Introduction

From the earliest stages of the COVID-19 pandemic, the impact of COVID-19 on people’s lives has been extensively documented, and the disease’s negative consequences for general health and the burden on health services have been highlighted (Singh et al., 2021; Duden et al., 2022). In many countries, it has been difficult to meet the increased demands for care and to integrate mental and physical health services (Giorgi et al., 2020; Thome et al., 2021). Particularly in the early months of the pandemic, shortages of staff and protective equipment, along with unclear guidance for safety procedures, were frequently cited as reasons for difficulties in ensuring citizens’ access to health services and care (De Girolamo et al., 2020; Koralnik and Tyler, 2020; Qiu et al., 2020). Increased anxiety, depression, burnout, and post-traumatic stress disorder were observed among staff members in mental health services (MHSs), particularly in inpatient settings (Rapisarda et al., 2020).

Although the literature documents COVID-19’s negative impact on the general population and healthcare workers, some studies have also underscored the potential for positive change that the pandemic has brought to healthcare settings (Bommersbach et al., 2021; Amerio et al. 2023; Magliano et al. 2022, 2023). MHS staff have remained a point of reference for users in charge, and have tried to respond to people’s psychological distress by providing treatment and psychosocial support. In some cases, the process of adapting to emergencies has led to positive changes in clinical practice, staff–user relationships, and the organisation of MHSs (Carpiniello & Vita, 2022; Magliano et al., 2023). The provision of remote care ensured a greater continuity of care for people with serious clinical situations, while forced adaptation to the pandemic emergency led to streamlined bureaucratic procedures (Johnson et al., 2021). Healthcare workers also developed strategies for coping with unforeseen difficulties (Pinkham et al., 2020; Italia et al., 2021) and, in the process, (re)discovered a sense of cohesion in their teamwork (Magliano et al., 2022).

Italy was the first country in Europe to be severely affected by COVID-19 (Carpiniello et al., 2020) and one of the first countries worldwide to take national security measures to prevent the further spread of infection (Onder et al., 2020; Carpiniello and Vita, 2022). In Italy, from the beginning of the pandemic until 31 March 2022, a public health emergency was in force, with restrictive measures whose intensity varied over time and that significantly affected the organisation of health services throughout the country (Magliano et al., 2022). In MHSs, in the first wave of the pandemic (i.e. February–May 2020) mental health centres were able to provide basic clinical treatment for the most severely affected users along with crisis management. Residential facilities greatly reduced their rehabilitative activities and users’ contacts with their families, and day care centres partly converted rehabilitative activities into remote activities (Carpiniello et al., 2020). Although the standard of care was gradually restored in summer 2020 (Carpiniello & Vita, 2022), subsequent waves of COVID-19 significantly affected MHS activities in the first 2 years of the pandemic.

Coinciding with the end of the 2-year public health emergency, a study was conducted in Italy on the responsiveness of MHS staff to the pandemic (Magliano et al., 2023). Data were collected online using the MHS COVID-19 Transformation Questionnaire (QT-19; Magliano et al., 2022), an instrument containing a main section of 30 quantitative multiple-choice items answered on a 6-point scale ranging from 1 (not really true) to 6 (really true) about positive changes and a qualitative section with two open-ended items examining the most positive and negative changes experienced by respondents. The 1077 participants who completed the main section of the QT-19 reported that in the 2 years of the pandemic, they discovered unexpected resources in users, experienced greater closeness with colleagues, paid more attention to users’ physical health and environmental hygiene, revised users’ care plans, and learned digital skills. Those quantitative results provided a snapshot of staff members’ perceptions of the positive changes in their work environment in terms of MHS practices and staff–user relationships.

However, the results did not capture the complexity of each participant’s experience, nor did the data describe which changes were perceived as being the most positive and negative from the participants’ perspectives. Understanding the significance of the impact of the pandemic on MHS staff may be helpful for understanding what aspects of COVID-19 should be considered in designing MHSs in the post-pandemic period.

In this secondary analysis study, the responses of the 714 participants who completed at least one item on the qualitative QT-19 section were analysed using a mixed-methods approach. The approach can be particularly useful for investigating the nature of novel phenomena such as the pandemic emergency (Pluye & Hong, 2014). In particular, qualitative responses were categorised according to the content of the quantitative subscales, after which qualitative responses were examined in relation to professional role and type of service.

