key: cord-032261-no2mojz3
authors: Gaddy, Sarah; Gallardo, Ressa; McCluskey, Shelley; Moore, Leanna; Peuser, Alex; Rotert, Rachel; Stypulkoski, Corinne; LaGasse, A Blythe
title: COVID-19 and Music Therapists’ Employment, Service Delivery, Perceived Stress, and Hope: A Descriptive Study
date: 2020-09-08
journal: Music Ther Perspect
DOI: 10.1093/mtp/miaa018
sha: 
doc_id: 32261
cord_uid: no2mojz3

In early 2020, the COVID-19 pandemic was declared, which impacted music therapists in terms of employment, service delivery, and mental health. However, the extent of changes within the profession was unknown. The purpose of this study was to determine the impact of the pandemic on the employment, service delivery, stress, and hope of music therapy professionals in the United States. Music therapists (N = 1,196) responded to a 51-item survey including questions related to employment and service delivery. The study also included the Adult Hope Scale and the Perceived Stress Scale-10 (PSS-10). Results indicated that many music therapists experienced changes in their positions, including a decrease in client contact hours and an increase in using alternative services, such as telehealth. Changes in service hours and delivery were higher for individuals who worked in private practice than for other settings. Primary respondent concerns included being a carrier of COVID-19, being isolated from loved ones, and income loss. Compared with prior general population samples from the United States, respondents reported higher levels of hope, with a majority of respondents also reporting a high level of hope for the profession. Respondents also indicated a moderate level of perceived stress on the PSS-10. Open response comments provided additional insights into the situational stressors and feelings of hope at this time in the pandemic. The results of this study indicate that music therapists adapted to service delivery changes and continued to provide services to clients, despite the many difficulties faced during the pandemic.

ABSTRACT: In early 2020, the COVID-19 pandemic was declared, which impacted music therapists in terms of employment, service delivery, and mental health. However, the extent of changes within the profession was unknown. The purpose of this study was to determine the impact of the pandemic on the employment, service delivery, stress, and hope of music therapy professionals in the United States. Music therapists (N = 1,196) responded to a 51-item survey including questions related to employment and service delivery. The study also included the Adult Hope Scale and the Perceived Stress Scale-10 (PSS-10). Results indicated that many music therapists experienced changes in their positions, including a decrease in client contact hours and an increase in using alternative services, such as telehealth. Changes in service hours and delivery were higher for individuals who worked in private practice than for other settings. Primary respondent concerns included being a carrier of COVID-19, being isolated from loved ones, and income loss. Compared with prior general population samples from the United States, respondents reported higher levels of hope, with a majority of respondents also reporting a high level of hope for the profession. Respondents also indicated a moderate level of perceived stress on the PSS-10. Open response comments provided additional insights into the situational stressors and feelings of hope at this time in the pandemic. The results of this study indicate that music therapists adapted to service delivery changes and continued to provide services to clients, despite the many difficulties faced during the pandemic.

Keywords: COVID-19 pandemic, employment, hope, music therapy service delivery On March 11, 2020, the COVID-19 pandemic (henceforth referred to as the pandemic) was declared by the World Health Organization (WHO, 2020) . The COVID-19 virus was originally detected in November 2019 and began to spread throughout the United States in early March 2020. The spread of a novel virus leads to uncertainty due to the unpredictable nature of the virus and continual changing information about risk, mortality, and severity (Harwood, 2020; Morens & Taubenberger, 2011) . Researchers and mental health professionals recognized the potential for the pandemic to affect stress and mental health (Mucci et al., 2020) , with researchers highlighting the negative impact of the pandemic on the mental health of healthcare professionals (Moazzami et al., 2020) . As healthcare professionals, music therapists (MTs) experienced personal and professional changes due to the pandemic; however, the extent of change within the United States was not yet established.

