Qualitative focus group findings reflected the experiences of n = 98 MPHs delivering services to children and youth and their families throughout the early days of the COVID-19 pandemic. Demographic information (gender, mental health provider role, years of service) of the sample is summarized in Table 2. The majority of participants were female (n = 82), and most of the participants had been employed in this field between 5 and 20 years. Participants worked in a wide range of professions in pediatric mental health, including roles of social worker, counsellor, psychiatrist, nurse, supervisor and various alternative mental health roles. Due to the large number of professional role designations, all participants are referred to MHPs hereafter.
Participants noted that providing mental health services during the early months of the COVID 19 pandemic was an unprecedented and ‘incomparable’ experience, with many struggling in experiencing the pandemic alongside the youth and their families with whom they worked. As one provider highlighted succinctly: “This is likely the first time that we as therapists are experiencing the same trauma or the same type of – I guess you can call it incident trauma whatever – as our clients are, and so we are trying to figure out how to navigate this while at the same time hold space and support not only [for] our staff but also our clients (FG9).” Three major themes developed from inductively analyzing the transcripts. First, MHPs reflected on what it was like to rapidly transition to virtual care and working from home to comply with public safety measures. Second, many providers conversely discussed their complicated feelings about working onsite during the pandemic and the mental health toll and stress of working outside of the home. Finally, while discussing their shift from in-person to virtual care, many MHPs experienced high levels of stress, exhaustion and burnout at work, with diminished boundaries between their personal and work lives.
Shift to virtual delivery and work from home
With the outbreak of the COVID-19 pandemic in March 2020, the mode of delivering mental health services moved rapidly from in person to virtual care due to new public health guidelines. As demonstrated by one provider: “Everything’s online, everything. The whole like medium of service delivery has completely changed and it changed within two weeks (FG2).” Many MHPs reported experiencing increased demands, and needed to concisely communicate changes in service delivery to their clients and reassure them that services would continue. As one participant noted: “I just remember sort of being both physically and like mentally exhausted … the anticipation of like potentially disappointing families that we couldn’t provide the service that they had hoped to gain from us or were gaining from us (FG6).” The pressure to inform clients to the shift in delivery, without knowing precisely for how long this type of care would be delivered was equalled by the pressure to quickly learn new modes of delivering mental health services. Some MHPs also felt that the shift in service modality lessened the perceived efficacy of their clinical work, as one noted: “In terms of the staff, a theme that has come up a lot is that they have been feeling just not very effective … (FG9).” Many providers stressed that they were concerned that they were not able to serve their client’s as effectively as prior to the pandemic, while balancing multiple changes and adapting their practice to providing services virtually.
Providers found that shifting to virtual delivery and work from home decreased variety in their days. Many saw an increase in monotonous computer work and highlighted that their focus and attention were diminished due to the newfound repetitive nature of their work. Some providers noted that previously their work had been mobile and provided diverse daily opportunities, however all this changed rapidly and their days now consisted of hours of computer time. As one provider elaborated, in the past: “our job used to be so diverse. Sometimes we were on the computer when we were report writing, sometimes we were in the office, sometimes we were out in the sunshine, even if you were just driving to a visit… now everything is on a screen for so much more of our day than it used to be. It didn’t used to be actually 8 hours a day (FG5).” Spending increased amounts of time at the computer appeared to diminish some providers feelings of satisfaction with their work.
MHPs noted that while working from home they felt less connection to co-workers and clients, as highlighted by one provider: “it’s like, oh it’s COVID, oh, you can’t see anybody. So I felt like I was completely cut off from, not only my clients that I only just had a few in person sessions with, but also the whole team (FG11).” One provider succinctly highlighted the increased feeling of isolation that many other MHPs touched on: “I mean at home you always feel a little bit more isolated from the team, which is the biggest part I guess I miss. You’re able to just go over to somebody else’s office and consult with them about a case or you know, if you can kind of see somebody’s having a rough day, you can kind of have a chat and hopefully help out a little bit, so that part’s missing (FG6).” The conversational and social aspect of the workplace diminished as individuals working from home were unable to have easy conversations with their co-workers. There was also a growing disconnection from supervisors, as MHPs noted fewer check-ins with leaders who, in some cases, had become responsible for addressing pandemic system-level issues. Further, the lack of ability to check in and have quick and casual conversations with other staff members left many providers feeling isolated and disconnected.
