Learning from adversity: Occupational therapy staff experiences of coping during Covid-19

Abstract

Introduction

The Occupational Therapy profession is adaptable and flexible (Thorner (1991) and these characteristics have the potential to act as protective factors during the COVID-19 pandemic. Understanding the mechanisms that support coping during adversity can help promote future wellbeing. The aim of this study was to explore how Occupational Therapy staff felt and coped during the first peak of the pandemic.

Method

A questionnaire was developed to explore the experiences of Occupational Therapy staff during the first wave of the COVID-19 pandemic. The questions explored feelings, mechanisms of support and challenges to both practice and wellbeing. A total of 75 staff responded across one NHS Health Board and reflections were analysed using inductive content analysis.

Findings

Staff reflected on how their ability to adapt and remain flexible were protective factors. This combined with supportive family members, friends and colleagues led respondents to reflect on how well they coped. Barriers to coping included organisational challenges, personal challenges and professional challenges.

Conclusion

The importance of consistent communication, the need for staff to remain connected to their profession and the importance of engaging in meaningful occupations were highlighted as key to maintaining wellbeing during adversity.

Introduction

Coronavirus disease 2019 (COVID-19) was declared a global pandemic by the World Health Organisation on 11 March 2020. In an attempt to manage the impact of COVID-19, when infection rates reached 6000 on the 23 March 2020, the UK Government implemented strict physical distancing measures, instructing individuals to stay at home and avoid leaving their house except for essential work, to take one form of exercise a day and to buy essential items such as food and medicines (Jarvis et al., 2020). Despite these measures, the course of the pandemic led to the National Health Service (NHS) being placed under unprecedented strain (Jeyabaladevan, 2020). Healthcare staff were at increased occupational risk of contracting COVID-19 (Shaukat et al., 2020), although the physical health risks of serious illness or death were reported to be equivalent to the general population (Cook et al., 2020). Health and care staff experienced increased workloads, reallocation of duties, a necessity to adapt to changing needs (such as the use of personal protective equipment) and concerns about personal and family risk of infection (Gemine et al., 2021), all of which has the potential to impact negatively on staff wellbeing. The aim of this study, therefore, was to explore how Occupational Therapy staff felt and coped during this period by gathering individual retrospective accounts in order to learn from these experiences.

Literature review

In ‘normal’ times, it is well established that healthcare workers are at a higher risk of experiencing burnout compared to the general population. For example, the incidence of physician burnout has been reported at 37.9% compared to 27.8% in a control population (Shanafelt et al., 2012). Healthcare workers also experience higher levels of work-related stress and lower levels of psychological wellbeing compared to the general population (Hofmann, 2018). Given the sustained and continued pressure on the NHS throughout the COVID-19 pandemic, it is therefore unsurprising that evidence is emerging that highlights the impact of the pandemic on the health and wellbeing of staff working within health and care organisations. For example, Ing et al. (2020) documented substantial mental and physical stress amongst health and care workers, during a tabulation of physician deaths from COVID-19. They argued for the widespread use of personal protective equipment (PPE) to reduce the risk of death and its associated psychological impacts (Ing et al., 2020). Similarly, a survey by Lai et al. (2020) found high rates of depressive symptoms (50.4%), anxiety (44.6%), insomnia (34.0%) and distress (71.5%) amongst hospital-based physicians and nurses in China. This is further supported by an Italian study that reported significantly higher rates of work-related psychological pressure, emotional burnout and somatic symptoms in healthcare professionals (Barello et al., 2020). Likewise, Serrano-Ripoll et al. (2020) reported increased levels of depression and posttraumatic stress symptoms amongst healthcare professionals working in Italian COVID-19 wards. Although the majority of literature to date has emerged from China, in a recent UK-based study, McFadden et al. (2021) explored the relationship between coping strategies and wellbeing in health and care staff. They found that positive coping strategies, including active coping and help-seeking, were associated with higher wellbeing and better quality of working life. However, negative coping strategies, such as avoidance, were risk factors for low wellbeing and poorer quality of working life. The authors emphasised the importance of organisational and management support during stressful times in order to better equip staff with coping skills (McFadden et al., 2021). This is consistent with an earlier systematic review which found that positive coping strategies were associated with lower levels of burnout amongst Chinese doctors, whereas stress was less effectively managed by adopting negative coping strategies (Chen et al., 2018).