One of the first responses to the pandemic in the United States was for state governments to implement social distancing, "stay at home," and/or quarantine protocols (Mervosh et al., 2020) , in an effort to slow the spread of the pandemic and decrease the impact on healthcare facilities (Centers for Disease Control and Prevention [CDC] , 2020). These protocols had a drastic impact on the economy and employment, as the United States reached an unemployment rate of 14.7% in April 2020 (Long, 2020) . Changes in employment were seen across many nonessential healthcare workers, as social distancing and quarantine protocols restricted the ability for these professionals to provide in-person services (e.g., Department of Health and Human Services, 2020). Balanzá-Martínez et al. (2020) highlighted how the combined impact of financial difficulties and social isolation could further impact mental health and the overall feelings of stress.

Social distancing and quarantine protocols created an immediate need for many professionals to shift away from in-person services to telehealth and other alternative services (CDC, 2020). On March 16, 2020, the American Music Therapy Association (AMTA, 2020) posted a statement indicating that MTs were needing to make difficult decisions about in-person services, given the risk of viral spread during face-to-face contact. The shift to telehealth within the profession was documented on April 16, 2020, with a statement from AMTA supporting telehealth as a beneficial means for providing services to clients. Resources were added to the AMTA website, including a guide for virtual service delivery that provided suggestions for curating/creating virtual content and providing telehealth services (Block & Knott, 2020) . Although these alternative services provided an opportunity for clients to continue receiving music therapy, professionals were required to quickly learn about online service delivery, including securing permissions and ensuring compliance with the Health Insurance Portability and Accountability Act (HIPAA). Furthermore, the extent to which these services were employed by MTs was still unknown.

The rapid changes required in response to the pandemic, combined with uncertainty about the future of employment and/or service delivery, may have impacted the perception of stress and feelings of hope in music therapy professionals. According to Folkman (2010) , decreased control over one's own circumstances can impact a person's feelings of hope, particularly in times of high psychological stress. Furthermore, uncertainty can exist within stressful situations, and hope is one way to cope with uncertainty. According to Snyder (2002) , hope is comprised of two concepts (ways of thinking): pathways and agency. Pathways relate to an individual's ability to produce a plan to meet a goal, whereas the agency describes an individual's motivation to meet those goals by the determined pathways. Individuals with high hope are more likely to generate alternative routes to goal attainment and be more adaptable when encountering obstacles (Snyder, 2002) . Measuring perceptions of hope and stress could provide the music therapy community with information on how music therapy professionals responded to circumstances surrounding their careers during the pandemic.

The purpose of this project was to determine the impact of the pandemic on the employment, service delivery, hope, and stress of music therapy professionals. To this effect, the researchers asked the following research questions: (1) What changes are music therapy professionals experiencing in terms of contracts/job hours? (2) What changes are music therapy professionals experiencing in terms of income? (3) What changes are music therapy professionals experiencing in types of services provided? (4) What are the feelings of hope reported by music therapy professionals? and (5) What is the level of stress reported by music therapy professionals?

This study received ethical approval from the University Institutional Review Board (IRB 20-9997H). The survey was sent via email from the Certification Board for Music Therapists (CBMT) roster, which included 8,080 MTs in the United States. The survey link was also posted on social media platforms such as Facebook and LinkedIn. Consent was obtained from 1,216 individuals, yielding a 15% response rate. Five individuals working outside the United States and 15 individuals who did not complete the demographics section were excluded from the results. The remaining 1,196 (14.80%) survey respondents were included in the data analysis, of which 1,047 completed the entire survey. At the end of the survey, respondents had an option to enter their email for a chance to win a $25 gift card and could elect to receive notification of follow-up surveys. Individuals were provided with a list of resources in case they experienced stress. The full survey is available in Appendix A of online Supplementary Material.

