28 Mar For this assignment, you will be using the article that you identified earlier in the course.? The final product should answer the questions below and demonstrate that you

Professional Psychology: Research and Practice The Impact of the COVID-19 Pandemic on Psychological Service Provision, Mental Health Practitioners, and Patients in Long-Term Care Settings: Results From a Rapid Response Survey Lisa M. Lind, Rachel N. Ward, Savannah G. Rose, and Lisa M. Brown Online First Publication, September 1, 2022. http://dx.doi.org/10.1037/pro0000486 CITATION Lind, L. M., Ward, R. N., Rose, S. G., & Brown, L. M. (2022, September 1). The Impact of the COVID-19 Pandemic on Psychological Service Provision, Mental Health Practitioners, and Patients in Long-Term Care Settings: Results From a Rapid Response Survey. Professional Psychology: Research and Practice.

The Impact of the COVID-19 Pandemic on Psychological Service Provision, Mental Health Practitioners, and Patients in Long-Term Care Settings: Results From a Rapid Response Survey Lisa M. Lind1 , Rachel N. Ward2 , Savannah G. Rose2 , and Lisa M. Brown2, 3 1 Chief Clinical Leadership Team, Deer Oaks Behavioral Health, San Antonio, Texas, United States 2 Pacific Graduate School of Psychology, Palo Alto University 3 Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford University

Due to the rapid spread of COVID-19 in long-term care (LTC) settings and the subsequent mandatory visitor restrictions that were put in place, the provision of behavioral health services in LTC settings was impacted. To examine the pandemic’s effect on the provision of psychological services in this setting and its impact on clinicians and their patients, we surveyed 126 licensed mental health clinicians working in LTC settings during the pandemic. The sample consisted of psychologists, social workers, and psychiatry mid-level practitioners from 31 states who had provided mental health care services in LTC settings during the initial 7 months after the COVID-19 pandemic was declared a national emergency. This exploratory study revealed that the pandemic significantly impacted the availability and use of mental health services in LTC settings. Although there was a reported increase in the use of telehealth services compared to prepandemic frequency, it was noted that LTC residents went long periods of time without access to mental health services. Government-imposed visitor restrictions and pandemic-related restrictions were perceived as negatively impacting the emotional well-being, loneliness, and quality of life of LTC residents. Perceived factors contributing to the financial and emotional impact of COVID-19 on clinicians were explored, and it was noted that more than half of the sample reported experiencing burnout and nearly one third of surveyed clinicians believed they had experienced trauma by providing mental health services in LTC settings during the COVID-19 pandemic. Understanding this impact has implications for providing mental health services during the current and future pandemics

Public Significance Statement The COVID-19 pandemic has disrupted the provision of mental health services in long-term care (LTC) settings, resulting in negative impacts not only for LTC residents who had previously been receiving mental health services but also the clinicians providing the services. This study examines the impact of the COVID-19 pandemic on mental health providers’ ability to provide mental health services in LTC settings, patient functioning, and providers’ personal well-being and professional functioning. The authors hope that information within this article will assist in elucidating critical insights that can serve as a guide for policymakers, administrators, employers, and mental health clinicians regarding the provision of mental health services to residents in LTC settings during future pandemics.

The severe acute respiratory syndrome coronavirus (SARS-CoV-2), commonly referred to as COVID-19, had its first known U.S. outbreak in a long-term care (LTC) facility in February 2020. Within days, the well-being of older people and those with health conditions who were residing in congregate housing was of great concern to clinicians, public health workers, the government, and LTC residents and their families. Based on recommendations from the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services (CMS) directed nursing homes (NHs) nationwide to significantly restrict visitors and nonessential personnel from entering facilities, as well as cease communal activities inside nursing homes beginning on March 13, 2020 (Department of Health and Human Services, 2020). Although these well-intended measures were designed to reduce the spread of the COVID-19 virus to vulnerable older adults, the impact these restrictions would have on the mental health care of LTC residents was likely not considered at the time. We wanted to learn more about the impact on the provision of psychological services in LTC settings during the initial phase of the COVID-19 pandemic due to the pandemic’s observed disruption on the lives of LTC residents.