The current literature typically groups healthcare professionals into a singular category and as such, the impact of COVID-19 on specific Allied Health Professionals is limited. Occupational Therapy is an Allied Health Profession that supports people to continue, return to or take up everyday activities that are meaningful to them (their occupations) so that people can engage in their roles (e.g. parent, spouse and worker). Throughout the pandemic, Occupational Therapists have contributed their skills, experience and expertise by either working within a team supporting the direct medical care of people with COVID-19 in intensive care units and acute care settings, or changing roles to work with people who have been affected in the community (Powers Dirette, 2020). A recent survey of 1500 Occupational Therapy professionals and students from all four UK nations by the Royal College of Occupational Therapists (RCOT) found that 97.5% reported that the pandemic had impacted on their role, responsibilities and duties which included either changing location, working hours, demands, role or services (Ward and Casterton, 2020). Survey respondents reported positive changes including opportunities to work in new and innovative ways (64.2%) and learning new skills (51.3%), and negative changes including the impact on work–life balance (49.6%) and reduced access to support/supervision or mentorship (32.9%) (Ward and Casterton, 2020). The finding that 46.3% of respondents reported negative changes to their personal health and wellbeing (Ward and Casterton, 2020) is significant given that all healthcare workers who have been involved in the diagnosis, treatment and care of patients with COVID-19 have been identified as at risk of experiencing psychological distress and mental ill health (Lai et al., 2020). This is further supported by the RCOT survey findings from Ward and Casterton (2020) who reported that some Occupational Therapists in acute services reported feeling undervalued. Although there is literature exploring a range of contributions that Occupational Therapists have made during the pandemic (e.g. Kamalakannan and Chakraborty, 2020; Priyadharsini and Chiang, 2020), only one paper has explored the experiences of Occupational Therapists by collecting reflective accounts. A study of Fillipino Occupational Therapists conducted by Sy et al. (2020) reported feelings of isolation, an increased awareness of alternative service delivery options and creative ideas for the future; however, they did not explore explicitly the support mechanisms for reducing the psychological impact of the pandemic on Occupational Therapists. Furthermore, there are differences in health and care service delivery models between the UK and the Philippians and in their responses to COVID-19; hence, experiences may differ. Previous studies exploring resilience and maintaining the means to cope during adversity within Occupational Therapy more widely have identified theoretical knowledge core to the professional identity of Occupational Therapists as an important protective factor (Ashby et al., 2013; Brown et al., 2019). It could be argued that whilst similar risks have been posed to challenge the wellbeing of a range of healthcare workers during the pandemic, by applying the fundamental principles of the profession, Occupational Therapists have the knowledge and skills to effectively cope through adaptation. This concept has not been previously addressed within the context of a pandemic. The aim of this study was, therefore, to explore how Occupational Therapy staff felt and to identify what mechanisms supported coping during this period.

Method

Inductive reasoning involves making predictions about novel situations based on existing knowledge (Hayes et al., 2010). Taking an inductive approach allowed issues to emerge from the data that were important to the participants. This enabled the raw textual data to be condensed into an understanding of how Occupational Therapy staff had felt about their involvement during the pandemic and how they had coped. As an aim of the project was to identify mechanisms that supported coping to promote effective future management of wellbeing, collecting responses using structured open-ended questions to elicit experiences and feelings was deemed an appropriate method. Having obtained written informed consent from all participants, their responses were gathered during July and August 2020 by an Occupational Therapy researcher.

