The Covid-19 pandemic had a substantial impact on healthcare systems and service users, challenging service delivery and placing pressure on the workforce, while increasing the needs of vulnerable patient groups (Marmot et al, 2020). According to the Institute of Health Visiting (iHV, 2021), 0–19 services in England entered the pandemic with significant cuts to funding, heavy caseloads and reduced staffing levels. During the pandemic, these services were then required to rapidly adapt with many staff facing redeployment (iHV, 2020).
The most recent iHV survey (2023) indicated that health visitors have seen a rise in poverty, foodbank use and perinatal mental illness. The pandemic meant that more restrictions were imposed on the way in which services could be delivered. The inability to deliver the quality of care that was in line with the expectations of their role has led to reported increases in moral distress among health professionals (British Medical Association (BMA), 2021; Spilg et al, 2022) working over the pandemic period. Moral distress or moral trauma ‘refers to the psychological unease generated where professionals identify an ethically correct action to take but are constrained in their ability to take that action’ (BMA, 2021). However, the impact on staff wellbeing as a result of these factors since the pandemic has not been fully investigated.
During the height of the pandemic in March 2020, Derbyshire 0–5 services prioritised the face-to-face Day 10 universal birth visits and safeguarding. Other contacts, such as antenatal, were delivered remotely and a Single Point of Access (SPA) phone line was used to help with the demand. Staff were assigned to different workstreams depending on their own health needs and skills.
Redeployment was widespread across the service in an attempt to redistribute staff to areas that were predicted to become busier or overwhelmed. Although health visitors were identified as vital to delivering the key workstreams of the service and were exempt from redeployment, other members of the 0–19 team were redeployed, including nursery nurses and members of the Infant Feeding and Nutrition Service.
Four key areas requiring further investigation post-pandemic have been highlighted: 1) innovation and best practice; 2) quality and safety; 3) leadership of services; and 4) the wellbeing of staff and service users (Manning et al, 2021). Across all of these, there is also a need to respond to the broader socio-economic factors affecting families, and the disproportionate impact felt by the most disadvantaged (Sycamore, 2021; Morton and Adams, 2022). Therefore, this investigation aimed to understand how the pandemic affected client needs, workload and changes in service delivery, and the resulting impact on the wellbeing of staff.
Methods
The study adopted an evaluative, mixed-method design which involved two datasets. First, a quantitative secondary analysis of anonymised routine patient data was drawn from the past 5 years as a measure of service demand. Second, a qualitative primary interpretive analysis of data collected via focus groups and an interview with staff who have delivered the service during the pandemic. Ethical approval was obtained from the Northeast, Newcastle and North Tyneside 2 Research Ethics Committee and has Health Research Authority (HRA) approval.
Quantitative dataset
Data were extracted from SystmOne patient information system representing active cases from the health visitor caseload with referral dates between 1 January 2017 and 21 September 2022. After duplicates were removed, 544981 records were used in the analysis. For the individual contact events described below, the date of the event within the selected records was used, with the cut-off date for the pre-Covid-19 period being 23 March 2020 to create two categorical groups.
All cases referred before the first national lockdown date of 23 March 2020 were designated ‘pre-lockdown’ and all those on or after were designated ‘post-lockdown’. A dichotomous before and after split was chosen for this analysis as the aims of the research were focused on the broad impacts of the ongoing local and national response to the pandemic compared to prepandemic delivery.
To determine the statistical significance of findings in this section, service data were coded for a three-way analysis of variance, with factors being: 1. Period (pre-lockdown, post-lockdown); 2. Tier of service used (Universal, Universal Plus, Universal Partnership Plus, Other); and 3. Deprivation (as measured by the 10 Index of Multiple Deprivation (IMD) decile levels).
Qualitative dataset
Recruitment of staff members took place via Trust communications between November 2022 and January 2023. Staff members were selfselecting in this way to avoid any nomination and obtain a wide range of people across all localities. Staff were able to participate if they were a current employee who had worked within the 0–19 services for at least 12 months and therefore were able to provide experiences over post-lockdown service delivery.
» The qualitative findings have highlighted that one of the most prominent effects during the height of the pandemic on staff wellbeing and overall service was their experience of redeployment «
Those who expressed an interest were sent a participant information sheet and provided the opportunity to ask questions. Informed consent was obtained before scheduling a focus group and consent was reconfirmed before data collection commenced. For convenience for the participants, qualitative data collection was conducted virtually and recorded using Microsoft Teams. The focus group/interview schedules were piloted with a staff member from the Trust before being administered to the study participants.