The survey demographic and employment questions were created by the researchers, using Kern and Tague (2017) as a model. The survey was sent to two researchers with experience in descriptive research and piloted with 22 MTs prior to release. The survey was administered using Qualtrics beginning on April 7, 2020, and remained open for two weeks. The survey consisted of 51 items within four sections: (1) Demographics, (2) Employment/Services Provided, (3) Levels of Hope, and (4) Levels of Stress. Respondents were allowed to select all options that applied in sections pertaining to current situation, job position, and client populations, due to the multiple roles held by MTs. Participants were permitted to advance without answering all questions, and items that were not relevant to them were skipped. The survey included two standard scales: The Adult Hope Scale and the Perceived Stress Scale-10 (PSS-10).

Adult Hope Scale. The Adult Hope Scale is a standardized questionnaire that asks respondents to self-report degrees of agreement to 12 statements on an 8-point Likert scale (Snyder, 2002) , with a range from 8 (low hope) to 64 (high hope). Eight of the 12 statements are broken down to two subscales representing participants' agency (items 2, 9, 10, and 12) and pathways (items 1, 4, 6, and 8), with each subscale ranging from 4 (low hope) to 32 (high hope). The additional four questions are filler items. Agency and pathways scores are added to determine a total hope score, with higher scores reflecting higher levels of hope. Snyder (2002) noted the mean total hope score for the general population was 49 (SD = 7). The instrument has shown high internal consistency, with alphas from .74 to .88, across samples (Snyder, 2002; Snyder et al., 1991) . The researchers added an additional question to capture respondents' feelings of hope for the state of the profession.

Perceived Stress Scale. The PSS-10 (Cohen et al., 1983; Cohen, 1994 ) was used to measure MTs' perceptions of stress during the pandemic. The PSS-10 asks the respondent about the stress in the previous month using questions about perceived feelings. Individuals rate their frequency of each feeling on a 5-point Likert scale from 0 (Never) to 4 (Very Often). There are four positively worded questions that are reverse scored. Scores on the PSS-10 are compiled into a single score that ranges from 0 (lowest perceived stress) to 40 (highest perceived stress). The instrument has been shown as reliable, with relatively high internal consistency (ɑ > .70) across studies of different populations (Lee, 2012) . In 1983, the PSS-10 was administered to 2,387 individuals in the United States, with an overall mean score of 13.02 (SD = 6.35) (Cohen and Williamson, 1988) . The PSS-10 has been used in previous music therapy research with student participants (Moore & Wilhelm, 2019) .

The online survey included quantitative and qualitative data in order to more comprehensively capture MTs' experiences during the pandemic. The research team completed a descriptive analysis for multiple choice, ranked, and percentage answer questions. This included a tally (number of responses and percentage) for questions regarding changes in workload/assignments and providing different services. It should be noted that response counts for each individual question varied, as respondents could advance through the survey without answering all questions.

There were two standard scales included in the study. For the Adult Hope Scale, the researchers calculated the mean and standard deviations of the agency subscale, pathways subscale, and total score (summation of agency and pathways scores). The researcher-added question about hope in the music therapy profession was not included in the subscales or total score calculations. For the PSS-10, the researchers calculated the total score by reverse scoring the positively worded items and then adding the items for each participant. The researchers computed a Cronbach's alpha value to determine internal consistency. Levels between .70 and .95 are considered within an acceptable range (Tavakol & Dennick, 2011) .

The researchers conducted Pearson's correlations to examine the strength of the relationship between PSS-10 scores and three scores related to the Adult Hope Scale (agency subscale, pathways subscale, and the overall hope scores). The researchers also conducted a correlation to examine the relationship between the total Adult Hope Scale score and the hope for the music therapy profession score.

In this survey, there were two open-ended questions, one focused on feelings of hope for the profession and the other allowing respondents to comment regarding their experiences during the pandemic. Similar to the procedures used in Rushing et al. (2019) , two members of the research team independently read comments, developing a list of possible codes. The researchers then clustered these codes into themes and subthemes. The researchers completed these steps separately, and then discussed discrepancies to agree upon themes. Each pair of researchers used Excel to individually count the frequency of the themes and subthemes and reported these counts within the results.