Methods

Study Design and Participants

The study was coordinated by the Department of Psychology of the University of Campania “Luigi Vanvitelli”—Italy and conducted in accordance with the Declaration of Helsinki. The protocol was approved by the ethics committee of the Department of Psychology of the University of Campania “Luigi Vanvitelli” (authorization no. 1 dated 2/2/2021).

The study was conducted in 17 MHSs located in 15 regions of Italy: nine in northern Italy, two in central Italy, and six in southern Italy. The sample included professionals working in the adult patient sector of the participating MHSs and third sector agencies (i.e. cooperatives) contracted with the participating MHSs. Data were collected online from 1 March to 30 April 2022, a period that coincided with the end of the national health emergency. Eligible staff members were invited via email from the head of the department to participate in an online study about their views regarding the pandemic’s impact on their MHS. The invitation email contained a link to the QT-19, and reminder messages to complete the questionnaire were sent via email and WhatsApp to potential participants during data collection. Participants completed the QT-19 anonymously using their personal devices. Details of the study protocol, data collection procedures, and the sample’s characteristics are reported in Magliano et al. (2023). Of the 1077 professionals who participated in the study, 714 (66.3%) responded to at least one of the two open-ended items in the qualitative section of the questionnaire and were thus included in the sample for our secondary analysis study. As shown in Table 1, most of the 714 participants were women, middle-aged, and highly educated; they were mostly psychiatrists, nurses, and psychosocial staff who were working primarily in mental health centres, residential facilities, and social cooperatives.

Table 1 Participants’ socio-demographic and professional characteristics (N = 714)
Full size table

Assessment Instrument

The QT-19 is a self-report tool developed in an ad hoc way following a participatory research approach (Magliano et al., 2022). The tool consists of three sections. Section 1, as mentioned, is a 30-item quantitative section addressing healthcare staff members’ opinions on five subscales: (a) Acknowledgement of Users’ Capabilities (i.e. 5 items), (b) Awareness and Value of Teamwork (i.e. 8 items), (c) Flexibility and Ability to Reinvent the Service (i.e. 4 items), (d) Maintenance and Introduction of Best Practices (i.e. 12 items), and (e) Acknowledgement of Positive Aspects of the Pandemic Experience (i.e. 1 item). Those 30 items are rated on a 6-point scale ranging from 1 (not really true) to 6 (really true), and each respondent’s mean score is calculated for each subscale. Section 2 contains two open-ended items addressing the most positive and most negative changes in the MHS during the pandemic from the staff member’s perspective (Table 2). Last, Section 3 addresses the staff member’s socio-demographic and professional characteristics. The psychometric properties of Section 1 had previously been tested and found to be satisfactory (confirmatory factor analysis: c2(396) = 900.24, p < . 001; nonnormalized fit index [NNFI] = 0.90; comparative fit index [cfi] = 0.91; root mean square error of approximation [RMSEA] = 0.087, c.i. 90% (0.080; 0.095; standardized root mean square residual [SRMR] = 0.086. All factor loadings significant at the p < 0.001 level. Cronbach's α values from 0.68 to 0.83; Magliano et al., 2022). Responses to the 30 items in that section and Section 3 were previously analysed in the full sample of 1077 respondents in Magliano et al.’s (2023) study, whereas responses to items in Section 2 (n = 714) had not previously been analysed.

Table 2 Operational criteria for coding responses to open-ended items addressing the most positive and negative changes in Mental Health Services (MHSs) during the 2-year pandemic emergency (N = 714)
Full size table

