Psychological impact of an epidemic/pandemic on the mental health of healthcare professionals: a rapid review

Protective Elements of Mental Health Status during the COVID-19 Outbreak in the Portuguese Population

The outbreak of COVID-19 might produce dramatic psychological effects on individuals’ lives. In this study, we aimed to explore the elements that may reduce the negative effects on mental health of the quarantine period imposed by most governments during this worldwide crisis. We conducted an online survey to evaluate demographic, lifestyle and mental health variables in a sample of 1280 Portuguese individuals (79.8% females) with an average age of 37 years. We observed that factors related to living conditions, maintaining work either online or in the workplace, frequency of exercise and absence of previous psychological or physic disorders are protective features of psychological well-being (anxiety, depression, stress and obsessive-compulsive symptoms). Finally, the individuals previously receiving psychotherapeutic support exhibited better psychological indicators if they did not interrupt the process as a consequence of the outbreak. Our results indicate that the practice of physical exercise, reduced consumption of COVID-19 information and the implementation of remote mental healthcare measures might prevent larger impacts on mental health during the COVID-19 outbreak.

COVID-19: Causes of anxiety and wellbeing support needs of healthcare professionals in the UK: A cross-sectional survey

BACKGROUND

COVID-19 has caused acute changes in healthcare delivery; this may impact mental health and wellbeing needs of healthcare professionals (HCPs).

AIMS

We aimed to identify the causes of anxiety in HCPs during the COVID-19 pandemic, to assess whether HCPs felt they had adequate mental health and wellbeing support and to identify their unmet support needs.

METHOD

We used a web-based survey utilising an online tool circulated to UK HCPs over 5 weeks. Self-perceived anxiety levels prior to and during the COVID-19 pandemic were measured on a 10-point Likert-type rating scale.

RESULTS

The survey was completed by 558 HCPs. During the pandemic, self-perceived anxiety scores significantly increased from a median of 2 to 7 (paired Wilcoxon signed-rank test; p<0.001). The main reasons were concerns about exposure to SARS-CoV-2 and lack of personal protective equipment. Other wide-ranging reasons were identified. Only 41% of respondents felt there was adequate support. Thematic analysis of what support HCPs wanted identified 13 wide-ranging themes; including effective leadership and peer support.

CONCLUSION

Anxiety levels in HCPs significantly increased during the COVID-19 pandemic and the main causes were identified. Many HCPs felt there was inadequate support and identified what support they needed. Implementing effective strategies to support HCPs' unmet wellbeing needs are required as a matter of urgency.

What We Have Learned from Two Decades of Epidemics and Pandemics: A Systematic Review and Meta-Analysis of the Psychological Burden of Frontline Healthcare Workers

In light of the current coronavirus disease 2019 (COVID-19) pandemic and potential future infectious disease outbreaks, a comprehensive understanding of the negative effects of epidemics and pandemics on healthcare workers' mental health could inform appropriate support interventions. Thus, we aimed to synthesize and quantify the psychological and psychosomatic symptoms among frontline medical staff. We searched four databases up to March 19, 2020 and additional literature, with daily search alerts set up until October 26, 2020. Studies reporting psychological and/or psychosomatic symptoms of healthcare workers caring for patients with severe acute respiratory syndrome, H1N1, Ebola, Middle East respiratory syndrome, or COVID-19 were eligible for inclusion. Two reviewers independently conducted the search, study selection, quality appraisal, data extraction, and synthesis and involved a third reviewer in case of disagreement. We used random effects modeling to estimate the overall prevalence rates of psychological/psychosomatic symptoms and the I2 statistic. We included 86 studies, reporting data from 75,991 participants. Frontline staff showed a wide range of symptoms, including concern about transmitting the virus to the family (60.39%, 95% CI 42.53-76.96), perceived stress (56.77%, 95% CI 34.21-77.95), concerns about own health (45.97%, 95% CI 31.08-61.23), sleeping difficulties (39.88%, 95% CI 27.70-52.72), burnout (31.81%, 95% CI 13.32-53.89), symptoms of depression (25.72%, 95% CI 18.34-33.86), symptoms of anxiety (25.36%, 95% CI 17.90-33.64), symptoms of posttraumatic stress disorder (24.51%, 95% CI 18.16-31.46), mental health issues (23.11%, 95% CI 15.98-31.10), and symptoms of somatization (14.68%, 95% CI 10.67-19.18). We found consistent evidence for the pervasive and profound impact of large-scale outbreaks on the mental health of frontline healthcare workers. As the CO-VID-19 crisis continues to unfold, guaranteeing easy access to support structures for the entire healthcare workforce is vitally important.