Disruption of Mental Health Services in LTC Settings Prior to the COVID-19 pandemic, there were minimal restrictions on psychologists’ access to residents of LTC settings who were referred for mental health assessment and treatment, other than the requirement of a physician’s order for services being in place before the initiation of services. Psychologists and other mental health clinicians were allowed to freely enter LTC settings with minimal restrictions other than standard credentialing requirements. No special precautionary measures were required, except for having to wear personal protective equipment (PPE) with residents who were diagnosed with an infectious condition, such as methicillinresistant Staphylococcus aureus or Clostridium difficile. After CMS directed LTC facilities in all states to restrict nonessential nursing home visits as a means to prevent the virus from spreading, mental health clinicians who were providing behavioral health services to LTC residents began to encounter difficulties when attempting to see their patients (Graham, 2021; Nierengarten, 2021). Lack of clarity about who was considered an essential health care worker resulted in many mental health clinicians being refused entry into LTC facilities and disrupted their ability to provide mental health services to their patients (Graham, 2021). The term “patient” is used moving forward to reference any LTC resident who was receiving psychological and/or psychiatric services by a clinician in the sample. In settings outside of LTC, mental health care was often delivered or supplemented with telehealth as a way to maintain and increase the accessibility of services for community-dwelling older adults (Pierce et al., 2021) and has become an accepted service provision for many psychologists throughout the pandemic (Sammons et al., 2021; Sammons, VandenBos, & Martin, 2020; Sammons, VandenBos, et al., 2020). In a survey of psychologists who were primarily in private practice, 68% reported a rapid shift from seeing no patients via telepsychology prepandemic to seeing all or almost all via telepsychology within 6 months into the pandemic (Sammons et al., 2021). Although the CMS allowed facilities to be reimbursement by Medicare for each telehealth session that is facilitated by their staff regardless of the duration of the service facilitation, and despite staff not requiring any special training to do so, many psychologists incidentally reported that facilities encountered difficulties finding available staff who could assist with telehealth delivery (Hartman-Stein, 2021). Although allowances were made for relaxing Health Insurance Portability and Accountability Act rules and privacy restrictions during the nationwide public health emergency that allowed for the use of nontraditional platforms and audio-only telehealth (U.S. Department of Health and Human Services, 2021), the actual frequency of telehealth utilization in LTC settings is unknown.

Impact of COVID-19 Pandemic on Mental Health

Recent research suggests that the COVID-19 pandemic has adversely impacted the general population in terms of increased stress, depression, anxiety, substance abuse, and suicidal ideation (American Psychological Association [APA], 2021, 2022; Czeisler et al., 2020; Dozois & Mental Health Research Canada, 2021; Gallagher et al., 2020; Serafini et al., 2020; Wang et al., 2020). Although existing evidence indicates that community-dwelling older adults may be less negatively affected by adverse mental health outcomes than other age groups during the COVID-19 pandemic (Czeisler et al., 2020; Vahia et al., 2020), recent reports suggest that the emotional and social well-being of LTC patients has been negatively impacted (Montgomery et al., 2021; Van der Roest et al., 2020). In an online survey of nursing home residents that asked questions about their daily life before the COVID-19 restrictions were imposed, and afterward, 76% reported feeling lonelier (Montgomery et al., 2021). In a Dutch cross-sectional study examining LTC residents without severe cognitive impairment, their family members, and care staff, high levels of loneliness, depression, and a significant exacerbation in mood and behavioral problems were reported 6–10 weeks after implementation of the visitor ban (Van der Roest et al., 2020). Despite the recognized need and demand for psychological services, it is unclear if mental health clinicians were able to meet the growing demand for assessment and treatment, and if not, what the barriers were to providing care in LTC settings. The vast majority of studies that have examined the impact of COVID-19 on health care providers have focused on frontline medical workers in hospital settings. Overall, these studies have reported increased rates of distress and emotional symptoms (Lai et al., 2020; Lu et al., 2020; Ruiz & Gibson, 2020; Spoorthy et al., 2020). At present, little is known about the impact that providing mental health services has had on mental health clinicians working in LTC during the pandemic. Providing mental health care in an environment where both health risks and regulatory-related actions are unpredictable, and evolving has been reported to be stressful (Graham, 2021; Hartman-Stein, 2021). Knowledge of the perceptions of behavioral health care providers and an understanding of their experiences could inform planning for future situations and identify helpful and needed resources to prepare staff adequately. Given our current knowledge of the COVID-19 virus, it is highly probable that we will be contending with new variants during the coming years. Moreover, even if we were successful in stopping the transmission of the COVID virus, this will not be the last time we experience a highly infectious and rapidly spreading virus in future years. The objectives of this research were to elucidate the impact of the COVID-19 virus on (a) mental health providers’ ability to provide mental health services in LTC settings, (b) the functioning of patients who had been receiving mental health services, and (c) the effects on psychological providers’ personal well-being and professional functioning. In 2020, there were over 1.2 million persons residing in nursing homes in the United States (Kaiser Family Foundation, 2022). Although it is unknown how LTC facilities will fare in the coming years as a result of the pandemic, it is well recognized that a rapidly growing number of people are living longer in late life and that new LTC models need to be developed to better serve residents, their families, and staff. Lessons learned from the experiences of mental health providers who were on the front lines in LTC settings during this pandemic can inform future endeavors to integrate mental health care, enhance access to care, and improve mental health services offered during future public health emergencies.

