ( 27 ) coordinated scheduling and administration. Participants selected from two pre-defined time slots based on their availability; once a group reached sufficient numbers, the session was confirmed. Each focus group was facilitated by two researchers ( 28 ). The lead facilitator directed the discussion, while the co-facilitator ensured participant access, managed technical issues, took observational notes, and monitored participant wellbeing. At the start of each session, participants were reminded of the information contained in the participant information sheet and the expectations for engagement, including equitable participation, respectful interaction, and management of disagreement. Given all participants were UK Nursing and Midwifery Council registrants, they were reminded of their obligation to adhere to the NMC Code ( 29 ), which also defined the ethical boundaries of the discussion. A flexible, non-directive approach guided facilitation and topic guides were tailored to specific subgroups. Following each session, facilitators debriefed to consolidate observations and contextual insights. All sessions were audio-recorded and transcribed verbatim by a member of the research team. Transcripts were analysed using qualitative descriptive analysis, treating each focus group as a discrete unit of analysis ( 30 ). The analytic process included familiarisation, open coding, theme development, and a final confirmatory phase, aligning with the principles of qualitative descriptive design ( 31 ). Trustworthiness To ensure the trustworthiness of this work, we focused on quality and rigour at each stage of the design process ( 32 ), through a receptive interchange between the project team to check and recheck our shared understanding. We established strategies for recording activities and organising data, using NVivo's memo function to document observations and decision-making. Interviewer field notes were logged with recordings and transcripts. To ensure transferability, intelligibility, and authenticity, we consistently revisited the transcripts to compile rich explanations from raw data. Despite debates on transferability ( 33 ), we sought to provide detailed information for readers to compare outcomes with their situations, including verbatim narratives to link raw data with our findings. Ethical considerations This study was approved by the Anglia Ruskin University Research Ethics Committee (REF: ETH2324-3616). We obtained gatekeeper permission before approaching participants, and participants were informed about the study aims and procedures. Participants then gave informed consent before a focus group was scheduled, which was then reconfirmed at the start of the focus groups and at the end of the focus groups. Results Our sample (see Table ) included 53 participants across 13 focus groups comprising of those who had accessed PA, those who had not accessed PA, those who are PAs and those training to be a PA. Table 2: Sample characteristics Group Participants Those who have used PA services 7 Those who have not used PA services 27 Registered PA 11 Trainee PA 7 Through the context-sensitive focus group conversations we identified four key themes (see Figure 1): (1) awareness and understanding of PA, (2) barriers to engagement, (3) perceived benefits of PA, and (4) participant recommendations for strengthening PA. Awareness and understanding of PA A recurring theme across focus groups was the limited awareness of PA roles and how to access them. Many participants, particularly those who had not accessed advocacy services, had little understanding of what the role entailed or how it could benefit them. Some described PA as an “ under the rada r (P17)” resource that from their point of view was not actively promoted within their teams. Those who had accessed PA, however, spoke positively about its impact. They highlighted their appreciation of how both informal contacts and formally structured, confidential sessions could provide emotional and professional support, particularly during times of stress. These PA interactions were seen as valuable for helping individuals navigate challenging situations and for offering a safe, professionally aware space to express concerns and seek guidance. However, the partial and incomplete understanding of others allowed misunderstandings to creep in, and inferences were made to previous unhelpful conceptualisations of practice-based supervision associated to situations where “ things had gone wrong . (P3)” While some understood the peer-to-peer aspect of PA, this was not consistently realised. Consequently, collegiateness of PA was viewed as a central asset, providing separation from tricky assumptions about previous supervisory models. Barriers to engagement Several factors were identified as barriers to engaging with PA services. Many participants felt that seeking advocacy support added to their already overwhelming workloads, with the perception that it required time away from clinical duties discouraging participation. Concerns about stigma and fears that accessing advocacy might be viewed as an admission of weakness were also prevalent. One participant shared, "I wanted to seek help, but I was worried about my colleagues finding out and judging me . (P8)" The observation of a ‘foggy start’ to PA resulted in concerns that advocacy roles were not effectively embedded into leadership structures, limiting their influence and causing angst about the paraments of PA practice, for example who they ‘reported to’, how PAs were ‘managed’ and what ‘they could do’. Inconsistent availability of trained advocates across departments further led to unequal access across the organisation and a sense of “ some people seem to know more than others .” (P20) Additionally, traditional hierarchical structures were perceived to sometimes discouraged staff from seeking advocacy support, although the reasons for this were unclear. Therefore, in these early stages of PA adoption, recognising and addressing the influence of the combined real and perceived barriers is crucial for increasing engagement and utilisation of PA services. Perceived benefits of Professional Advocacy For those who engaged with PA, several key benefits were identified. The ability to discuss professional challenges in a confidential and supportive environment was highly valued, with participants describing advocacy sessions as opportunities for " offloadin g" without fear of being negatively viewed. One participant noted, " Having an advocate to talk to made a huge difference in how I handled work-related stress .”(P6) The support provided by PAs was seen as instrumental in fostering a positive work environment and promoting staff well-being, and mainly due to the ‘understanding’ PAs had of the clinical environment. The apparent professional empathy associated with this theme underscores the value of PA in enhancing both individual and organisational outcomes. Some participants believed that access to advocacy influenced their decision to stay within the NHS rather than seeking opportunities elsewhere, thereby contributing to workforce retention and resilience. Additionally, by recognising the ‘ground up’ impact of staff stress and burnout, PA was seen as directly benefiting patient outcomes by promoting a more engaged, informed and supported workforce. Participant recommendations for strengthening PA The participants provided a plethora of practical ideas to improve the accessibility and effectiveness of PA. There was a strong sense of wanting to make PA work in practice. They recommended more vigorous promotion and awareness campaigns to increase the visibility of advocacy roles and offered suggestions to include at induction events and a wide range of staff communications to invigorate engagement. The overarching message emphasised the need for frequent and repeated communication for incorporating advocacy services more seamlessly into the workplace. One suggestion was, " Regular workshops and information sessions could help demystify what professional advocacy is and how it can benefit us. "(P31) Furthermore, the participants accentuated the importance of organisational support and resources to sustain and expand PA services. Implementing these recommendations was seen as mechanisms to enhance the effectiveness of PA across healthcare settings and work towards building on successes. To boost its legitimacy and impact, they encouraged more overt integration of PA into organisational structures and governance frameworks, rather than treating it as an add-on service. Flexible and accessible methods for PA were also suggested, such as including advocacy sessions into routine staff well-being initiatives to make them more reachable without requiring additional time