Procedure

The study was approved by the Research and Development (R&D) Department of Swansea Bay University Health Board (SBUHB) as a service evaluation. As no suitable instrument existed, a questionnaire was developed to promote participants to consider their experiences of working within Occupational Therapy during the first wave of the COVID-19 pandemic. The questions explored feelings during and after the first peak of the pandemic, considered mechanisms of support and drew upon the challenges they faced both in practice and to personal wellbeing. The questionnaire was initially piloted with 10 members of Occupational Therapy staff within the Health Board to check for clarity of expression and ease of completion. On the basis of the comments received, minor modifications were made to the questionnaire, which included rephrasing some questions for clarity. The final online questionnaire was circulated to approximately 350 Occupational Therapy staff in SBUHB via email networks. Staff included registered, unregistered and administrative roles and incorporated those working in physical health, mental health, learning disabilities and community integrated services hosted within the Health Board. Questionnaire responses were entirely anonymous, as such a debrief sheet was provided at the end of the questionnaire with contact information for the Health Boards staff wellbeing service that could be contacted if respondents needed support or advice. To avoid coercion, the questionnaire was distributed by a member of staff located within the wider Health Board research and development team. To avoid bias and increase the trustworthiness of the findings, the project team also comprised a member of staff who joined after the first wave of the COVID-19 pandemic, a member of staff from the Health Boards staff wellbeing service and an external academic colleague.

Participants

A total of 75 participants took part in this study, 69 participants were female and six were male. The majority of participants were aged between 31 to 60 years (81%), 60 (80%) respondents were registered Occupational Therapists, 13 (17%) were unregistered Occupational Therapy staff working in a support role and 2 (3%) were in an administrative role. A total of 49 (65%) respondents were in a full time role and 26 (35%) were in a part time role. During the first peak of the pandemic, the majority of respondents were either located in a hospital (43%) or community setting (36%) changes in setting are shown in Table 1, a total of five respondents were shielding and working at home due to being identified as particularly clinically vulnerable to Covid-19.

Table 1.

Number of respondents by setting during the first peak of the pandemic.

Setting	Number of respondents
Role in normal place of work	40
Working from home	13
Redeployed to acute site	12
Role in normal place of work with a different team	5
Other	5

Data Analysis

The text-based responses to open-ended questions were explored using inductive content analysis, meaning that categories were created from the raw data in the absence of a theory-based categorisation matrix (Elo and Kyngä, 2008). Content analysis was undertaken, using the process displayed in Figure 1, as informed by Bengtsson (2016). Following immersion in the data, the authors used NVivo software to distill the textual data into content related categories through open coding (Strijbos et al., 2006; Erlingsson and Brysiewicz, 2017). The data was then recontextualised to ensure that no meaning had been lost. Following the condensation of extended meaning units, categories and themes were formed and manifest analysis was completed and appropriate meaning units were presented using quotations from the text, as demonstrated in Table 2.

Figure 1.

Manifest content analysis process (Bengtsson 2016: p10).

Table 2.

Example of content analysis from data collected.

Meaning unit	Condensed meaning unit	Code	Category	Theme
I feel that I’ve coped very well. I have not found the period too challenging	Coped well during the pandemic	Coped well	Facilitators to coping	Coping
I feel generally I have coped well - at times I have struggled with childcare/working and found this stressful	Coped well but some challenges that were stressful	Coped well Challenges faced	Facilitators to coping	Coping
Compared with many, my life was not significantly impacted by the restrictions put in place. I tend to have a positive outlook on life and therefore saw the changes as a positive challenge. There were odd days where I felt rather helpless, but on the whole I have learned a lot and feel that I coped well	Some challenges and difficult days but feel have coped well	Coped well Challenges faced	Facilitators to coping	Coping
I feel I have coped well	Coped well	Coped well	Facilitators to coping	Coping
Good	Coped well	Coped well	Facilitators to coping	Coping
Well	Coped well	Coped well	Facilitators to coping	Coping
Very well considering I was unwell this time last year	Coped well	Coped well	Facilitators to coping	Coping
I feel I have coped well with the additional pressures, and the change in work	Coped well with challenges	Coped well Challenges faced	Facilitators to coping	Coping
Reasonably well	Coped well	Coped well	Facilitators to coping	Coping
Very well and embraced the challenge	Coped well with challenges	Coped well	Facilitators to coping	Coping

Content analysis was appropriate as textual responses were related to specific questions in the questionnaire and as such required analysis at a literal level (Bengtsson, 2016; Carpenter and Suto, 2008). The third author completed the analysis with reference to the study aim to explore how Occupational Therapy staff felt and coped during the first peak of the pandemic. The first and second authors examined preliminary themes, alongside illustrative quotes, which were discussed with the third author resulting in the refinement of the themes. The themes and accompanying illustrative quotes were reviewed and validated by an independent peer reviewer.

