“Band-Aids on Bullet Holes”: Experiences of pediatric hospital social workers after 1 year of the COVID-19 pandemic

Abstract

COVID-19 has continued to bring devastation to children and families, even 1 year into the pandemic. The rise of the Black Lives Matter movement has also led to renewed attention to systemic racism in the United States and awareness of how the pandemic has further exacerbated health inequities that disproportionately affect communities of color. Pediatric hospital social workers have played a key role since the beginning of the pandemic in responding to the resulting behavioral health crisis and helping to address social disparities. There is a need to understand how the roles and experiences of pediatric social workers have evolved during the first year of the pandemic. In this qualitative study, a series of practice-setting based focus groups were conducted with social workers to capture (a) what has changed or stayed the same since the beginning of COVID-19, (b) thoughts and experiences on diversity, equity, and inclusion with particular attention to race and racism, and (c) perspectives about the long-term implications of COVID-19 on the profession of social work. The Framework Method was used to analyze data, from which six superordinate themes emerged: burnout/coping; the impact of patient acuity; awareness of racial inequity in patient care; awareness of social determinants of health; social worker inclusion in hospital decision-making and policy reform; and grief/racial inequity. An overview of what has stayed the same, what has changed, and what the future may hold for pediatric hospital social workers is reviewed.

Introduction

On 11 March 2020, the World Health Organization declared a global pandemic due to the worldwide spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), commonly known as COVID-19 (Liu et al., 2020). Government and healthcare systems across the globe have struggled immensely to contain the spread of the virus (The Lancet Editorial Board, 2020) and, to date, over 80 million cases having been reported in the United States alone (Centers for Disease Control, 2020). One year since the emergence of COVID-19 in the United States has brought about multiple waves of infection, locally prescribed social distancing and self-isolation practices, and changes in safety protocols occurring in response to the rise of new variants (e.g., Reicher and Drury, 2021).

It is well-documented that the COVID-19 pandemic has led to a global mental health crisis for both the general population and front-line health care workers (e.g., Galli et al., 2020). The pandemic has also magnified disparities in health and access to healthcare that particularly impact communities of color (Devakumar et al., 2020). Although not directly related to the pandemic, during this period the murders of George Floyd, Breonna Taylor, among many others, led to the rise of the #BlackLivesMatter movement and brought renewed focus to the problem of police brutality and the pervasiveness of racism as a public health issue that endangers the lives of ethnically and racially marginalized individuals (Johnson-Agbakwu et al., 2020). In the United States, healthcare workers, and especially social workers, have witnessed the intersection of the COVID-19 pandemic and upsurge in racism that has contributed to the unprecedented demand for mental health services (e.g., Kaslow et al., 2020).

In response to what has become known as “America’s mental health crisis” (American Hospital Association, 2022) and other health disparities exacerbated by the COVID-19 pandemic, social workers have stepped forward to support patients’ increasing socioemotional and economic needs, help patients gain access to necessary technology for safe communication, and simultaneously offer ongoing emotional support to colleagues (Cook et al., 2020; Walter-McCabe, 2020). Social workers serving youth populations have also been tasked with responding to the widespread detrimental emotional, social, and academic effects that school closings have had on child wellbeing, as well as the ways in which the pandemic has amplified housing and food insecurity that disproportionately affects communities of color (e.g., Daftary et al., 2021). Essential child protective services have also been impacted by the COVID-19 pandemic as home visits took place virtually, which was accompanied by both new challenges and new opportunities (Ferguson et al., 2022). Although the COVID-19 pandemic has significantly affected social workers and the services provided (e.g., Miller and Cassar, 2021), there is evidence to suggest that the challenges that pediatric social workers face are unique (Ross et al., 2021).