commitments. Summary of Findings The focus groups members highlighted the importance to PA as a way of supporting healthcare professionals through the amalgamation of empathic, practice-driven and peer-positioned understanding. While there are barriers to engagement, the perceived benefits and participant recommendations provided clear and contextually orientated pathways for strengthening advocacy services. The overarching message was that with an informed understanding and clear, accessible and flexible access pathways, PA can play an important role in creating and sustain a more supportive and resilient workforce, ultimately improving patient care and health outcomes. Discussion Professional Advocates are a valuable yet underutilised asset The findings from this focus group analysis align with existing literature identifying PA as a valuable yet underutilised asset in the NHS. Despite its potential to enhance staff well-being and support workforce retention, PA remains inconsistently embedded across healthcare organisations. Prior studies have documented PA’s positive impact on psychological safety, stress management, and resilience (34,35), but our data suggest that implementation is undermined by both structural and cultural barriers, particularly workload pressures, professional hierarchies, and low role visibility. Activity Theory (36) offers a useful analytical framework for interrogating these dynamics. By examining how individual roles, organisational structures, and cultural norms intersect, this perspective enables a systemic understanding of PA engagement. Implementation challenges are not isolated or easily remedied; rather, they emerge from contradictions between subjects (healthcare staff), objects (PA engagement), and mediating artefacts (e.g. communication tools, policy, and governance mechanisms). These contradictions highlight the need for coordinated structural change to fully integrate PA into NHS workforce models. A key barrier identified was the widespread lack of awareness and conceptual clarity surrounding the PA role (37). Participants unfamiliar with the service frequently conflated PA with patient advocacy or were unaware of its existence altogether. This confusion was compounded by fluctuating levels of promotion of PA through external and internal communications, training, or leadership discourse, leading to a perception of PA as peripheral. For many, the lack of visibility translated into passive disengagement; time constraints and information fatigue further discouraged staff from seeking out support. This lack of engagement can be understood, in Activity Theory terms, as a failure of mediating artefacts. When essential tools such as effective messaging, integration into onboarding processes, and clearly defined referral pathways are absent or underdeveloped, the activity of accessing PA becomes fragmented and difficult to navigate. Participants emphasised the importance of immediacy and relevance in communication. As a result, interventions should prioritise the end-user experience and adopt professionally empathetic design tenets to ensure that PA is visible, meaningful, and embedded in everyday practice. These structural challenges intersect with cultural ones. The marginalisation of PA within everyday clinical practice reflects broader disciplinary assumptions and long-standing hierarchies. Structurally, participants described a lack of formal integration of PA into team workflows, limited visibility in leadership models, and the absence of clear referral mechanisms. As a result, PA was not widely perceived as embedded within organisational systems, rendering it conceptually and operationally peripheral. Despite this, even those who had not accessed PA acknowledged its potential value. Participants emphasised that the principles of PA felt rooted in their professional world, described as grounded, authentic, and oriented toward practice, rather than imposed as an external agenda (38). Once understood, PA was seen as a meaningful resource for guiding professional and service development, offering emotional support, and helping staff navigate workplace challenges. However, the barriers to engagement extend beyond visibility. Time pressures were consistently cited as a deterrent. The perception that seeking PA support would require time away from clinical duties discouraged participation, particularly among already overstretched staff (39). More insidiously, cultural stigma around help-seeking contributed to disengagement. Engaging with PA was sometimes seen as a sign of professional vulnerability, deterring staff from using the service for fear of reputational damage (40). The inconsistent availability of trained PAs across departments further compounded access inequities, resulting in uneven service provision within the same organisation. Among participants who had engaged with PA, the benefits were profound. PA was described as a safe, confidential space for emotional decompression and professional reflection. This aligns with existing evidence that PA supports psychological safety and enhances workforce resilience (34,35,41). Some participants reported that PA access directly influenced their decision to remain within the NHS, highlighting its role in staff retention (42). The correlation between staff well-being and patient care quality is well established (43), and our findings reinforce that PA not only mitigates stress and burnout but also contributes to improved service delivery through enhanced morale and professional commitment (41). In this context, PA must be understood not merely as a well-being intervention, but as a lever for cultural transformation. Normalising PA within healthcare teams can dismantle stigma and promote a culture of openness and resilience (44). This aligns with The King's Fund’s (45) emphasis on cultivating inclusive, supportive workplaces to improve staff retention and patient outcomes. Our analysis identified seven key components of effective PA integration (see Table 3), each contributing to a more resilient and psychologically safe clinical environment. Recommendations for practice Applying Activity Theory clarified how systemic contradictions underlie barriers to PA engagement. The gap between the need for PA and its limited accessibility can be understood as a tension between practitioners’ needs and the underdeveloped mediating tools available to support them. Perceived cultural norms and organisational hierarchies act as “rules” that discourage help-seeking and inhibit PA’s integration. To address these challenges, a systemic reconfiguration is required. Recommended strategies include: Increasing visibility: Embedding PA roles in team structures and regular communications. Incorporating PA in education: Including advocacy in induction, continuing professional development activities, and mandatory training. Embedding PA in governance: Integrating PA within leadership and quality assurance systems and policy. Accommodating PA in wider well-being strategies: Aligning PA with existing organisational support mechanisms, services and frameworks. These findings indicate that PA, when properly embedded, offers both personal and organisational benefits. It creates protected space for professional challenges to be constructively addressed and contributes to broader workforce stability. The potential gains in areas such as retention, morale, and patient care present a compelling case for expanding and formalising the role of PA across NHS services. [INSERT TABLE 3 HERE] Strengths and Limitations The study demonstrated several strengths that contribute to its robustness and value. The inclusion of participants from diverse backgrounds generated a rich variety of perspectives, deepening insight into the research questions and enhancing the interpretive depth of the findings. The use of online focus groups not only increased accessibility and convenience but also broadened the reach to participants who might otherwise have been unable to attend. Skilled moderation by experienced facilitators ensured that discussions remained both inclusive and focused, enabling the capture of high-quality data. Recruitment efforts, led by the in place coordinator (Goldspink et al., 2025), were highly effective in fostering strong engagement and sustaining participation. While certain limitations were noted, these do not diminish the overall quality of the work. The possibility of self-selection bias should be acknowledged, yet such engagement also enriched the discussions. The coordination of 13 focus groups reflects the commitment to comprehensive data collection and allowed for a more nuanced and multifaceted understanding of the topic. Conclusion In conclusion, PA offers wide-ranging benefits for NHS staff, including