A total of 1,196 responses were received from MTs working in the United States. Respondent ages ranged from 18 to 84, with nearly half the respondents representing the 25 to 34 age group (47.07%). The majority (52.22%) reported having a bachelor's degree as their highest level of education while 43.77% reported having a master's degree. All regions of AMTA were represented. Over half (54.43%) of respondents reported working in the profession between 1 and 10 years (Table I) .

The first research question involved changes in contracts/ job hours during the pandemic. Out of 1,189 respondents, 634 (53.32%) reported working full time, 225 (18.92%) reported working part-time, and 240 (20.18%) reported contracting for an agency or private practice prior to the pandemic (Table I) . Only 3.36% of respondents reported being either unemployed or not currently working in the profession prior to the pandemic. When providing information about changes in employment (n = 1,096), 210 (19.16%) respondents reported no changes to their work duties. Respondents reporting changes in employment (n = 886) were most often providing remote clinical services from home (67.40%). Fewer respondents reported being assigned different duties to complete on-site (14.78%) or from home (14.11%). One hundred and forty (15.83%) reported having their positions furloughed, and 23 (2.60%) reported having their positions eliminated.

Of the respondents who reported working at the time of this survey, 924 provided information about their hours at this time in the pandemic (compared with 1,135 before the pandemic). Sixty-one respondents (6.60%) reported having ≥30 client contact hours per week, compared with 244 (21.49%) prior to the pandemic. Eighty-six (9.31%) reported 10 to 29 client contact hours per week, in comparison to 373 (32.86%) prior to the pandemic. The greatest increase was seen in the category of 1 to 9 hours per week, with 395 (42.75%) compared with 199 (17.53%) before the pandemic. Figure 1 shows the change in contact hours by selected settings.

The second research question explored income changes that MTs have experienced as a result of the pandemic. When asked about their pay situation at the time of the survey, half of the 1,097 respondents indicated no changes in at least one source of income since the onset of the pandemic (50.14%). Some respondents indicated reduced compensation (18.41%) or no compensation (14.77%) as MTs. One hundred and forty-six MTs (13.31%) reported using paid time off, public assistance/unemployment, or sick leave. Of the respondents (16.77%) who indicated "other (please describe)," nearly half of the write-in comments indicated reduced income. The most commonly mentioned reasons for this reduction included drastically reduced clinical hours, lack of virtual service availability, and lack of client/facility willingness to accept virtual services.

Various subgroups reported negative income changes more frequently than others. When analyzing reported income changes across clinical settings, private practice MTs reported the lowest rates of stable income (20.94%) and the highest rates of decreased (31.29%) or eliminated (22.82%) income. Private practice owners seemed to be the most affected subgroup, with just under a third of this subgroup (32.20%) reporting no MT-related income at the time of the survey. Approximately, a third of MTs in schools (36.17%) and skilled nursing facilities (35.68%) reported maintenance of full income, compared with over half of respondents working in universities (65.43%), medical settings (56.57%), and mental Table I) .

The third research question was focused on changes in types of services provided, with 1,049 respondents providing information about their pre-pandemic service provision and 713 providing information during the pandemic. Respondents who indicated no current clinical hours due to a furloughed or eliminated position were not asked about current service delivery. Individual services accounted for a mean of 55.49% of services provided (SD = 37.72) prior to the pandemic, compared with 61.58% (SD = 41.26) at the time of survey. This corresponded with a decrease in group services from a mean of 38.93% (SD = 38.60) of services provided to 24.97% (SD = 37.56) at the time of survey. Other services provided during the pandemic were offered 9.39% (SD = 26.26) of the time, and open responses indicated that these services primarily included alternative services (such as prerecorded videos/material creation, staff support, and administrative tasks; Online Supplementary Figure 1) .