During the early phases of the pandemic, our team examined the impact of the pandemic and associated public health precautions on pediatric social workers providing care in a hospital setting. We conducted virtual focus groups with social workers employed across various settings in a large urban, pediatric hospital to better understand the evolution of social workers’ responsibilities and roles within integrated teams in response to the pandemic. Multiple themes emerged from analyses that elucidated (a) the impact the pandemic has had on the practice of social work and social workers themselves, (b) institutional assistance and obstacles to effective social work across hospital settings, and (c) perspectives on how social work will respond to future pandemic recovery efforts (Ross et al., 2021). Additional analyses about the essential worker designation revealed that many social workers agree their work is essential regardless of whether services are provided in-person or virtually, and that it is important that other healthcare professionals acknowledge social workers as essential team members through the same recognition, compensation, and support offered to healthcare workers of other professions (Schneider et al., 2022). Although salient themes related to the need to more adequately address health disparities exacerbated by the pandemic did emerge, it was not possible to assess how the rise in racist rhetoric and violence had impacted the lives and work of pediatric social workers during the acute phase of COVID-19 due to the timing of the focus groups (Spring 2020). As such, the present study had three primary aims: (1) to examine what had and had not changed for pediatric social workers in a hospital setting 1-year into the COVID-19 pandemic; (2) to directly analyze social workers’ thoughts and experiences on diversity, equity, and inclusion with particular attention to race and racism; and (3) to understand social worker perspectives about the long-term implications of the COVID-19 on the profession of social work.

Methods

All participants were recruited from the Social Work Department of a large, urban, quaternary pediatric hospital located in the northeastern United States. The Social Work Department is comprised of over 200 Masters’ level licensed clinical social workers who employed across more than 50 clinics and programs. Within the hospital enterprise, social workers practice across a wide range of settings, including emergency, inpatient, outpatient, primary care, specialty programs spanning both inpatient and outpatient locations.

We intentionally employed the same recruitment methodology used in previous research with this population (Ross et al., 2021; Schneider et al., 2022), wherein participants were recruited via an internal departmental email listserv with the permission of department administrators. Consenting participants were asked to enroll themselves in a focus group designated by their primary practice setting or role: Leadership/Administration, Specialty Program, Outpatient/Primary Care, Inpatient, or Emergency.

All focus groups were conducted asynchronously using Focus Group It, a qualitative research cloud-based focus group software platform previously employed in similar research studies (Ross et al., 2021; Schneider et al., 2022). Asynchronous focus group participation enabled participants to type responses to various research questions and engage in dialogue with other participants via posting responses to their answers, and logging in and out of the platform over the time period the focus group was operational (Gamarel et al., 2021). A unique advantage of this data collection method is that it allowed participants to respond to questions and comment on others’ responses when it was most convenient for them as opposed to having to attend a live virtual focus group. This method also preserved participant anonymity, as no video component was employed, and participants could choose the name under which their replies were posted.

Similar to the first round of focus groups conducted in April 2020, 12 discussion topics were designed to elicit perspectives on social work roles, responsibilities, and practice 1 year into the pandemic, the intersection of race and racism with COVID-19, and challenges and future directions for the social work field were released over a 21-day period (May 17th and 4 June 2021). New questions were released every 3 days and participants could access their designated group at any time. Reminders were sent to all participants when new questions were released. Each group remained open for the duration of the 21-day period to give participants time to complete their responses and dialogue with others asynchronously.

