SOCIOLOGY

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 participate as fully compared to in-person services. Providing telehealth in LTC settings has also been noted by some to be more difficult to ensure confidentiality, given that it is often difficult to determine if others may unknowingly be present in the room, in addition to a facilitator often being present. Some types of psychological services, such as neuropsychological assessment, are not conducted as easily via telehealth, and testing is often limited by constraints of not being able to physically manipulate stimuli. However, despite the limitations experienced related to the use of telehealth in LTC settings, it did increase access to care for some during a time when in-person services were significantly limited. Visitor restrictions and disruption of mental health service delivery were perceived to have negatively impacted patients’ emotional, behavioral, cognitive, loneliness, and quality of life, with emotional status and loneliness most significantly affected. These findings are consistent with results from a recent cross-sectional study that revealed observations of increased loneliness, depression, and exacerbation of behavioral problems after the implementation of visitor restrictions (Van der Roest et al., 2020). In this study, the effect of being in quarantine for COVID-19 was perceived to have a significant influence on patients’ failure to thrive as well as increased suicidal thinking, weight loss, helplessness, and a greater need to engage with staff. Further studies utilizing objective measures of patient outcomes would be beneficial in further exploring these clinical observations. In addition, the impact of contracting COVID19 on the emotional and behavioral functioning of LTC patients would need to be separately examined because of the virus’ potential short- and long-term effects on the brain. Additionally, exploring the relationship between the emotional well-being of LTC patients and perceived loss of social support (i.e., social isolation, emotional support, and loneliness) may improve our understanding of how visitation restrictions and quarantine precautions impact patients’ emotional well-being. Mental health clinicians working in LTC settings during the COVID-19 pandemic were emotionally and financially impacted by the pandemic. Despite the majority of the sample having worked in LTC settings for over 10 years, approximately one third reported that they contemplated working in a different setting, and 23% considered quitting their job altogether. Clinicians reported that inconsistent access to their patients was the primary contributory factor to their financial stress. Despite experiencing financial stress, clinicians indicated that personal stress and concerns about making patients sick were the most difficult aspects of the pandemic. Similar to other health care workers (Mercado et al., 2022; Rodriguez et al., 2021), a majority of clinicians reported experiencing burnout, primarily attributable to trying to balance work and homelife expectations and the unpredictability of available work. A majority of clinicians also reported emotional exhaustion that was coupled with a decreased sense of success and excitement about their work. Many clinicians also experienced grief that they believed was largely not recognized by the general public. Notably, one third reported feeling traumatized by the pandemic. To offset these deleterious effects, in addition to promoting continued clinician engagement in self-care activities, these results suggest that it is important that employers recognize the emotional toll that a pandemic can have on employees and offer appropriate support.

This study is the first step in quantifying the experiences of mental health clinicians working in LTC settings after the COVID-19 national emergency declaration and their perception of the impact of the COVID-19 pandemic on the functioning of their patients. We have learned that the uninterrupted delivery of psychological services is essential because the alternative can have an adverse effect on the emotional well-being, behavioral functioning, and quality of life of LTC patients. Although the COVID-19 pandemic was and continues to be traumatic and stressful for many people, it is likely that future pandemics and similar large-scale public health emergencies will also be equally challenging, particularly for LTC patients who experience social isolation. Failure to thrive, depression, anxiety, cognitive decline, and behavioral disturbances are outcomes that adversely impact physical, medical, emotional, and behavioral functioning. As the virus continues to mutate and new variants are detected, it is unknown what the future holds in regard to the delivery of mental health care and the well-being of patients and clinicians. However, we do know that treating mental health is an essential part of enhancing an individual’s overall health. Examining the long-term effects of COVID-19, particularly for those who tested positive, will be important in the future, as it is likely that the long-term mental health implications of COVID-19 are still yet to be determined.