improved wellbeing, job satisfaction, and workforce stability. Focus group data show that a culture of openness, supported by PA peer-to-peer connections, enhances relationships with colleagues and management, reduces stress, and promotes professional growth. These benefits must be considered alongside the organisational costs of staff turnover and lost working days. Co-designing PA services with staff strengthens relevance and uptake, while supporting collaborative service development. PA aligns with national workforce strategies and, if implemented strategically, can contribute to a more resilient, empowerment-based healthcare system. Abbreviations NHS – National Health Service PA – Professional Advocate/Advocacy UK – United Kingdom Declarations Ethics approval and consent to participate We obtained approval from the Anglia Ruskin University Research Ethics Committee. Participants provided informed consent before focus group sessions were scheduled, and consent was reconfirmed at the start and end of the focus group sessions. All methods in this study were performed in accordance with the relevant ethical guidelines and regulations. Consent for publication Not applicable Availability of data and materials 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, including 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: 10.25411/aru.29910641 (46). Data access requests will be reviewed by the authors and key collaborators as named on the repository. Competing interests N.V., S.G., H.E. and N.A. declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. A.T. and M.A. are employed by East Suffolk and North Essex NHS Foundation Trust, who funded this work, but contributed in their individual professional roles, rather than on behalf of the funder. East Suffolk and North Essex NHS Foundation Trust had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript. Funding This work was funded by the East Suffolk and North Essex NHS Foundation Trust Authors' contributions S.G., H.E., and M.A. conceived the project. N.V., S.G. and H.E. developed the methods. S.G., H.E. and A.T. collected the data. 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National evaluation of the professional nurse advocate programme in england: SUSTAIN – supervision, support, advocacy for improvement in nursing [Internet]. Coventry: Coventry University; 2022. Available from: https://pureportal.coventry.ac.uk/en/publications/national-evaluation-of-the-professional-nurse-advocate-programme- Sharman VL, Gadher A, Shipperlee F. Benefits and challenges of implementing the professional nurse advocate programme: a service evaluation. Mental Health Practice. 2024; Engeström Y. Expansive learning at work: Toward an activity theoretical reconceptualization. Journal of Education and Work. 2001;14(1):133–56. Engward H, Goldspink S, van Veggel N, Abdulmohdi N, Tuckwell A, Alexander M. Advocating for Professional Advocates in Nursing and Midwifery. Policy, Politics, & Nursing Practice. 2025 Aug 1;26(3):208–18. Goldspink S, Veggel N van, Engward H, Abdulmohdi N, Tuckwell A, Alexander M. Beneficent Disruptors: A qualitative descriptive study of professional advocacy in healthcare. F1000Research. 2025 July 7;14:647. Morrell-Scott N, Robinson N. The professional nurse advocate model and use of A-EQUIP: a tool to support the nursing workforce. British Journal of Nursing. 2025 Feb 20;34(4):242–6. NHS England. Implementing the PNA role into practice: a community nurse perspective. 2023. Griffiths K, Reynolds J. ‘Nursing the nurses’: the experiences of professional nurse advocates’ application of the A-EQUIP model. British Journal of Nursing. 2025 July 17;34(14):724–31. Butler S. Understanding burnout in nurses: Identification and coping strategies. British Journal of Nursing. 2025;34(4). Daniel O, Mesharck G, Otor C. Effects of stress and burnout among NHS adult nurses in the UK: a systematic literature review. Journal of Medicine and Public Health. 2024;5(1):1098. Whatley V. Learning from the professional midwifery advocate role to revise clinical supervision in nursing. British Journal of Healthcare Management. 2022;28 7 159-207. The King’s Fund. Improving NHS culture [Internet]. London: The King’s Fund; 2023. Available from: https://www.kingsfund.org.uk/insight-and-analysis/projects/improving-nhs-culture van Veggel N, Goldspink, S., Engward H, et al. : Data set: Professional Advocacy in Focus: A Qualitative Descriptive Study of Nurses and Midwives Perceptions in one UK NHS Trust. Dataset. Anglia Ruskin Research Online (ARRO). 2025. 10.25411/aru.29910641 Tables Tables 1 is not available with this version. Table 3 is available in the Supplementary Files section. Additional Declarations Competing interest reported. N.V., S.G., H.E. and N.A. declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. A.T. and M.A. are employed by East Suffolk and North Essex NHS Foundation Trust, who funded this work, but contributed in their individual professional roles, rather than on behalf of the funder. East Suffolk and North Essex NHS Foundation Trust had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript. Supplementary Files Table3.xlsx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7374915","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":502724504,"identity":"2dc09c03-8fce-4a9b-99a1-b93c2d936849","order_by":0,"name":"Nieky van Veggel","email":"data:image/png;base64,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","orcid":"","institution":"Anglia Ruskin University","correspondingAuthor":true,"prefix":"","firstName":"Nieky","middleName":"van","lastName":"Veggel","suffix":""},{"id":502724505,"identity":"f2bbb95c-813c-4f53-bfdf-ca31a1a90643","order_by":1,"name":"Sally Goldspink","email":"","orcid":"","institution":"Anglia Ruskin University","correspondingAuthor":false,"prefix":"","firstName":"Sally","middleName":"","lastName":"Goldspink","suffix":""},{"id":502724506,"identity":"f25d8caf-785e-4210-91d0-121d40a8c306","order_by":2,"name":"Hilary Engward","email":"","orcid":"","institution":"Anglia Ruskin University","correspondingAuthor":false,"prefix":"","firstName":"Hilary","middleName":"","lastName":"Engward","suffix":""},{"id":502724507,"identity":"4fd89485-1680-439b-81f8-cdb3d478f46c","order_by":3,"name":"Naim Abdulmohdi","email":"","orcid":"","institution":"Anglia Ruskin University","correspondingAuthor":false,"prefix":"","firstName":"Naim","middleName":"","lastName":"Abdulmohdi","suffix":""},{"id":502724508,"identity":"568ea75d-642f-44d1-a88c-549248c769dd","order_by":4,"name":"Andrea Tuckwell","email":"","orcid":"","institution":"East Suffolk and North Essex NHS Foundation Trust, Colchester Hospital","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Tuckwell","suffix":""},{"id":502724509,"identity":"834d41c4-7c39-40dc-9a84-66c67cf7bd6b","order_by":5,"name":"Marie Alexander","email":"","orcid":"","institution":"East Suffolk and North Essex NHS Foundation Trust, Colchester Hospital","correspondingAuthor":false,"prefix":"","firstName":"Marie","middleName":"","lastName":"Alexander","suffix":""}],"badges":[],"createdAt":"2025-08-14 14:38:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7374915/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7374915/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89465365,"identity":"60d5357e-3f68-4cfe-a902-3e709db42450","added_by":"auto","created_at":"2025-08-20 08:26:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":462692,"visible":true,"origin":"","legend":"\u003cp\u003eSummary of or themes and subthemes identified in focus group data\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7374915/v1/1c4909c5ca4f984f03b518c6.png"},{"id":89465894,"identity":"0ce60646-2afe-47a9-8396-0d22b72ad973","added_by":"auto","created_at":"2025-08-20 08:34:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1097348,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7374915/v1/11b64996-232d-4a64-b6aa-4e295a2c6f04.pdf"},{"id":89463209,"identity":"e3c40452-9059-4489-89f9-fd8dc03dbac4","added_by":"auto","created_at":"2025-08-20 08:10:13","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":10839,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7374915/v1/81ac250bdb25ff901791070b.xlsx"}],"financialInterests":"Competing interest reported. N.V., S.G., H.E. and N.A. declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. A.T. and M.A. are employed by East Suffolk and North Essex NHS Foundation Trust, who funded this work, but contributed in their individual professional roles, rather than on behalf of the funder. East Suffolk and North Essex NHS Foundation Trust had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.","formattedTitle":"Professional Advocacy in Focus: A Qualitative Descriptive Study of Nurses and Midwives Perceptions in one UK