Data analysis

A team of three researchers, all doctorally trained in psychology or social work, analyzed focus group data using the Framework Method, an approach to thematic analysis that is widely used among interdisciplinary teams in the conduct of health-related research (Ritchie and Spencer, 2002; Ritchie et al., 2013). A core feature which differentiates the Framework Method from other qualitative approaches is the development of a matrix that enables researchers to systematically analyze data by both participants and themes. This allows for consideration of how themes occur across participants while being able to also consider a particular participant’s experience (Gale et al., 2013). Consistent with well-established framework analytic procedures (see Gale et al., 2013), all members of the research team initially read each focus group transcript in full to familiarize themselves with the data. After familiarization, team members used line-by-line open coding to classify data from each focus group to facilitate systematic comparisons with other parts of the dataset. Upon completion of initial line-by-line coding, the coding team met regularly to develop and refine a working analytical framework. All data from focus groups were subsequently indexed by all team members using the working analytical framework and charted into the framework matrix. To interpret the charted data and generate themes, the research team met weekly to interrogate data categories through comparisons between and within both individual participants and practice setting groups. Findings are presented using a narrative analytic framework situated within Bronfenbrenner’s (1979) ecological systems model.

Results

Thirty-four social workers participated in the second round of focus groups, representing three emergency room social workers, eleven specialty program-based social workers, eleven outpatient or primary care social workers, six inpatient social workers, and three social workers from leadership or administration. Bronfenbrenner’s (1979) ecological systems model was employed as the primary analytic framework, with six superordinate themes emerging from qualitative analyses. Themes spanned four primary categories, with three corresponding to individual-, professional/hospital-, and societal-level factors, and one spanning all ecological systems model levels (see Figure 1). Themes captured (a) experiences of burnout and coping among social workers 1 year into the COVID-19 pandemic, (b) the impact of patients’ behavioral acuity on social workers, (c) renewed awareness of racial inequity in patient care, (d) increased awareness of social determinants of health (SDOH), (e) the need for social workers to have more involvement in hospital decision making and policy reform, and (f) the long-lasting implications of grief and racial inequity. Subthemes also emerged as part of the qualitative analysis. In the sections that follow, themes and subthemes are presented within the four categories noted above.

Figure 1.

Qualitative themes.

Individual-level experiences

Burnout and coping

One year into the COVID-19 pandemic, social workers reported feeling exhausted, overworked, and, at times, demoralized. Multiple participants emphasized how challenging it was to be a social worker during this time because they were tasked with not only providing support to patients and their families, but also co-workers and hospital staff who were struggling with the trauma and overwhelm of working in a pediatric healthcare center during a global pandemic. One participant commented:

“It feels hard to be a social worker right now. The overall morale on my unit is very low and staff has been relying on me for support more than ever. I feel burnt out from providing intensive support to patient families as well as to staff.” [Inpatient social worker A]

Several participants also commented on how the onset of pandemic fatigue (i.e., the exhaustion that comes with repeated safety precautions and demotivation to keep up such practices; WHO, 2020) had contributed to feelings of burnout and negatively impacted their work. This appeared to be particularly notable among social workers in inpatient and emergency department settings, as well as for those social workers located in specialty program or outpatient clinics who were required to deliver in-person care:

“The idea of pandemic fatigue is real and it really set in for me back in January. [...] I think I was mostly on autopilot and able to come and do what was needed. When we entered the new year of 2021 I felt like I had hit a brick wall head on and even the most menial of tasks took herculean effort.” [Outpatient/primary care social worker A]

Across all groups, participants shared that the development and practice of new coping skills were, at times, an effective combatant to pandemic fatigue as well as mounting work and personal distress. For example, one participant reported that they felt as though their coping abilities significantly improved in order to meet the demands on social workers:

“I think that overall my coping capacity increased, mostly out of necessity. [...] I think my repertoire of coping skills is significantly bigger than it was a year and a half ago.” [Specialty social worker A]

Two subthemes emerged from analyses that significantly exacerbated experiences of burnout. These themes captured: (a) the incongruence between expectations placed on social workers and the insufficient resources available, and (b) the impact of trauma and racism on burnout.