Information on job roles, experience levels and job location was received from the participants at the beginning of data collection. The main questions for the qualitative data collection were:
A set list of prompts was provided for use with these questions to help encourage more discussion. There was a total of three focus groups and one interview conducted. Two groups contained five staff members, one group contained three and a final interview with just one staff member, which included 14 staff members distributed across groups. Lastminute cancellations caused one focus group to be reduced to a one-participant interview. It was felt that the inclusion of an interview with one participant would be the most ethical and pragmatic approach to ensure that their voice was heard in the research project.
A combination of these types of data has been used in previous studies to help enrich the data (Lambert and Loiselle, 2008) and to make pragmatic decisions about ensuring all voices are heard (Hunter and Magill-Cuerden, 2014).
All staff from the 0–5 service were invited to attend and all the focus groups contained a mix of staff roles. Two focus groups were held in December 2022 and one focus group and the interview were held in January 2023. Qualitative data collection lasted between 45 mins and 1 hour 10 minutes. Nine out of 14 participants were health visitors, with other staff groups representing the Infant Feeding and Nutrition Service, nursery nurses and management.
There were staff members representing five out of the seven place locations in Derbyshire with some staff who work across the county. The length of time that staff members had worked in 0–5 services ranged from 2 years 3 months to 20 years, with an average of approximately 8.5 years of experience. The newest member of staff joined in October 2020 and was, therefore, able to provide experiences over post-lockdown service delivery. However, all the other staff members had been at the Trust before the beginning of the pandemic.
An inductive approach to thematic analysis was utilised for the analysis, which followed a process of identifying and grouping codes (Braun and Clarke, 2006). The analysis was conducted by two researchers, whereby one researcher started the coding process and the second checked the coding to corroborate the theme descriptors. This process of co-coding was performed simultaneously during the data analysis. This was to ensure the codes applied were consistent and mitigated researcher bias (Church et al, 2019). Pseudonyms were assigned to participants to elicit direct quotes for theme illustrations.
Results
Results were analysed by the count of contacts and by the duration of contacts. The total number of contacts trend showed the expected dip in all activity at the point of lockdown around quarter two of 2020. In each quarter before this lockdown period, there were an average of 9052 universal contacts recorded, but this rose by 30% to 11882 per quarter in the post-lockdown period.
When contact time is added to the analysis, a similar pattern emerges. The average recorded time per contact across the service increased from 51.9 minutes in the pre-Covid period to 57.7 minutes after March 2020. The average time spent per contact is a measure likely to reflect case complexity. Table 1 shows that the time taken to complete a contact increased in all tiers of provision after Covid-19, but that the universal tier and ‘other services’ experienced the greatest increase. This interaction between contact tier and period was significant (F=340.33; p <0.001), as were the main effects for tier (F=741.46; p<0.001) and period individually (F=21037.80; p<0.001).
| Period | Univ | UnivPlus | UPP | Other | All contacts |
|---|---|---|---|---|---|
| Pre-lockdown | 50.8 | 52.9 | 51.0 | 53.6 | 51.9 |
| Post-lockdown | 57.8 | 56.6 | 51.8 | 60.4 | 57.7 |
| % change | +14% | +7% | +2% | +13% | +11% |
A subset of face-to-face and video consultation contacts with service users, excluding complex cases such as safeguarding, was examined to assess the impact of deprivation on service demand during the pandemic. Across the 442954 of these contacts for which IMD information was available, there was a main effect of both IMD (F=20.65; p<0.001) and Covid-19 period (F=21,203.71; p<0.001). The interaction between these factors was also significant (F=57.01; p<0.001) and showed a tendency for contact times to be similar across IMD deciles pre-lockdown, but with the least deprived areas taking more time in the period after lockdown (Figure 1).