Of the 869 respondents indicating current contact hours, a majority (70.54%) reported that they were providing alternative services due to the pandemic. Alternative services used often or very often included telehealth services (54.81%), virtual music lessons (17.01%), prerecorded songs/playlists (16.98%), and prerecorded video sessions (16.00%). Figure 2 shows the number of MTs using alternative services often or very often within different settings. The shift of resources was also prevalent for alternative profession-related activities, with 462 MTs (43.06%) reporting learning to use/researching telehealth often or very often during this time of the pandemic (see Supplementary Table II for all professional activities).

The Adult Hope Scale had good internal consistency for the pathways subscale (ɑ = .81), the agency subscale (ɑ = .76), and the total scale (ɑ = .86). Internal consistency remained high with the researcher-added question about hope for the music therapy profession (ɑ = .85). Respondents' (n = 1,054) mean total hope score was 52.01 (SD = 8.08) during this time in the pandemic. This score is greater than the score published by Snyder (2002) as a typical mean score (M = 49, SD = 7). Subscale scores for agency (M = 26.61, SD = 4.26) were higher than pathways (M = 25.40, SD = 3.82).

When asked how they agreed with the statement "I feel hopeful about the music therapy profession," respondents most often indicated mostly true (31.88%), definitely true (26.00%), somewhat true (18.60%), and slightly true (11.01%). Collectively, 87.49% of respondents indicated agreement of feeling hopeful about the profession during the pandemic. Mean hope scores and response to the question on hope about the music therapy profession were broken down according to respondents' reported employment status (Supplementary Figure 2) . Subgroups with lowest scores of hope for the profession included those experiencing furlough (M = 6.01, SD = 1.88) or eliminated positions (M = 6.13, SD = 1.92). There was a weak positive correlation (r = .39, p < .01) between hope for the profession and total hope score.

Of the 1,196 respondents, 600 (50.17%) provided responses to the prompt "please comment on your feelings of hopefulness in the music therapy profession." A total of 678 statements were included in the final analysis. Ten major themes and representative statements identified from the analysis of the responses are displayed in Table II (and expanded  Supplementary Table III) . The most common theme was ongoing professional issues (17.11%) that were unrelated to the pandemic. The next most common themes were: COVID-19 as a source of growth for the profession (15.48%), the adaptability and resilience of MTs (13.86%), and telehealth (11.65%). Of those who commented on telehealth, most respondents viewed telehealth as beneficial.

A descriptive analysis of the 10-item PSS-10 was completed for the respondents who answered all 10 questions (n = 1,094). A Cronbach's alpha showed that the PSS-10 had good internal consistency (ɑ = .89). The mean scores for the respondents indicated that the MTs perceived a moderate level of stress (M = 20.08, SD = 6.50). Individuals who had their position eliminated reported a slightly higher stress level (M = 21.61, SD = 7.41) compared with the overall mean score. Respondents who provided telehealth services (n = 326; M = 20.06, SD = 6.37) and who worked in different settings had perceived stress scores similar to the mean overall score (Table III) .

Results of correlational analyses between the PSS-10 total scores and Adult Hope Scale total scores indicated a significant negative correlation, with a weak relationship between higher hope scores and lower stress scores (n = 1,054, r = −.35, p < .01). A correlation between the two subscales and the PSS-10 total score indicated a significant weak negative correlation for both pathways (r = −.35, p < .01) and agency subscales (r = −.29, p < .01). Across all clinical settings and age groups, respondents (n = 1,025) reported that their top concerns at the time of this survey included: becoming a carrier of COVID-19 (getting self or others sick; 28.81%), being separated from loved ones (24.20%), and loss of income (21.04%). Although nearly all age and setting subgroups reported getting self or others sick as their top-ranked concern, respondents working in private practice reported the loss of income as their most prominent concern at the time of this survey. Fewer than 1% of respondents (n = 25) reported that they had no concerns related to the pandemic at the time of this survey. Open responses regarding "other concerns" (n = 231, 7.51%) most often related to health and safety of self and family (24.24%), client wellness/access to services (20.78%), financial security (12.12%), and shifting work responsibilities (9.52%).