It isn’t enough

Many of the social workers who participated in this study expressed ongoing frustration and stress from being expected to “fix” complex, systematic issues that children and their families faced during the COVID-19 pandemic but not being provided with the resources to do so. One participant commented on how such expectations from medical teams precipitated changes in job requirements, and further contributed to burnout:

“The level of stress as a social worker has significantly increased since the start of the pandemic as the psychosocial needs of the patients and families continue to outweigh the resources available. The expectations of the medical team for social work to ‘fix it’ has at times felt overwhelming, and I have not felt empowered to manage their expectations or set boundaries.” [Outpatient/primary care social worker B]

For social workers who voiced these experiences, they generally appeared to be more closely correlated with interprofessional team dynamics and functioning, or lack thereof, as opposed to circumstances associated with work location or practice setting.

The impact of trauma and racism

Participants also commented on how the broader context of systemic racism and ongoing violence against communities of color had significantly impacted social workers’ mental health and experiences of burnout from clinical care. For example, a participant wrote about how the intersection of a global pandemic, rising racial tension, and resulting violence had been stressful and draining and had negatively impacted their own emotional wellbeing:

“I think the pandemic and societal stressors such as racial tensions and violence have had a significant impact on my own mental health. As Social Workers, we are present to support our patients and families, who during the past year and a half have also been under significant stress due to the pandemic and racial tensions and violence. It has been hard to not feel impacted by carrying the weight of helping patients and families, while also experiencing a significant amount of stress and anxiety. It was rough for a long time, experiencing anxiety, sleep disturbances, and symptoms of depression.” [Inpatient social worker B]

In addition, many participants shared that they experienced guilt and depression for not having the time or resources to devote to directly helping communities of color and creating change at mezzo- and macro-levels. Although numerous participants reported prioritizing health equity and racial inclusion in their roles as social workers, they also questioned the level of impact they could have given the enormity of systemic racism and injustice.

Professional and hospital-level factors

Behavioral health crisis in the context of the great resignation

As a result of considerable burnout among social workers and limited institutional support, many individuals resigned within the first year of the COVID-19 pandemic. What is often referred to as “The Great Resignation” has undoubtedly contributed to the scarcity of mental health resources amid an ongoing behavioral health crisis for children and their families. Participants in the present study noted how staffing shortages and long wait times had negatively impacted the type of acute care patients and their families receive:

“The number of inpatient beds is not enough to meet the demand. [...] For example, a child who was engaging in, or thinking about engaging in, non-suicidal self-injury might be treated on an outpatient basis. Now, because outpatient resources are scarce, we are hospitalizing those kids who would normally be treated in less restrictive environments.” [Emergency department social worker A]

Across all groups, participants also reported that this scarcity of resources for patients and families had resulted in more behavioral health acuity of patients and increasing caseloads. One participant noted these factors had decreased morale and increased stress among social workers:

“I feel most supported by the floor RNs and other I/P [inpatient] Social Workers, and I think that both groups feel quite exhausted and morale remains low in both groups. One common theme is not feeling supported with staff ratios to patients or acuity.” [Inpatient social worker B]

Mental health needs of new patients

An important subtheme to emerge from analyses captured how the negative emotional impact of the COVID-19 pandemic caused many children and families to access behavioral health services for the first time, which added additional demand to an already stressed system. For example, one participant commented on how children/families who had never previously needed or engaged in mental health support required more time, education, and resources from social workers:

“The main difference in the work has been that more time/attention is spent with parents/families regarding their child’s need for psych treatment. Many families are experiencing mental health crises for the first time, and as such require more psychoeducation and management.” [Emergency department social worker B]

Working with patients and families new to mental health crises is considerably more time-consuming than working with families who are well known to an emergency department or agency, and/or have experience navigating behavioral and mental health services. This extra effort and time, in combination with higher volumes of patients needing to be seen, further increased stress and may have led social workers to resign from their positions.

