key: cord-0712964-lpcifacz
authors: Bentham, Charlotte; Driver, Katie; Stark, Daniel
title: Wellbeing of CAMHS staff and changes in working practices during the COVID‐19 pandemic
date: 2021-03-19
journal: J Child Adolesc Psychiatr Nurs
DOI: 10.1111/jcap.12311
sha: 72b8577fe38652c7cc4ba9ba025413969a04d26e
doc_id: 712964
cord_uid: lpcifacz

INTRODUCTION: The coronavirus disease 2019 pandemic has necessitated significant changes in working practices across healthcare services. The current study aimed to assess the wellbeing of health professionals and quantify the adaptations to working practices in a Child and Adolescent Mental Health Service (CAMHS) during the pandemic. METHOD: The study was conducted in a UK CAMH team six weeks into lockdown measures. All clinicians were invited to complete a survey eliciting their experiences of working practices during the pandemic, degree of worry about the virus and mental wellbeing. RESULTS: Clinicians had significantly lower levels of mental wellbeing during the pandemic than population normative data, to the extent that some clinicians were classified as at heightened risk of depression. A significant shift to remote working, reduction in face‐to‐face appointments, and decrease in clinicians' perceived ability to undertake clinical tasks was observed. Themes emerging from clinicians' experiences of working during the pandemic include being supported within the team, providing a service, working adaptations, and working as a team. A further theme highlights the needs of clinicians to complete their clinical role effectively. CONCLUSION: CAMHS clinicians require additional support, training, and guidance during a pandemic to promote mental wellbeing and effectiveness in completing clinical tasks.

adolescent mental health services (CAMHS) nationwide. Rates of anxiety in the population are predicted to increase as a result of the direct effects of fears of contamination, stress, grief, and depression triggered by exposure to the virus, and as a result of distal social and economic consequences occurring at an individual and societal level (Druss, 2020) .

Furthermore, a high proportion of children and families accessing CAMHS are classified as "vulnerable" by the UK government, due to special educational needs and disabilities. These young people and families have been found to be at a greater risk of experiencing poor mental health, and under substantially greater pressure than less vulnerable families during the pandemic , resulting in families/carers requiring additional CAMHS support .

It is predicted that social isolation in children, insecurity in parental employment and increased parental distress may result in a rise in childhood mental health problems and a subsequent upsurge in demand for CAMHS input (Crawley et al., 2020) .

As well as increased demand, CAMHS clinicians are required to make significant changes to working practices as a result of the virus. The restrictions on physical contact have demanded a transition to novel formats for facilitating clinical contacts, including telephone and video consultations, to continue service provision. Before the pandemic, a survey of 154 CAMHS clinicians in the UK estimated that only 4.5% were using videoconferencing technology in their clinical role on a weekly basis (Cliffe et al., 2020) . Research has highlighted several barriers to the use of technology in health settings, including the limited integration as a part of routine practice (Topooco et al., 2017) , resulting from clinicians' uncertainties about the availability of technologies and the technical aspects regarding privacy and security, reliability, and safety of use (Cliffe et al., 2020) . It is also noteworthy that the evidence-base for CAMHS intervention is predominantly based upon face-to-face working.

Although there are a minority of studies evaluating the effectiveness of telehealth modalities (e.g. Gloff et al., 2015) , this is not yet the norm in clinical practice and the majority of clinicians are not trained or familiar with intervention in such a format. In the UK, the pandemic has proven to be a catalyst for managers, information technology (IT) staff, and health professionals to rapidly overcome barriers to telehealth to continue service delivery (Wind et al., 2020) .

The transition to remote working has the potential to further influence service delivery and staff wellbeing during the pandemic. In other occupational settings, remote working has been found to have a negative impact on workforce wellbeing, due to the collapsing of boundaries between work and private lives and reduced social interaction and relationships with colleagues (Grant et al., 2013) . For instance, in the context of a nationwide lockdown, working from home may mean that many staff members are required to balance the demands of work with caring responsibilities for vulnerable family members or providing education and care for dependents. Similarly, reduced social interactions and more distanced relationships with colleagues can potentially impose challenges in managing clinical risk effectively, providing high quality care, as well as in ensuring staff are adequately supported at times of change.

Finally, research has been conducted investigating factors associated with increased risk of anxiety and depression in frontline hospital workers during emerging virus outbreaks. Factors found to be associated with increased psychological distress include being female, having fewer years clinical experience, having a chronic health condition, younger age, and living with children (Kisely et al., 2020; Zhu et al., 2020) . Furthermore, health workers perceptions of the sufficiency of precautionary measures in the workplace, such as personal protective equipment (PPE), have been associated with an improvement in virus-related concern and psychological outcomes (Kisely et al., 2020) . To date, there is a paucity of research investigating risk factors for psychological distress in mental health professionals during a pandemic.