An open-response question at the end of this survey asked the following: "is there anything else that you would like to tell us about your experience since the COVID-19 outbreak?" Five hundred ten individuals (42.64%) submitted responses to this question. Ten central themes emerged within these comments, all of which are outlined in Table IV (and expanded  Supplementary Table IV benefits than the difficulties of such services, with many mentioning the lack of access to virtual service delivery options at the time of survey and some expressing mixed perspectives regarding this type of service delivery.

This descriptive study explored how the pandemic had affected music therapy employment, contact hours, and service delivery in the United States as of early April 2020. Research questions also explored MTs' perceived stress and hope during this time in the pandemic. Open-ended comments were analyzed in order to gain a greater understanding of the most prominent experiences of MTs during this time.

The majority of MTs (70.54%) reported a shift toward alternative service delivery methods during the pandemic, with telehealth emerging as the most frequently utilized service in this category. It is possible that MTs shifted to telehealth out of consideration for shelter-in-place orders and quarantine restrictions. MTs also serve high-risk populations; therefore, the need for telehealth during the pandemic likely increased in order to keep clients and MTs safe. One respondent stated, "Telehealth has, by necessity, become a way we can access people who are either in remote locations or who are among the very sick or immunocompromised." Therefore, when social distancing protocols began emerging, it appears that many MTs recognized the potential of technology to allow continuity of care while also optimizing client and clinician safety. MTs quickly adapted to telehealth and used this service more frequently than any other reported service. Telehealth, while not an in-person service, still provides a live interaction between the client and therapist, making it useful for working in real-time.

MTs who continued to deliver on-site clinical services largely shifted from group to individual sessions, again highlighting the impact of the pandemic on the provision of services. Despite the willingness of many MTs to utilize virtual service delivery methods, many still experienced stark reductions in contact hours or lack of agency/client willingness to consent to alternate services. Overall, the private practice/ contractual and education settings appeared to have the largest shift of weekly client contact hours, going from at least 20 hours a week down to nine hours or fewer.

Respondents employed full-time by agencies and universities reported stable income levels during the pandemic more often than contract-based and private practice MTs. Private practice employees retained full pay slightly more than practice owners. Several private practice owners shed light on this phenomenon by mentioning within comments that they were more willing to cut their own pay than staff pay. This points to the difficult decisions that many MTs faced, including choosing the security of others before themselves. MTs in medical, mental health, and university settings reported the highest rates of income stability, with fewer of these respondents reporting income elimination. Conversely, MTs in schools and skilled nursing facilities reported much lower rates of income stability, along with private practice MTs.

When analyzing income changes across pre-pandemic primary settings and professional roles, private practice MTs were the most affected group across both factors. Respondents primarily working in private practice were also the only subgroup Table IV . to report "loss of income" as their number one current concern. All other respondent subcategories reported carrying or contracting COVID-19 as their most prominent concern.

These data indicate that private practitioners may have experienced unique barriers during the pandemic that prevented the continuity of income and services.

Overall, MTs who responded to the survey reported levels of hope that were higher than Snyder's (2002) published mean score on the Adult Hope Scale. Respondents had higher agency scores than pathways scores, which may suggest that they felt a strong sense of determination or motivation to attain their goals, even though the plausible route may have been less clear. Comments from MTs indicated that many were ready resume services and "normal" activities. Furthermore, comments indicated that MTs were faced with many barriers, such as difficulties with telehealth or billing issues. These comments may indicate that, despite a motivation to get back to "normal," MTs were dealing with uncertainties as to how they would return to services/daily activities at this point in the pandemic. Furthermore, the higher agency scores may be a reflection of motivation that some MTs felt in learning new skills to utilize within service delivery.