NHS Trust","fulltext":[{"header":"Background","content":"\u003cp\u003eHealthcare professionals in the UK face increasing occupational pressures, with rising rates of work-related stress, burnout, and sickness absence (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The NHS, the largest employer in England, is currently managing significant workforce shortages, with over 112,000 vacancies reported, undermining the system’s ability to meet escalating service demands (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Findings from the 2023 NHS Staff Survey reveal deep-seated dissatisfaction among staff, with only a third reported satisfaction with pay and staffing levels, nearly 30% considered leaving, and almost 20% experienced bullying or harassment (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These pressures, exacerbated by the COVID-19 pandemic, have highlighted chronic systemic failings, including insufficient staff, poor infrastructure, and inadequate support environments (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThere is compelling evidence that poor staff wellbeing negatively impacts patient safety and care quality (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e–\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In response, calls have intensified for urgent system-level interventions to support, develop, and retain healthcare professionals (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). One such intervention is the introduction of the Professional Advocacy (PA) role, an adaptation of the Professional Midwifery Advocate model initially implemented following the removal of statutory supervision in midwifery (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The PA role emerged during the COVID-19 recovery period, designed to support midwives and nurses through structured reflection, peer support, and leadership in quality improvement. Its objectives align with NHS strategic aims to improve retention, foster a positive workplace culture, and embed continuous professional development into clinical practice (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePAs are trained to facilitate reflective discussions, lead service improvements, and foster psychological safety in clinical environments (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e–\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Early evaluations suggest that PA enhances resilience, supports staff wellbeing, and contributes to better patient outcomes. For example, Devereaux (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) highlights the benefits of restorative clinical supervision; Smythe et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) examine implementation using a quality framework; and Flack and Abdulmohdi (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) focus on PA training. Context-specific studies explore PA’s role in mitigating stress and supporting care delivery in district nursing (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and gerontology settings (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite a growing body of evidence supporting PA, limited attention has been paid to how the role is understood and experienced by practitioners more broadly. In particular, little is known about how PA services are perceived by both users and non-users within single provider settings, and how these perceptions influence service implementation. This study addresses that gap by exploring the experiences and views of nurses and midwives within one large NHS Trust in England. It asks what an effective PA service looks like in practice and aims to identify both the perceived and tangible opportunities and barriers to its integration, while examining how its purpose and function are understood across clinical roles.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e\u003cp\u003eWe utilised a exploratory qualitative descriptive design (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) to align with the study's descriptive aim. The intention of this design is to comprehensively summarise participants' subjective understandings, opinions, and experiences (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Embedded in naturalistic inquiry, qualitative descriptive studies often use focus groups to gather information because the interactive group setting offers a space where participants' attitudes, beliefs, and experiences may be revealed (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The facilitated conversation fosters idea-sharing and deeper insights, and the flexible format allows the exploration of new topics as they arise. By bringing together nurses and midwives from diverse clinical backgrounds and experiences in PA, the purpose of the focus groups was to shed light on a range of perspectives and uncover common themes.\u003c/p\u003e\u003cp\u003eSetting and recruitment\u003c/p\u003e\u003cp\u003eThis project took part in a large NHS Trust in the UK, a public sector organisation responsible for delivering healthcare services, including hospitals and community health services. Serving roughly one million residents across diverse settings that include urban, countryside, and seaside regions, this NHS Trust operates an extensive network of inpatient and community-based facilities. It offers comprehensive care covering all stages of life, from neonatal and paediatric care to geriatric services. The Trust workforce comprises of 11,600 individuals, including approximately 3,300 nurses and 320 midwives.\u003c/p\u003e\u003cp\u003eOnline focus groups using MS Teams were conducted between May and June 2024. We were cognisant of the opportunities and challenges of conducting online data collection (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) and paid careful attention to the format of the meetings to ensure the focus group conversations were ethically constructed and facilitated, with particular attention to the psychological comfort and confidentiality of both participants and facilitators (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Online contact was chosen due to the participants’ wide geographical distribution and varied working patterns within the NHS Trust, making in-person meetings difficult to organise. Our decision was further supported by the ability to eliminate travel requirements and to schedule meetings at times and in formats that suited the participants’ availability (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eData Collection and Analysis\u003c/p\u003e\u003cp\u003eThirteen focus groups were conducted, each lasting one hour and comprising 3–6 participants. A member of the research team (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) coordinated scheduling and administration. Participants selected from two pre-defined time slots based on their availability; once a group reached sufficient numbers, the session was confirmed. Each focus group was facilitated by two researchers (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The lead facilitator directed the discussion, while the co-facilitator ensured participant access, managed technical issues, took observational notes, and monitored participant wellbeing.\u003c/p\u003e\u003cp\u003e At the start of each session, participants were reminded of the information contained in the participant information sheet and the expectations for engagement, including equitable participation, respectful interaction, and management of disagreement. Given all participants were UK Nursing and Midwifery Council registrants, they were reminded of their obligation to adhere to the NMC Code (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), which also defined the ethical boundaries of the discussion.\u003c/p\u003e\u003cp\u003eA flexible, non-directive approach guided facilitation and topic guides were tailored to specific subgroups. Following each session, facilitators debriefed to consolidate observations and contextual insights. All sessions were audio-recorded and transcribed verbatim by a member of the research team. Transcripts were analysed using qualitative descriptive analysis, treating each focus group as a discrete unit of analysis (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The analytic process included familiarisation, open coding, theme development, and a final confirmatory phase, aligning with the principles of qualitative descriptive design (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTrustworthiness\u003c/p\u003e\u003cp\u003eTo ensure the trustworthiness of this work, we focused on quality and rigour at each stage of the design process (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), through a receptive interchange between the project team to check and recheck our shared understanding. We established strategies for recording activities and organising data, using NVivo's memo function to document observations and decision-making. Interviewer field notes were logged with recordings and transcripts. To ensure transferability, intelligibility, and authenticity, we consistently revisited the transcripts to compile rich explanations from raw data. Despite debates on transferability (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), we sought to provide detailed information for readers to compare outcomes with their situations, including verbatim narratives to link raw data with our findings.