Limitations

Because the survey data were collected 7 months after the COVID-19 national emergency declaration, it is likely that assessing clinicians a second time after more time had elapsed may reveal different experiences with and perceptions of the pandemic. Many more would likely endorse an even larger impact on their emotional well-being. For example, over time, many clinicians would have more patients who have become ill or died from COVID-19, prolonged difficulty accessing and treating their patients as facilities struggle to manage outbreaks, and continued exposure to other institutional and system factors that contribute to burnout. It is unknown how many clinicians quit their jobs because of COVID-19 or how those who quit would have responded to the survey questions. The results of this study indicate a need for follow-up studies that use objective measures of burnout, stress, and other pertinent indicators of clinicians’ satisfaction with their work environment. These findings could be used to inform the development of programs to decrease the risk of burnout, enhance resilience, and increase staff morale. It should be noted that the sample mainly consisted of Caucasian female, middle-aged psychologists, which may limit the generalizability to other mental health professionals. Because the study questionnaire was administered online, there is a risk of nonresponse bias and social desirability. In addition, the order of survey items was not varied, which could impact response bias and/or order effects. This study only examined clinicians’ perceptions of the impact COVID-19 and the subsequent impact visitor restrictions had on their patients. It will be important for future studies to examine quantifiable and objective data related to the emotional functioning of LTC residents pre- and post-pandemic. It is also noted that it may be difficult to differentiate the emotional impact of confounding stressors that simultaneously occurred during the pandemic, such as racial tensions and political unrest. Examination of various communications reported and observed between mental health care providers and other health care providers, patients, and administrators in LTC facilities both before and during the pandemic would also be of benefit.

Conclusions

The COVID-19 pandemic has taken a toll on the nation’s LTC facilities. Both residents and mental health clinicians have suffered because of inadequate preparation, resources, and guidance for managing an evolving and potentially deadly virus. The increased rates of morbidity and mortality resulting from COVID-19 have been well-documented. However, the deleterious impact of social isolation and loneliness on LTC residents is still not fully understood. Because LTC facilities are an integral part of the U.S. health care system, future planning focused on enhancing infectious disease practices should include the perspectives of mental health clinicians. Based on findings from this study, several recommendations are offered to LTC medical directors, administrative staff, public health planners, and policymakers. First, it is vitally important to ensure that disruption of mental health services does not occur. One of the major causes of disruption in mental health services in LTC settings during the pandemic was the lack of immediate designation of psychologists and other mental providers as being essential health care providers. The only place where documentation of this could be located was on the Department of Homeland Security’s Cybersecurity and Infrastructure Security Agency’s website (https:// www.cisa.gov/identifying-critical-infrastructure-during-covid-19), but even showing this information to LTC facility administration staff did not always result in the ability for mental health providers to gain entry into the LTC facility. In this study, 7 months into the pandemic, some clinicians reported that their patients went 7 months without any kind of mental health services. In discussions with mental health providers across the United States since this study, we have become aware of many situations where patients have gone without mental health services for over a year, and longer, during the duration of the pandemic. More needs to be done to ensure that mental health clinicians are nationally designated as essential health care providers, and that this designation is well-documented in order to prevent any future misunderstanding regarding this issue. If this is better documented by national, state, and local authorities, then there should be little left for interpretation the next