Societal-level factors

Racial inequity

The behavioral health crisis fueled by the COVID-19 pandemic also highlighted enormous, longstanding, and macro-level healthcare inequities that are rooted in systemic racism. Multiple social workers in the present study reported becoming significantly more aware of how medical systems fail children and families of color, particularly Black children and families. One participant discussed how structural racism has negatively impacted the care families of color have received and how past traumatic experiences with healthcare systems has understandably led these families to be wary of healthcare professionals and doubtful they will be well taken care of:

“I have been able to see firsthand how a crisis like the pandemic painfully exposes the systemic racism that many of our clients experience on a daily basis. This year has also taught me how broken our public health care system is and the extreme vulnerability this presents to so many Americans, especially families of color. I have observed how access to COVID related care is vastly unequal and the lack trust people of color have in the medical system to this day, as a result of past racist abuse, is yet another embarrassing fact of white supremacy culture.” [Outpatient/primary care social worker B]

Many participants wrote about knowing that racism is a major problem that affects healthcare long before the COVID-19 pandemic, but that social work as a profession needs to prioritize direct action and advocacy in combating institutional racism. Social workers in this study commented on how their past silence on issues of racism have been harmful, and how essential it is for social workers self-reflect and take an active, anti-racist stance in their work:

“[...] the pandemic has brought all of the inequities in our hospital, community, the culture, and country at large to light. If you are black, brown or a POC [person of color] your experience is vastly different to those who are white. If anything, the pandemic has revealed how little I had been doing as social worker to focus on these issues and lift marginalized voices. My previous efforts were not enough. [...] Our profession needs to acknowledge our racist roots and do more to improve the lives of all people.” [Outpatient/primary care social worker A]

Another participant offered a striking simile of how different communities are impacted by the pandemic based on privilege and access:

“Inequities that existed before the pandemic were exacerbated during the pandemic, evident in the glaring disparities across races. A colleague said to me that the pandemic is like we are all in the same storm, but different size boats.” [Inpatient social worker C]

Greater awareness of social determinants of health

Across all groups, participants noted that greater awareness SDOH is a critical component in addressing social inequities that place children and families of color at a social and medical disadvantage in healthcare. Many participants shared that attention to SDOH within the context of the COVID-19 pandemic was important for better understanding how to respond in health emergencies in underserved communities. For example, one participant emphasized how the health crisis has disproportionately and negatively impacted SDOH for communities of color:

“The glaring systemic racism that was evident in the number of cases in minority communities, lack of testing available, lack of vaccinations when they initially became available, length of lines at food pantries, limited amount of employment opportunities and struggle between childcare and maintaining employment.” [Inpatient social worker D]

To help address such inequities, another participant shared their belief that social workers should be part of each hospital department in order to adequately respond to institutional inequities that contributed to poor SDOH for families during the pandemic:

“Access to social work uniformly across the hospital will have to be addressed in order to address the mental health concerns post pandemic, as well as address access inequities, and ultimately, the inequities of our systems that result in housing instability and food insecurity, and access to health care. If we’re truly going to address social determinants of health, then we need to increase advocacy supports in all areas for all of the above.” [Leadership/administration social worker A]

Across participants and groups, there was agreement that an increased awareness of the inequities in access to healthcare, food, shelter, and reliable employment was essential for helping the most vulnerable and at-risk community members. As exemplified above, many respondents shared that social workers must do their part to help enhance SDOH for children and their families during the COVID-19 pandemic response.

Need for advocacy and policy change

Another societal-level theme to emerge from analyses was that social workers in our sample felt strongly that advocacy within healthcare systems was needed to address the mounting mental health crisis exacerbated by the COVID-19 pandemic. Many participants described how the current approaches and responses to this crisis have been temporary, short-term solutions that do not address longstanding and problematic underlying inadequacies and deficiencies. One participant stated:

“It feels like putting band-aids on bullet holes because of the degree to which the weaknesses in our healthcare and welfare systems have been exacerbated by the pandemic.” [Specialty social worker B].