In the qualitative findings, staff described the varying changes in service delivery. For instance, antenatal visits were suspended, and other contacts became virtual. This provided a context of what the staff experienced and its impact on wellbeing. Three major themes emerge as having significant impact: redeployment, increased workload and remote working (see Table 2).
| Themes | Sub-themes |
|---|---|
| Redeployment | Devalued and Incompetent Guilt and Anxiety |
| Increased workload | Frustration and Responsibility Stress and Moral Trauma |
| Remote working | Isolation and Loneliness Adapting and Flexibility |
Redeployment
Staff described the impact of redeployment on themselves and their colleagues. In some cases, there were inconsistencies in communication, which led to difficult experiences. This resulted in staff feeling devalued and inadequate in terms of training or skills required:
‘You felt like the rug has been pulled out from under your feet and nothing was the same.’ [Chloe] ‘I didn't feel I had the skills to go and work on an adult ward … as a healthcare assistant and, yeah, so it was quite hard.’ [Charlotte] ‘Every day, a team rushed off their feet, saying “Quickly, go out and do a catheter quick, this lady's bleeding” … and I've constantly said, “I'm sorry. I can't do that”.’ [Catherine]
Staff who were not redeployed also felt a sense of guilt for their colleagues:
‘You feel bad for the colleagues that have been redeployed.’ [Emma]
There was also disappointment felt in the lack of support received by management and a lack of understanding of the impact redeployment had:
‘You know that's what they needed to do but they needed to be a lot more supportive.’ [Chloe]
Some staff also felt like they did not have a choice:
‘What are the other options? I was told I probably wouldn't have a job to come back to.’ [Charlotte]
This level of uncertainty manifested in anxiety. For some staff, the levels of anxiety were exacerbated by fear of contracting the virus:
‘I was shipped across the city to a completely alien environment, I felt completely isolated because I was isolating from family. I got two family members that were in the shielding group.’ [Chloe]
Increased workload
An increase in workload was described as having a major impact on wellbeing. The increase in service demand, staff shortages and taking on duties from other services were all contributing factors:
‘I'm doing more enhanced reviews than I've ever done before Covid.’ [Suzanne]
The increased workload also meant staff often worked over their contractual hours:
‘I worked to try and fit everything in, the paperwork and the referral.’ [Sophie]
The staff felt frustrated that, despite identifying a family need, there was a lack of support available. Staff also suggested that when making referrals, knowing there was a long waiting list and a lack of wider services available increased their frustration:
‘That's the biggest frustration, yeah. The long waiting list.’ [Jane]
Staff also reported experiencing a sense of responsibility towards the families:
‘You get your job satisfaction from helping people, so when you can't help people it's personally painful.’ [Eve] ‘It's a constant stress that you might make a mistake, that you might not do enough, that you might not, you know, prevent something you should have prevented.’ [Freya]
This led them to experience moral trauma:
‘Your personal morals, your reason for working, your work ethic, all of those things can get impacted by something outside of your control. I feel like Covid was a massive moral trauma for us, you know, hearing the desperate need over the phone or seeing the desperate need and knowing that you are gonna fall massively short of what they needed.’ [Eve]
Remote working
The staff reflected on the impact of remote working:
‘So that's hard, that you don't see, that you don't see anybody anymore, we're all social people being nurses. We wanna help. We wanna chat. And then that's sort of been lost now. So yeah, that's been a struggle.’ [Alice]
Working from home increased their sense of isolation:
‘Working from home was really lonely.’ [Sophie]
It also had financial implications for Sophie:
‘It has a further impact on us working from home as well because we have the heating on more than we would … and things like that.’ [Sophie]
However, there were staff who described the positive aspects of working from home:
‘That flexibility of people working from home & I don't think it's all a bad thing at all.’ [Charlotte]
The staff did highlight that management put some measures in place to reduce isolation and support their wellbeing:
‘They offered a coffee group so that randomly you can be picked with somebody else in the Trust and you have a protected half hour or so for coffee.’ [Sian]
Eve described ‘Mindfulness Fridays’:
‘So every Friday we'd join a link at 12:30 for half an hour, or quarter might have even been, 15-minute, mindfulness practice.’ [Eve]
However, while some participants found this a positive experience, some found it negative due to the level of trauma they experienced during this time:
‘You know, people are having counselling because of these things that they've gone through, we don't want to chat about it in a room full of people we don't know.’ [Emma]
Finally, despite their experiences, staff recognised that this was a time of unprecedented circumstances:
‘Whether or not we met the needs of the population at the time in Covid, I doubt it. I don't think anybody did. But we, we managed to minimise the clinical risk, I think, in the best way we could without putting the staff at risk.’ [Eve]
These reflections gave them a sense that they could learn from their experiences and move forward in the delivery of their service in the future.