Overall, the scores of the Adult Hope Scale were reflected in many of the open-ended hope question responses. Comments indicated that MTs frequently identified the challenges presented by the pandemic as a positive source of growth for the profession. Furthermore, MTs made frequent statements on the adaptability and resilience of MTs. Many respondent comments noted that MTs would likely be needed more following the pandemic, specifically to assist in grief work and trauma processing. Some MTs felt that the public use of the arts for coping and expression during the pandemic may lead to an increased need for creative arts therapies in the future. Others identified ways in which the pandemic would provide the means necessary to reach new clients through remote services and new skills acquired during the pandemic. Though some MTs were frustrated with the transition to telehealth, most who commented on telehealth viewed it as beneficial at the time of the survey. Several MTs noted the temporality of the situation and shared hope that services would return to "normal" in time.

Financial instability appeared to cause the most concern for respondents. This included concerns for themselves, for other MTs (particularly those in private practice), and for clients and facilities who may no longer have room for services in their budgets. Some respondents noted that they were considering leaving the profession, but most cited reasons that were unrelated to the pandemic. Although these concerns were prominent, respondents also shared that they felt an increased sense of connection to the music therapy community through resource sharing and emotional support provided online.

In regard to the music therapy profession, the majority of respondents (87.49%) reported having hope. Subgroups with lowest scores on hope for the profession included MTs experiencing furlough or eliminated positions. However, a correlation indicated that there was not a strong relationship between hope for the profession and the overall hope score. Comments indicated that feelings of hope (and concern) about the profession extended beyond the current pandemic, as ongoing professional issues were at the forefront of responses.

Many respondents stated that their current levels of hope pertained to advocacy needs, education standards, equity in music therapy practice, state licensure, and ongoing research practices. Although not the focus of this study, these topics were clearly of importance to the respondents.

The MTs in this study had a mean PSS-10 score of 20.08, which is higher than the published normative score of 13.02 (Cohen and Williamson, 1988) . According to Cohen and Williamson (1988) , this score reflects the degree to which participants felt unpredictability, uncertainty, and overload in their lives. This seems to confirm literature indicating that novel pandemics create uncertainty (Harwood, 2020) , which may result in heightened stress for healthcare professionals (Moazzami et al., 2020) . This may be further confirmed by the similarity of the mean PSS-10 scores across subgroups for employment changes, essential status, and job settings. Although these findings may be an indication of the current situation, more research is needed to determine the perceived stress levels of MTs outside of a global pandemic.

There was a weak negative correlation between the PSS-10 and total Adult Hope Scale scores, which may indicate that MTs maintain a higher perception of hope regardless of situational stressors. Since the Adult Hope Scale is meant to capture a person's overall feelings of hope, it may be less sensitive to situational stress, whereas the PSS-10 is designed to capture situational stress. Snyder et al. (1991) explored the interaction between stress and hope, finding that people with higher hope scores were able to maintain hope when confronted with stressors. Conversely, people with lower overall hope scores demonstrated decreased hope when confronted with stressors (Snyder et al., 1991) . Therefore, the observations in this study may indicate that MTs were able to maintain hope, despite varying levels of stress at this time in the pandemic.

Open response analysis revealed an assortment of information that sheds light on the professional, personal, financial, and emotional experiences of MTs related to the pandemic. Regarding virtual services (the most frequent topic), some MTs expressed gratitude for the opportunity to continue earning money and providing services during this time of social distancing. Others expressed frustration that virtual service technology is difficult to learn, not appropriate for all clients, and cost prohibitive for many clients and clinicians. Additionally, MTs mentioned barriers and inequities, which kept clients from accessing these services.

Personal mental health was the second-most frequent concern within these comments, and respondents in this group often described multiple sources of stress, anxiety, and negative affect change related to the pandemic. Many who reported personal mental health concerns also mentioned health/safety concerns, symptoms of burnout, and family balance difficulties. Concerns categorized within the personal mental health theme often intersected with expressions of loss and uncertainty related to the pandemic.