\u003c/p\u003e\u003cp\u003eEthical considerations\u003c/p\u003e\u003cp\u003e This study was approved by the Anglia Ruskin University Research Ethics Committee (REF: ETH2324-3616). We obtained gatekeeper permission before approaching participants, and participants were informed about the study aims and procedures. Participants then gave informed consent before a focus group was scheduled, which was then reconfirmed at the start of the focus groups and at the end of the focus groups.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOur sample (see Table ) included 53 participants across 13 focus groups comprising of those who had accessed PA, those who had not accessed PA, those who are PAs and those training to be a PA.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2: Sample characteristics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eParticipants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eThose who have used PA services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eThose who have not used PA services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eRegistered PA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eTrainee PA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThrough the context-sensitive focus group conversations we identified four key themes (see Figure 1): (1) awareness and understanding of PA, (2) barriers to engagement, (3) perceived benefits of PA, and (4) participant recommendations for strengthening PA.\u003c/p\u003e\n\u003ch3\u003eAwareness and understanding of PA\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eA recurring theme across focus groups was the limited awareness of PA roles and how to access them. Many participants, particularly those who had not accessed advocacy services, had little understanding of what the role entailed or how it could benefit them. Some described PA as an \u0026ldquo;\u003cem\u003eunder\u003c/em\u003e\u003cem\u003e\u0026nbsp;the rada\u003c/em\u003er (P17)\u0026rdquo; resource that from their point of view was not actively promoted within their teams. Those who had accessed PA, however, spoke positively about its impact. They highlighted their appreciation of how both informal contacts and formally structured, confidential sessions could provide emotional and professional support, particularly during times of stress. These PA interactions were seen as valuable for helping individuals navigate challenging situations and for offering a safe, professionally aware space to express concerns and seek guidance. However, the partial and incomplete understanding of others allowed misunderstandings to creep in, and inferences were made to previous unhelpful conceptualisations of practice-based supervision associated to situations where \u0026ldquo;\u003cem\u003ethings had gone wrong\u003c/em\u003e. (P3)\u0026rdquo; While some understood the peer-to-peer aspect of PA, this was not consistently realised. Consequently, collegiateness of PA was viewed as a central asset, providing separation from tricky assumptions about previous supervisory models.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eBarriers to engagement\u003c/h3\u003e\n\u003cp\u003eSeveral factors were identified as barriers to engaging with PA services. Many participants felt that seeking advocacy support added to their already overwhelming workloads, with the perception that it required time away from clinical duties discouraging participation. Concerns about stigma and fears that accessing advocacy might be viewed as an admission of weakness were also prevalent. One participant shared, \u003cem\u003e\u0026quot;I wanted to seek help, but I was worried about my colleagues finding out and judging me\u003c/em\u003e. (P8)\u0026quot; The observation of a \u0026lsquo;foggy start\u0026rsquo; to \u0026nbsp;PA resulted in concerns that advocacy roles were not effectively embedded into leadership structures, limiting their influence and causing angst about the paraments of PA practice, for example who they \u0026lsquo;reported to\u0026rsquo;, how PAs were \u0026lsquo;managed\u0026rsquo; and what \u0026lsquo;they could do\u0026rsquo;. Inconsistent availability of trained advocates across departments further led to unequal access across the organisation and a sense of \u0026ldquo;\u003cem\u003esome people seem to know more than others\u003c/em\u003e.\u0026rdquo; (P20) Additionally, traditional hierarchical structures were perceived to sometimes discouraged staff from seeking advocacy support, although the reasons for this were unclear. Therefore, in these early stages of PA adoption, recognising and addressing the influence of the combined real and perceived barriers is crucial for increasing engagement and utilisation of PA services.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003ePerceived benefits of Professional Advocacy\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eFor those who engaged with PA, several key benefits were identified. The ability to discuss professional challenges in a confidential and supportive environment was highly valued, with participants describing advocacy sessions as opportunities for \u0026quot;\u003cem\u003eoffloadin\u003c/em\u003eg\u0026quot; without fear of being negatively viewed. One participant noted, \u0026quot;\u003cem\u003eHaving an advocate to talk to made a huge difference in how I handled work-related stress\u003c/em\u003e.\u0026rdquo;(P6) The support provided by PAs was seen as instrumental in fostering a positive work environment and promoting staff well-being, and mainly due to the \u0026lsquo;understanding\u0026rsquo; PAs had of the clinical environment. The apparent professional empathy associated with this theme underscores the value of PA in enhancing both individual and organisational outcomes. Some participants believed that access to advocacy influenced their decision to stay within the NHS rather than seeking opportunities elsewhere, thereby contributing to workforce retention and resilience. Additionally, by recognising the \u0026lsquo;ground up\u0026rsquo; impact of staff stress and burnout, PA was seen as directly benefiting patient outcomes by promoting a more engaged, informed and supported workforce.\u003c/p\u003e\n\u003ch3\u003eParticipant recommendations for strengthening PA\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eThe participants provided a plethora of practical ideas to improve the accessibility and effectiveness of PA. There was a strong sense of wanting to make PA work in practice. They recommended more vigorous promotion and awareness campaigns to increase the visibility of advocacy roles and offered suggestions to include at induction events and a wide range of staff communications to invigorate engagement. The overarching message emphasised the need for frequent and repeated communication for incorporating advocacy services more seamlessly into the workplace. One suggestion was, \u0026quot;\u003cem\u003eRegular workshops and information sessions could help demystify what professional advocacy is and how it can benefit us.\u003c/em\u003e\u0026quot;(P31) Furthermore, the participants accentuated the importance of organisational support and resources to sustain and expand PA services. Implementing these recommendations was seen as mechanisms to enhance the effectiveness of PA across healthcare settings and work towards building on successes. To boost its legitimacy and impact, they encouraged more overt integration of PA into organisational structures and governance frameworks, rather than treating it as an add-on service. Flexible and accessible methods for PA were also suggested, such as including advocacy sessions into routine staff well-being initiatives to make them more reachable without requiring additional time commitments.