Here, Carole Young, professional nurse advocate, independent nurse consultant and associate lecturer, Anglia Ruskin University, reflects on the impact of the pandemic on specialist nurses in the last two years and considers what is needed next in terms of support and recovery of self and service. The role of compassionate leadership and professional nurse advocacy (PNA) will be discussed to share an understanding of how restorative clinical supervision (RCS) can be used to support emotional recovery and plan for future development. Models including A-EQUIP and the GROW coaching model used by PNAs to guide RCS will be explained as tools which can support personal reflection and recovery through personal actions for quality improvement. 

Nurses and other healthcare professionals (HCPs) spend a large proportion of their roles acting as patient advocates, giving compassionate care, and ensuring best practice to promote recovery and healing. But, how often do we show the same level of advocacy and compassion to ourselves and colleagues?  

The last two years has had a significant impact on individuals, teams, and organisations within health care (Butterworth, 2022). As the world begins to ‘live with Covid’, there is a desire to ‘return to normal’. For HCPs, this is easier said than done. Many nurses report feeling physically exhausted and emotionally drained, living in fear of the next wave, not knowing if this will ever really end (Ford, 2021). Many specialist nurse teams have undergone huge changes, whether it be redeployment, reduction of their normal services or even halting of their service completely, and this has resulted in significant distress and uncertainty among those impacted (Ballantyne and Achour, 2022).  

For HCPs to achieve a goal of ‘returning to normal’, the author has identified that several steps of recovery and restoration need to be followed:  

• Time to reflect is needed, in a psychological safe space that is neutral and non-judgemental  
• A need to acknowledge what has happened and how things have changed, acknowledge feelings of selves and those of others, recognise the highs and lows of experiences  
• A need to recognise that things were not perfect pre-pandemic, particularly in specialist nurse services — often these are isolated or small teams with poor resources and sometimes with non-nursing management or sitting under corporate teams  
• A need to recharge, regain energy, motivation, and inspiration to re-find a drive  
• A need to make goals and plan our reset, re-start and develop personal quality improvement action plans. 

REFLECTIONS  

The first step to reset and restoration will naturally include a period of reflection. To look forward, we must at first look back and acknowledge what has happened. Reflection allows us to unpack and notice the emotional impact of our work, analyse events, learn, and develop action plans for future occurrences (Cook, 2022).  

Informal conversations between the author and other specialist colleagues and teams in the local trust and further afield over 2020–2022 identified recurring themes, some positive and many negative impacts of the pandemic. Challenges that were highlighted were also seen by Ballentyne and Achour (2022) in their interviews with staff to capture experiences following redeployment during the pandemic. Many resonated personally with the author and when shared at a recent conference (Young, 2022) identified a realisation that no one person was alone in how they felt or what they had experienced. 

Many of the lows expressed derived from experiences of redeployment; specialist nurses in acute settings were moved to critical care areas and those in the community found themselves working in district nurse teams. These moves were frequently reported to areas not seen since the practitioners had been student nurses, and there was a real fear of causing harm by following an outdated practice or feeling pressured to work outside their normal scope of practice. Moves were often at short notice, leaving no time to re-organise normal specialist workloads or inform patients of changes to the service.  

Some specialist nurses found they were met with resentment on arrival at their redeployment destination, receiving comments such as ‘why are you here? If you can’t do xxx task, then there’s no point in you being here’.  

In some areas, there was an expectation to maintain some level of normal specialist service alongside redeployment, resulting in many working over hours and the feeling of working two full-time jobs. Specialist services were still needed, in some cases more than normal, as numbers of critically sick and high-risk patients were admitted to hospital and community services battled to keep patients with longterm conditions out of hospital.  

Some services were stopped completely, and specialist nurses feared for their continued employment post pandemic — ‘would managers think their service was not needed anymore if it’s been closed for a period’. Some noted their service base had been redeployed for other uses, clinic rooms became triage rooms for emergency departments, offices became personal protective equipment (PPE) distribution hubs — ‘will there even be an office for us after this?’ was a common question.  

One hundred percent of staff who spoke with the author reported feelings of exhaustion and frustration. There was a feeling that no one really recognised the uniqueness of specialist nurses and teams and what specific support they needed. Many reported to the author that there had been no time or offer of debriefs or reflection sessions, like those in critical care and emergency roles were receiving.  