Some participants also underscored the strong need for a concentrated effort by the social work profession to advocate for change at the hospital-, state-, and policy-levels to help address the growing mental health challenges, grief, and trauma that have existed for families and were magnified by the COVID-19 pandemic:

“Our profession has a key role in advocacy and policy. Our voice in the areas of police reform, racism, LGBTQ+, social inequalities is essential! We need to be vocal in how some communities have been disproportionately impacted by COVID.” [Specialty social worker C]

Two subthemes emerged that captured how social workers can better advocate for systemic change and contribute to policy reform. These themes captured the need for social workers to (a) be included at the many different levels of a hospital healthcare system, and (b) be part of specialized disaster response teams.

Social work inclusion at all levels

In order for social workers to be able to advocate for system-wide change and contribute to efforts to “fix” the complex problems they are tasked with by other professionals, participants in this study stated that social workers must work at all levels of a hospital healthcare system. This included social worker’s holding higher administrative positions so that social worker voices could be appropriately amplified when emergency response and hospital-wide policy decisions were being made. One participant (Specialty social worker D) commented that social workers becoming included in more positions of power might also unify social workers who are otherwise siloed onto specific specialty teams by stating: “The profession should be doing all levels of practice and working to tear down the walls that divide one social worker/team from another.” Another participant shared their belief that if social workers had initially been listened to at the start of the COVID-19 pandemic, many challenges and the mental health crisis could have been diminished:

“[...] I think social workers need to be more involved in the planning and oversight of pandemic response. [...] I suspect that certain aspects of this disaster could have been mitigated, if not avoided, if the response had been planned through a social work lens. I think that clinical social workers would have been able to give some really valuable insight into how macro policies would realistically play out at the micro level.” [Specialty social worker A]

Needs for a social worker response team

Some participants in the study shared the perspective that hospital systems would greatly benefit from a team of social workers that are prepared to respond to emergencies related to future disasters or pandemics. One participant shared how they thought such a specialized group could be of assistance:

“I strongly believe that the creation of a specialized unit of social workers trained in psychological first aid should be incorporated into the emergency management strategic planning. Whether the next disaster is man-made, biological, or natural there should be team of social workers ready to be deployed to serve our patients as part of an emergency response. I think social workers are a forgotten, vital, and underutilized resource in emergency management and mitigation.” [Specialty social worker E]

It is clear that social workers felt a need for representation at higher levels of management in order to take a more active role in important decision making when responding to emotional and behavioral crises that come from traumatic world events.

Looking towards the future

Grief and social inequity

The final theme to emerge from participants’ responses related to the long-lasting implications that the COVID-19 pandemic will have on mental health and our understanding of social inequity. Numerous respondents shared that they anticipated that grief and a sense of loss would remain long after the pandemic had passed, especially for minoritized communities.

“I think the pandemic has exposed the weak points in our society, which we will continue to deal with for many years to come. Even if the pandemic is winding down, the problems we have as a result will take much more time to address.” [Emergency department social worker C]

However, they also expressed that in communal hardship comes the possibility for reflection, collaboration, and action to better support those who are most vulnerable and underserved. As shared by one participant:

“The impact that COVID had on our minority communities is overwhelming, and the collective grief is so significant - the loss of time, the loss of lives, the loss of livelihood, the loss of stability, the loss of feeling safe. With that, though, people have been brought to our knees, and opportunities have existed for more compassionate listening, self-awareness, and learning.” [Inpatient social worker E]

In general, social workers who participated in this study felt they would be tasked with helping to manage the socioemotional difficulties that have arisen from the pandemic for years to come and that they have the skills that are needed to help children and their families manage these difficult and traumatic experiences.

Discussion

To our knowledge, this is the first study to capture experiences and thoughts of pediatric hospital social workers 1 year into the COVID-19 pandemic. Results of this present study are important for understanding and contextualizing what has remained the same and what has changed for this population of social workers since the acute phase of the pandemic, as well as the implications the COVID-19 pandemic has for the future of social work.

What has remained the same?