\u003c/p\u003e\n\u003ch3\u003eSummary of Findings\u003c/h3\u003e\n\u003cp\u003eThe focus groups members highlighted the importance to PA as a way of supporting healthcare professionals through the amalgamation of empathic, practice-driven and peer-positioned understanding. \u0026nbsp;While there are barriers to engagement, the perceived benefits and participant recommendations provided clear and contextually orientated pathways for strengthening advocacy services. The overarching message was that with an informed understanding and clear, accessible and flexible access pathways, PA can play an important role in creating and sustain a more supportive and resilient workforce, ultimately improving patient care and health outcomes.\u003c/p\u003e"},{"header":"Discussion","content":"\u003ch3\u003eProfessional Advocates are a valuable yet underutilised asset\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe findings from this focus group analysis align with existing literature identifying PA as a valuable yet underutilised asset in the NHS. Despite its potential to enhance staff well-being and support workforce retention, PA remains inconsistently embedded across healthcare organisations. Prior studies have documented PA\u0026rsquo;s positive impact on psychological safety, stress management, and resilience (34,35), but our data suggest that implementation is undermined by both structural and cultural barriers, particularly workload pressures, professional hierarchies, and low role visibility.\u003c/p\u003e\n\u003cp\u003eActivity Theory (36) offers a useful analytical framework for interrogating these dynamics. By examining how individual roles, organisational structures, and cultural norms intersect, this perspective enables a systemic understanding of PA engagement. Implementation challenges are not isolated or easily remedied; rather, they emerge from contradictions between subjects (healthcare staff), objects (PA engagement), and mediating artefacts (e.g. communication tools, policy, and governance mechanisms). These contradictions highlight the need for coordinated structural change to fully integrate PA into NHS workforce models.\u003c/p\u003e\n\u003cp\u003eA key barrier identified was the widespread lack of awareness and conceptual clarity surrounding the PA role (37). Participants unfamiliar with the service frequently conflated PA with patient advocacy or were unaware of its existence altogether. This confusion was compounded by fluctuating levels of promotion of PA through external and internal communications, training, or leadership discourse, leading to a perception of \u0026nbsp;PA as peripheral. For many, the lack of visibility translated into passive disengagement; time constraints and information fatigue further discouraged staff from seeking out support.\u003c/p\u003e\n\u003cp\u003eThis lack of engagement can be understood, in Activity Theory terms, as a failure of mediating artefacts. When essential tools such as effective messaging, integration into onboarding processes, and clearly defined referral pathways are absent or underdeveloped, the activity of accessing PA becomes fragmented and difficult to navigate. Participants emphasised the importance of immediacy and relevance in communication. As a result, interventions should prioritise the end-user experience and adopt professionally empathetic design tenets to ensure that PA is visible, meaningful, and embedded in everyday practice.\u003c/p\u003e\n\u003cp\u003eThese structural challenges intersect with cultural ones. The marginalisation of PA within everyday clinical practice reflects broader disciplinary assumptions and long-standing hierarchies. Structurally, participants described a lack of formal integration of PA into team workflows, limited visibility in leadership models, and the absence of clear referral mechanisms. As a result, PA was not widely perceived as embedded within organisational systems, rendering it conceptually and operationally peripheral. Despite this, even those who had not accessed PA acknowledged its potential value. Participants emphasised that the principles of PA felt rooted in their professional world, described as grounded, authentic, and oriented toward practice, rather than imposed as an external agenda (38). Once understood, PA was seen as a meaningful resource for guiding professional and service development, offering emotional support, and helping staff navigate workplace challenges.\u003c/p\u003e\n\u003cp\u003eHowever, the barriers to engagement extend beyond visibility. Time pressures were consistently cited as a deterrent. The perception that seeking PA support would require time away from clinical duties discouraged participation, particularly among already overstretched staff (39). More insidiously, cultural stigma around help-seeking contributed to disengagement. Engaging with PA was sometimes seen as a sign of professional vulnerability, deterring staff from using the service for fear of reputational damage (40). The inconsistent availability of trained PAs across departments further compounded access inequities, resulting in uneven service provision within the same organisation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong participants who had engaged with PA, the benefits were profound. PA was described as a safe, confidential space for emotional decompression and professional reflection. This aligns with existing evidence that PA supports psychological safety and enhances workforce resilience (34,35,41). Some participants reported that PA access directly influenced their decision to remain within the NHS, highlighting its role in staff retention (42). The correlation between staff well-being and patient care quality is well established (43), and our findings reinforce that PA not only mitigates stress and burnout but also contributes to improved service delivery through enhanced morale and professional commitment (41).\u003c/p\u003e\n\u003cp\u003eIn this context, PA must be understood not merely as a well-being intervention, but as a lever for cultural transformation. Normalising PA within healthcare teams can dismantle stigma and promote a culture of openness and resilience (44). This aligns with The King\u0026apos;s Fund\u0026rsquo;s (45) emphasis on cultivating inclusive, supportive workplaces to improve staff retention and patient outcomes. Our analysis identified seven key components of effective PA integration (see Table 3), each contributing to a more resilient and psychologically safe clinical environment.\u003c/p\u003e\n\u003ch3\u003eRecommendations for practice\u003c/h3\u003e\n\u003cp\u003eApplying Activity Theory clarified how systemic contradictions underlie barriers to PA engagement.\u003cem\u003e\u0026nbsp;\u003c/em\u003eThe gap between the need for PA and its limited accessibility can be understood as a tension between practitioners\u0026rsquo; needs and the underdeveloped mediating tools available to support them. Perceived cultural norms and organisational hierarchies act as \u0026ldquo;rules\u0026rdquo; that discourage help-seeking and inhibit PA\u0026rsquo;s integration. To address these challenges, a systemic reconfiguration is required. Recommended strategies include:\u003c/p\u003e\n\u003cp\u003eIncreasing visibility: Embedding PA roles in team structures and regular communications.\u003c/p\u003e\n\u003cp\u003eIncorporating PA in education: Including advocacy in induction, continuing professional development activities, and mandatory training.\u003c/p\u003e\n\u003cp\u003eEmbedding PA in governance: Integrating PA within leadership and quality assurance systems and policy.\u003c/p\u003e\n\u003cp\u003eAccommodating PA in wider well-being strategies: Aligning PA with existing organisational support mechanisms, services and frameworks.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese findings indicate that PA, when properly embedded, offers both personal and organisational benefits. It creates protected space for professional challenges to be constructively addressed and contributes to broader workforce stability. The potential gains in areas such as retention, morale, and patient care present a compelling case for expanding and formalising the role of PA across NHS services.\u003c/p\u003e\n\u003cp\u003e[INSERT TABLE 3 HERE]\u003c/p\u003e\n\u003ch3\u003eStrengths and Limitations\u003c/h3\u003e\n\u003cp\u003eThe study demonstrated several strengths that contribute to its robustness and value. The inclusion of participants from diverse backgrounds generated a rich variety of perspectives, deepening insight into the research questions and enhancing the interpretive depth of the findings. The use of online focus groups not only increased accessibility and convenience but also broadened the reach to participants who might otherwise have been unable to attend. Skilled moderation by experienced facilitators ensured that discussions remained both inclusive and focused, enabling the capture of high-quality data. Recruitment efforts, led by the \u003cem\u003ein place\u003c/em\u003e coordinator (Goldspink et al., 2025), were highly effective in fostering strong engagement and sustaining participation. While certain limitations were noted, these do not diminish the overall quality of the work. The possibility of self-selection bias should be acknowledged, yet such engagement also enriched the discussions. The coordination of 13 focus groups reflects the commitment to comprehensive data collection and allowed for a more nuanced and multifaceted understanding of the topic.