Statistical Analysis

Frequencies and means, as appropriate, were calculated for the main socio-demographic and professional characteristics of the participants indicated in Section 3 of the QT-19. Meanwhile, percentages and mean subscale scores were calculated for items in Section 1. Based on the textual content and themes addressed on the quantitative subscale, one author (LM) developed a preliminary set of operational criteria to code the responses to the open-ended items in Section 2 dichotomously as “yes” or “no” into eight thematic categories. Responses that fell into more than one thematic category were coded into all appropriate categories. Next, two authors (CP and GDM) independently coded 40 randomly selected sets of responses according to the preliminary operational criteria. Inter-rater reliability was found to be poor (Cohen’s kappa = 0.40–0.69) in five of the eight thematic categories but adequate (Cohen’s kappa = 0.70–0.74) in the remaining three categories. Following a collegial discussion among the authors about the discrepancies in scores, the operational criteria were revised to reduce ambivalence in coding (Table 2). The two authors (CP and GDM) classified another 40 randomly selected sets of responses, and inter-rater reliability was satisfactory for all categories (Cohen’s kappa = 0.80–1.0). Those authors next independently scored all responses to open-ended items according to the revised operational criteria, and frequencies of the scores assigned to the yes or no categories were calculated. A chi-square test was performed to examine differences in the assigned scores for categories in relation to the respondents’ professional roles (i.e. psychiatrist, psychologist, nurse, rehabilitation staff, and healthcare assistant) and work settings (i.e. community mental health centre, day care centre, general hospital psychiatric unit or day hospital, residential facility, and cooperative). All analyses were performed in SPSS version 21 (IBM, 2012), with the level of statistical significance set at p < 0.05.

Results

Quantitative Data

As reported in Table 3, the Flexibility and Ability to Reinvent the Service subscale in Section 1 of the QT-19 had the highest mean score, followed by the Maintenance and Introduction of Best Practices subscale. Across the five subscales, the highest item response rates at levels 5 (true) and 6 (really true) and related to recognising the importance of simple gestures and habits (83%), the ability to mediate between users’ requests and the procedures necessary to work safely (80.7%), increased attention to the work environment’s cleanliness (87%), and discovery of users’ unexpected personal resources (54.6%). Last, 57.5% of participants agreed with the statement “I found positive aspects in this experience”.

Table 3 Participants’ opinions on positive changes in the mental health service (MHS) during the 2 years of the COVID-19 pandemic emergency (total sample N = 714)
Full size table

Qualitative Data

Overview

Of the 714 participants, 611 (85.5%) answered the item about the most positive changes and 667 (93.8%) answered the item about the most negative changes (Table 4). Participants provided 981 and 1064 responses to the two open-ended items, respectively. The content of the thematic categories is detailed in the following subsections, and examples of the content appear in Tables 5, 6, 7, 8.

Table 4 Participants’ opinions on the most positive and negative changes in the mental health service (MHS), by thematic category (N = 714)
Full size table
Table 5 Examples of responses regarding the most positive and negative changes in the mental health service (MHS) in the category of MHS practices
Full size table
Table 6 Examples of responses regarding the most positive and negative changes in the mental health service (MHS) in the category of MHS organisation
Full size table
Table 7 Examples of responses regarding the most positive and negative changes in the mental health service (MHS) in the category of teamwork values
Full size table
Table 8 Examples of responses regarding the most positive and negative changes in the mental health service (MHS) in the category of relationships with users and their families
Full size table

Changes in MHS Practices

Responses concerning the most positive changes were in the thematic category of MHS practices in 49.1% of cases (Table 4). Those changes were reported more frequently by psychiatrists (63.4%) and psychologists (61.1%) than by rehabilitation staff (49.4%), nurses (37.1%), and healthcare assistants (43.2%; χ2 = 26.1, df 4, p < 0.001). Responses related to aspects such as increased attention to users’ physical health, closer collaboration with professionals in other medical disciplines, and the review of treatment plans (Table 5). Some practices were reported to have been delivered remotely in the early stages of the pandemic and later in a hybrid form. Pilot experiences in the first wave of the pandemic sometimes led to the development of structured interventions in later waves. The usefulness of digital platforms for delivering remote clinical interventions and socialisation initiatives was also highlighted. A proactive attitude of staff towards users emerged, supported by increased telephone contact with them and the delivery of home-based interventions. Increased attention to environmental hygiene to reduce the risk of nosocomial infections and COVID-19 was highlighted as well.

Responses concerning the most negative changes were in the thematic category of changes in MHS practices in 39% of cases (Table 4). Those responses were more frequently reported by staff at mental health centres (42.9%) and day care centres (45.9%) than by staff at cooperatives (38.4%), residential facilities (29.3%), and general hospital psychiatric units (22%; χ2 = 13.5, df 4, p < 0.01). Difficulties included the disruption of socialisation and rehabilitation activities and the reduced availability of beds for crisis care (Table 5), which were compounded by difficulties in ensuring the continuity of community care, over-medicalisation, and detrimental effects on rehabilitation interventions. The increased use of digital technology was reported to have hindered relationships with users in the long term, while cleaning rooms was seen as taking time away from working with users.