time an emergency or pandemic occurs. Specifically, next time a national emergency declaration occurs, federal administrators should explicitly designate who is considered essential after hopefully putting thought and planning into it. One of the other major issues that negatively impacted mental health providers during the pandemic was the lack of, or inconsistent, communication about vitally important information from facility staff. Many clinicians have reported that they would arrive at an LTC facility expecting to see their patients, only to be turned away because there was an outbreak in the facility. Others were turned away because they were asked to get COVID tested within a certain time frame of arriving at the facility (e.g., 48 hr) despite limited community-based testing available. In addition, some reported that there was a lack of, or untimely, communication about the COVID status of their own patients. Hopefully, we can learn from this experience and make necessary improvements so that we are better prepared for future pandemics. Some suggestions include that facility administrators designate an automated communication system of alerting staff, consultants, and family members of changes in policies, such as visitation and status of the emergent situation. Second, administrators should designate a staff person (e.g., director of nursing or facility social worker) to inform all consulting health care providers of any important current issues, such as requirements to enter the facility (e.g., PPE, testing requirements) and if/when any of their patients are being impacted by the current emergency situation. In addition, mental health clinicians should be offered the same opportunities for testing availability and PPE usage as facilities offer to their medical consultants. Although in other settings telehealth was able to expand quickly and successfully to offer access to mental health services during the pandemic, similar attempts to deliver mental health services via telehealth in LTC settings were often challenging and replete with technological and personnel barriers. In the event that in-person mental health services are not feasible due to infection control guidelines, allocating and designating staff to support telehealth facilitation is vital. Making this a mandatory requirement by the government may be what is needed to ensure this happens. Moreover, facilities investing in multiple devices that could be used for telehealth and providing technology training to patients who are capable of independently engaging in telehealth may foster increased independence for patients and result in less reliance on staff for technical assistance. Although staff facilitation could primarily focus on patients with visual impairments or those who could benefit from assistance based on their cognitive or physical limitations, the challenges in maintaining adequate staffing levels may hinder the ability of LTCs to provide this type of basic technical support. The Wall Street Journal found that at 18 months after the start of the pandemic, LTC facilities were continuing to lose workers because of low wages, fear of COVID-19, and burnout when job losses in other sectors had already begun to show significant recovery (Weber, 2021). Additionally, a recent report revealed that many LTC facilities are experiencing significant financial difficulties because of rising expenses and sharp declines in occupancy as a result of the COVID-19 pandemic (Mathews & Kamp, 2020). Upgrades to existing buildings that would enhance the ability of residents and staff to get a good internet connection for telehealth and social use can be costly. Many older LTC buildings were built with materials that block Wi-Fi signals and make it challenging to lay new cables or fiber optics. Overall, for telehealth to be successful in LTC settings, financial investments will need to occur. Allowing LTC residents to go without medical care for 7 months during a national emergency would not be allowed. Why should it be different for mental health care? Prioritizing the mental health needs of patients with the same level of importance as their medical needs would ideally prevent exacerbation of preexisting conditions and help ensure that facilities maintain compliance with regulations intended to ensure that the mental health needs of residents are being met. This may be a challenging goal to achieve in the short term as recent workforce projections by the National Center for Health Workforce Analysis reveal that the existing number of clinicians who provide mental health services