The extent to which home visiting programmes in the US can achieve high-quality implementation depends on the service delivery system – or implementation support system. Prior research has identified three different levels of the home visiting system: system level, organisational level, and the service delivery level. Organisational level influences on implementation quality include organisational climate, which includes leadership capacities (Ryan et al, 2021). Effective leadership has been identified as a key implementation support, but it also has the potential to influence other aspects of a programme, including organisational climate, communication, and establishing a collective vision (Durlak, 2013; Kirby et al, 2020).
It must be acknowledged that there are a variety of approaches to leadership. An approach or style to leadership can be defined by the behaviours exhibited by an individual in a formal position of authority designed to drive a group towards a goal, with many leaders having their own style (Bass and Bass, 2009; Northouse, 2021). For example, leadership is key to driving a programme's ability to respond to changes and/or emergent needs, including COVID-19 (Roben et al, 2022).
Leadership and supervision are a critical aspect of workforce development for home visiting programmes, and research has illustrated the need to understand how leadership can mitigate implementation barriers (Azzi-Lessing, 2013; Boller et al, 2014). Leaders exhibiting clear communication, trust and empathy have lower employee burnout (Gabel, 2012; Begic et al, 2019). In contrast, home visitors who perceive a lack of supervisory support had lower levels of client engagement (Jones Harden et al, 2010; Burrell et al, 2018). Yet, a large national study of home visiting recently noted that home visitors are not receiving the recommended number of hours of supervision recommended by their evidence-based model (Duggan et al, 2018).
To our knowledge, there has not yet been a leadership assessment of home visiting supervisors, by supervisor and the home visitors that they supervise. Thus, work is needed to assess leadership skills and components among supervisors of home visitors in the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) programme. The purpose of this study was to assess leadership skills and competencies among supervisors, and to identify strengths and areas for growth using a sample of MIECHV home visitors and supervisors in South Carolina (SC).
Findings from this study can be used by the home visiting community to target training efforts for home visitors and supervisors, to improve workforce development in the home visiting field and to improve implementation for home visiting clients.
Methods
Children's Trust of South Carolina, a state leader in improving the health and wellbeing of SC families and children, serves as the lead agency for the SC MIECHV programme. The aim of the SC MIECHV programme is to provide voluntary home visiting services to at-risk families with the intent of preventing child abuse and neglect, and improving health, development, and early learning outcomes of its participants. The SC MIECHV programme is locally implemented by different agencies across the state, including health departments, non-profit organisations, hospital-based and other clinics, and primary medical homes. Each local agency selects a MIECHV-approved, evidence-based home visiting model for implementation. In the 2021–2022 reporting year, 15 MIECHV-funded agencies delivered services through three different evidence-based home visiting models (Nurse-Family Partnership, Healthy Families America, Parents as Teachers) to reach participants in 38 of the 46 SC counties. Two MIECHV lead implementing agencies implement multiple home visiting models to serve their community's needs.
The SC MIECHV evaluation team collaborated with an Evaluation Advisory Board, comprised of a group of supervisors and home visitors representing lead implementing agencies (LIAs), to identify a set of qualities, characteristics, and skills specific to leadership in home visiting. Then they created an evaluation tool to assess comprehensive, high-quality leadership (CHQL) among programme supervisors. All MIECHV supervisors and home visitors (76 total) were invited to complete the online CHQL leadership assessment survey via Qualtrics in February 2023. The survey gathered information on demographics and each identified component of CHQL (see Appendix A, at the end of this article). Supervisors were asked to complete the tool as a self-assessment, while home visitors were asked to rate their supervisor. An incentive was provided for each respondent ($30/survey).
Descriptive statistics were calculated using SAS, version 9.3 (SAS Institute Inc.). CHQL component scores were created using the following process: first we assigned a number value to each Likert response choice (1=area for growth, 2=needs attention, 3=meets standards, 4=excels in practice); second, we calculated the average of all survey items within each component; third we categorised mean component scores back into the Likert scale for ease of interpretation. For reporting, Likert response choices ‘area for growth’ and ‘needs attention’ were collapsed into one category. The study was deemed non-human subjects by the Institutional Review Board.