Changes in the MHS Organisation

Responses regarding the most positive changes were in the thematic category of changes in the MHS organisation in 34.5% of cases (Table 4). Greater flexibility in organising shifts and adapting schedules to sudden changes was reported, as were benefits resulting from recruiting new staff and introducing operational protocols to regulate access to services (Table 6). The improved planning of service activities and reduced bureaucracy, including the greater use of IT-based procedures, were highlighted as well, along with a clearer allocation of tasks among staff.

Responses about the most negative changes were in the thematic category of changes in the MHS organisation in 36.9% of cases (Table 4). The disorganisation and rigidity of the MHS, staff reductions and transfers to other departments, and changes in assigned tasks were among the most negative organisational changes reported by participants (Table 6). Staff members’ difficulties in adapting to new regulations, sometimes perceived as being meaningless or confusing, were also mentioned. Poor links between community services and hospital units, municipalities, and court offices, along with inappropriate referrals of potential cases to the MHS, were highlighted as well.

Changes in Teamwork Values

Responses regarding the most positive changes were in the category of teamwork values in 45.0% of cases (Table 4). Those responses were reported more frequently by nurses (54.3%), healthcare assistants (50.0%), and rehabilitation staff (42.7%) than by psychologists (38.9%) and psychiatrists (36.6%; χ2 = 12.1, df 4, p < 0.02); and by staff of cooperatives (57.6%) and residential facilities (56.9%) more frequently than by staff of general hospital psychiatric units (43.6%), mental health centres (42.9%), and day care centres (30.8%; χ2 = 12.1, df 4, p < 0.02). Responses emphasised the strengthening of teamwork and the more active involvement of professional groups that had had limited involvement in managing treatment in the pre-pandemic period (Table 7). The increased ability to work in teams and to collaborate with professionals from other health services and different medical disciplines was reported, as was heightened closeness between colleagues, both objectively (i.e. working side by side to solve problems) and subjectively (i.e. greater solidarity and authenticity in relationships with colleagues). Last, the acquisition of new professional skills was also reported.

When staff members were asked about the most negative changes, 43% of the responses were in the category of teamwork values (Table 4). Participants described worsening formal and informal relationships with team members and conflicts with colleagues, the latter sometimes due to colleagues’ anti-vaccination attitudes and, as a result, increased workloads for vaccinated staff (Table 7). Physical and mental fatigue, feelings of inadequacy in responding to new needs among users, and an increased burden of clinical responsibility were also reported, along with feelings of low esteem on the part of management.

Changes in Relationships with Users and Their Families

Responses about the most positive changes were in the thematic category of relationships with users and their families in 31.9% of cases (Table 4). Those responses were more frequently reported by staff in cooperatives (43.9%) and residential facilities (41.7%) than by staff in community mental health centres (29.7%), day care centres (28.2%), and psychiatric units of general hospitals (18.2%; χ2 = 13.4, df 4, p < 0.01). Staff perceived users to be as capable of responding to the pandemic as well as anyone else. At the same time, staff mentioned an increased awareness of their own capabilities among users, too (Table 8). Those aspects were compounded by the participants’ perception of increased recognition by users and family members of the staff’s efforts to cope with the pandemic. Participants also reported developing more informal ways of being close to users and paying more attention to aspects of users’ lives that had previously received little attention. A renewed focus on staff–user relationships and a less paternalistic attitude towards users were reported as contributing to greater autonomy among users. Values such as closeness and solidarity with users and a sense of being “in the same boat”, so to speak, also emerged.

When staff were asked about the most negative changes, 40.6% of responses were in the thematic category of relationships with users and their families (Table 4). Suspicions of mutual contagion between staff and users were mentioned, as were demanding attitudes and aggressive behaviour among users and family members towards staff (Table 8). Users’ marked distress, worsened clinical status, and reduced functional autonomy were also highlighted.

Discussion

These findings paint a complex picture of the impact of the 2-year COVID-19 pandemic emergency on MHSs in Italy by highlighting some of the positive effects of a situation characterised by enormous difficulties for health services. The use of a mixed-methods approach made it possible to qualitatively showcase the diversity of staff members’ experiences and quantitatively examine their importance in relation to professional role and type of service. Moreover, the development of operational criteria facilitated the interpretation of responses to open-ended items based on both textual content and quantitative themes (Pluye & Hong, 2014).