Impact of the COVID-19 Pandemic on Psychiatric Admissions to a Large Swiss Emergency Department: An Observational Study

The coronavirus disease 2019 (COVID-19) pandemic is a public health emergency with profound mental health consequences. The psychiatric emergency department (ED) plays a key role during this mental health crisis. This study aimed to investigate differences in admissions at a Swiss psychiatric ED from 1 April to 15 May during a “pandemic-free” period in 2016 and a “during-pandemic” period in 2020. The study included 579 consultations at psychiatric ED in the “during-pandemic” period and 702 in the “pandemic-free” period. Sociodemographic and clinical characteristics were compared, and logistic regression analysis was performed to identify variables associated with psychiatric admissions during the pandemic. A reduction in total psychiatric ED admissions was documented during COVID-19. Logistic regression analysis predicted the independent variable (ED admission during the pandemic) and estimated odds ratio (OR) for being unmarried/not in a relationship, arrival in an ambulance, suicidal behavior, behavioral disorders and psychomotor agitation. Though only statistically significant in bivariate analysis, patients were also more likely to be involuntarily hospitalized. This picture appears to be reversed from a sociodemographic and clinical point of view to our observation of psychiatric ED consultation in 2016. These findings highlight that the reduction in psychiatric ED admissions during the pandemic seems to be associated with living alone and more severe psychopathologies, which must alert psychiatrists to ensure access to mental health care in times of pandemic.

Grace Under Pressure: Resilience, Burnout, and Wellbeing in Frontline Workers in the United Kingdom and Republic of Ireland During the SARS-CoV-2 Pandemic

The coronavirus pandemic has necessitated extraordinary human resilience in order to preserve and prolong life and social order. Risks to health and even life are being confronted by workers in health and social care, as well as those in roles previously never defined as "frontline," such as individuals working in community supply chain sectors. The strategy adopted by the United Kingdom (UK) government in facing the challenges of the pandemic was markedly different from other countries. The present study set out to examine what variables were associated with resilience, burnout, and wellbeing in all sectors of frontline workers, and whether or not these differed between the UK and Republic of Ireland (RoI). Individuals were eligible if they were a frontline worker (in health and social care, community supply chain, or other emergency services) in the UK or RoI during the pandemic. Part of a larger, longitudinal study, the participants completed an online survey to assess various aspects of their daily and working lives, along with their attitudes toward their government's handling of the crisis, and measurement of psychological variables associated with heroism (altruism, meaning in life, and resilient coping). A total of 1,305 participants (N = 869, 66.6% from the UK) provided sufficient data for analysis. UK-based workers reported lower wellbeing than the RoI-based participants. In multivariate models, both psychological and pandemic-related variables were associated with levels of resilience, burnout, and wellbeing in these workers, but which pandemic-related variables were associated with outcomes differed depending on the country. The judgment of lower timeliness in their government's response to the pandemic appeared to be a key driver of each outcome for the UK-based frontline workers. These findings provide initial evidence that the different strategies adopted by each country may be associated with the overall wellbeing of frontline workers, with higher detriment observed in the UK. The judgment of the relatively slow response of the UK government to instigate their pandemic measures appears to be associated with lower resilience, higher burnout, and lower wellbeing in frontline workers in the UK.

Measuring COVID-19-related fear and threat in Australian, Indian, and Nepali university students

The present study describes the adaption and validation of a brief measure of contagion-related fear and threat in Australian, Indian, and Nepali university students in Australia at the height of the first wave of the COVID-19 pandemic. Adapted from Ho, Kwong-Lo, Mak, and Wong's (2005) SARS-related fear scale, the Contagion Fear and Threat Scale (CFTS) was rapidly adapted to capture the experience of COVID-19 pandemic-related fear. The factor structure and validity of the 6-item scale were established among Australian (n = 154), Indian (n = 111), and Nepali (n = 149) university students studying in Australia in May–June 2020. Factor analysis revealed two 3-item factors in the Australian student sample: Fear of Infection and Existential Threat. These factors were confirmed in the Indian and Nepali student samples and mirror those found by the Ho et al. (2005) in their original instrument. The convergent and discriminant validity of the full CFTS, Fear of Infection, and Existential Threat scales are indicated via correlations with established measures of depression, anxiety, stress, subjective wellbeing, and religiosity. Differences in the performance of the Fear of Infection and Existential Threat scales are considered in terms of the respective objective and subjective nature of the constructs.