Results
All SC MIECHV home visitors and supervisors (100%; n=76) responded to the survey; 74% (n=56) were home visitors and 26% (n=20) were supervisors. Respondents represented all three MIECHV-funded home visiting models: Nurse Family Partnership (n=34; 45%), Healthy Families America (n=20; 26%), and Parents as Teachers (n=22; 29%). All respondents were female and full-time employees (100%). Of the home visitors who responded (n=56), most were in their 30s (32%) or 40s (30%), identified as White (45%) or Black (43%) and said English was their native language (91%; Table 1).
| Home visitors (n=56) | Supervisors (n=20) | |||
|---|---|---|---|---|
| Frequency | Percentage | Frequency | Percentage | |
| Age | ||||
| 22–29 | 5 | 8.9 | 0 | 0.0 |
| 30–39 | 18 | 32.1 | 7 | 35.0 |
| 40–49 | 17 | 30.4 | 6 | 30.0 |
| 50–59 | 12 | 21.4 | 5 | 25.0 |
| 60 or over | 4 | 7.1 | 2 | 10.0 |
| Ethnicity | ||||
| White | 25 | 44.6 | 10 | 50.0 |
| Black | 24 | 42.9 | 9 | 45.0 |
| Asian | 1 | 1.8 | 0 | 0.0 |
| Mixed race or unknown | 6 | 10.7 | 1 | 5.0 |
| Hispanic | 6 | 10.7 | 2 | 10.0 |
| Non-Hispanic | 47 | 83.9 | 17 | 85.0 |
| Other | 3 | 5.4 | 1 | 5.0 |
| Native language | ||||
| English | 51 | 91.1 | 18 | 90.0 |
| Spanish | 4 | 7.1 | 2 | 10.0 |
| Japanese | 1 | 1.8 | 0 | 0.0 |
| Highest level of education | ||||
| Associate's Degree | 7 | 12.5 | 1 | 5.0 |
| Bachelor's Degree | 37 | 66.1 | 14 | 70.0 |
| Master's Degree | 10 | 17.9 | 5 | 25.0 |
| Some college, no degree | 1 | 1.8 | 0 | 0.0 |
| Technical or vocational school diploma | 1 | 1.8 | 0 | 0.0 |
Home visitors primarily had at least a bachelor's degree (66%) or a master's degree (18%). Of the supervisors who responded (n=20), most were in their 30s (35%) or 40s (30%), identified as White (50%) or Black (45%), and said English was their native language (90%). Supervisors primarily had at least a bachelor's degree (70%) or a master's degree (25%).
The majority of home visitors and supervisors had degrees in the field of nursing or education and had more than 6 years of home visiting experience (Table 2). Most home visitors' salaries ranged from $50 000 to $74 999 (54%) and over half of home visitors said they were either somewhat satisfied (55%) or very satisfied (14%) with their salary. Most supervisors' salaries ranged from $50 000 to $74 999 (45%) or from $75 000 to $99 999 (30%). The majority of supervisors were either somewhat satisfied (45%) or very satisfied (30%) with their salary. That said, 30% of home visitors and 25% of supervisors said they were not at all satisfied or somewhat dissatisfied.
| Home visitors (n=56) | Supervisors (n=20) | |||
|---|---|---|---|---|
| Frequency | Percentage | Frequency | Percentage | |
| Educational field | ||||
| Nursing | 26 | 46.4 | 8 | 40.0 |
| Education | 9 | 16.1 | 5 | 25.0 |
| Social work | 7 | 12.5 | 4 | 20.0 |
| Psychology | 4 | 7.1 | 0 | 0.0 |
| Business/business management | 3 | 5.4 | 0 | 0.0 |
| Other | 1 | 1.8 | 1 | 5.0 |
| Counselling | 1 | 1.8 | 0 | 0.0 |
| Human services | 1 | 1.8 | 0 | 0.0 |
| Interdisciplinary studies | 1 | 1.8 | 0 | 0.0 |
| Library and information science | 1 | 1.8 | 0 | 0.0 |
| Sociology | 1 | 1.8 | 0 | 0.0 |
| The arts | 1 | 1.8 | 0 | 0.0 |
| Master of Divinity | 0 | 0.0 | 1 | 5.0 |
| Public health | 0 | 0.0 | 1 | 5.0 |
| Number of years of home visiting experience | ||||
| Less than 1 year | 6 | 10.7 | 1 | 5.0 |
| 1–2 years | 6 | 10.7 | 0 | 0.0 |
| 3–5 years | 16 | 28.6 | 3 | 15.0 |
| 6–10 years | 17 | 30.4 | 12 | 60.0 |
| More than 10 years | 11 | 19.6 | 4 | 20.0 |
| Salary | ||||
| $20,000 to $34,999 | 4 | 7.1 | 0 | 0.0 |
| $35,000 to $49,999 | 15 | 26.8 | 3 | 15.0 |
| $50,000 to $74,999 | 30 | 53.6 | 9 | 45.0 |
| $75,000 to $99,999 | 4 | 7.1 | 6 | 30.0 |
| Prefer not to say | 3 | 5.4 | 2 | 10.0 |
| Salary satisfaction | ||||
| Not at all satisfied | 5 | 8.9 | 2 | 10.0 |
| Somewhat dissatisfied | 12 | 21.4 | 3 | 15.0 |
| Somewhat satisfied | 31 | 55.4 | 9 | 45.0 |
| Very satisfied | 8 | 14.3 | 6 | 30.0 |
The most frequent CHQL components that home visitors assessed their supervisors as an area for growth or needing attention were: Experience in the Field; Fiscal Management; Advanced Skills and Education; Clear, Flexible, and Adaptive Approach; and Diversity, Equity, and Inclusion (Table 3). The most frequent CHQL components that supervisors self-assessed as an area for growth or needing attention were: Fiscal Management; Community and Early Childhood Systems Development/Resource coordination; Experience in the Field; Use of Programme Data; Programme Vision; Advanced Skills and Education; and Advocates for Home Visiting (Table 4).