Overall, changes in MHSs in Italy appear to have occurred in three major dimensions that cut across the four thematic categories explored by the QT-19: the subjective dimension, including individual values, feelings, and skills; the interpersonal dimension, including therapeutic relationships and relationships with colleagues; and the institutional dimension, including MHS practices and organisation. Within that interpretive framework, the study revealed that the professional role and type of service can significantly influence the importance that staff attached to changes in MHSs during the pandemic. Most often, participants attached great importance to positive changes in the thematic categories of MHS practices and teamwork values. However, those results only partly overlapped with the quantitative results, in which the highest mean subscale scores were for Awareness of Teamwork Values, followed by Maintenance and Introduction of Best Practices. The discrepancy between the most frequent and most important changes highlights the usefulness of collecting qualitative data in studies dominated by quantitative data (Pluye & Hong, 2014).

The thematic category of MHS practices that we identified includes several subthemes, including making home visits, attention to users’ physical health, renewal of treatment plans, attention to cleanliness of services, and staff members’ digital literacy. In line with the findings of other studies (Benudis et al., 2022; Witteveen et al., 2022), participating staff in our study considered telepsychiatry to be an important resource for continuity of care and for maintaining relationships within the team and between staff and users. It cannot be ruled out, however, that the positive changes found in our study were a temporary response to extraordinary stress and that in some countries those changes risk disappearing once the emergency had ended (Ndwabe et al., 2024). Ad hoc studies are therefore needed to confirm the effectiveness of telepsychiatry on the clinical and social dimensions of mental health services in the post-pandemic period and to identify which users may benefit from remote interventions (Liberati et al., 2021; Bareis et al., 2023; Zhong et al., 2023). Further studies should also examine the sustainability of changes in MHS practices (e.g. telepsychiatry) in post-pandemic MHSs and the extent to which those changes are supported by different stakeholders. In a co-produced study on views of telepsychiatry conducted at two sites in England and two sites in Italy (Sheriff et al., 2023), remote consultation was viewed as being appropriate for routine follow-up appointments but less so for new assessments or for people with acutely disturbed mental states. That study revealed that clinicians had a more positive view on video consultations than service users and carers did and that users did not believe that telepsychiatry had improved during the COVID-19 pandemic.

Staff members in this study additionally emphasised changes in the value of teamwork, the rediscovery of themselves as being part of a team, and the reality that everyone was facing the pandemic together (Johnson et al., 2021; Hamano et al., 2022). Beyond that, the relationships with users and their families category was particularly rich in positive reports about the strengthening of staff–user relationships and users’ capacity to mobilise personal and family resources. That finding is consistent with the results of previous qualitative research showing an increased respect for the resilience and self-management of MHS users during the pandemic (Leeming et al., 2022; McKeown et al., 2023). Of note is the recognition by users themselves of previously unexpressed personal capabilities. That aspect, which requires further ad hoc studies, could be useful in planning rehabilitation interventions, facilitating staff’s proximity to people with mental disorders, empowering users, and reducing stigma (Magliano et al., 2016; Di Carlo et al., 2021).

The study found significant differences in the importance attached to positive changes by different professional groups. Participants identified that changes in areas in which their professional roles had more opportunities to be expressed and valued during the pandemic were the most relevant. Psychiatrists and psychologists were more likely than other professionals to report positive aspects related to clinical practice; the leadership mandate may have made those professionals especially sensitive to recognising changes in care practices (Sanghera et al., 2020). Nurses, healthcare assistants, and, to a lesser extent, rehabilitation workers were more positive than psychiatrists and psychologists about changes affecting the team and the meaning of their work. Most likely, non-medical staff’s greater sensitivity to teamwork stemmed from a greater sense of professional belonging and/or an inclination towards multidisciplinary work (Gray et al., 2019). Improved colleagueship and the greater empowerment of non-clinical staff may have also related to the forced reduction of doctor-centredness due to the pandemic emergency. Greater collaboration between MHS staff members in different roles and between MHS staff and professionals in other medical disciplines may have enabled the development of new problem-solving strategies. In turn, that dynamic may have further facilitated the strengthening of relationships among staff members and revitalised a sense of teamwork (Viking et al., 2022; Westbrook et al., 2022).