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, PA offers wide-ranging benefits for NHS staff, including improved wellbeing, job satisfaction, and workforce stability. Focus group data show that a culture of openness, supported by PA peer-to-peer connections, enhances relationships with colleagues and management, reduces stress, and promotes professional growth. These benefits must be considered alongside the organisational costs of staff turnover and lost working days. Co-designing PA services with staff strengthens relevance and uptake, while supporting collaborative service development. PA aligns with national workforce strategies and, if implemented strategically, can contribute to a more resilient, empowerment-based healthcare system.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eNHS \u0026ndash; National Health Service\u003c/p\u003e\n\u003cp\u003ePA \u0026ndash; Professional Advocate/Advocacy\u003c/p\u003e\n\u003cp\u003eUK \u0026ndash; United Kingdom\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eWe obtained approval from the Anglia Ruskin University Research Ethics Committee. Participants provided informed consent before focus group sessions were scheduled, and consent was reconfirmed at the start and end of the focus group sessions. All methods in this study were performed in accordance with the relevant ethical guidelines and regulations.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eDue 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, including 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: 10.25411/aru.29910641 (46). Data access requests will be reviewed by the authors and key collaborators as named on the repository.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eN.V., S.G., H.E. and N.A. declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. A.T. and M.A. are employed by East Suffolk and North Essex NHS Foundation Trust, who funded this work, but contributed in their individual professional roles, rather than on behalf of the funder. East Suffolk and North Essex NHS Foundation Trust had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThis work was funded by the East Suffolk and North Essex NHS Foundation Trust\u003c/p\u003e\n\u003ch3\u003eAuthors' contributions\u003c/h3\u003e\n\u003cp\u003eS.G., H.E., and M.A. conceived the project. N.V., S.G. and H.E. developed the methods. S.G., H.E. and A.T. collected the data. N.V. and S.G. analysed the data. N.V., S.G. and H.E. interpreted the data. S.G. and H.E. supervised the project. All authors contributed to the final manuscript and to the overall parent project.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eThe authors would like to thank the ESNEFT team for help with distribution of information, and the participants who took part in this study.\u003c/p\u003e\n\u003ch3\u003eAuthors' information (optional)\u003c/h3\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKinman G, Dovey A, Teoh K, Doyle N, Greenberg N, Harriss A. Burnout in healthcare: risk factors and solutions [Internet]. London: Society of Occupational Medicine; 2023. Available from: https://www.som.org.uk/sites/som.org.uk/files/Burnout_in_healthcare_risk_factors_and_solutions_July2023.pdf\u003c/li\u003e\n\u003cli\u003eNHS England. NHS long term workforce plan [Internet]. NHS England; 2023. Available from: https://www.england.nhs.uk/publication/nhs-long-term-workforce-plan/\u003c/li\u003e\n\u003cli\u003eEngland NHS. NHS national staff survey: National results briefing. NHS England; 2024. \u003c/li\u003e\n\u003cli\u003eSquires A. How staff burnout and change were escalated by the Covid-19 pandemic. Nursing Times [Internet]. 2022 Oct 31 [cited 2025 Aug 14];118(11). Available from: https://www.nursingtimes.net/nurse-wellbeing/how-staff-burnout-and-change-were-escalated-by-the-covid-19-pandemic-31-10-2022/\u003c/li\u003e\n\u003cli\u003eDelgado C. Simplify safety advice, report warns as harms rise in NHS in England. BMJ. 2024;387. \u003c/li\u003e\n\u003cli\u003eWest M, Bailey S, Williams E. The Courage Of Compassion: Supporting Nurses And Midwives To Deliver High-Quality Care [Internet]. London: The King\u0026rsquo;s Fund; 2020 [cited 2025 Aug 14] p. 156. Available from: https://www.kingsfund.org.uk/insight-and-analysis/reports/courage-compassion-supporting-nurses-midwives\u003c/li\u003e\n\u003cli\u003eIllingworth J, Fernandez Crespo R, Hasegawa K, Leis M, Howitt P, Darzi A. National state of patient safety 2024: Prioritising improvement efforts in a system under stress [Internet]. London: Imperial College London; 2024. Available from: https://www.imperial.ac.uk/media/imperial-college/institute-of-global-health-innovation/centre-for-health-policy/public/National-State-of-Patient-Safety-2024_Technical-Annex.pd\u003c/li\u003e\n\u003cli\u003eDarzi A. Independent investigation of the national health service in England [Internet]. London, United Kingdom: Department of Health and Social Care; 2024. Available from: https://www.gov.uk/government/publications/independent-investigation-of-the-nhs-in-england\u003c/li\u003e\n\u003cli\u003eAriss SM, Earley V, al JR. Final evaluation report: pilot for new model of midwifery supervision [Internet]. 2017. Available from: http://eprints.whiterose.ac.uk/117456/1/1-NMOMS%20Pilot%20Evaluation_19.04.17_Final%20Report.pdf\u003c/li\u003e\n\u003cli\u003eMartin T, Stephens L, Dennis T. Introduction and background to the role of professional midwifery advocate. MIDIRS Midwifery Digest. 2018;28(2):161\u0026ndash;3. \u003c/li\u003e\n\u003cli\u003eMay R. I am pleased to announce the roll-out of the professional nurse advocate programme. Nursing Times [Internet]. 2021; Available from: www.nursingtimes.net/opinion/i-am-pleased-to-announce-the-roll-out-of-the-professional-nurse-advocate-programme-05-03-2021/\u003c/li\u003e\n\u003cli\u003eNHS England. We are the NHS: People Plan for 2020/21 \u0026ndash; action for us all [Internet]. NHS England; 2020. Available from: https://www.england.nhs.uk/publication/we-are-the-nhs-people-plan-for-2020-21-action-for-us-all/\u003c/li\u003e\n\u003cli\u003eRouse S. The role of the PMA and barriers to the successful implementation of restorative clinical supervision. British Journal of Midwifery. 2019;27 6 381-386. \u003c/li\u003e\n\u003cli\u003eNHS Improvement. Professional nurse advocate A-EQUIP model. A model of clinical supervision for nurses [Internet]. 2021. Available from: https://www.england.nhs.uk/publication/professional-nurse-advocate-a-equip-model-a-model-of-clinical-supervision-for-nurses/\u003c/li\u003e\n\u003cli\u003eHandley S. Using PNA A-EQUIP to support the wellbeing and resilience of the public health nursing workforce. Br J Nurs. 2024 Feb 22;33(4):224\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eDevereaux E. Professional nurse advocates having \u0026lsquo;phenomenal\u0026rsquo; impact on staff wellbeing. British Journal of Nursing. 2023;32(10):512\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eSmythe A, Flatt C, Mahachi L, Whatley V. Introduction of the professional nurse advocate role using a quality implementation framework. Br J Nurs. 2023 Apr 20;32(8):378\u0026ndash;83. \u003c/li\u003e\n\u003cli\u003eFlack l, Abdulmohdi N. Professional nurse advocate training: Enhancing staff wellbeing and patient care. British Journal of Nursing. 2023;32(10):512\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eMiles B. A review of the potential impact of professional nurse advocates in reducing stress and burnout in district nursing. British Journal of Community Nursing. 2023;28(3):132\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eFrancis E. Exploring the professional nurse advocate role and restorative clinical supervision. Nurs Older People. 2024 Apr 2;36(2):22\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eSandelowski M. Focus on research methods: Whatever happened to qualitative description? Research in Nursing \u0026amp; Health. 2000;23(4):334\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003eDoyle L, McCabe C, Keogh B, Brady A, McCann M. An overview of the qualitative descriptive design within nursing research. Journal of Research in Nursing. 2020;25(5):443\u0026ndash;55. \u003c/li\u003e\n\u003cli\u003eBarbour R. Doing focus groups. SAGE Publications; 2021. \u003c/li\u003e\n\u003cli\u003eEngward H, Goldspink S, Iancu M, Kersey T, Wood A. Togetherness in Separation: Practical Considerations for Doing Remote Qualitative Interviews Ethically. International Journal of Qualitative Methods. 