The current study aimed to quantify the impact of the COVID-19 virus on adaptations to CAMHS working practice including workforce perceptions of: (1) the primary method of delivery of clinical contacts, (2) the ability to undertake clinical roles, (3) the supportive structures in the service, and (4) outstanding needs to work effectively. The study also sought to examine levels of staff wellbeing and worry about the virus, as well as to elicit CAMHS clinicians' broader experiences of working during the COVID-19 pandemic.

The study was conducted in a community CAMH service in the UK, comprised of several community and specialist teams providing mental healthcare for children and families experiencing a range of difficulties.

The service is made up of multidisciplinary professionals including medical, psychological, therapy, nursing, and social work clinicians.

A questionnaire survey was designed to elicit staff members' views of working during the pandemic. The survey consisted of 40 items, requiring respondents to provide open-ended qualitative reflections and multiple-choice or Likert scale responses. The questionnaire aimed to capture clinicians' attitudes to changes in their working practices and perceived ability to complete core clinical tasks in CAMHS (namely; building rapport, assessing risk, and completing an assessment and intervention) before and during the pandemic.

Further items were included that related to staff perceptions of (a) formal and informal support systems within the service, (b) the information and guidance about COVID-19 provided by the organisation, and (c) the adequacy of IT and PPE provision. The questionnaire was developed by senior members of the service informed by ongoing consultation with the staff team, in addition to the available guidance and literature relating to healthcare services during emerging pandemics (e.g. British Psychological Society COVID-19 Staff Wellbeing Group, 2020; Kisely et al., 2020) . Two questions relating to the degree and type of worry associated directly with the pandemic were assessed using adapted items developed by Goulia et al. (2010) . During the survey development, questions were iteratively reviewed and modified, before a final review by an independent third party.

The Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) was used as a measure of staff wellbeing (Tennant et al., 2007) . The WEMWBS is a 14-item, self-report measure. Items on the measure are positively worded and related to the main components of mental wellbeing, capturing both the eudaimonic (e.g., respondents' functioning, social relationships, and sense of purpose) and hedonic (e.g., feelings of happiness) perspectives of wellbeing (Ng Fat et al., 2017) .

The responses from each of the 14 items on the WEMWBS are summed to create a total scale score (range: 14-70), with a high score indicating a high level of mental wellbeing (Taggart et al., 2015) . The measure has robust psychometric properties (Tennant et al., 2007) and sensitivity to change (Maheswaran et al., 2012) . Previous research comparing the WEMWBS to the Centre for Epidemiological Studies Depression Scale (CES-D) indicates that individuals with a WEMWBS score of less than 40 can be classified as "at risk" of psychological distress and depression (Bianco & Gremingni, 2012; Taggart et al., 2015) . The necessary permissions were granted to use the WEMWBS measure as part of the current study (registration ID: 518453203).

Open-ended questions were also included to elicit (a) staff members' views on aspects of their current working environment and (b) staff perceptions of childrens' and families' service needs during the pandemic. The survey questionnaire is available on request.

All staff members working in a clinical capacity across the service were invited to anonymously complete either a paper or online version of the survey. The online survey was administered using Survey Monkey, with most questions requiring a response for completion. The survey responses were collected between May 4th and 12th, 2020, approximately six weeks after a national lockdown was instigated.

Ethical approval was granted by the NHS Foundation Trust Quality and Standards Department. All participants provided informed consent when taking part in the study.

Quantitative statistical analysis was conducted using Statistical Package for Social Sciences (IBM Corp. SPSS Statistics for Windows, Version 26, 2019). The sample was first characterized using descriptive statistics. Following this, data were analyzed for normality by generating standardized skewness and kurtosis scores. Most of the data were found to be non-normally distributed (Z = 1.96 standard deviations from the mean) and therefore nonparametric statistics were used. Individuals with incomplete responses on survey items were excluded from relevant analyses. To test hypotheses examining the differences between staff groups, and to compare staff attitudes and working practices before and during the pandemic, Wilcoxon signed-ranks tests were calculated. A one-sample Wilcoxon signed-rank test was used to establish if there were significant differences between the median wellbeing scores in the current sample, when compared to population normative data.