| CHQL component | Area for growth and needs attention | Meets standards | Excels in practice | I don't know or missing | ||||
|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | |
| Experience in the Field | 14 | 25.0 | 11 | 19.6 | 23 | 41.1 | 8 | 14.3 |
| Fiscal Management | 10 | 17.9 | 12 | 21.4 | 12 | 21.4 | 22 | 39.3 |
| Advanced Skills and Education | 7 | 12.5 | 37 | 66.1 | 12 | 21.4 | 0 | 0.0 |
| Clear, Flexible, and Adaptive Approach | 7 | 12.5 | 36 | 64.3 | 13 | 23.2 | 0 | 0.0 |
| Diversity, Equity, and Inclusion | 7 | 12.5 | 26 | 46.4 | 23 | 41.1 | 0 | 0.0 |
| Community and Early Childhood Systems Development/Resource Coordination | 4 | 7.1 | 30 | 53.6 | 22 | 39.3 | 0 | 0.0 |
| Programme Vision | 4 | 7.1 | 23 | 41.1 | 27 | 48.2 | 2 | 3.6 |
| Good Communication | 4 | 7.1 | 17 | 30.4 | 35 | 62.5 | 0 | 0.0 |
| Reflective Supervision | 3 | 5.4 | 35 | 62.5 | 17 | 30.4 | 1 | 1.8 |
| Targeted Problem Solving | 3 | 5.4 | 26 | 46.4 | 27 | 48.2 | 0 | 0.0 |
| Supervisor Self-Awareness | 3 | 5.4 | 10 | 17.9 | 35 | 62.5 | 8 | 14.3 |
| Positive Relationships with Staff | 2 | 3.6 | 25 | 44.6 | 29 | 51.8 | 0 | 0.0 |
| Advocates for Home Visiting | 2 | 3.6 | 15 | 26.8 | 39 | 69.6 | 0 | 0.0 |
| Empathy | 2 | 3.6 | 10 | 17.9 | 43 | 76.8 | 1 | 1.8 |
| Promotes Self-Care | 1 | 1.8 | 10 | 17.9 | 45 | 80.4 | 0 | 0.0 |
| Use of Programme Data | 1 | 1.8 | 7 | 12.5 | 43 | 76.8 | 5 | 8.9 |
| Responsiveness and Timely Follow-Up | 0 | 0.0 | 15 | 26.8 | 41 | 73.2 | 0 | 0.0 |
| CHQL component | Area for growth and needs attention | Meets standards | Excels in practice | I don't know or missing | ||||
|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | |
| Fiscal Management | 13 | 65.0 | 5 | 25.0 | 0 | 0.0 | 2 | 10.0 |
| Community and Early Childhood Systems Development/Resource Coordination | 6 | 30.0 | 11 | 55.0 | 3 | 15.0 | 0 | 0.0 |
| Experience in the Field | 4 | 20.0 | 3 | 15.0 | 13 | 65.0 | 0 | 0.0 |
| Use of Programme Data | 3 | 15.0 | 9 | 45.0 | 8 | 40.0 | 0 | 0.0 |
| Programme Vision | 2 | 10.0 | 17 | 85.0 | 1 | 5.0 | 0 | 0.0 |
| Advanced Skills and Education | 2 | 10.0 | 16 | 80.0 | 2 | 10.0 | 0 | 0.0 |
| Advocates for Home Visiting | 2 | 10.0 | 14 | 70.0 | 4 | 20.0 | 0 | 0.0 |
| Diversity, Equity, and Inclusion | 1 | 5.0 | 17 | 85.0 | 2 | 10.0 | 0 | 0.0 |
| Clear, Flexible, and Adaptive Approach | 1 | 5.0 | 16 | 80.0 | 3 | 15.0 | 0 | 0.0 |
| Promotes Self-Care | 1 | 5.0 | 6 | 30.0 | 13 | 65.0 | 0 | 0.0 |
| Reflective Supervision | 0 | 0.0 | 18 | 90.0 | 2 | 10.0 | 0 | 0.0 |
| Good Communication | 0 | 0.0 | 17 | 85.0 | 3 | 15.0 | 0 | 0.0 |
| Targeted Problem Solving | 0 | 0.0 | 12 | 60.0 | 8 | 40.0 | 0 | 0.0 |
| Positive Relationships with Staff | 0 | 0.0 | 11 | 55.0 | 9 | 45.0 | 0 | 0.0 |
| Supervisor Self-Awareness | 0 | 0.0 | 11 | 55.0 | 8 | 40.0 | 1 | 5.0 |
| Responsiveness and Timely Follow-Up | 0 | 0.0 | 6 | 30.0 | 14 | 70.0 | 0 | 0.0 |
| Empathy | 0 | 0.0 | 1 | 5.0 | 19 | 95.0 | 0 | 0.0 |
Discussion
This is the first study, to our knowledge, to examine and assess home visiting leadership among home visiting supervisors by themselves and by the home visitors they supervise. Prior work looked at home visitor readiness but had not assessed leadership capabilities among home visiting supervisors (Nathans et al, 2019). Earlier research called for the need ‘to examine home visitors' perceptions of supervision needs’ and this is one of the first studies to do so (Nathans et al, 2019).