Findings

Concepts explored in the questionnaire were as follows: (1) mechanisms for coping and (2) past and present feelings, in order to provide an insight into the experiences of Occupational Therapy staff during the pandemic. The concept of mechanisms for coping emerged through four questions: (1) How do you feel you have coped generally during this time? (2) What has helped you to cope during this time? (3) In relation to how you have coped, what have you found most challenging and/or unhelpful? and (4) Do you think anything could have been done differently to enable you to cope more effectively during this time? The concept of past and present feelings emerged through two questions: (1) How did you feel when working at the peak of the pandemic? and (2) How do you feel now? The findings are presented within the context of these concepts and consistent with the aim of capturing Occupational Therapy staff experiences, anonymised quotes remain unedited and are included to illustrate the points made.

Facilitators and barriers to coping

In responding to the question ‘How do you feel you have coped generally during this time’? 85% of respondents provided positive comments that reflected a general sense that staff had coped well under the circumstances. For example:

Some increased stressed due to a dependent family member but otherwise very well.

When asked ‘What has helped you to cope during this time’? respondents reflected on the importance of their support networks throughout the pandemic, which included support from home, for example, one respondent stated:

My family, were my rock, they picked me up every time I came home in tears. They encouraged me to go in each day and were and still are very proud of all those who put their own lives and theirs at risk.

Whilst others reflected on the support they received from their colleagues and in the work place, for example, one respondent stated:

All the support, kindness and understanding from my team manager and colleagues.

Other respondents cited that the combined support from family members and from within the work place was important, for example:

Family and friends. Virtual meetings and chats. Supportive colleagues.

As well as the support received from family, friends and work colleagues, respondents reflected on the importance of engaging in their meaningful occupations as a coping strategy. For example, one respondent stated:

Support from my OT colleagues in work. Setting up a creative projects to help bring feelings of hope to the wards. Making sure I engaged in meaningful activities e.g. going to the beach, in my spare time. Avoiding spending too much time reading about covid on social media, not watching the news before bed. Spending time as a family unit doing DIY and sorting out the garden area to make it a more user friendly space.

For those staff who reported that they had not coped well, respondents generally reflected on the challenges of adapting to a changing situation, for example:

I have had to adapt to working from home, finding the best ways to get ready and mentally prepared for work, and to wind down after work. I have also had to adapt physically, with less walking and the gyms closed. I have found it challenging to manage relationships at times. My job can feel emotionally exhausting and balancing my OT role of supporting people with their emotional/mental health, and that of my family also became hard to manage at times.

When asked ‘In relation to how you have coped, what have you found most challenging and/or unhelpful’? respondents reflected on organisational challenges, personal challenges and professional challenges. In relation to organisational challenges, these predominantly referred to communication and clarity, for example, one respondent referred to information bombardment whilst others referred to uncertainty, for example:

Lack of clarity or varying messages from HB led to frustrations at times due to changes in processes.

Confusion about my role, what I should be doing, how I could help. Early on in particular, I felt a moral obligation to do as much as I could to contribute but it wasn’t clear what I could do… Over time I found a role for myself and felt I was contributing a lot.

In terms of personal challenges, multiple respondents referred to the challenges of working from home and childcare, for example,

Working from home, not looking after the children and feeling guilty not having the time to talk to them. I felt I neglected my children because I put work first. I felt I had to still be working efficiently when I had 3 kids at home.

Professional challenges predominantly related to feeling isolated from the profession and a concern for patients/service users, for example,

I found the lack of engagement with the profession most challenging.

Knowing patients are becoming unwell due to many of them being unable to leave their homes, access the community and work towards future goals and being almost powerless to help them.

When asked ‘Do you think anything could have been done differently to enable you to cope more effectively during this time’? a large proportion of respondents indicated that on reflection, nothing could have been done differently. For those respondents who did make recommendations, these included greater connectedness with colleagues, for example:

I would have liked to have had more contact with other OTs especially others that remained working in an outpatient setting so that we could share ideas and support each other.

As well clearer and consistent communication, for example:

Clear messages regarding restrictions within work and consistent strategies imposed.

Taken together Occupational Therapy staff generally reflected on how well they had coped, which was facilitated by supportive family members, friends and colleagues. Barriers to coping included organisational challenges, personal challenges and professional challenges.