Method

The authors developed a 90-item survey that was based on clinical and behavioral observations made by providers working in LTC settings and issues raised by practicing LTC mental health clinicians on several professional psychological listservs. The survey inquired about six areas that the authors determined as being pertinent to capturing key data: demographic information, mental health service delivery, facility characteristics, patient variables, employer and employment attributes, and clinician functioning and well-being. The survey was an online, self-report survey that was sent out on professional listservs that tailored to psychologists working in LTC and those focused on older adults. The survey began with a screening question, “Are you a licensed mental health professional who has provided clinical services to patients of LTC facilities in the United States during the COVID-19 pandemic (either in-person or via telehealth).” To proceed with the survey, participants had to positively endorse the screening question. Response formats were varied, including styles such as yes/no, multiple-choice, free response, ranking, and Likert-style responses. Changes to the response format were clearly stated in the survey to ensure participant understanding. Questions about mental health service delivery from the start of the declaration of the national emergency to the time the survey was administered (e.g., March 2020–October 2020) included questions about the location and number of LTC facilities where clinicians provided services, the number of patients who had COVID, the use of service delivery methods used (e.g., telehealth vs. in-person), the experience of being locked out of facilities, and if and how mental health services were provided to patients who had contracted COVID-19. The facility characteristics section examined facility communication (e.g., the clinician being informed about visitation restrictions and positive COVID cases), the impact of visitor restrictions, and observations of safety guidelines. The patient variables assessed the clinician’s perception of how visitation restrictions, service modifications, and other changes resulting from the COVID-19 lockdown influenced patient well-being (e.g., emotional status, behavioral status, cognitive status). For example, clinicians were asked, employers. Lastly, questions regarding clinician impact explored the effect of COVID-19 on the clinician’s financial, physical, and emotional well-being. After obtaining institutional review board approval, an online questionnaire was developed and administered to mental health clinicians who had provided psychological or psychiatric services to patients in LTC facilities during the COVID-19 pandemic and consented to participate in the study. Potential participants were recruited via two professional listservs of psychological and LTC organizations whose members worked with older adults in LTC settings. The invitation included a description of the study, informed consent, and a link to the survey that was administered via SurveyMonkey. Survey data were collected during a 2-week period in October 2020.

Results

As this study was exploratory and cross-sectional, analyses primarily consisted of descriptive statistics. To facilitate interpretability, some items were reverse-scored so that all higher individual and average scores that are reported in this article indicate greater impact. Additionally, demographic location data were aggregated up to reflect census region rather than state data to protect identifying information. We used a repeated measures t test to explore changes related to clinicians’ job functions before and after the start of the pandemic LTC facility lockdowns. We handled missing data using listwise deletion (Brown, 1994), and all analyses were run using SPSS V. 27 (IBM Corp, 2020).