is insufficient to meet the current demands and will continue to worsen in the coming years (Health Resources & Services Administration [HSRA], 2021). Training programs that are designed to increase the number of qualified psychologists should be encouraged and supported by federal funding. The Age-Friendly University initiative has the potential to foster interest in learning about older adults and life span development issues for undergraduate and graduate students. Priming the pipeline is an excellent starting point for envisioning how LTC facilities could better meet the needs of residents and staff in the coming years. Although psychological first aid (PFA) is now recognized as the intervention of choice for disaster-affected populations (Fox et al., 2012; Minihan et al., 2020), it has not been widely adopted by nursing homes for use with residents. The PFA intervention was initially developed and disseminated by the National Child Traumatic Stress Network and the National Center for PTSD in 2006. PFA was designed to be used after disasters to reduce initial distress and promote adaptive functioning and coping. Because the PFA field guide primarily focused on children, adolescents, and community-dwelling adults, the Psychological First Aid Field Operations Guide for Nursing Homes (PFA-NH) was developed (Brown & Hyer, 2008) and later expanded to include a broader range of traumatic events such as palliative care and end-of-life issues, behavioral interventions for people with dementia, and how to help older adults deal with significant life changes, events, or losses that can result in significant emotional distress and sometimes escalate to a state of crisis (Brown et al., 2009). Death of a loved one or friend, accidents, and illness are a few examples of traumatic events that commonly occur in late life. Because PFA, like medical first aid, does not have to be delivered by highly trained licensed mental health clinicians, all NH staff who provide care to residents could be trained to provide the intervention. PFA training could enhance NH staffs’ ability to detect changes in mood or cognition and intervene appropriately and quickly with those who are distressed. Finally, the emotional well-being of mental health workers should be a priority for administrators, policymakers, and program developers. More than half of the clinicians in this sample reported experiencing emotional exhaustion, burnout, and grief, and nearly one third believed they had experienced trauma by providing mental health services in LTC settings during the COVID-19 pandemic. Moreover, despite the majority of clinicians in the sample having worked in LTC settings for at least 10 years, approximately one third reported that they had contemplated working in a different setting, and almost one quarter considered quitting their job altogether. These findings are important and suggest that emphasizing employee and personal mental health should be actively supported. A strong support system is not just relevant to mental health practitioners who work in LTC settings. It is a necessary component of self-care that can help to ward off emotional fatigue. A recent Stress in America survey (APA, 2022) indicated that 58% of their sample experienced the pandemic as a daily stressor. Almost the same number (56%) believed that they could have used more emotional support than they received during the pandemic. As clinicians, we should pay attention to signs, symptoms, and triggers related to stress and engage in self-care to prevent burnout and other medical sequelae associated with stress. As colleagues, we should create supportive work relationships and not hesitate to reach out to one another when needed to offer aid and support. Employers should assess for and be cognizant of factors that can contribute to stress in the workplace and offer employee assistance resources and programs. Finally, policymakers should continue to focus on ensuring that mental health is prioritized by decreasing barriers and increasing access to mental health services, particularly for those in the workforce who are routinely exposed to stress and trauma.

References

