Background As COVID-19 hit the UK, it was apparent that frontline healthcare workers would be faced with challenges they had never encountered before. The longer-term leadership support needs of nurses and midwives were considered central to how they would psychologically emerge from the COVID-19 response. In response, a national leadership support service for nurse and midwife leadersat all levels, was rapidly established.
Methods A collaborative approach was used, drawing from an established community of healthcare leadership development consultants and senior healthcare leaders. Practical plans for how the service would run were formulated via online meetings, held between February and March 2020. An internal questionnaire was distributed to attendees, requesting demographic data and feedback to capture the perceived impact of the service on leadership.
Results Overall, confidence in leadership ability/skills increased after attending the service; 68.8% of those who completed post-attendance questionnaires reported having learnt new leadership skills and a motivation to facilitate co-consulting sessions for their teams. The service was positively appraised and there were reports of a degree of influence on leadership, and improved confidence after attending.
Conclusion Leadership and well-being support provided by an independent and external organisation can offer a unique and safe forum for reflection and for healthcare leaders to decompress. This requires a sustainable investment to mitigate the predicted impact of the pandemic.
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In this article, we discuss the creation of Nightingale Frontline (NF), a national leadership support service for nurses and midwives during the COVID-19 pandemic. Leadership is essential for supporting the additional challenges and extraordinary responsibilities during a crisis.1 Such issues can be suitably managed by leaders who are closest to the concerns raised by staff2 3 and possess the essential skills and values to effectively manage crisis situations. For instance, flexible, critical thinking can facilitate change and support well-being.4 While nurse and midwife leaders were in a position to make decisions to effectively manage and support teams, the UK’s top-down approach failed to draw on the combined intelligence and leadership talent of frontline nurses and midwives.5 To enable the continued guidance and well-being of healthcare teams after this crisis, ongoing leadership would be critical.6–9
The Florence Nightingale Foundation (FNF) (the FNF is a UK-based charity organisation that exists to support the leadership development of nurses and midwives)10 believed that how nurses and midwives would psychologically emerge from the COVID-19 response would be dependent on the support they received. Support via external organisations is thought to offer a psychologically safe space for individuals to speak openly and honestly.11 12 However, existing interventions(examples of well-being interventions include reflective practice,13 critical incident stress debriefing14 and mindfulness stress reduction15), involving peer support,16 are often not available to all staff or lack continuity.14 17 An argument existed for a virtual service that could offer support in real time. With this knowledge, FNF refocussed its activity on creating NF. The objectives were to provide a safe space to deliver leadership support, allow attendees to identify strategies for self-care and explore current and future leadership challenges.
Setting up NF
FNF formed a workforce of highly skilled facilitators from an established community of healthcare leadership development consultants and senior healthcare leaders. The structure, process and guidance for sessions were devised collaboratively. Weekly meetings provided the basis for facilitators to reflect on session content and continually adjust and improve the process. Facilitators were required to have a recognised postgraduate coaching qualification. Onboarding involved providing facilitators with information and minutes of previous meetings, in relation to NF. Non-participatory observations of existing sessions were undertaken, and (based on personal characteristics) facilitators were given the option to choose sessions they felt comfortable running. For example, a male facilitator may have chosen to run a session of all male attendees. The number of sessions was split equally between the number of facilitators on a monthly rota. Debriefing sessions were provided to support facilitator well-being.
National Health Service (NHS) organisations used funds distributed by NHS Charities Together.18 NHS Charities Together is a national, independent, network of over 240 charities across the UK, providing funds to support NHS staff and projects offering well-being support for NHS staff.19 The service was advertised via social media and promoted through FNF’s networks. The NHS England People Directorate (The NHS England People Directorate provide a focal point for the delivery of the NHS People Plan 2020/21. Part of this plan is to support the well-being of NHS staff at national level)20 and Chief Nursing Officer for England (The Chief Nursing Officer works strategically to deliver workforce priorities for nursing and midwifery) endorsed the service. Once established, FNF disseminated a video (online supplemental material) describing the service, to share the themes of the sessions and influence continuous investment in forums which support psychological safety.
Each session is held for 3 hours with a maximum of six attendees per group. Each attendee has the opportunity to take up the role of ‘client’ or ‘consultant’. The client presents a real and current work problem/situation that is not neatly defined. The consultant role is to establish a supportive and challenging consultancy relationship to help the client develop their understanding of what is going on and to think about what they might do to improve things.
The consultant monitors time and session structure (table 1). Open questions are used to: establish what is problematic; widen the description of the issue raised; establish connections between people and events; understand any power dynamics; explore how meaning is being constructed and refine potential work-based solutions. After one session, attendees are encouraged to self-organise subsequent sessions. It was not possible (ethically or practically) to record NF sessions.