Participants

Participants were 126 licensed mental health professionals from 31 states who were working as consultants in LTC facilities during the COVID-19 pandemic. The sample was primarily comprised of White (73.8%), female (74.6%) clinicians, with the majority of the sample ranging between the ages of 45 and 54. Of the sample, 63.5% were licensed psychologists, 22.2% were social workers, and 5.6% were psychiatry mid-level practitioners (e.g., psychiatric mental health nurse practitioner, adult-gerontology nurse practitioner). The majority of clinicians reported that they had worked in LTC facilities for more than 10 years and had been licensed for an average of 17 years (SD = 11.63). In addition, almost one in five clinicians reported serving in a leadership or administrative role (see Table 1, for participant demographics).

Service Delivery and Patient Variables

Of the sample, 84.9% reported that at least one of the patients in their facility had tested positive for COVID-19 during the first 7 months of the pandemic. When COVID-19 cases were detected in a facility, 52.4% of clinicians reported that they continued to provide in-person services to patients who had not tested positive for COVID-19. When their personal patient(s) were known to be positive for COVID-19, only 12.7% of clinicians continued to provide in-person services to them, while 28.6% provided telehealth services to patients who tested positive for COVID-19. An average of 22 LTC patients (SD = 32.23) per facility were estimated to have died due to COVID-19 (range = 0–150), while each clinician estimated losing an average of five personal patients (SD = 9.30)’

Table 1 Participant Demographics Patient demographics N % Age 25–34 12 9.50 35–44 21 16.70 45–54 29 23.00 55–64 25 19.80 65–74 24 19.00 75+ 3 2.40 Missing 12 9.50 Gender Male 20 15.90 Female 94 74.60 Prefer not to say 1 .80 Missing 11 8.70 Ethnicity Black 4 3.20 White 93 73.80 Hispanic/Latinx 7 5.60 Asian 4 3.20 Native American 1 .80 Other 2 1.60 Prefer not to say 4 3.20 Missing 11 8.70 Highest degree Masters 34 27.00 Doctoral 81 64.30 Missing 11 8.70 Number of years working in LTC

due to COVID-19 (range = 0–50). About 54.8% of participants reported losing at least one patient due to COVID-19. Immediately prior to the pandemic being declared a national emergency, the average mental health clinician in the sample reported providing care in an average of four (M = 4.05, SD = 1.57) facilities. There was a small (d = .24) significant, t(111) = 2.51, p = .01, difference between the number of facilities the average clinician worked in prior to the pandemic compared to 7 months into the pandemic (M = 3.8, SD = 1.66). Of the clinicians surveyed, 71.4% reported being locked out of a facility and unable to provide services at some point during the first 7 months of the pandemic. Prior to the pandemic, most clinicians preferred providing in-person services (82.5%). This shifted to only 33.3% of the sample preferring to provide in-person services during the pandemic. Many indicated a desire to provide services using a combination of telehealth and inperson methods (32.5%). Despite endorsed preferences, practice patterns revealed that services via telehealth were provided at nearly the same rate as in-person services during the pandemic, with 77% of clinicians reporting that they provided in-person services and 72.2% endorsing that they provided services via telehealth. Of clinicians who provided inperson services, 60.3% reported also providing services via telehealth at some point during the pandemic. When providing telehealth, 19% of clinicians reported solely using a traditional telehealth platform, 17.5% reported using a nontraditional platform (e.g., FaceTime, Zoom), 3.2% used audio-only with no video component, while 28.6% used a combination of these delivery modalities. Once the pandemic was under better control, slightly more than half of the clinicians surveyed indicated that they would like to return to solely providing in-person services. However, some indicated a preference to continue providing services using a combination of telehealth and in-person methods (30.2%). This finding is relatively consistent with the percentage of providers who indicated that they experienced greater exhaustion from providing telehealth services compared to in-person services (44.4%). In regard to PPE, slightly more than half (59.5%) of respondents were able to secure PPE in a timely fashion at the beginning of the pandemic, which rose to 81.7% reporting that they were able to secure PPE at the time this survey was administered. Only half (51.6%) of clinicians believed that wearing PPE adequately protected them from contracting COVID-19 while working in LTC facilities. In addition, many clinicians believed that PPE had negatively impacted in-person clinical services, with 65.1% of clinicians noting that their patients experienced difficulties with engaging in services due to the use of PPE. It has been noted that hearing and visual loss can make communication difficult when clinicians wear multiple PPE layers (Agronin, 2021). Government-imposed visitor restrictions were perceived by clinicians to have had a negative impact on patient emotional, behavioral, and cognitive status, in addition to loneliness and quality of life, with the greatest effect on emotional well-being, loneliness, and quality of life (see Table 2, for perceived impact of governmentimposed visitor restrictions and COVID-19 restrictions on patients and providers). Of the various ways COVID-19 restrictions adversely affected patients, most clinicians reported that increased sadness was the most prevalent outcome, followed by reports of loneliness and increased anxiety, fear, and worry (see Table 2).