As with many areas, there were specialist nurses who found themselves shielded and had to come to terms with their own vulnerability. These staff reported feelings of being disconnected, a loss of sense of team and their place in it; they missed the companionship of being in a workplace. While some received excellent remote support from managers, there was a sense of a loss of leadership in teams, such as if the team lead was shielding leaving the team without direction and struggling with resilience.  

While there were many lows and challenges, the change of working ways also brought some positive experiences, e.g. specialist nurses used the opportunity of redeployment to refresh generalist skills and practice. Being redeployed also meant an opportunity to raise the profile and visibility of a specialist field within areas where there may have previously been little interaction.  

Many found innovative ways to teach staff and assess patients remotely, meetings suddenly became virtual often with surprising effective outcomes not seen during long drawn-out face-to-face meetings. For those who were shielded, some expressed that they used the opportunity to take a breath, reset and review their service from a different perspective.  

RESTORATION AND RECOVERY  

Compassionate leadership  

This has never been more high profile than in the last couple of years — the pandemic has heightened the awareness in health care of the need for a focus on staff wellbeing (Bosanquet, 2022). Healthcare staff were already heading towards or in burnout and stress states before Covid hit (Fischer, 2017; Butterworth, 2022). In the midst of the pandemic ‘survival mode’ kicked in. HCPs got on and did what was needed to be done to save lives, as the pressure eased and the adrenalin reduced, the exhaustion and emotions kicked in. There have been reports of staff leaving the NHS and healthcare roles, citing they are just too tired or have had enough, and have no more energy to keep going. The NHS Confederation reported in 2021 that there was a real risk that thousands of staff would leave the NHS unless they are given time to recover following the pandemic, highlighting that if staff core needs are not taken care of, patients would not receive best care. 

West et al (2020) suggest that staff have three core needs to be content and fulfilled at work:  

• Autonomy in that they need to have control of their work life and be able to act within their values. Staff need to feel they have fairness and justice with authority, empowerment, and influence in their workplace  
• Belonging within a team, to feel connected and cared for by colleagues — to feel valued and supported within a positive culture and leadership  
• Contribution in their work is effective, managed and recognised. They need to feel they can learn and develop in their role.  

Embedding these core needs into everyday working in an organisation or service requires compassionate, inclusive leadership and effective team working. Stacey et al (2018) explain that a compassion-focused approach:  

• Increases resilience  
• Reduces anxiety  
• Enables staff to feel more able to cope in stressful situations.  

Additionally, compassionate leadership enables staff to feel valued, respected and cared for so they can reach their full potential and do their best work (Bailey and West, 2022). It promotes trust, understanding and mutual support, resulting in more engaged and motivated staff with high levels of wellbeing (West, 2021).  

West (2021) states that compassionate leadership is made up of four main principles:  

• Attending — being present, as a leader give 100% attention to the person/team at the time they need it. Put aside any distractions and protect the time being given, listen with fascination, i.e. be truly interested in what the other person is expressing  
• Understanding — showing that you understand the other person’s situation through active listening, using open questioning to guide them through an exploration of their situation and different perspectives  
• Empathising — mirroring the other person’s feelings through mirroring, being aware of continually changing conditions in yourself and others, be genuine in your expressions of concern without becoming too overwhelmed to help  
• Helping — giving practical advice and support to enable a person to take action to change or develop, removing obstacles such as workloads and barriers.  

Compassionate leadership is essential for the recovery of healthcare services and the retention of staff going forward (NHS Confederation, 2021). Compassionate leaders are proactive in implementing the strategies required for restoration and recovery, they have the vision to support personal growth through clinical supervision, reflection, education and quality improvement. This is supported by Cook (2022), who identifies that effective clinical supervision needs to be valued at all levels of the organisation and supported with adequate resources to allow nurses to access time for reflection.  

PROFESSIONAL NURSE ADVOCATE (PNA)  

The author believes that professional nursing leadership and clinical supervision are essential to enable nurses to protect their own wellbeing and continually improve care for their patients. However, as Butterworth (2022) points out, clinical supervisors need to be appropriately trained and prepared to take on the role. The professional nurse advocate (PNA) scheme was launched by Ruth May (chief nursing officer [CNO], NHS England) in 2021 to equip the nursing workforce for clinical supervision and recovery; it builds on an existing scheme for professional midwife advocates (PMAs) which has been in place since 2017 (Dunkley-Bent, 2017). The aim is for one in 20 registered nurses to be trained as PNAs by 2025 (NHS England and NHS Improvement, 2021), giving every registered nurse in England access to clinical supervision. The PNA scheme aims to have a positive impact on staff wellbeing, retention, professional resilience and patient outcomes. 