Each group is guided through a structured process known as co-consulting, which combines peer coaching with action learning. Co-consulting is a methodology that enables leaders to develop coaching skills through a process of double-loop learning.21 Double-loop learning allows the person attending the session to engage in a ‘continual process of in depth learning’22 (p26) about their own and others experiences. Transformative learning was introduced by Mezirow,23 who suggested that individuals can be transformed through a process of critical reflection. Influences on the theory include the work of Paulo Freire (1921–1997) and constructivist thought. Freire describes what he calls the process of conscientisation, by which individuals ‘achieve a deepening awareness of both the sociocultural reality which shapes their lives and… their capacity to transform that reality through action on it’24 (p27). For Mezirow,23 the role of the educator is to help the learner focus on and examine the assumptions that underlie their beliefs, feelings and actions; to assess the consequences of these assumptions; to identify and explore alternative sets of assumptions and to test the validity of assumptions through effective participation in reflective dialogue. Hence, transformative learning involves developing reflective and critical thinking, being open to the perspectives of others and less defensive (and accepting) of new ideas. This is considered to bring about strategic changes within teams, enabling growth and positive relationships. Problems can be explored and solved without telling people what to do.
NF commenced on 6 April 2020. Over the first 6 months, 37 NHS organisations and 1374 individuals attended; 21 facilitators ran 332 sessions. Internally prepared post-service questionnaires were used to capture demographic data and feedback from attendees (tables 2 and 3, figure 1). With permission, attendees provided self-assessment data regarding perceived impact of the service on leadership. We followed FNF’s policy on ethical conduct for evaluation and research. Personal information was considered confidential and maintained on FNF’s secure information security management compliant service, observing the UK guide to general data protection regulation.25 Data were deidentified prior to commencing the analysis and qualitative comments examined (CB & JM) to ensure respondents could not be inadvertently identified via the content.
Those who completed (n=64) (completion rate=4.7%) questionnaires were predominantly female (87.5%) and aged 44.84 years (SD=8.53). Overall, NF was rated 8.39/10. Overall, 88.6% of survey respondents said they would recommend the service.
It has been our intention, through this brief report, to share insights concerning how NF was set up, the underpinning concepts and insights from those who attended. Previous evidence indicated that well-being support would be critical for the healthcare workforce through the pandemic.6–8 The data we obtained indicated that receiving support had the biggest personal impact on those who attended NF. However, in terms of well-being and in the absence of any measure, it is not possible to ascertain whether NF had a direct effect on well-being by itself.
It was anticipated that the educational concepts, employed in the design of NF, would offer nurse and midwife leaders the opportunity to share, reflect and solve the problem of some of the dilemmas they encountered.23 The data we received showed that NF was positively evaluated, and there was some influence on leadership. Overall, confidence in leadership ability was perceived to have increased as a result of attending a NF session—68.8% of those who completed a post-attendance questionnaire (n=64) reported having learnt new leadership skills through engaging with the service. Attendees described having used co-consulting methodology among their own teams, which demonstrates the potential influence of NF on healthcare personnel more broadly. We believe that reported satisfaction may be the result of having felt invested in at a time when there was a need for increased support. Thus, we will continue to offer NF as a resource to sustain the support required, which is necessary to enable nurses and midwives to continue to lead and care for their patients, staff and the NHS.
The data presented in this report are from our initial assessment, which is limited owing to a low response rate. This makes it difficult to generalise the effect(s) on leadership. Nevertheless, qualitative feedback highlights the value of NF for building self-confidence. The comments we have presented also show how NF provided an environment that supported individuals emotionally, prompted reflection and problem solving and improved communication in teams. Opportunities for improvement include offering more than one session and designing future questionnaires such that they are able to capture both pre-attendance and post-attendance data—paired so that any effects of attending NF can be accurately appraised. Accepting that well-being is a multidimensional concept,26 future questionnaires should also incorporate a more robust measure of well-being. This approach will expand understanding regarding the impact of NF on leadership, and well-being.
Leadership support provided by an independent and external organisation can offer a unique and safe forum for reflection and for healthcare leaders to decompress. This requires a sustainable investment to mitigate the predicted impact of the pandemic on compassion fatigue, burnout and workforce attrition.
Patient consent for publication
This study does not involve human participants.
The Florence Nightingale Foundation would like to thank those who completed service evaluations. It has been our privilege to provide support to help so many nurse and midwife leaders during the COVID-19 pandemic.
Contributors CB analysis of evaluations; conceptualisation of intellectual content of manuscript; produced initial draft of manuscript; revised manuscript after all author comments. GS conception and planning of service outlined in manuscript; conducted sessions described in manuscript; reviewed manuscript. JM conducted sessions described in manuscript, appraisal of qualitative data; drafted 'Fig'; reviewed manuscript. GW conception and planning of service outlined in manuscript;
conducted sessions described in manuscript; reviewed manuscript.
Funding CB was supported by an Economic and Social Research Council doctoral studentship—grant number ES/P000711/1.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Author note Professor Greta Westwood is CEO of the Florence Nightingale Foundation (FNF), she was awarded a CBE in the New Year Honours List 2021 for services to Nursing and Midwifery.
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