Facility Characteristics and Employer/Employee Questions

More than half of clinicians (61.1%) felt that LTC facilities minimized patients’ emotional well-being while focusing on their physical health during the pandemic. Clinicians reported that there were long periods of time when LTC patients went without receiving mental health services, with the average time period being 9.28 weeks (SD = 10.05) and up to 7 months. Patients who were not on an isolation hall for treatment of COVID-19 were observed to have a decrease in staff interaction, with 59.5% of clinicians noting that their patients were isolated in their rooms with little staff contact. More than half endorsed perceiving that their patients had been negatively affected by physical distancing (62.7%) and restriction of physical contact with staff (86.5%). Regarding facility communication characteristics, 44.4% of clinicians experienced being turned away from a facility without advanced notice that they would not be allowed to provide inperson mental health services that day. Of clinicians who had a patient test positive, less than half (39.6%) felt that they received timely communication from facility administration about their possible exposure to the virus. Of clinicians who worked at more than one facility, 56.6% received inconsistent messaging regarding mandatory visitation restrictions that affected their ability to provide mental health services. About one third (37.9%) reported feeling unsupported by their employer during the pandemic

Impact on Clinician

Clinicians were asked to rank the following aspects of their work during the COVID-19 pandemic from least to most difficult: caregiver and parenting responsibilities, financial strain, losing patients to death due to COVID, concerns related to personal health, concerns of inadvertently making patients sick, personal stress, and fatigue/burnout. Clinicians consistently reported that personal stress and concerns about making patients sick were the most challenging aspects of the pandemic (see Table 3, for specific factors contributing to the financial and emotional impact of COVID-19 and clinician burnout during the pandemic). Respondents reported missing an average of 8.88 (SD = 20.29) days of work due to COVID-19 testing requirements. At the time the questionnaire was administered, most testing occurred at outpatient settings with limited hours during the workday, with restrictions about who was eligible to be tested, and required quarantine after possible COVID-19 exposure. Not surprisingly, many clinicians (74.6%) reported being financially impacted by the pandemic. Approximately half (51.6%) indicated that inconsistent access to their patients adversely affected their income. Factors that contributed most to their financial difficulties are presented in