When comparing themes that emerged in these focus groups to those in our initial series of focus groups at the start of the pandemic, many persisted. For example, COVID-19 has continued to impact social work as a profession and social workers themselves. Many participants of this study explained that the combination of role expansion in a hospital setting to meet the needs of children and families, in combination with caring for colleagues and the expectation that social workers should fix large, systemic challenges without the necessary resources, has led to chronic experiences of stress. During the acute phase of the pandemic, social workers felt overwhelmed and powerless, and it appears that these experiences have persisted and evolved into feelings of burnout and pandemic fatigue (Ross et al., 2021). Other researchers have also documented the impact of burnout on social workers (e.g., Peinado and Anderson, 2020) and other essential healthcare workers, as well as the negative effects burnout can have on mental health and completion of professional responsibilities (Sharifi et al., 2021).

Similar to experiences participants shared at the beginning of the pandemic (Ross et al., 2021), some social workers continued to feel as though other members of multidisciplinary teams do not fully understand social workers’ roles in the context of the pandemic. In the initial phase of this research, results suggested that a joint effort between social work as a profession educating other disciplines, and institutions working to shift organizational cultures to value social work, could lead to increased awareness of the role and value of social workers (Ross et al., 2021). Social worker’s perspectives captured in the current study expanded upon this recommendation by advocating for social workers to be included at all institutional levels to better inform other disciplines of services and expertise offered. It is likely that this representation will lead to a better sense of community among social workers and increase morale, which has been linked to improved job satisfaction and decrease in turnover (e.g., Martin, 1981).

Another recommendation that has remained consistent since the beginning of the pandemic has been the call for a social worker preparedness response team (Ross et al., 2021). Findings from the current study highlight social workers’ continuing belief that the organization of an emergency/disaster response team of social work professionals could be tremendously helpful, based on first-hand observations of healthcare shortcomings from the earlier stages of the COVID-19 pandemic. The utilization and deployment of such social work teams have been found to offer essential support to patients and other hospital healthcare systems (e.g., Yu et al., 2020) and thus it is likely such benefits would be applicable in the pediatric setting.

What has changed?

Findings from the current study have also highlighted multiple changes and evolutions in social worker’s experiences after enduring 1 year of the COVID-19 pandemic. A new but expected evolution of chronic burnout was found to contribute to worsening mental health, which multiple participants discussed during the focus group. Specifically, group members shared that the stress of the pandemic, coupled with social stressors such as racial tension and violence, had deleterious effects on their own mental health. This is, unfortunately, a common outcome of frontline healthcare workers during the pandemic (e.g., Santarone et al., 2020). Another noteworthy change from the beginning of the pandemic was that many social workers, and other healthcare professionals, resigned from their positions after the incredible surge in case management and patient complexity, and the toll such demands had taken on emotional and physical wellbeing. The resignations of healthcare professionals across the world underscore how difficult and traumatic working in a hospital setting during the pandemic has been (e.g., Jiskrova, 2022). It is important to note, however, that many of the social workers who participated in this study also described how the nature of social work during a global pandemic has led to increased coping capacity and the development of new self-care strategies. Although increased institutional economic and socioemotional support remains essential so that coping skills are not inherently necessary in the profession, this ability to adapt is just one of many examples of social worker resiliency during COVID-19 (see Cook et al., 2020; Tosone, 2020).