Hypotheses exploring the factors associated with wellbeing and COVID-19 worry were examined using Kruskal-Wallis H and Mann-Whitney U-tests. Fisher's exact tests were used to determine if there were nonrandom differences between the proportion of staff endorsing different modes of working and levels of ability to complete clinical tasks before and during the pandemic. To explore hypotheses positing associations with wellbeing and COVID worry, a series of Spearman's rank correlation tests were performed.

Qualitative data collected from the open-ended survey questions were analyzed using thematic analysis using the procedure described by Braun and Clarke (2006) . To promote anonymity, researchers were blind to the demographic variables of respondents when completing the qualitative analysis. The primary authors formed a research team, led by the primary author (CB). Each author independently immersed themselves in the data, before collaboratively highlighting key sections of text to develop an initial list of codes. The initial codes were then debated, reviewed and consolidated, with constant reference to the original text, to arrive at a final coding list. A process of searching for themes was then undertaken through examination of these codes and the collated data to identify broader patterns of meaning until a position of consonance was achieved. The final themes were identified and labeled.

Authentic anonymous citations were used to illustrate the findings.

The thematic analysis process was aided by NVivo qualitative data analysis software (QSR International Pty Ltd. Version 12, 2018).

A total of 51 responses were returned from clinicians working in the service invited to participate (total n = 99; 51.5% response rate). Table 1 reports the demographic characteristics of the respondents.

Years of professional experience ranged from 6 months to 40 years (median = 17 years; interquartile range (IQR): 10-25 years). Thirteen respondents (25.5%) reported an underlying health condition classifying themselves as a vulnerable worker in the pandemic.

Forty-six of the clinicians responding to the survey completed the WEMWBS measure (90%). A one-sample Wilcoxon signed-rank test was used to compare CAMHS clinicians' wellbeing score to normative data collected as part of the Health Survey for England in 2012 (Bridges, 2012) . The wellbeing scores of CAMHS clinicians during the BENTHAM ET AL. | 3 pandemic were found to be significantly lower than scores found in the general population before the pandemic (see Table 2 ). There was no significant difference in wellbeing scores between male and female clinicians (U = 179.0; p = 0.364). However, relative to general population medians, reported wellbeing scores amongst male clinicians did not differ, whereas female clinicians' median ratings of wellbeing were significantly lower than population normative data collected before the pandemic. However, cautious interpretation of this finding is required given the small sample of male clinicians responding to the survey (n = 9). Eight clinicians (17%) completing the WEMWBS reported a wellbeing score of 40 or less, a cut-off posited to indicate an increased risk of depression and psychological distress.

Clinicians were asked to subjectively rate their level of worry about the COVID-19 pandemic. A value of 0 represented no current worry, whereas as a value of 10 represented the highest possible level of worry about the pandemic. Clinicians' median responses indicated a high degree of worry overall (median = 7; IQR: 5-7). Clinicians were then asked to identify the particular source of worry relating to COVID-19. Table 3 displays clinicians' reported concerns relating to the virus.

It was hypothesized that clinicians endorsing high levels of worry related to the COVID-19 pandemic would exhibit lower overall wellbeing scores. However, a Spearman's rank correlation found no significant association between the COVID-19 worry score and wellbeing score (r s = −0.193; p = 0.099).

It was also hypothesized that individuals self-classified as "vulnerable" during the pandemic would report higher levels of COVID-19 concern and lower levels of wellbeing. However, no significant differences were found in ratings of COVID-19 worry Overall, the level of wellbeing reported by CAMHS clinicians six weeks into the lockdown period was significantly lower compared with the general population normative data (before the pandemic), with approximately 17% of respondents endorsing answers that would classify them "at risk" for depression. Concordant with this, a high-level of worry was also reported by CAMHS staff. Interestingly however, low-levels of wellbeing and high-levels of worry were not found to be related to one another, or associated with variables such as age, underlying health conditions or years of professional experience. 

During the pandemic, seventy percent of clinicians (n = 36) worked from home for three-quarters of their working week or more, which was significantly more than reported before the lockdown (Fisher's exact < 0.001; p < 0.001). It was hypothesized that clinicians working remotely Clinicians were asked to report the change in the format of clinical contacts provided to patients (Table 4 ). The results of repeated-measures Wilcoxon signed-ranks tests suggest a significant decrease in face-to-face appointments with young people and families, and a significant increase in appointments administered using telephone and video platforms (Table 4) .