Seven months into the pandemic, 41.3% of the sample reported having been exposed to COVID-19 while performing their work duties, although only 7.9% had contracted the virus. One third (34.9%) of clinicians stopped providing face-to-face in-person services due to fear of contracting COVID-19. As a result of COVID-19-related stressors, approximately one third (32.5%) reported that they contemplated working in a different setting, and 23% considered quitting their job altogether. More than half (67.5%) of the clinicians surveyed reported experiencing burnout during the COVID-19 pandemic. Clinicians almost evenly endorsed the main perceived causes of burnout as trying to balance work and homelife expectations, the unpredictability of available work, not having consistent access to patients, and fear of contracting COVID-19. At some point during the pandemic, the majority of clinicians (70.6%) indicated experiencing emotional exhaustion, while approximately half also experienced a decreased sense of success at work (50.8%) and a loss of excitement about work (47.6%). More than half of clinicians surveyed (65.1%) endorsed experiencing grief that was not readily recognized by society, and almost one third of the sample (31.7%) believed that they had been traumatized when providing mental health services during the pandemic (see Table 3, for factors contributing to emotional impact and burnout). Discussion and Implications The results of this study make a unique contribution to the literature on the challenges mental health clinicians encountered when attempting to provide care to patients in LTC settings during the COVID-19 pandemic. This is the only study that we are aware of that has focused on mental health providers who were working in LTC settings during the initial months of the COVID-19 pandemic being declared a national emergency. LTC settings were particularly impacted by the pandemic, as over 1 million LTC residents and staff contracted COVID-19, and over 150,000 LTC residents died from the virus (Centers for Medicare and Medicaid Services [CMS], 2022). The results of this study reveal that the pandemic has adversely impacted mental health clinicians working in LTC settings, the emotional well-being of their patients, and the provision of mental health services in LTC facilities. Even though psychologists are considered essential health care providers, it was not uncommon for clinicians to be turned away from facilities without advance notice when visitor restrictions were initially put in place. The disruption to services was profound. Many clinicians reported that some of their patients went without mental health services for several months or had not received any mental health services since the start of the pandemic. Although most clinicians preferred providing in-person services prior to the pandemic, many attempted to offer services via telehealth. Despite these efforts, many providers indicated they experienced difficulties using telehealth, especially when there were COVID-19 positive patients in the facility and particularly when their own patients were ill with the virus. Several of the major obstacles in providing telehealth in LTC settings during the pandemic have been noted to include lack of access to available technology and lack of available facilitators due to staff shortages. CMS approved telehealth waivers during the pandemic, allowing for audio-only telehealth, which increased access to care for some older adults who did not have available video technology or available LTC staff to facilitate. However, Seven months into the pandemic, 41.3% of the sample reported having been exposed to COVID-19 while performing their work duties, although only 7.9% had contracted the virus. One third (34.9%) of clinicians stopped providing face-to-face in-person services due to fear of contracting COVID-19. As a result of COVID-19-related stressors, approximately one third (32.5%) reported that they contemplated working in a different setting, and 23% considered quitting their job altogether. More than half (67.5%) of the clinicians surveyed reported experiencing burnout during the COVID-19 pandemic. Clinicians almost evenly endorsed the main perceived causes of burnout as trying to balance work and homelife expectations, the unpredictability of available work, not having consistent access to patients, and fear of contracting COVID-19. At some point during the pandemic, the majority of clinicians (70.6%) indicated experiencing emotional exhaustion, while approximately half also experienced a decreased sense of success at work (50.8%) and a loss of excitement about work (47.6%). More than half of clinicians surveyed (65.1%) endorsed experiencing grief that was not readily recognized by society, and almost one third of the sample (31.7%) believed that they had been traumatized when providing mental health services during the pandemic (see Table 3, for factors contributing to emotional impact and burnout). Discussion and Implications The results of this study make a unique contribution to the literature on the challenges mental health clinicians encountered when attempting to provide care to patients in LTC settings during the COVID-19 pandemic. This is the only study that we are aware of that has focused on mental health providers who were working in LTC settings during the initial months of the COVID-19 pandemic being declared a national emergency. LTC settings were particularly impacted by the pandemic, as over 1 million LTC residents and staff contracted COVID-19, and over 150,000 LTC residents died from the virus (Centers for Medicare and Medicaid Services [CMS], 2022). The results of this study reveal that the pandemic has adversely impacted mental health clinicians working in LTC settings, the emotional well-being of their patients, and the provision of mental health services in LTC facilities. Even though psychologists are considered essential health care providers, it was not uncommon for clinicians to be turned away from facilities without advance notice when visitor restrictions were initially put in place. The disruption to services was profound. Many clinicians reported that some of their patients went without mental health services for several months or had not received any mental health services since the start of the pandemic. Although most clinicians preferred providing in-person services prior to the pandemic, many attempted to offer services via telehealth. Despite these efforts, many providers indicated they experienced difficulties using telehealth, especially when there were COVID-19 positive patients in the facility and particularly when their own patients were ill with the virus. Several of the major obstacles in providing telehealth in LTC settings during the pandemic have been noted to include lack of access to available technology and lack of available facilitators due to staff shortages. CMS approved telehealth waivers during the pandemic, allowing for audio-only telehealth, which increased access to care for some older adults who did not have available video technology or available LTC staff to facilitate. However, clinicians working in LTC settings have noted that some patient characteristics, such as being visually or hearing impaired and those individuals with higher levels of cognitive impairment, may not be able to par

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