This work highlights several future areas for training of supervisors and emerging leaders in home visiting. Future training topic areas for supervisors in this study may include some of these CHQL components that were rated as an area for growth or needing attention by both home visitors and supervisors, such as Experience in the Field, Fiscal Management, and Advanced Skills and Education.
Interestingly, home visitors and supervisors did not always align in their assessment of the needs for growth or improvement in leadership. Supervisors may not be able to reflect on their weaknesses, thus making the anonymous survey of home visitors an important part of this study. The top components where home visitors ranked their supervisors as an area for growth or needing improvement were Experience in the Field, Fiscal Management, Advanced Skills and Education, Clear, Flexible, and Adaptive approach, and Diversity, Equity, and Inclusion. The top components where supervisors ranked themselves as an area for growth or needing improvement were Fiscal Management, Community and Early Childhood Systems Development/Resource Coordination, Experience in the Field, Use of Programme Data, Programme Vision, Advanced Skills and Education, and Advocates for Home Visiting.
Funding for programmes to incentivise and invest in skills and education for supervisors may help to improve the leadership abilities of home visiting supervisors, who may not be able to improve in this area without further support. Fiscal management training by state leads, both to home visiting supervisor groups and one-on-one, could be useful to supervisors as they manage their lead site programme funding. While little can be done to rapidly improve experience in the field, in a job with high turnover rates, peer support among supervisors can help to create a network for them to share things that did and didn't work with their employees. As well, establishing a formal mentoring programme for supervisors may be beneficial and create a sense of empowerment (Lee et al, 2013).
Supervisors may benefit from guidance on managing job responsibilities that are new to them when they transfer from home visitor to supervisor such as expanded workloads, managing of people, human resources training, and organising budgets and additional paperwork (Alitz et al, 2018). Home visiting programmes have recently begun to implement further supervision training (Duggan et al, 2018), and there is currently a formalised leadership academy being implemented from the federal MIECHV programme to states.
States are often tasked to develop these trainings on their own, with such programmes as SC MIECHV's leadership academy, which is tailored to state programme-specific needs. However, if an assessment of supervisory needs is not done, it is difficult to plan for such academies, underscoring the usefulness of the findings from this study's survey.
Strengths and limitations
There are several strengths and limitations to this study. This is the first study to assess home visiting leadership competencies among supervisors, and by home visitors rating their supervisors. Therefore, this study may be highly beneficial to state leadership who manage and train home visiting supervisors. Limitations of this study include the use of a single state survey with a small sample size (n=76).
Conclusions
This study shares important findings on the role of leadership competencies among home visiting supervisors, rated by themselves and their subordinates. Data collection from this study could be generalisable to other home visiting programmes to assess leadership and subsequent training needs for their programmes.
Findings from this study can be used to tailor leadership trainings for home visiting supervisors across programmes.