Clinicians were also asked to rate their perceived level of competence in completing core aspects of their role. There were statistically significant differences reported in clinicians' ability to undertake core aspects of their role during the pandemic compared with the prepandemic period. Clinicians' self-ratings of their ability to build rapport with families (Z = −5.80; p < 0.001), conduct an assessment (Z = −5.77;

p < 0.001), assess risk (Z = −5.53; p < 0.001), and provide an intervention (Z = −5.70; p < 0.001) were all rated as significantly worse during the COVID-19 pandemic. Before the pandemic, none of the staff reported they were unable to perform aspects of their role. However, during the pandemic period, seven respondents reported being unable to build or maintain rapport with families (Fisher's exact = 0.0125, p < 0.05), nine respondents reported being unable to conduct an assessment (Fisher's exact = 0.0027, p < 0.01), 11 were unable to assess risk, (Fisher's exact = 0.0005, p < 0.01) and 12 reported being unable to provide an intervention (Fisher's exact = 0.0002, p < 0.01). It was hypothesized that clinicians reporting that they were no longer able to complete clinical tasks during the pandemic would experience lower levels of wellbeing.

However, no significant differences in wellbeing scores were observed between those able and not able to complete an assessment (U = 184.5; 

Clinicians were asked to report their perceptions of the adequacy of PPE available to complete their job safely during the pandemic. Table 5 displays clinicians' perceptions of PPE provision, which were largely neutral at the specified timepoint in the pandemic. It was hypothesized that clinicians reporting a lack of adequate PPE would experience greater levels of worry related to COVID-19, however, this was not supported by an independent-samples Kruskal-Wallis H test ( χ² (5) = 9.83; p = 0.080).

Daily team meeting and supervision attendance were largely perceived to be more important during the pandemic (Table 5) .

Furthermore, the majority of respondents indicated they had been negatively impacted by a reduction in informal staff support since the increase in remote working in response to the COVID-19 outbreak ( Overall, the results identified a substantial move to working from home compared with pre-pandemic levels, with 70% of the CAMHS team working from home for three-quarters of the week or more. It was evident that clinicians relied upon telephone contact with children and families rather than adopting new technologies such as video calls six weeks into the lockdown period of the pandemic. Interestingly, whilst there was no relationship between those with an underlying health condition and the degree of worry/adverse wellbeing experienced, those working from home 100% of the time were found to have higher levels of COVID related worry. One of the most striking findings related to the change in perceived competence of CAMHS clinicians, with the pandemic having a highly significant adverse effect on clinician's self-rated ability to establish rapport, assess risk, undertake an assessment, and provide an intervention remotely. Concordant with this, a substantial proportion of respondents reported being unable to undertake core aspects of their roles. Reports also highlighted the increased need for frequent contact with the team, and more importance placed on supervision and mechanisms of informal staff support. 3.5.2 | Being supported within the team A further pervasive theme across clinicians' narratives was the value of support provided by the team during the pandemic. Respondents frequently highlighted the benefits of informal support, including having a space to "chat" and "check-in," and share "mutual support and feeling for each other" (Clinician 34). The opportunity to share light-hearted moments of interaction, including connecting through "humour" appeared to provide some balance to discussions related to COVID-19. The formal support mechanisms within the service, including line management, clinical supervision and the daily team meeting, were also highly appreciated by clinicians.

"The humbling experience of the extraordinary support from colleagues…the support I have received has been phenomenal."

"Humour in the workplace allows me to still feel con- 

A prominent subtheme of working adaptations in the pandemic was the reflection on the advantages and disadvantages of working remotely. Many clinicians felt that face-to-face appointments are necessary to establish engagement and rapport. However, clinicians stated that for some young people virtual appointments are preferable as they mitigate practical and psychological barriers to engagement and have resulted in a reduction in cancellations.

"It has been difficult to engage young people who I've not met before or who struggle to relate to people on the phone." | 7 "The situation may bring forward new ways of working that have previously been unavailable to us, such as video sessions. This may really help certain clients, such as those with agoraphobia or practical issues limiting their ability to get to CAMHS clinic sessions."

The next subtheme focused on the protection of staff members, young people and families. Clinicians valued the efforts of colleagues to maintain social distancing procedures and access to PPE when needed.

"[I appreciate] the opportunity to access PPE if I need it… being able to access spacious offices that allows respect for social distancing."

There was recognition that the adaptations in working practice were resulting in tasks taking longer to complete especially with regard to IT systems and accessibility of information.

"Everything takes longer to perform, resources or historical data…are not available. It is not as easy to work creatively which is so important for children, so this requires more thinking and planning time for both the clinician and the family."

A subtheme emerged highlighting clinicians' uncertainty about future working, including a plan for the reintegration of face-to-face appointments and clarity about the direction of service delivery. The final subtheme is the need for time to reflect and adapt to different ways of working. There was a sense from clinicians that a shared space to reflect on the personal and professional implications of the pandemic and space to adapt to the new working "normal" was needed.