Any registered nurse or midwife can train as a PNA/PMA. PNAs are trained to use the A-EQUIP model to support colleagues through restorative clinical supervision, supporting development through education and quality improvement.  

A-EQUIP MODEL  

The A-EQUIP (Advocating and Educating for Quality Improvement) model includes restorative, formative and normative approaches to support staff wellbeing and development. It was originally developed to support clinical midwifery supervision (NHS England and NHS Improvement, 2021). The restorative element enables advocacy for staff and patients, providing clinical supervision and allowing supervisees time for reflection and understanding of emotional aspects of their experiences (Chapman, 2017), which reduces burnout, stress, and absence, and improves job satisfaction.  

The formative part promotes education and development of nurses to enable them to undertake a quality improvement personal action plan. This supports a continuous improvement process to build personal and professional clinical leadership which, in turn, enhances care for patients.  

Finally, the normative element monitors and evaluates the outcome of the restorative and formative elements through review, appraisal, and revalidation (Chapman, 2017).  

RESTORATIVE CLINICAL SUPERVISION (RCS)  

PNAs are expert reflective practitioners who are self-aware, open minded and use the principles of compassionate leadership to support HCPs to reflect, reset and recover through restorative clinical supervision (RCS) sessions.  

Clinical supervision has been used in health care for a number of years, more so in mental health than general nursing (Butterworth, 2022). Bosanquet (2022) informs that there is much confusion about what clinical supervision is and is not. It is important to understand that clinical supervision is not manager led or an HR process. It is not about performance management or a checking up or finding fault process.  

RCS sessions should provide a psychologically safe place where the emotional needs of staff can be addressed confidentially without the fear of repercussions. The session should provide thinking space, promote reflection, enable personal and professional development, and encourage innovative thinking. Staff should feel more confident and less isolated because of attending RCS sessions. RCS improves communication and understanding between individuals, teams and organisations, supports staff wellbeing (Cook, 2022), develops clinical competence and knowledge, and improves patient care (Stacey et al, 2018). 

The PNA may utilise reflective models such as Gibbs reflective cycle (Bulman and Schutz, 2004), or coaching models such as GROW (Whitmore, 2017) or OARs (Miller and Rollnick, 2013), and sessions may be offered on an individual or team basis. Butterworth (2022) suggests that individual sessions should ideally be offered with an ‘expert professional from a nurse specific field or speciality’. This has been experienced in the author’s own practice, where there is an understanding and empathy between tissue viability nurses in similar situations. Equally, group supervision sessions can bring together lone workers into a collective of those with similar roles to enable peer support and learning (Chapman, 2017; Fowler and Dooher, 2010 in Butterworth, 2022).  

Many nurses are familiar with Gibbs, this reflective cycle links with the nursing process and has formed the backbone of nursing reflective practice for many years. It is based on six distinct stages that work through a particular event: description of what happened, feelings and thoughts, evaluation and analysis of the event, conclusion and action planning (Bulman and Schutz, 2004). Gibbs works well for reflecting on a singular or specific experience or event but is less helpful when reflecting on a period of time.  

GROW is a coaching model that encourages the supervisee to reflect back and look forward by considering their own questions and answers (Whitmore, 2017). It also allows the PNA to keep the session on track and guide in a semi-structured way to achieve a personal action plan. GROW is a useful tool that frames the steps of reset and recovery:  

• G Goal, what do we want to achieve (our new normal)?  
• R Reality, where are we now, where have we been?  
• O Opportunities and obstacles, what is stopping us achieving our goal, what can help us?  
• W Way forward, what do we need to do now to move on?  

While the GROW model focuses on the supervisee, the OARs model can fit within the GROW elements as it focuses on the role and actions of the PNA or supervisor in prompting:  

• O Open questioning  
• A Active listening  
• R Reflecting or re-affirming and summarising the conversation or session (Miller and Rollnick, 2013).  

Thus, mirroring the principles of compassionate leadership.