COVID-19 welbeing study: a protocol examining perceived coercion and psychological well-being during the COVID-19 pandemic by means of an online survey, asynchronous virtual focus groups and individual interviews

INTRODUCTION

The COVID-19 pandemic has resulted in many countries applying restrictive measures, such as lockdown, to contain and prevent further spread. The psychological impact of lockdown and working as a healthcare worker on the frontline has been chronicled in studies pertaining to previous infectious disease pandemics that have reported the presence of depressive symptoms, anxiety, insomnia, and post-traumatic stress symptoms. Potentially linked to psychological well-being and not yet studied is the possibility that lockdown and working on the frontline of the pandemic are associated with perceptions of coercion.

METHODS AND ANALYSIS

The present study aimed to examine perceived coercion in those who have experienced COVID-19-related lockdown and/or worked as a frontline healthcare worker across three European countries. It aimed to describe how such perceptions may impact on psychological well-being, coping and post-traumatic growth. It will employ an explanatory mixed-methods research methodology consisting of an online survey and online asynchronous virtual focus groups (AVFGs) and individual interviews. χ² tests and analyses of variance will be used to examine whether participants from different countries differ according to demographic factors, whether there are differences between cohorts on perceived coercion, depression, anxiety and post-traumatic growth scores. The relationship between coercion and symptoms of distress will be assessed using multiple regression. Both the AVFGs and the narrative interviews will be analysed using thematic narrative analysis.

ETHICS AND DISSEMINATION

The study has been approved by University College London's Research Ethics Committee under Project ID Number 7335/004. Results will be disseminated by means of peer-reviewed publications and at national and/or international conferences.

Mental Health Burden of the COVID-19 Pandemic in Healthcare Workers in Four Latin American Countries

The aim of the study was to assess the mental health burden of the COVID-19 pandemic in healthcare workers in four Latin American countries in 2020.An online survey was carried out with 1721 participants from Argentina, Chile, Colombia and Mexico in 2020. A non-probabilistic convenience sampling method was used to recruit voluntary participants. Post-traumatic stress symptoms were assessed with the SPRINT-E scale, Perceived Discrimination was assessed with a Spanish version of the scale developed by Molero, and anxiety toward death was assessed with the Spanish version of the Templer scale. All instruments were assessed for internal consistency.The overall frequency of post-traumatic stress symptoms was 23.9%. The frequency by countries was 26.4% in Argentina, 29.8% in Chile, 19.9 in Colombia, and 23.8% in Mexico. Post-traumatic stress symptoms were associated with individual subtle discrimination, anxiety toward the death of the elderly, lack of Personal Protective Equipment, and exposition to the death.The COVID-19 pandemic has imposed a mental health burden on health workers in the countries included in the study, not only due to the implications of the disease in the face of exposure to death, but also due to institutional conditions and in which they carry out their work.

Time Trends of the Public's Attention Toward Suicide During the COVID-19 Pandemic: Retrospective, Longitudinal Time-Series Study

Background

The COVID-19 pandemic has overwhelmed health care systems around the world. Emerging evidence has suggested that substantially few patients seek help for suicidality at clinical settings during the COVID-19 pandemic, which has elicited concerns of an imminent mental health crisis as the course of the pandemic continues to unfold. Clarifying the relationship between the public’s attention to knowledge about suicide and the public’s attention to knowledge about the COVID-19 pandemic may provide insight into developing prevention strategies for a putative surge of suicide in relation to the impact of the COVID-19 pandemic.

Objective

The goal of this retrospective, longitudinal time-series study is to understand the relationship between temporal trends of interest for the search term “suicide” and those of COVID-19–related terms, such as “social distancing,” “school closure,” and “lockdown.”