"[We need] a space to think about the challenges of containing clients when clinicians are also facing uncertainty."

The global pandemic has been associated with high levels of mortality as well as significant changes in the social and working environment. In addition, a substantial strain on mental health services has been forecast (Druss, 2020) . This is the first study to investigate the impact of the COVID-19 pandemic on a UK based CAMHS service. The response rate in the current study (51.5%) was high compared with existing research recruiting mental health professionals (e.g., 35%; Sherring & Knight, 2009) , potentially reflecting the emotional salience of the topic and respondents' desire to express their views on the personal and professional impact of the pandemic.

The main finding of the current study is that clinicians' wellbeing six weeks into the lockdown phase of the pandemic is significantly below normative population levels, to the extent that 17% of clinicians were classified as "at risk" for depression. A correspondingly high rate of COVID-19 related worry was also observed in the CAMHS workforce. 

The second key finding of the current research was the reported decrease in clinicians' ability to undertake clinical aspects of their role, to the extent that a proportion of clinicians (range: 14%-24%) no longer felt able to complete an assessment, provide an intervention, assess risk or build and maintain rapport with patients. The current study was not able to establish the direct causal factors contributing to this for some clinicians. However, some inferences can be made from the qualitative analysis of clinicians' outstanding needs. The qualitative data suggested that, at the specified time-point in the pandemic, clinicians lacked the physical resources, training and guidance, as well as support to maximize their effectiveness in completing their role. As expected, there was a significant shift to remote working and offering clinical contacts to young people and families by telephone or video, with telephone calls being the predominant format of appointments. This could potentially offer a further explanation of perceived inability, as clinicians are less able to examine vital forms of nonverbal communication which are relied upon to form clinical impressions and maintain engagement (Reinhard & Sporer, 2008) . Furthermore, frequent or sustained use of videoconferencing platforms has been found to be more cognitively demanding than face-to-face interactions, with a greater potential for miscommunication and misattribution (Schoenenberg et al., 2014) .

The current study found no association between clinicians' reported ability to complete clinical tasks and wellbeing. It may be that clinicians perceive the change in work competency as a shared experience with their colleagues, transitory and temporary, and outside of their locus of control, therefore limiting the impact on their selfesteem and wellbeing. It was, however, observed those working remotely for the entirety of their contracted hours reported experiencing significantly higher levels of COVID-19 worry than those working predominantly in the service base. One potential explanation posits that those working entirely remotely may have less exposure to the reality of the world during the pandemic and less connection with familiar routines, exacerbating levels of worry. Alternatively, those individuals reporting greater levels of COVID-19 worry may be more likely to have made the behavioral choice to stay at home, where possible.

A key aspect running throughout the study was the value of human support and connectedness at a time when clinicians are working increasingly in isolation. A high percentage of the workforce indicated they had been negatively impacted by the reduction in informal staff support. However, many reflected on their appreciation of moments of connection and informal support with their colleagues, either remotely or physically at a social distance. Formal support mechanisms, including supervision and daily team meetings, were largely deemed to be more important in the context of the pandemic and continued the sense of working together as a team.

Despite this, there was an expressed need to build in additional support structures, such as space for reflection or tailored psychological support, which was observed to be of particular importance to those individuals experiencing higher degrees of COVID-19 worry.

The assessment of staff wellbeing was based on comparison to population normative data, rather than baseline data collected from clinicians at a timepoint before the pandemic, therefore limiting the ability of the current study to make substantive inferences about the factors influencing wellbeing in the CAMHS workforce. Similarly, there was no available WEMWBS data collected during a pandemic, limiting the ability of the current study to ascertain if CAMHS clinicians' reportedly low wellbeing was in the normative range given the global context. Although an online survey allows for timely collection of responses from larger numbers of individuals, the questions are static and are not able to evolve, as they can with interview methodologies, to elicit information about new lines of inquiry or encourage individuals to expand on their responses, therefore potentially reducing the richness of the qualitative data collected.

Finally, the qualitative strand of the research identified potential protective factors, for example, feeling supported in the team, which were not quantified in the survey and may mitigate a proportion of the negative impact of the pandemic on staff wellbeing. Further research is needed to assess clinicians' wellbeing longitudinally over

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The authors declare that there are no conflict of interests.

The study was approved by Sheffield Children's Hospital Foundation Trust Quality and Standards Department (Project No. SE1981).

The survey questionnaire is available on request from the authors.The study data is not available due to privacy/ethical reasons.

https://orcid.org/0000-0003-0345-4270Daniel Stark https://orcid.org/0000-0002-9929-8366