The journey of feelings

In responding to the question ‘How did you feel when working at the peak of the pandemic’? 33% of respondents used the word anxious, and 25% of respondents used the word stressed. This compared to the responses to the question ‘How do you feel now’? where only 1% of respondents used the words anxious or stressed.

During the peak of the pandemic, the reported anxieties focused on personal protective equipment (PPE), and concern for patients/service users, colleagues and family. For example:

I was concerned initially when we did not have sufficient PPE and not even enough hand gel as we had been waiting for it to arrive before the peak of the pandemic. All staff were anxious about patients having Covid and us bringing it home to loved ones. I also felt that I was not given enough information from mental health OT, most of the guidance was coming from physical health OT and our situation was a little different. There was also confusion as to whether people were able to work from home, other staff in other areas were doing so but we were not given that option.

The phrase ‘stressed’ was mainly used to describe the rapid changes that were experienced and the uncertainty that comes with change, for example:

Stressed because we were being asked to work in different areas as well as the general stress and anxiety regarding covid.

When participants were asked how they felt now, staff reported that they had adapted and accepted the situation. For example:

I’ve become a bit more accepting of the situation and appreciate trying to keep people as well as I can with only virtual contact is all I can do at present. I am missing the contact with my patients. Being able to still work in the office and have the support from my colleagues has been important.

There was a general sense of uncertainty about the future. For example:

Very uncertain about the future implications of the pandemic for services and patient care. Very anxious about the long term effect on both clinical demand and patient outcomes. No clear plan as to how services will resume and how the backlog will be managed. Very much a feeling of being left to get on with it without adequate information, guidance and support of senior management.

For some respondents, the ability to offer high quality patient/service user care was still compromised in July 2020, for example:

Generally happy to return to my normal place of work, but concerned RE: patient care as many services are not fully resumed or those whereby virtual input do not meet their needs.

Access to clients is still restricted, yet clinical decisions are required.

In summary, Occupational Therapy staff reported anxieties focused on personal protective equipment (PPE), and concern for patients/service users, colleagues and family during the peak of the pandemic. However, for most respondents, despite some residual anxieties relating to the uncertain future, Occupational Therapy staff reflected on how well they had adapted and accepted the situation.

Discussion

The rapid transmission of COVID-19 and limited effective treatments placed substantial strain on health and social care systems worldwide (Rathnayake et al., 2020), including the National Health Service (NHS) in the United Kingdom (Jeyabaladevan, 2020). In an attempt to manage the impact of the pandemic, NHS staff were reallocated to different roles (Gemine et al., 2021). The current finding that 16% of respondents were redeployed to an acute site and 17% worked from home support previous findings highlighting the widespread redeployment of resources. The impact of this can be understood in the context of occupational therapy literature which describes how a change in role represents a critical adaptive process. Adaptation is an important construct in occupational therapy and occupational science, with occupational adaptation referring to the outcome of engagement in occupations and the ability to find meaning and satisfaction in them (Grajo et al., 2018). Therefore, whilst redeployment may be necessary, the respondents feelings of isolation, anxiety and stress may have impacted on their psychological wellness and their ability to cope due to disruption in roles that are valued and promote a sense of belonging and connectedness (Hammell, 2020), both of which foster positive mental wellbeing (Mahar et al., 2013). Furthermore, a loss of professional identity (Mackey, 2007) due to changing roles and working within new environments and the perceived impact on personal and family members’ safety (San Juan et al., 2021) were all described as barriers to coping.

Respondents also described how inconsistent communication acted as an organisational challenge that was perceived as a barrier to coping. This is in line with previous findings that have identified that experiences associated with major events may be exacerbated by problematic or inconsistent communication (Houston, 2012). Additionally, the World Health Organisation (2020) have urged organisations to consider the long-term impact of the pandemic on staff and ensure clear communication, perceived inconsistencies may therefore have contributed to the respondents reporting feelings of frustration and confusion.