Another important change from reported experiences during the acute phase of the pandemic (Ross et al., 2021) was social workers’ increased awareness of racial violence, longstanding healthcare inequities that have failed children and families of color, and how the pandemic has disproportionately and negatively impacted social determinants of health for communities of color. Participants shared that these deeper reflections and enhanced awareness were spurred by the murders of George Floyd and Breonna Taylor—among many others, the rise of the Black Lives Matter movement, and calls to reckon with systemic racism as a profession. Many social workers have called for their colleagues to acknowledge their own history of complicity and participate in the dismantling racist systems that perpetuate social injustices against Black people in America (e.g., McCoy, 2020; Ioakimidis and Maglajlic, 2020). Themes from the present study indicated that pediatric social workers in hospital settings share in this perspective and agree it is an ethical obligation of social work as a profession to pursue social change, particularly on behalf of vulnerable and oppressed community members. However, multiple group participants shared that they were not able to devote as much of their time and emotional resources to this critical social justice issue as they would like because of the unrelenting demands on the healthcare systems and consequential rapid role expansion of social workers. Although the COVID-19 pandemic has brought about enhanced awareness of racism, some social workers have not yet been able to behaviorally implement the changes that align with their anti-racist and social justice values.

Where do we go from here?

Looking towards the future, many pediatric hospital social workers voiced beliefs that approaches and responses to the mental health crisis exacerbated by the COVID-19 pandemic—even 1 year later—are both insufficient and often only temporary, short-term solutions that do not offer adequate, sustainable solutions to underlying deficiencies and disparities of the healthcare system. One participant offered a striking visual that compared the current efforts of social workers and institutional pandemic responses to placing band-aids on bullet holes. In other words, this participant was making the case that quick fixes do not make for effective, long-term solutions, in the same way that band-aids are not an effective way to address a bullet wound. Many participants discussed how the need for advocacy and change at hospital-, state-, and policy-levels that directly target major and complex challenges are crucial for progress. Examples included addressing chronic staffing shortages, including social work at higher levels of administration, developing a social worker crisis response team in preparation for future disasters, and protecting social workers’ time so they can properly advocate for system-wide change and engage in actively anti-racist initiatives that amplify voices of communities of color and move the profession towards social justice. Scholars have emphasized the critical importance of social workers being agents of change and advocates of social justice and human rights (e.g., Finn, 2020), which underscores the necessity of social workers being provided the time and resources to accomplish such initiatives (see McCoy, 2020). Devotion of resources and expertise to address these systemic issues will likely also aid in the management of the chronic grief and negative economic and socioemotional devastation that will surely continue to impact our most vulnerable communities long after the pandemic has ended.

Limitations

There are several major limitations in our study. The first is the lack of demographic information, which was not collected due to low response rates to the demographic survey in the initial wave (Ross et al., 2021). The second limitation is that participants were recruited exclusively from one large, urban pediatric hospital in New England and so all themes may not be generalizable to hospital social workers in other contexts or geographic locations. It may be helpful for this study to be replicated with social workers serving adult populations or providing services in other areas of the United States. Finally, the respondents may be a non-representative subset of hospital social workers in the institution.

Conclusion

The current study is one of the first to explore how the experiences of pediatric hospital social workers have changed over the course of the COVID-19 pandemic. Identified themes represented individual-, professional/hospital-, and societal-level factors, as well as implications for the future. Key shifts from perspectives shared during the initial acute phase of the pandemic include experiences of the ways in which chronic stress has evolved into burnout and a need for improved coping skills, the impact trauma and racism has had on social workers’ own mental health, the impact of the “great resignation” on social work as a profession, and an increased awareness of racial inequity and social determinants of health. Looking towards the future, social workers acknowledge the need for social justice advocacy to best support the needs of the communities of color who have been disproportionately impacted by the pandemic, as well as the necessary resources to address their anticipated, long-term grief. Finally, this research shows that social workers continue to recognize and underscore the need for additional institutional support to not only meet the demands of the current mental health crisis, but to address complex, longstanding structures that promote health disparities in the healthcare system—especially in the area of mental health. The COVID-19 pandemic has raised awareness of a mental health crisis that was already affecting many under-resourced communities, particularly communities of color. This study suggests the social work workforce recognizes their role in advocating for change.

ORCID iDs

John L McKenna https://orcid.org/0000-0003-0937-8299

Elizabeth R Boskey https://orcid.org/0000-0002-4982-1323