PNAs and reflective practice in mental health services


South West London an St. George’s Mental Health NHS Trust.

What was the aim/problem?

Access to consistent, supportive, and high-quality spaces for reflective practice is challenging across many mental health services. We recognise this is not just a local issue and affects nursing colleagues throughout the country. The theory and knowledge underpinning clinical supervision is well embedded in mental health nursing, but the application is somewhat disparate. By virtue of the profession, nurses can (consciously or unconsciously) neglect our own well-being and not putting our own oxygen masks on, in favour of focusing their energies on providing the highest of quality of care of people we provide support for. This is not sustainable; we have to ensure we look at ourselves and one another just as well as we look after anyone who accesses the services we provide. Enabling nurses across of the organisation to have access to spaces to process the experiences we face in our work with good governance underpinning this was vital. This need had been corroborated through feedback from our preceptorship programmes, student nurses, informal discussions with nurses throughout the organisation and appreciative inquiries. Reflective practice would offer this linguistic space in which nurses would be able to consider, explore and reflect on the challenges they face in their work.

What was the solution?

The Nursing Development Team (NDT) at South West London & St. George’s Mental Health NHS Trust work across the organisation and facilitate pre-registration and post-registration professional development programmes. The ask from nurses in the trust was clear and it was really important that if nurses wanted to access and facilitate reflective practice spaces, they had to be suitably prepared and feel empowered to do so.

Our approach was two pronged: we sought and commissioned reflective practice training which nurses in the organisation were able to apply to take part in. The training was bespoke for the needs of the trust and in turn enabled us to develop a community of practice for anyone who completed the course. We also developed a project which would facilitate people with lived experience of access mental health services either directly or as a carer to work alongside student nurses during their practice placements in the trust to offer a triangulated approach with students and practice assessors / supervisors, offering a greater breadth and depth of feedback from multiple perspectives with a critical friend approach.

What were the challenges

The demand for the reflective practice training was much higher than expected which meant the application process took slightly longer and some staff were added to a waiting / reserve list in order to ensure there was equitable representation from all services in the trust. It is without doubt that the coronavirus pandemic was very much an unexpected challenge and meant maintaining momentum with competing demands proved difficult at times, but continued support from senior nurses in the trust ensured we were still able to progress as planned. In addition, moving rapidly to a more virtual way of working proved difficult as not everyone had access to the IT infrastructure or physical spaces to enable good engagement in the initiative, we worked through this on a case-by-case basis and were as creative as possible.

At times during the pandemic, face to face visitors were reduced and virtual visits were encouraged to reduce risks of transmission of the virus. This informal support from family and friends whilst someone may be an inpatient is of vital importance and meant the initiative with the professional nurse advocate programme was timely to support the nursing staff and ensuring we provide the best of care.

The lived experience element of the initiative saw several delays because of changes to way student nurses were on placement in the organisation but we maintained engagement through virtual workshops. Open and honest conversations were key to overcoming all of the challenges and finding collaborative solutions.

What were the results?

We have seen significantly higher demand from clinical services requesting reflective practice, either individually or as group sessions and although there is not hard data to prove this, it would suggest nurses are experiencing the benefits of reflective practice actively seeking out the support. Measuring the quality impact of this would be done over time through staff surveys, improved recruitment and retention levels,

The lived experience practitioner element of the initiative has had profound effects for all those who took part. Although the pilot was small there is significant scalability and translatability across other clinical services which could also impact placement capacity in the organisation. Quotes from those that took part include:

It is so important that the nurses hear from people with lived experience because the whole nursing concept is to empathetically interact with patients. By talking and listening to the LXPs, nurses can gain valuable person to person insight into what it feels like to be a patient and what matters to the patient. This aids the whole therapeutic experience” – Lived Experience Practitioner

I found the session incredibly inspiring. When the LXP open to us about her story, she mentioned that it can trigger but throughout the entire session, she was strong and empowering” – Student Nurse

What were the learning points?

  • Reflective practice is vital for all nurses and ensuring those who facilitate sessions have been provided with training and feel suitably prepared to delivering sessions is key.
  • Developing a community of practice for mutual support was greatly beneficial to maintain momentum but also the commitment from those who completed the training to use their skills and expertise.
  • We developed a ‘referral form’ for services requesting reflective practice which meant there were good audit trails but also that each facilitator did not become overstretched themselves.
  • The value of promoting inclusivity on every level.
  • If nurses were to receive 1 hour every 6 weeks of reflective practice / clinical supervision, this equates to around 1 working day per year. This is not a lot to ask for and should be an essential element of our practice.

Next steps

  • Review our clinical supervision policy to include this initiative and learning points.
  • Ensure that elements of practice such as reflective practice underpin all trust strategy and trust values.
  • Formally evaluate learnings and seek to share / publish.

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