Limitations
This study was conducted with the community health visiting teams in Derbyshire (excluding Derby city) and was only able to look at the impact of Covid-19 on this particular geographical area. Using a single area for this study provides value in that it gives a clear picture of what has happened and is happening in Derbyshire. It has its limitations in how generalisable it is to other areas.
The widespread variation in how 0–5 services worked and responded across different local authorities and NHS Trusts during the pandemic also contributes to the difficulties in being able to generalise across different areas and organisations (Morton and Adams, 2022). This work, however, aims to inform other studies on the impact of Covid-19 concerning the social determinants of health, such as rural deprivation. It provides a case study of a community service in a county where the relatively high level of sparselypopulated rural areas provides more challenges relating to access to services and digital health service options.
The study shows the potential for participant bias where self-selection for participation in the qualitative aspect means that those who were affected more strongly are more likely to volunteer to speak. The results should be considered in this context; however, the use of focus groups meant that ideas were discussed with a range of colleagues with experiences of the whole service at the time which helped to validate the data.
Conclusions
The quantitative data confirmed that universal contacts have dramatically increased since the pandemic period and all tiers have taken more investment in duration per contact to complete. This suggests the population's needs have become more complex during this time, which has no doubt had an impact on the wellbeing of staff delivering the service.
The data revealed a pattern of families living in the least deprived areas requiring a greater level of contact in face-to-face consultations post-lockdown. This may appear counterintuitive but resonates with other findings that the pandemic may have widened health inequalities (Ford et al, 2021) in terms of struggling families’ ability to access and engage with services. Further research should be focused on exploring the role of advocacy in health visiting to empower disadvantaged families and facilitate better health outcomes (Carlisle, 2000).
The qualitative findings have highlighted that one of the most prominent effects during the height of the pandemic on staff wellbeing and overall service was their experience of redeployment. Through this experience, those who were redeployed expressed a feeling of being devalued and incompetent to work in their new setting. Not all staff groups who participated in the qualitative data collection were redeployed and those who were not redeployed felt guilty and concerned for those colleagues in their teams who had been, and all staff felt anxious about exposure to the virus while in practice.
Staff described their experiences of coping with the increased workload during the pandemic which remained elevated at the time of data collection. They conveyed a feeling of frustration for not being able to deliver the service families needed and have a sense of responsibility to them. This led to stress and moral trauma within their daily practice. Finally, they additionally described their experiences of adapting to remote working. This increased their feelings of social isolation and loneliness at work. Measures were put in place to support staff and enable them to adapt and work flexibly. However, for some, these measures were not addressing their needs to cope with their experiences.
A potential limitation of this study was the challenge in mapping specific local policy and practice to national policy in a rapidly evolving local situation over the 16 months of national Covid-19 restrictions, necessitating a broader level of analysis than originally intended. There may be potential in future research to unpick the detailed local timeline and examine how the nature of engagement with families; for example, switching to a video consultation approach, resultingly changed during this period. Reviewing case records and interviewing families using the service may support this approach.
Valuable lessons can be learnt from these findings concerning understanding how service pressures and increased workload have an impact on the wellbeing of the staff. Staff should be supported with adequate resources to help manage their personal responsibility when situations are beyond their control to minimise the impact this has on their wellbeing.
These opportunities for staff to be supported need to be cascaded through the organisation to ensure staff feel listened to during times of service pressure. It would also be useful to identify and define the specific dimensions of stresses that are felt individually (e.g. moral distress/trauma, workload pressure) so that attempts could be made to mitigate the risks in future and provide targeted support. This could be in the form of a staff wellbeing recovery plan, which not only promotes positive wellbeing, awareness and maintenance of our mental health but also takes into account the environment and culture of the workplace, the psychological needs of the team and highlights available support through the team, service and wider organisation.
Since April 2021, the children's service has started to put into place offers from the Trust clinical psychology team, including and extending beyond wellbeing interventions, such as team building, wellbeing days for teams focusing on resilience and individual psychological first aid support when needed; for example, after traumatic events. The team has taken a fully embedded approach to developing a more compassionate workplace to help support the service. They have implemented more restorative practices and promote the importance of strong governance structures, connectedness and psychological safety to help provide a more sustainable workforce.