Compared with other professional groups, staff in residential and social cooperative facilities were likely to report positive changes in their relationships with users and improvements in teamwork. In residential facilities, where the risk of passive intervention and staff demotivation is high (Magliano et al., 2016), restricted living space and limited external social contact may have fostered greater closeness between staff and users, along with the latter’s increased involvement in daily activities. By extension, those aspects may have led users to deploy previously neglected skills or staff to discover unexpected abilities in them (Magliano et al., 2022).

Participants most frequently identified negative changes in the thematic categories of teamwork values and relationships with users and their families. Those difficulties can directly or indirectly relate to the progressive depletion of human resources in MHS and inadequate investment in staff training and supervision, in both Italy and other countries (Sheridan Rains et al., 2021). As reported by other authors (Bommersbach et al., 2021; Lee et al., 2023), staff have reported increased stress due to intensified workloads and a greater burden of responsibilities, as well as a perceived lack of support from managers. Those negative changes, consistent with findings from other studies (Giorgi et al., 2020; Foye et al., 2021), highlight the need for increased attention to healthcare staff’s mental health (Ghahramani et al., 2023).

Participants reported that one of the most negative consequences of the pandemic was user withdrawal and loneliness. That finding highlights that for people with mental disorders, attending community services is sometimes also an opportunity to maintain social relationships, a dimension that was particularly compromised during the pandemic emergency (Lyne et al., 2020). That circumstance may partly explain the more frequent perception of negative changes in MHS practices among staff at community mental health centres and day centres than among staff at residential facilities and general hospital psychiatric units. The pessimistic view on MHS practices among staff on the front lines during the pandemic may relate to the reduction in rehabilitative, social, and vocational activities provided by those services in the community. In residential facilities, which are often managed by third sector staff, the marked reduction in external activities was partly compensated by social rehabilitation work within the facilities. In the psychiatric units at general hospitals, the medical–pharmacological treatments did not change significantly given the clinical conditions of the users.

These findings are valuable in that the study was conducted after 2 years of the COVID-19 emergency, when people and health services began to confront a more manageable pandemic. However, the reference to such a long period may have influenced participants’ responses as well. Moreover, the study’s cross-sectional design prevented us from capturing the temporal evolution of the changes recorded. For example, it prohibited us from determining whether positive changes had occurred primarily in the early phase of the pandemic or as an initial response to the public health emergency and/or whether negative changes became more burdensome as the pandemic progressed due to the depletion of resources and the drive for innovation. Those issues will be partly addressed in a forthcoming study comparing data collected at one and 2 years after the beginning of the pandemic emergency in MHSs in Trieste and Gorizia (Magliano et al., 2022).

Because 66% of the national study sample completed the additional section on the most important changes during the pandemic emergency, that percentage was likely influenced by the fact that the open-ended items took longer to complete than the items in the quantitative section. In interpreting the results, it should also be considered that the open-ended items followed the quantitative items addressing positive aspects; that circumstance may have led participants to respond to more positive changes based on the previous 30-item section, thereby limiting mentions of new issues and underestimating the reporting of the pandemic’s more negative consequences. It should also be considered that the sample did not fully reflect the distribution of professional roles in MHSs in Italy or regional differences in the provision of MHSs throughout the country (Ministero della Salute, 2022). Furthermore, it cannot be ruled out that characteristics of the geographical areas sampled may have influenced staff members’ opinions on the most important changes in MHSs, as shown in a quantitative analysis of the whole sample (Magliano et al., 2023). That possibility is supported by the interpretive analysis of the study’s results, which revealed that staff in MHSs in northern Italy mentioned negative changes in the organisation of services more frequently than staff from MHSs in central and southern Italy (41.4% vs. 32.5% vs. 29.8%, χ2 = 8.0, df 2, p < 0.02).. Last, as stated by Bommersbach et al. (2021), “The pandemic provided a unique opportunity to innovate and redesign systems of care. Institutions and their staff have proposed transformative ideas to meet the evolving needs of patients during this unprecedented period”. In that light, additional studies are needed to examine whether and how the positive changes that occurred in MHSs during such a dramatic period affected practices, the organisation of MHSs, and staff–user relationships in the post-pandemic period. At the same time, it remains necessary to investigate whether the enormous strain that the pandemic placed on MHS staff was mitigated in the post-pandemic period by strengthening the human capital via investments in staff recruitment, training, and supervision.