As well as organisational challenges, respondents reflected on personal challenges, this is consistent with existing literature, which has highlighted concerns about being exposed to the virus at work and taking the disease home to their family (Shanafelt et al., 2020). Although the respondents expressed concern for the safety of members of their support network, family, friends and colleagues, they were also identified by respondents as sources of support, all of which promoted wellbeing. This is in line with research that has emerged from China that has identified the importance of family as a means of sharing beyond the workplace and colleagues for workplace affirmation (Pan et al., 2020). Participants in the current study also reflected on how they used meaningful occupations as a means of distraction and challenge, in their attempt to manage increased levels of stress and to relax. They were noted to utilise their own professional theoretical principles to help maintain their own wellbeing.

Although previous literature has consistently described the reduction of healthcare services due to COVID-19 across multiple settings, for example, Hoyer et al. (2020) describe the decreased utilisation of mental health emergency services and Richards et al. (2020) describe how the pandemic has disrupted cancer care, the respondents in the current study provide a unique insight into the disruption of services from their perspective. Respondents consistently conveyed their concern for patients/service users and the difficulties in maintaining high quality patient/service user care. This is potentially linked to their in-depth knowledge of the needs of their specific service user groups and the potential impact of limited access to services. This is in addition to anxieties consistent with managing the challenges of adapting practice and working in new roles. In needing to limit and change the way they worked with patients/service users, their sense of professional identity appears to have been compromised, as it is grounded in the individual practitioner’s perception of what it means to ‘be’ (Ashforth et al., 2008).

Limitations

To capture insight into the experiences of Occupational Therapy staff working during the pandemic, there was a necessity to deliver this study in a pragmatic and timely fashion. To facilitate this, the project was conducted within a single Health Board. This arguably may impact on the transferability of the findings; however, the Occupational Therapy services represented include a wide scope of settings. Both registered and unregistered staff were also included. This would therefore support an application of the findings to Occupational Therapy staff working in the typically diverse selection of settings observed in NHS UK practice. A further limitation may be the risk of non-response bias and representativeness of the data analysed given the sample size. Ongoing redeployment and disruption in service provision may have impacted on the questionnaire response rate and been a drawback of conducting a qualitative study during COVID-19. However, the questionnaire was circulated after an extensive Health Board wide digital mobilisation program, and the response rate is typical for emailed questionnaires (Yun and Trumbo, 2000). Increased access to the online questionnaire may have supported the response rate for the study rather than disadvantaged it and the findings may uphold the results of other qualitative research emerging from working within the pandemic.

A notable strength of this study is that it was produced collaboratively through academia and practice. This supported processes throughout the project as in the early stages, the first and second author were employed within the participating organisation. A risk of bias during data analysis was identified which could have impacted on the trustworthiness of the findings. To address this and improve trustworthiness, the third author completed the analysis, and the first and second authors examined preliminary themes, alongside quotes prior to agreeing findings. To increase the confirmability (the degree of neutrality) of the study further, a fourth independent peer reviewer was consulted. This was undertaken in an attempt to manage some of the limitations observed in conducting a qualitative study of this nature where credibility (confidence in the findings), transferability to other contexts, dependability or stability of the findings and confirmability can typically be more challenging to control (Korstjens and Moser, 2018; Elo et al., 2014).

Conclusion

Adaptability and flexibility are considered core characteristics of the Occupational Therapy profession (Thorner, 1991) and respondents reflected on how their ability to adapt and remain flexible. There appeared to be protective factors, despite feelings of anxiety, stress and concerns about the uncertain future. These protective factors combined with supportive family members, friends and colleagues led respondents to generally reflect positively on how well they had coped. There were however barriers to coping, which included organisational challenges such as inconsistent communication, personal challenges which included concern for patients/service users, colleagues and friends, and professional challenges, which related to feeling isolated from the profession and professional networks. The implications of these findings mirror those from other professions. The importance of consistent communication, the need for staff to remain connected to their profession and the importance of engaging in meaningful occupations as coping strategies could be considered as key recommendations, and this learning could be applied to support the wellbeing of staff groups and individuals during future adverse events.

Key Findings and Recommendations

• ⁃ Consistent and concise communication is important.

• ⁃ Ensuring staff remain connected to colleagues and patients, as a means of support and maintaining professional identity.

• ⁃ Sharing and promoting coping strategies.

What has this study added

An insight of the experiences of occupational therapists during the first wave of COVID-19, a unique understanding of how the profession coped and how staff felt throughout this period.