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Reflections on leadership in health visiting during COVID-19

21st July 2020

A Voices blog by Maggie Fisher, Professional Development Officer at the Institute of Health Visiting, on health visiting leadership during COVID-19.

Maggie Fisher, Professional Development Officer at the Institute of Health Visiting

During this epidemic, I have had contact with different health visiting service leads in England and the Channel Islands. During these numerous and varied conversations over the last few months, I have been struck by the huge difference good leadership has made to staff morale and services.

I noticed some key themes that seemed to emerge in organisations that appear to make a huge difference to staff morale and how they cope with the changes:

  • The importance of strong kind compassionate leadership for staff morale.
  • The difference that collaborative leadership makes by actively involving staff in the decision-making process which helps to engage and involve staff, so they do not feel ‘done to’ or ‘dictated to’.
  • How vital it is that leaders use clear open communication with weekly or daily briefings, so staff are aware of what is happening and feel connected, included and valued.
  • The importance of culturally sensitive and inclusive practices, especially around support and recovery. One size does not fit all, and a range of different support needs to be available that is inclusive of male and female staff, as well as culturally sensitive and appropriate.
  • That it is OK not to be OK – and it is a sign of courage that you can admit you feel vulnerable, these are tough times.
  • Planned recovery for staff from this pandemic, and its effects that have touched everybody’s lives, may take years to recover from the aftermath, and this is normal.
  • The need for bereavement and relationship support, and trauma-informed care.
  • The attitude of managers and the senior hierarchy appears to make a huge difference to how staff feel and cope. Kindness and compassion are key attributes, alongside listening, and clear communication.

However, the response to the pandemic has required decision-making with incomplete evidence and at a pace and scale that has not been needed before, as safety remained a top priority. Unfortunately, in some instances, this has led to more directive, top-down, command-based models of communication, rather than our preferred person-centred decision-making that lies at the centre of health visiting and nursing practice.  Health visitors have reported examples where staff have not been consulted but told they had to be redeployed, with no preparation for this, or matching of their skills so these could be used appropriately. Because of this autocratic approach, staff have not had time to hand over vulnerable families, or families who they may have had concerns over but did not meet the vulnerability criteria. This has left health visitors feeling anxious and worried about these families and a feeling they have let them down by not being able to prepare these families for their abrupt departure. Below are some direct quotes from health visitors that illustrate this (1).

“The tone of the communication from management has been hostile when questions are asked.”

“With less than a day’s notice, our service was reduced by 50% as half of us were redeployed to other areas, not necessarily ones we had any experience in. There was no opportunity to prepare our caseload or families, or conduct any kind of handover to colleagues left in post.”

“I have found myself suffering high levels of anxiety and uncertainty over the past 10 weeks but have stuck with it and tried to embrace the experience.”

“I have been told by my new manager that I may be (in redeployed role) until October and it feels like my health visiting managers have just accepted this. I miss my caseload and worry about the families I was working so intensively with before lockdown.”

“The sheer lack of communication is staggering. The District Nursing staff don’t know why we are there as there is not enough work, as they have closed a lot of their clinics and care homes are reluctant to allow them in.”

A cornerstone of health visiting practice is health visitors’ ability to build up trusting therapeutic relationships with all families, which they carefully nurture over time. For vulnerable families, this takes even longer and is more fragile, hence the distress of health visitors who had to abandon these families suddenly. The Centre for the Developing Child (2) noted that it can take 10 or more contacts with a vulnerable family to get them to engage as they often mistrust services. The importance of frequent contact underpins the success of intensive home visiting programmes like the Family Nurse Partnership.

The impact of contrasting styles of leadership is very striking, and the effects this has had on staff morale, anxiety and stress levels. Compassionate leadership is needed in a challenging environment where staff may be struggling with new ways of working and fear over the pandemic and their own health, and that of their families. Listening, responding and asking is a much more effective style of leadership.

Valuing staff skills, experience and contributions is so much more nurturing than an autocratic approach, which appears very damaging to a workforce that in many areas already feels overwhelmed, undervalued and fragile. The experience of health visitors who have been redeployed, and those that remained with a greatly increased workload, has been very different and time needs to be taken to reintegrate teams and allow for debriefing and recovery.

The pandemic has also shone a light on the many positive leadership skills of health visitors who have rapidly transformed their service models, maintained the safety of vulnerable children and families by working collaboratively across their local systems, and ensured that their staff were safe, equipped and supported to work in new ways.

There have been some inspirational examples of how the health visiting service has responded with innovative and creative ways of providing a service to families which appear to be highly valued by parents. Leaders have worked collaboratively in a sensitive compassionate way, valuing staff skills, experience and contributions. The Institute of Health Visiting will shortly be publishing some case studies to highlight the numerous ways that health visitors rose to the challenge of managing caseloads under lockdown.

Maggie Fisher, Professional Development Officer, Institute of Health Visiting

  1. Institute of Health Visiting (2020) Health visiting during COVID-19. Institute of Health Visiting
  2. Center on the Developing Child at Harvard University (2007). A Science-Based Framework for Early Childhood Policy: Using Evidence to Improve Outcomes in Learning, Behavior, and Health for Vulnerable Children http://www.developingchild.harvard.edu