Methods

We used the Google Trends platform to collect data on daily interest levels for search terms related to suicide, several other mental health-related issues, and COVID-19 over the period between February 14, 2020 and May 13, 2020. A correlational analysis was performed to determine the association between the search term ‘‘suicide’’ and COVID-19–related search terms in 16 countries. The Mann-Kendall test was used to examine significant differences between interest levels for the search term “suicide” before and after school closure.

Results

We found that interest levels for the search term “suicide” statistically significantly inversely correlated with interest levels for the search terms “COVID-19” or “coronavirus” in nearly all countries between February 14, 2020 and May 13, 2020. Additionally, search interest for the term ‘‘suicide’’ significantly and negatively correlated with that of many COVID-19–related search terms, and search interest varied between countries. The Mann-Kendall test was used to examine significant differences between search interest levels for the term “suicide” before and after school closure. The Netherlands (P=.19), New Zealand (P=.003), the United Kingdom (P=.006), and the United States (P=.049) showed significant negative trends in interest levels for suicide in the 2-week period preceding school closures. In contrast, interest levels for suicide had a significant positive trend in Canada (P<.001) and the United States (P=.002) after school closures.

Conclusions

The public’s attention to suicide might inversely correlate with the public’s attention to COVID-19–related issues. Additionally, several anticontagion policies, such as school closure, might have led to a turning point for mental health crises, because the attention to suicidality increased after restrictions were implemented. Our results suggest that an increased risk of suicidal ideation may ensue due to the ongoing anticontagion policies. Timely intervention strategies for suicides should therefore be an integral part of efforts to flatten the epidemic curve.

Coping Mechanisms: Exploring Strategies Utilized by Japanese Healthcare Workers to Reduce Stress and Improve Mental Health during the COVID-19 Pandemic

The COVID-19 pandemic is a major problem affecting the mental health of millions of people, including healthcare workers. In this study, we analyzed risk factors and coping mechanisms that could reduce the risk of poor mental health among healthcare workers during the COVID-19 pandemic in Japan. A cross-sectional survey was conducted for 7 days from 30 April 2020 using a web-based questionnaire. The survey assessed various outcome measures, including the General Health Questionnaire-12 (GHQ-12), health status, satisfaction with daily life activities, work, leisure, and new activities, and anxiety over COVID-19. Data from 661 participants were analyzed, and 440 participants (66.6%) showed poor mental health (GHQ-12 ≥ 4). Also, our result showed that female gender, lower levels of communication with friends, and high anxiety were associated with poorer mental health. In contrast, good health status, high work satisfaction, and high satisfaction from new activities were associated with buffering mental health problem. Most participants chose an escape-avoidance coping strategy, and participants with worse mental health were more likely to adopt seeking social support as a coping strategy. These results may support healthcare workers to cope with mental health problems associated with the COVID-19 pandemic.

Bibliotherapy: Reading OVID During COVID

An epidemic of an infectious disease such as COVID-19 is often a source of emotional distress, even among those who have not been directly exposed to the disease. The period following the acute phase of the coronavirus epidemic and the mitigation measures will likely be hardest for medical professionals in terms of psychological impact. Bibliotherapy is a systematic intervention regarding the use of carefully selected reading materials in order to help persons to cope with stress and personal problems. This therapy can be used easily during the pandemic. The review of evidence shows that this kind of intervention can be helpful in educational and clinical contexts. During the crisis, it can be an alternative to video and film entertainment and a transition from serious medical journal clubs to a softer medical humanities experience. In this article, we summarized the historical background of bibliotherapy. We also proposed a reading list from different times, and cultures relating to pandemic, quarantine, symptoms, confinement, and social impacts (e.g., Camus, Moravia, London, Le Clezio etc.). Bibliotherapy can be a way for doctors and healthcare workers fighting on the frontline of the pandemic to find psychological support and for debriefing. Bibliotherapy can help individuals that need support for emotional distress during the pandemic to verbalize their feelings and emotions and identify new ways of addressing problems.