Agronin, M. E. (2021). The impact of COVID-19 on mental health in longterm care settings. Psychiatric Times. Retrieved January 3, 2021, from https://www.psychiatrictimes.com/view/the-impact-of-covid-19-on-mentalhealth-in-long-term-care-settings American Psychological Association. (2021). Stress in the time of COVID19. Retrieved January 3, 2021 from, https://www.apa.org/news/press/relea ses/stress/2020/stress-in-america-covid.pdf American Psychological Association. (2022). Stress in America: Money, inflation, war pile on to nation stuck in COVID-19 survival mode. Retrieved March 22, 2022, from https://www.apa.org/news/press/relea ses/stress/2022/march-2022-survival-mode Brown, L. M., Bruce, M. L., Hyer, K., Mills, W. L., Vongxaiburana, E., & Polivka-West, L. (2009). A pilot study evaluating the feasibility of psychological first aid for nursing home residents. Clinical Gerontologist, 32(3), 293–308. https://doi.org/10.1080/07317110902895317 Brown, L. M., & Hyer, K. (2008). Psychological first aid field operations guide for nursing homes. https://www.hhs.gov Brown, R. L. (1994). Efficacy of the indirect approach for estimating structural equation models with missing data: A comparison of five methods. Structural Equation Modeling, 1(4), 287–316. https://doi.org/ 10.1080/10705519409539983 Centers for Medicare and Medicaid Services. (2022). COVID-19 nursing home data. Retrieved March 12, 2022, from https://data.cms.gov/covid19/covid-19-nursing-home-data Czeisler, M. E., Lane, R. I., Petrosky, E., Wiley, J. F., Christensen, A., Njai, R., Weaver, M. D., Robbins, R., Facer-Childs, E. R., Barger, L. K., Czeisler, C. A., Howard, M. E., & Rajaratnam, S. M. W. (2020). Mental health, substance use, and suicidal ideation during the COVID-19 pandemic—United States, June 24–30, 2020. MMWR: Morbidity and Mortality Weekly Report, 69(32), 1049–1057. https://doi.org/10.15585/ mmwr.mm6932a1 Department of Health and Human Services, Center for Clinical Standards and Quality, & Quality, Safety and Oversight Group. (March 13, 2020). Guidance for infection control and prevention of coronavirus disease 2019 (COVID-19) in nursing homes. https://www.cms.gov/files/docume nt/3-13-2020-nursing-home-guidance-covid-19.pdf Dozois, D. J. A., & Mental Health Research Canada. (2021). Anxiety and depression in Canada during the COVID-19 pandemic: A national survey. Canadian Psychology, 62(1), 136–142. https://doi.org/10.1037/cap0000251 Fox, J. H., Burkle, F. M., Jr., Bass, J., Pia, F. A., Epstein, J. L., & Markenson, D. (2012). The effectiveness of psychological first aid as a disaster intervention tool: Research analysis of peer-reviewed literature from 1990–2010. Disaster Medicine and Public Health Preparedness, 6(3), 247–252. https://doi.org/10.1001/dmp.2012.39 Gallagher, M. W., Zvolensky, M. J., Long, L. J., Rogers, A. H., & Garey, L. (2020). The impact of COVID-19 experiences and associated stress on anxiety, depression, and functional impairment in American adults. Cognitive Therapy and Research, 44(6), 1043–1051. https://doi.org/10 .1007/s10608-020-10143-y Graham, J. (2021). Prayers and grief counseling after COVID: Trying to aid healing in long-term care. Retrieved January 3, 2021, from https://www .cnn.com/2020/11/13/health/covid-long-term-care-facilities-wellness-khnpartner/index.html Hartman-Stein, P. (2021). COVID-19 brings change to behavioral health for older adults. Retrieved February 15, 2021, from https://www.national psychologist.com/covid-19-brings Health Resources & Services Administration. (2021, August). Workforce projections. Retrieved October 26, 2021, from https://data.hrsa.gov/ topics/health-workforce/workforce-projections IBM Corp. (2020). IBM SPSS statistics for windows (Version 27.0). Kaiser Family Foundation. (2022). State health facts: Total number of residents in certified nursing facilities. Retrieved March 12, 2022, from https://www.kff.org/other/state-indicator/number-of-nursing-facility-reside nts/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location% 22,%22sort%22:%22asc%22%7D Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., Wu, J., Du, H., Chen, T., Li, R., Tan, H., Kang, L., Yao, L., Huang, M., Wang, H., Wang, G., Liu, Z., & Hu, S. (2020, March 2). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Network Open, 3(3), Article e203976. https://doi.org/10.1001/jamanetworkopen.2020.3976 Lu, W., Wang, H., Lin, Y., & Li, L. (2020). Psychological status of medical workforce during the COVID-19 pandemic: A cross-sectional study. Psychiatry Research, 288, Article 112936. https://doi.org/10.1016/j .psychres.2020.112936 Mathews, A. W., & Kamp, J. (2020). COVID-19 pandemic hits nursinghome finances. The Wall Street Journal. Retrieved October 26, 2021, from https://www.wsj.com/articles/covid-19-pandemic-hits-nursing-home-fina nces-11590604049?cx_testId=3&cx_testVariant=cx_5&cx_artPos= 4&mod=WTRN#cxrecs_s Mercado, M., Wachter, K., Schuster, R. C., Mathis, C. M., Johnson, E., Davis, O. I., & Johnson-Agbakwu, C. E. (2022). A cross-sectional analysis of factors associated