2022 Jan;21:160940692110732. \u003c/li\u003e\n\u003cli\u003eSim J, Waterfield J. Focus group methodology: Some ethical challenges. Quality \u0026amp; Quantity. 2019;53(6):3003\u0026ndash;22. \u003c/li\u003e\n\u003cli\u003eSanthosh L, Rojas JC, Lyons PG. Zooming into Focus Groups: Strategies for Qualitative Research in the Era of Social Distancing. ATS Sch. 2(2):176\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eGoldspink S, Engward H, Veggel N van, Abdulmohdi N, Tuckwell A, Alexander M. Professionals In-Place: The Role of the Practice-Based Research Coordinator. Nurse Researcher. 2025 Feb 13;0(0):in press. \u003c/li\u003e\n\u003cli\u003ePoliandri D, Perazzolo M, Pillera GC, Giampietro L. Dematerialized participation challenges: Methods and practices for online focus groups. Frontiers in Sociology. 2023;8:1145264. \u003c/li\u003e\n\u003cli\u003eNursing and Midwifery Council. The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates [Internet]. 2018. Available from: https://www.nmc.org.uk/standards/code/\u003c/li\u003e\n\u003cli\u003eSandelowski M. Qualitative analysis: what it is and how to begin. Research in nursing \u0026amp; health. 1995;18(4):371\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eSandelowski M. What\u0026rsquo;s in a name? Qualitative description revisited. Research in Nursing \u0026amp; Health. 2010;33(1):77\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eNowell LS, Norris JM, White DE, Moules NJ. Thematic Analysis: Striving to Meet the Trustworthiness Criteria. International Journal of Qualitative Methods. 2017 Dec 1;16(1):1609406917733847. \u003c/li\u003e\n\u003cli\u003eDrisko JW. Transferability and Generalization in Qualitative Research. Research on Social Work Practice. 2025 Jan 1;35(1):102\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eLees-Deutsch L, Kneafsey R, Amorim Adegboye AR, Bayes N, Palmer S, Chauntry A, et al. National evaluation of the professional nurse advocate programme in england: SUSTAIN \u0026ndash; supervision, support, advocacy for improvement in nursing [Internet]. Coventry: Coventry University; 2022. Available from: https://pureportal.coventry.ac.uk/en/publications/national-evaluation-of-the-professional-nurse-advocate-programme-\u003c/li\u003e\n\u003cli\u003eSharman VL, Gadher A, Shipperlee F. Benefits and challenges of implementing the professional nurse advocate programme: a service evaluation. Mental Health Practice. 2024; \u003c/li\u003e\n\u003cli\u003eEngestr\u0026ouml;m Y. Expansive learning at work: Toward an activity theoretical reconceptualization. Journal of Education and Work. 2001;14(1):133\u0026ndash;56. \u003c/li\u003e\n\u003cli\u003eEngward H, Goldspink S, van Veggel N, Abdulmohdi N, Tuckwell A, Alexander M. Advocating for Professional Advocates in Nursing and Midwifery. Policy, Politics, \u0026amp; Nursing Practice. 2025 Aug 1;26(3):208\u0026ndash;18. \u003c/li\u003e\n\u003cli\u003eGoldspink S, Veggel N van, Engward H, Abdulmohdi N, Tuckwell A, Alexander M. Beneficent Disruptors: A qualitative descriptive study of professional advocacy in healthcare. F1000Research. 2025 July 7;14:647. \u003c/li\u003e\n\u003cli\u003eMorrell-Scott N, Robinson N. The professional nurse advocate model and use of A-EQUIP: a tool to support the nursing workforce. British Journal of Nursing. 2025 Feb 20;34(4):242\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eNHS England. Implementing the PNA role into practice: a community nurse perspective. 2023. \u003c/li\u003e\n\u003cli\u003eGriffiths K, Reynolds J. \u0026lsquo;Nursing the nurses\u0026rsquo;: the experiences of professional nurse advocates\u0026rsquo; application of the A-EQUIP model. British Journal of Nursing. 2025 July 17;34(14):724\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eButler S. Understanding burnout in nurses: Identification and coping strategies. British Journal of Nursing. 2025;34(4). \u003c/li\u003e\n\u003cli\u003eDaniel O, Mesharck G, Otor C. Effects of stress and burnout among NHS adult nurses in the UK: a systematic literature review. Journal of Medicine and Public Health. 2024;5(1):1098. \u003c/li\u003e\n\u003cli\u003eWhatley V. Learning from the professional midwifery advocate role to revise clinical supervision in nursing. British Journal of Healthcare Management. 2022;28 7 159-207. \u003c/li\u003e\n\u003cli\u003eThe King\u0026rsquo;s Fund. Improving NHS culture [Internet]. London: The King\u0026rsquo;s Fund; 2023. Available from: https://www.kingsfund.org.uk/insight-and-analysis/projects/improving-nhs-culture\u003c/li\u003e\n\u003cli\u003evan Veggel N, Goldspink, S., Engward H, \u003cem\u003eet al.\u003c/em\u003e: Data set: Professional Advocacy in Focus: A Qualitative Descriptive Study of Nurses and Midwives Perceptions in one UK NHS Trust. Dataset. \u003cem\u003eAnglia Ruskin Research Online (ARRO).\u003c/em\u003e 2025. 10.25411/aru.29910641\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 is not available with this version.\u003c/p\u003e\n\u003cp\u003eTable 3 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Professional, Advocate, Qualitative, Descriptive, Focus Groups, Workforce, Nurse, Midwife","lastPublishedDoi":"10.21203/rs.3.rs-7374915/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7374915/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThis study was conducted within the National Health Service (NHS), the publicly funded healthcare system in the United Kingdom (UK), which provides hospital and community care to a diverse population. The NHS is currently facing significant workforce challenges, including high vacancy rates, staff burnout, and low morale. In response, the Professional Advocacy (PA) role was introduced to support midwives and nurses through structured peer support and restorative clinical supervision and has since been extended to include allied health professionals. While early evidence suggests PA can improve staff wellbeing and retention, there is limited understanding of how the role is perceived and experienced by practitioners. This study aimed to explore nurses\u0026rsquo; and midwives\u0026rsquo; perceptions of PA, focusing on its implementation, accessibility, and impact within one NHS Trust.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA qualitative descriptive design was used, involving online focus groups with nurses and midwives who had varying levels of engagement with PA services. Thirteen focus groups were conducted with fifty-three participants, including those who had accessed PA, those who had not, and those training or registered as professional advocates. Data were transcribed verbatim and analysed thematically using an inductive approach supported by NVivo software.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFour key themes surfaced during analysis: awareness and understanding of PA, barriers to engagement, perceived benefits, and recommendations for strengthening the service. Participants who had accessed PA described it as a valuable source of emotional and professional support, contributing to improved wellbeing and retention. Barriers included limited awareness, stigma around help-seeking, inconsistent availability, and unclear organisational integration. Participants recommended improving visibility and accessibility, and strengthening the perceived legitimacy of PA by ensuring it is recognised as a credible, well-supported part of the organisation, rather than a peripheral or optional service.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003ePA is a promising but underutilised resource within the NHS. While it offers clear benefits for staff wellbeing and retention, its impact is constrained by systemic and cultural barriers. Addressing these challenges through targeted organisational strategies could enhance the integration and effectiveness of PA services. This study contributes to the growing evidence base and offers insights into embedding PA into routine practice to support a more resilient workforce.\u003c/p\u003e","manuscriptTitle":"Professional Advocacy in Focus: A Qualitative Descriptive Study of Nurses and Midwives Perceptions in one UK NHS Trust","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-20 08:10:08","doi":"10.21203/rs.3.rs-7374915/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"15f57a5b-8c68-4b72-b87b-d35410c7dc47","owner":[],"postedDate":"August 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-20T08:10:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-20 08:10:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7374915","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7374915","identity":"rs-7374915","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}