Job Demands and Resources among Healthcare Professionals during Virus Pandemics: A Review and Examination of Fluctuations in Mental Health Strain during COVID-19

The present article examines how job demands and resources are related to indices of strain among healthcare professionals during virus pandemics. The article also presents the results of a study examining the relationships between COVID‐19 demands (e.g., lack of personal protective equipment, concerns about infecting family members), resources (meaningful work, social support), and mental health strain within a sample of emergency medicine personnel over six consecutive weeks. COVID‐19‐related demands and hours worked were hypothesized to be positively related to mental health strain, whereas meaningful work and social support were hypothesized to be negatively related to mental health strain. Hours worked the prior week were hypothesized to exacerbate the positive relationships between COVID‐19 demands and mental health strain, whereas the resources of meaningful work and social support were expected to buffer the relationships. Multilevel models controlling for mental health strain the prior week revealed that COVID‐19 demands, along with hours worked, were each related to higher mental health strain during the week. Hours worked magnified the within‐person relationship between personal COVID‐19 demands and mental health strain. In contrast to the hypotheses, social support and meaningful work were not related to mental health strain. Discussion focuses on the implications of the findings for healthcare professionals.

Meaning in life and demoralization: a mental-health reading perspective of suicidality in the time of COVID-19

Consequences on mental health have been reported in general population, vulnerable individuals, psychiatric patients, and healthcare professionals. It is urgently necessary to study mental health issues in order to set priorities for public health policies and implement effective interventions. Suicidality is one of the most extreme outcomes of a mental health crisis. It is currently too early to know what the effect of COVID-19 will be on suicidality. However, authoritative commentary papers alert that most of the factors precipitating suicide are, and probably will be for a long time, present at several individual existence levels. A number of prevention measures and research considerations have been drawn up. A point of the latter, recommended by the International COVID-10 Suicide Prevention Research Collaboration, states that “the COVID-19 suicide research response should be truly multidisciplinary. This will foster research that addresses the different aspects and layers of risk and resilience […]. It will also foster research that informs prevention efforts by taking a range of perspectives” (Niederkrotenthaler et al., 2020). In this light, we would like to propose a reading perspective of suicidality that takes into account Meaning in Life (MiL) and demoralization. Both of the constructs were studied in heterogeneous populations with extreme life situations having led to a fracture between a “before” and an “after”, and play a role in affecting suicidality, respectively as resilience and risk factors. In clinical practice, during these unprecedent times, we wish that this more inclusive approach could: 1) contribute to prevention, by delineating more individualized suicidal risk profiles in persons conventionally non-considered at risk but here exposed to an extremely uncommon experience, 2) enrich supportive/psychotherapeutic interventions, by broadening the panel of means to some aspects constitutive of the existential condition of a person who is brutally confronted with something unexpected, incomprehensible and, in some ways, still unpredictable. (www.actabiomedica.it)

Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review

BACKGROUND

Evidence from disease epidemics shows that healthcare workers are at risk of developing short- and long-term mental health problems. The World Health Organization (WHO) has warned about the potential negative impact of the COVID-19 crisis on the mental well-being of health and social care professionals. Symptoms of mental health problems commonly include depression, anxiety, stress, and additional cognitive and social problems; these can impact on function in the workplace. The mental health and resilience (ability to cope with the negative effects of stress) of frontline health and social care professionals ('frontline workers' in this review) could be supported during disease epidemics by workplace interventions, interventions to support basic daily needs, psychological support interventions, pharmacological interventions, or a combination of any or all of these.

OBJECTIVES

Objective 1: to assess the effects of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic. Objective 2: to identify barriers and facilitators that may impact on the implementation of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic.

SEARCH METHODS

On 28 May 2020 we searched the Cochrane Database of Systematic Reviews, CENTRAL, MEDLINE, Embase, Web of Science, PsycINFO, CINAHL, Global Index Medicus databases and WHO Institutional Repository for Information Sharing. We also searched ongoing trials registers and Google Scholar. We ran all searches from the year 2002 onwards, with no language restrictions.

