Restorative reflection is an important approach for nurses, says Dr Sarah Bekaert
Investment in nursing is vital for effective, resilient and sustainable health services. The World Health Organization estimates a shortage of 4.5 million nurses globally by 2030.
Currently, there is a UK nursing shortage, with an expected shortfall of 10,000 nurses in 2025. Reasons for this UK picture include less students entering nursing programmes, an ageing workforce, and work-related pressures resulting in attrition.
Nurse burnout can be an occupational hazard, and frequent stated reason for leaving the profession. This has been significantly exacerbated by additional pressures on the nursing workforce during and post pandemic.
My recent research with school nurses, for example, has highlighted a range of additional challenging experiences during the pandemic such as harrowing safeguarding cases, exposure to traumatic experience, and redeployment to areas where they felt ill-equipped to practice.
‘Being redeployed was absolutely terrifying. The whole situation still winds me up. I’d buried this…’
Additional pressures on nurses in the acute sector during the Covid pandemic were well-documented – however the impact of redeployment on morale less so.
Pre-Covid, research into nurse redeployment showed challenges in working in an unfamiliar environment, limited orientation to the new unit, concerns over professional liability, schedule uncertainty, and workload, and a consequential increase in staff turnover and psychological challenge. Recommendations were that such crisis response should include debriefing for the nurses involved to mitigate some of the challenges associated with redeployment.
In our survey study with school nurses in the UK in spring 2022, 74.4% of participants reported an increase in workload as a result of the pandemic. Challenges continue, with similar reports of high general, and safeguarding, workloads.
In a recent UK national survey in early 2024 by the School and Public Health Nurses Association (SAPHNA), 82% reported that there weren’t enough staff to deliver a high quality, safe and caring service.
‘Since the pandemic referrals from other professionals have gone up. We are seeing more emotional health issues – including neurodiversity and sleep related issues. It all falls on us’
As part of a commitment to workforce wellbeing and recovery post-pandemic, the NHS Confederation has recommended the introduction of professional nurse advocates in the UK – with a specific role is to support the nursing workforce, one aspect being the provision of restorative supervision.
Restorative supervision aims to support the needs of staff working with complex caseloads and/or in roles which are emotionally demanding by offering a constructive space to think about, and process, work-related experiences. Restorative supervision has been shown to increase compassion satisfaction and reduce burnout and stress by up to 40% and has been linked to staff retention and reduced sickness.
Restorative supervision was cited as a positive example of what could be offered to support a compassionate NHS service in the government response to the Francis Report in 2013, an inquiry into failures in care in a specific health trust in England.
‘In the hamster wheel of managing, there’s no headspace to reflect’
Pause and Reflect is a guided restorative reflective resource that we have developed for use in restorative supervision with school nursing teams. Drawing on real-world examples from qualitative study with school nurses during and post-pandemic the resource guides the restorative discussion into the reflective process and realistic and practical goals for change, focusing on workforce support.
Reflective practice is the organising theory of nursing and therefore a familiar process. The guided restorative reflective resource starts with the restorative element: what happened/is happening and how does this feel, and then moves the group towards consideration of what needs to change and the practical steps to facilitate this change at an organisational level.
‘The session has been really helpful. I felt heard and listened to. I felt valued’
We have successfully trialled the guided resource with four teams across England. Assessment of burnout, compassion fatigue and trauma were carried out prior to delivering the restorative reflective sessions through the Professional Quality of Life (ProQoL) Questionnaire, a widely used tool designed to measure the positive and negative effects of working in helping professions.
ProQoL assessment highlighted presence of compassion fatigue and traumatic stress, and the majority of participants close to burnout. In the evaluation, school nursing team participants stated confidence in the process and impact of restorative reflective supervision. Feedback also indicated an increase in self-awareness; professional insight; confidence in how to raise professional issues in the workplace.
‘It has been useful to discuss elements and changes with the team. Usually when our team has these discussions, we end up arguing and it gets quite heated. It was interesting that we were able to have a debate in a positive way’
The guided restorative-reflective model is transferable to all areas of nursing, and is currently being piloted with student nurses at Oxford Brookes University. Alongside offering regular facilitated safe spaces to reflect on challenging experience, we hope that this may also contribute to reduced attrition as newly qualified nurses.
Restorative supervision is by no means a panacea to low staffing, mis- and under-commissioning of nursing services and increased demand on the nursing workforce, but should be routinely offered to all nurses as part of compassionate investment in the nursing workforce.
- The Pause and Reflect guided Restorative Reflective Resource can be found here: https://sites.google.com/brookes.ac.uk/pause-and-reflect/home
- Information about the School Nursing in the Time of Covid studies can be found here: https://sites.google.com/brookes.ac.uk/schoolnursinginthetimeofcovid/home
The quotes highlighted in this article were drawn from participants in Dr Bekaert’s research.
Dr Sarah Bekaert is senior lecturer at the Oxford Institute of Applied Health Research, PhD, RN Child