While many MHPs felt overwhelmed by the sudden changes to their mode of delivery, there were some that noted many positives in the shift. Many MHPs were able to adapt quickly to the changes and saw that shifts in their mode of delivery allowed for greater flexibility and increased likelihood of positive changes being accepted into the provincial health system, as one MHP highlighted: “…it’s been really positive to see how as health care providers how quickly we have changed, how quickly we have adapted, how quickly in the past if you wanted to put forward a policy or change in practice it took years to do (FG4).” Other MHPs also found that the shift to working from home allowed them to have extra flexibility within their schedules and more time due to eliminating their commute: “not being stuck in my car for 30, 40% of the day driving between sessions sometimes, created a lot more flexibility in my schedule. So that has been nice (FG11).” Mental health supervisors found positive changes among their staff, noting that MHPs showed increasing vulnerability and willingness to ask salient questions. Ultimately, many MHPs reported being able to continue performing their job to quite a high level, and were able to ensure that their clients could receive the help needed during an extremely tough time: “I think we’re as resilient as we could have been, and we maintained our professionalism, and we kept the clinic going as best that we could, and I’m very proud of the fact that we all just still manage that (FG10).” With the many substantial changes in their ways of practicing and offering mental health services, some MHPs noted that they were well suited for shifting to work from home; however overall, the lack of diversity in their daily duties wore on them over time.
Concerns about working in-person
While working from home brought very unique challenges to MHPs, working in person on-site also raised substantial concerns. For some, there was perceived to be less concern given by leadership to personal and family circumstances that might make in-person work uncomfortable, as highlighted poignantly by a MHP: “I have to say that at the beginning, it felt very uncomfortable that our first priority was around, you’ve got to be in at work, we have to still continue as a service, whereas out there, everybody’s taking all these safety measures and we weren’t… what makes me upset about some of that too, it puts me at risk, puts my family at risk, puts my parents at risk, because I am in the sandwich generation (FG5).” While MHPs wanted to offer services similar that prior to the pandemic, MHPs who had to work in-person were more anxious that they might bring the virus home to family members, many of whom were considered vulnerable. While most expressed frustration about working in person, especially during the early months of the pandemic when it seemed that most other mental health services had shut down, some clinicians preferred working on site, expressing that working from home did not allow them to have distance between their work and they felt much more effective when physically in the office.
Exhaustion and stress of working through the pandemic
Following multiple changes to service delivery, MHPs shared experiencing extreme levels of stress. MHPs who were working from home spoke about the competing needs between their families and their clients, and their increased levels of burden to provide adequate time and care to both. As one provider noted, the distinction between personal and professional lives was becoming blurred: “I find that the struggle for me is… before I could… more easily separate the professional and personal roles in my life. And now… I find a lot of times we’re in both at the same time, and it’s just really difficult (FG2).” Further, because schools were closed for in-person learning, MHPs with school-age children were also in charge of supporting and monitoring their children in their schooling. Some MHPs noted struggling with being able to give their clients their full attention while their children also required care, with one highlighting: “As parents we have children at home who are online schooling, and we’re struggling with that, but yet we have to be “on” and present in a well sort of packaged way for our clients who are experiencing the same thing (FG9).” MHPs found pressure to successfully support their children with online learning while still maintaining a full client load and providing the same level of care, leading to feelings of ineffectiveness. Being clinically responsible for their clients’ care while struggling to support their families left MHPs working longer hours in order to ensure that their clinical load was being handled and that they still had enough time to devote to their families.
Living through the pandemic and providing quality care to their clients, caused emotional and physical exhaustion for many providers. One clinician aptly stated this phenomenon, as follows: “it’s work work work and then for me, when I’m not working, I’m just exhausted – far more exhausted than I normally am…but there’s an exhaustion that I’ve never experienced before…. I think it’s emotional exhaustion (FG7).” Others expressed similar sentiments, noting that they felt like they were always on high alert to support their clients while remaining acutely attuned to the needs of their families, and there was minimal downtime because there was no travel or break time between meetings. MHPs felt they were increasingly becoming at risk for burnout and worried about the longevity of their ability to work at this pace. One MHP noted: “I do wonder if that’s part of the burnout… Now there’s almost less of that downtime because now, 100% of the time is client directed. (FG3).” Many MHPs noted that they were emotionally exhausted from their continued service provision, with one succinctly noting: “I’m exhausted…And I think the balance of balancing your own life, holding emotional space for other people, home schooling, the whole gamut is hard for us (FG5).” MHPs reported that the combination of isolation from their colleagues, limited opportunity for breaks in the day, and increased personal demands on their time to care for their own families, was leading to increased levels of personal and professional exhaustion.
As illustrated in these findings, the COVID-19 pandemic created uncertainty for MHPs, with many changes to the service delivery mode, blurring of boundaries between personal and professional lives, and physical and emotional exhaustion of working double and sometimes triple duty. They felt a strong sense of ethical and moral responsibility to maintain a high quality of care for their clients, while also struggling to care for their children and other members of their families. Despite these pressures and challenges, many MHPs perceived themselves and their colleagues as resilient in finding creative and supportive ways to collaborate, communicate and support one other, as summed up by one MHP: “I just feel so lucky to work with the team that I do because we are a team that [is] very cohesive, very innovative team. We really work well together, we have good professional relationships, and so that has definitely made the work easier. And I felt supported in that way because we’re as a program ‘all in the same boat’ trying to navigate this challenging scenario for our patients…(I1).”