with stress, burnout and turnover intention among healthcare workers during the COVID-19 pandemic in the United States. Health and Social Care in the Community. Advance online publication. https://doi.org/10.1111/hsc.13712 Minihan, E., Gavin, B., Kelly, B. D., & McNicholas, F. (2020). COVID-19, mental health and psychological first aid. Irish Journal of Psychological Medicine, 37(4), 259–263. https://doi.org/10.1017/ipm.2020.41 Montgomery, A., Slocum, S., & Stanik, C. (2021). Experiences of nursing home residents during the pandemic: What we learned from residents about life under COVID-19 restrictions and what we can do about it. Retrieved January 3, 2021, from https://altarum.org/sites/default/files/ uploaded-publication-files/Nursing-Home-Resident-Survey_Altarum-SpecialReport_FINAL.pdf Nierengarten, M. (2021). COVID and the ongoing mental health needs of long-term care residents. Retrieved February 15, 2021, from https://pro .psycom.net/special_reports/covid-and-mental-health-long-term-careresidents Pierce, B. S., Perrin, P. B., Tyler, C. M., McKee, G. B., & Watson, J. D. (2021). The COVID-19 telepsychology revolution: A national study of pandemic-based changes in U.S. mental health care delivery. American Psychologist, 76(1), 14–25. https://doi.org/10.1037/amp0000722 Rodriguez, R. M., Montoy, J., Hoth, K. F., Talan, D. A., Harland, K. K., Eyck, P. T., Mower, W., Krishnadasan, A., Santibanez, S., Mohr, N., & Project COVERED Emergency Department Network. (2021). Symptoms of anxiety, burnout, and PTSD and the mitigation effect of serologic testing in emergency department personnel during the COVID-19 pandemic. Annals of Emergency Medicine, 78(1), 35–43.e2. https://doi.org/10 .1016/j.annemergmed.2021.01.028 Ruiz, M. A., & Gibson, C. M. (2020). Emotional impact of the COVID-19 pandemic on US health care workers: A gathering storm. Psychological Trauma, 12(S1): S153–S155. https://doi.org/10.1037/tra0000851 Sammons, M. T., Elchert, D. M., & Martin, J. N. (2021). Mental health service provision during COVID-19: Results of the third survey of licensed psychologists. Journal of Health Service Psychology, 47(3), 119–127. https://doi.org/10.1007/s42843-021-00044-3 Sammons, M. T., VandenBos, G. R., & Martin, J. N. (2020). Psychological practice and the COVID-19 crisis: A rapid response survey. Journal of Health Service Psychology, 46(2), 51–57. https://doi.org/10.1007/s42843- 020-00013-2 Sammons, M. T., VandenBos, G. R., Martin, J. N., & Elchert, D. M. (2020). Psychological practice at six months of COVID-19: A follow-up to the first national survey of psychologists during the pandemic. Journal of Health Service Psychology, 46(4), 145–154. https://doi.org/10.1007/ s42843-020-00024-z Serafini, G., Parmigiani, B., Amerio, A., Aguglia, A., Sher, L., & Amore, M. (2020). The psychological impact of COVID-19 on the mental health in This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. THE IMPACT OF THE COVID-19 9 the general population. QJM: An International Journal of Medicine, 113(8), 531–537. https://doi.org/10.1093/qjmed/hcaa201 Spoorthy, M. S., Pratapa, S. K., & Mahant, S. (2020). Mental health problems faced by healthcare workers due to the COVID-19 pandemic– A review. Asian Journal of Psychiatry, 51, Article 102119. https://doi.org/ 10.1016/j.ajp.2020.102119 U.S. Department of Health and Human Services. (2021). Notification of enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. Retrieved January 3, 2021, from https://www.hhs.gov/hipaa/for-professionals/special-topics/ emergency-preparedness/notification-enforcement-discretion-telehealth/ index.html Vahia, I. V., Jeste, D. V., & Reynolds, C. F., III. (2020). Older adults and the mental health effects of COVID-19. JAMA, 324(22), 2253–2254. https:// doi.org/10.1001/jama.2020.21753 Van der Roest, H. G., Prins, M., van der Velden, C., Steinmetz, S., Stolte, E., van Tilburg, T. G., & de Vries, D. H. (2020). The impact of COVID-19 measures on well-being of older long-term care facility residents in the Netherlands. Journal of the American Medical Directors Association, 21(11), 1569–1570. https://doi.org/10.1016/j.jamda.2020.09.007 Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., Ho, C. S., & Ho, R. C. (2020). Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. International Journal of Environmental Research and Public Health, 17(5), Article E1729. https://doi.org/10 .3390/ijerph17051729 Weber, L. (2021, August 25). Nursing homes keep losing workers. The Wall Street Journal. Retrieved October 27, 2021, from https://www.wsj.com/ articles/nursing-homes-keep-losing-workers-11629898200