SELECTION CRITERIA

We included studies in which participants were health and social care professionals working at the front line during infectious disease outbreaks, categorised as epidemics or pandemics by WHO, from 2002 onwards. For objective 1 we included quantitative evidence from randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies, which investigated the effect of any intervention to support mental health or resilience, compared to no intervention, standard care, placebo or attention control intervention, or other active interventions. For objective 2 we included qualitative evidence from studies that described barriers and facilitators to the implementation of interventions. Outcomes critical to this review were general mental health and resilience. Additional outcomes included psychological symptoms of anxiety, depression or stress; burnout; other mental health disorders; workplace staffing; and adverse events arising from interventions.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently applied selection criteria to abstracts and full papers, with disagreements resolved through discussion. One review author systematically extracted data, cross-checked by a second review author. For objective 1, we assessed risk of bias of studies of effectiveness using the Cochrane 'Risk of bias' tool. For objective 2, we assessed methodological limitations using either the CASP (Critical Appraisal Skills Programme) qualitative study tool, for qualitative studies, or WEIRD (Ways of Evaluating Important and Relevant Data) tool, for descriptive studies. We planned meta-analyses of pairwise comparisons for outcomes if direct evidence were available. Two review authors extracted evidence relating to barriers and facilitators to implementation, organised these around the domains of the Consolidated Framework of Implementation Research, and used the GRADE-CERQual approach to assess confidence in each finding. We planned to produce an overarching synthesis, bringing quantitative and qualitative findings together.

MAIN RESULTS

We included 16 studies that reported implementation of an intervention aimed at supporting the resilience or mental health of frontline workers during disease outbreaks (severe acute respiratory syndrome (SARS): 2; Ebola: 9; Middle East respiratory syndrome (MERS): 1; COVID-19: 4). Interventions studied included workplace interventions, such as training, structure and communication (6 studies); psychological support interventions, such as counselling and psychology services (8 studies); and multifaceted interventions (2 studies). Objective 1: a mixed-methods study that incorporated a cluster-randomised trial, investigating the effect of a work-based intervention, provided very low-certainty evidence about the effect of training frontline healthcare workers to deliver psychological first aid on a measure of burnout. Objective 2: we included all 16 studies in our qualitative evidence synthesis; we classified seven as qualitative and nine as descriptive studies. We identified 17 key findings from multiple barriers and facilitators reported in studies. We did not have high confidence in any of the findings; we had moderate confidence in six findings and low to very low confidence in 11 findings. We are moderately confident that the following two factors were barriers to intervention implementation: frontline workers, or the organisations in which they worked, not being fully aware of what they needed to support their mental well-being; and a lack of equipment, staff time or skills needed for an intervention. We are moderately confident that the following three factors were facilitators of intervention implementation: interventions that could be adapted for local needs; having effective communication, both formally and socially; and having positive, safe and supportive learning environments for frontline workers. We are moderately confident that the knowledge or beliefs, or both, that people have about an intervention can act as either barriers or facilitators to implementation of the intervention.

AUTHORS' CONCLUSIONS

There is a lack of both quantitative and qualitative evidence from studies carried out during or after disease epidemics and pandemics that can inform the selection of interventions that are beneficial to the resilience and mental health of frontline workers. Alternative sources of evidence (e.g. from other healthcare crises, and general evidence about interventions that support mental well-being) could therefore be used to inform decision making. When selecting interventions aimed at supporting frontline workers' mental health, organisational, social, personal, and psychological factors may all be important. Research to determine the effectiveness of interventions is a high priority. The COVID-19 pandemic provides unique opportunities for robust evaluation of interventions. Future studies must be developed with appropriately rigorous planning, including development, peer review and transparent reporting of research protocols, following guidance and standards for best practice, and with appropriate length of follow-up. Factors that may act as barriers and facilitators to implementation of interventions should be considered during the planning of future research and when selecting interventions to deliver within local settings.

Experiences and needs of direct support staff working with people with intellectual disabilities during the COVID-19 pandemic: A thematic analysis

BACKGROUND

The present study aimed to explore the experiences and needs of direct support staff during the initial stage of the COVID-19 lockdown in the Netherlands.

METHOD

Overall, eleven direct support staff were recruited from five intellectual disability services to participate in this descriptive qualitative study. They recorded 34 audio messages during the considered period. Thematic analysis was used to analyse these audio recordings.

RESULTS

Four themes emerged: (1) Emotional impact, which pertained to various emotions they experienced in their work; (2) Cognitive impact, which referred to challenges and changes they had undergone in their work; (3) Practical impact, which centred on the practical impact of the pandemic on their work; and (4) Professional impact, which concerned their experiences with other professionals.

CONCLUSIONS

This study provides valuable insights into the experiences and needs of direct support staff during the COVID-19 pandemic, which, in turn, can help inform practice in preparation for a second wave of COVID-19 or another future pandemic.