Within the finance, gratitude, and systemic privilege themes, respondents often recognized the hardships and inequities faced by others. Even those reporting partial income loss due to the pandemic often expressed personal resilience and empathy for those experiencing increased barriers to economic stability. Within the health and safety theme, less than half (48.31%) of respondents mentioned concern for their own health risks related to the pandemic, while others focused primarily on protecting individuals at higher risk for severe outcomes. Many comments within this theme mentioned the limited availability of personal protective equipment in the workplace, creating barriers related to safe and ethical service delivery. Some mentioned that new safety regulations created barriers to effective service access for many clients.

Despite reports of increased adversity during the pandemic, many respondents used the open comments field as an opportunity to express gratitude for their jobs, for research on the pandemic, for employer support, for their own financial stability, and for the supportive nature of the MT community. In the face of increased collective stress and uncertainty due to the pandemic, the research team found it encouraging to witness evidence of support and resilience within the MT community.

As with most survey studies, there is great potential for nonconsent bias within the responses of participants. Several respondents mentioned that it can be stressful and unpleasant to reflect on the nature of this pandemic as effects are ongoing, which may have been a key reason for the low response rate. The research team elected to not send follow-up reminders via email due to the sensitivity of the topic; therefore, the survey was promoted via email once. The team wanted to be sensitive to additional stress at this time, thus completion reminders were not sent to non-completers. Another limitation was the lack of recent normative data for interpretation of the PSS-10 scores, as well as research regarding MTs' PSS-10 scores prior to the pandemic. Responses recorded in the open comment section were taken at the end of the survey. Given the length of the survey, participants may not have provided additional comments and therefore a broader description may have been missed.

This is the first known study on the impact of the COVID-19 pandemic on music therapy professionals' employment, service delivery, stress, and hope. Future research should consider the impact of the pandemic over time, as the lasting effects of the pandemic may change aspects of employment, service delivery, stress, and hope. Further research on stress and hope would also help indicate if the scores found in this study are outside common ranges for music therapy professionals. Additional information on telehealth delivery would be beneficial to inform the profession on how technology was used in service delivery, including platforms, difficulties, and changes to services.

The results of this survey provide an overview of changes in employment, service delivery, perceived stress, and level of hope in MT professionals as of April 2020, during the COVID-19 pandemic. The results of the study indicated that MTs adapted service delivery in order to continue providing services, despite various difficulties. Music therapists also experienced changes in income and client contact hours, with MTs in private practice impacted more than MTs in other settings. This survey indicated that MTs had a moderate perceived stress level while maintaining hope during the challenges of the pandemic. Overall, this survey indicated that the pandemic has impacted many MTs. As such, it is the central hope from this research team that all MTs will gain the resources needed to endure this unparalleled season.

Supplementary material is available online at Music Therapy Perspectives. Funding: None declared. Conflicts of interest: None declared.

COVID-19 and seeing clients

Lifestyle behaviours during the COVID-19 -Time to connect

Virtual music therapy service delivery: Developing new approaches & models

Perceived Stress Scale

Perceived stress in a probability sample of the United States

A global measure of perceived stress

Guidance for infection control and prevention of coronavirus disease 2019 (COVID-19) in nursing homes (Revised)

Stress, coping, and hope

Pandemic uncertainty: Considerations for nephrology nurses

Music therapy practice status and trends worldwide: An international survey study

May 8). U.S. unemployment rate soars to 14.7 percent, the worst since the depression era. The Washington Post

Review of the psychometric evidence of the perceived stress scale

See which states and cities told residents to stay at home. The New York Times

COVID-19 and telemedicine: Immediate action required for maintaining healthcare providers well-being

A survey of music therapy students' perceived stress and self-care practices

Pandemic influenza: Certain uncertainties

Lockdown and isolation: Psychological aspects of COVID-19 pandemic in the general population

What guides internship supervision? A survey of music therapy internship supervisors. Music Therapy Perspectives

Hope theory: Rainbows in the mind

The will and the ways: development and validation of an individual-differences measure of hope

Making sense of Cronbach's alpha

WHO Director-General's opening remarks at the media briefing on COVID-19 -11