The COVID-19 pandemic brought massive changes to all facets of society including human services organizations providing long-term congregate care to vulnerable populations such as adults with intellectual disability (ID) (Thompson & Nygren, 2020) and acquired brain injury (ABI) (Malec et al., 2021). Frontline personnel delivering services during the early stage of the pandemic experienced the brunt of responsibility for client care and consequently the most significant stressors. Notably, research on the impact of an epidemic/pandemic on healthcare workers demonstrates that an infectious outbreak may be associated with emotional exhaustion and burnout (Bussing and Glaser 1999; Marjanovic et al., 2007) as well as insomnia, alcohol and drug misuse, and symptoms of depression, anxiety, and post-traumatic stress disorder (Stuijfzand et al., 2020). In a survey of 353 healthcare professionals in Italy during the early months of the COVID-19 pandemic, Guisti et al. (2020) reported that more than 71% of respondents had clinically elevated scores for anxiety and depression. Other research suggests the healthcare workers with greater exposure risks (McAlonan et al., 2007) including COVID-19 (Lai et al., 2020; Zhang et al., 2020) experience more negative psychological symptoms than persons in secondary roles. However, work-related distress is also apparent among non-direct care employees who often receive less information and vocational support in times of a health crisis (Blake et al., 2020; Tan et al., 2020).

A thematic analysis by Embregts et al. (2020b) concerning the effects of infection outbreaks on healthcare workers at long-term care facilities revealed that they experienced (a) fear, tension between colleagues, stress, and confusion; (b) ethical dilemmas that involved isolation of infected clients, loneliness, and medical care that was not understood; and (c) problems with work attendance, refusing care to afflicted persons, and conflicting childcare and eldercare obligations. These stressors may further contribute to burnout and ill health already experienced by long-term staff due to shift assignments and demanding caseloads (Embregts et al., 2020b; McHugh et al., 2011; Westermann et al., 2014).

Care providers for persons with ID and ABI are at risk for burnout, physical and emotional distress, turnover, and related occupational struggles (Britton Laws et al., 2014; Firman et al., 2013; Mitchell & Hastings, 2001; Murray et al., 2019). These matters were intensified by the COVID-19 pandemic and necessitated increased staff support, training, and direction in service settings (Cox et al., 2020; Kornack et al., 2020; Maguire et al., 2021; Malec et al., 2021; Thompson & Nygren, 2020). Consider that the threat of virus infection and serious illness to adults with pre-existing conditions, physical health comorbidity, and cognitive limitations created the need for quarantine, social distancing, changes to routines, and activity restrictions that burdened direct care providers on many levels (Courtenay & Perera, 2020; Glover et al., 2017). Further, they were responsible for implementing multiple and sometimes novel risk mitigation strategies including but not limited to teaching clients to tolerate face coverings, donning personal protective equipment (PPE), following enhanced hygiene guidelines, and disinfecting environments (Gravina et al., 2020).

Embregts et al. (2020a) conducted a descriptive qualitative study on the impact of the COVID-19 pandemic among direct care providers of adults with ID. Four principal themes emerged highlighting emotions (e.g., fear of infection, sense of responsibility, disappointment), cognitions (e.g., coping, problem solving, perseverance), practices (e.g., preventive measures, remote consultation), and professional conduct (e.g., cooperation, mutual support). Summarizing their findings, the researchers recommended that managers at service settings for adults with ID communicate and express concern for direct-care staff, build collaborative teams across different levels and job functions within an organization, and support adherence to high priority policies and procedures. Also, “it is essential that healthcare organizations emphasize that direct support staff are not alone responsible for this endeavor and that they can count on the healthcare organization in general and on managers and psychologists in particular” (p. 489).

Among post-acute rehabilitation facilities for adults with ABI, Malec et al. (2021) reported that many group home and community settings established specialty-staffed “recovery houses” for patients who tested positive for COVID-19. Other alterations to conventional service delivery were increased utilization of telehealth therapies, remote consultations, and restricted visitation policies. Formal and informal feedback from care providers revealed that danger from the pandemic and the many adjustments to programming caused them stress regarding personal safety, job security, employee benefits (e.g., sick time, paid leave), and organizational viability.

Apropos to the significant challenges and risks to direct care providers serving adults with ID and ABI during the COVID-19 pandemic, perceived organizational support (POS) plays an important role in assuaging the effects of crisis situations on healthcare workers (Eisenberger et al., 1986; Marjanovic et al., 2007). The basis of POS is leadership assessment of workforce attitudes, opinions, and impressions about the care employees receive and efforts to improve occupational satisfaction. Information gleaned from POS assessment during a health crisis can inform leaders to consider performance enhancing initiatives such as asking employees to volunteer for new assignments rather than mandating deployments, regularly disseminating updated health information, and training new job tasks with personal infection control as a priority (Brooks et al., 2018; Stuijfzand et al., 2020). In function, POS is similar to the concepts and objectives of social validity assessment with direct and indirect consumers of educational, treatment, and habilitation services (Luiselli, 2021; Schwartz & Baer, 1991; Wolf, 1978).

The purpose of the present two-phase study was to assess the perceptions of direct care providers at a human services organization for adults with ID and ABI at the onset of the COVID-19 pandemic. In phase 1, we formed care provider focus groups that responded to the actions of organizational leaders toward risk mitigation, health safety, and support of service-recipients and employees. These preliminary qualitative findings informed the direction of phase 2 which assessed approval and acceptance of leadership initiatives from a large sample of direct care providers throughout the organization. The study represents a mixed method approach to program evaluation (Jason & Glenwick 2016) that is applicable to healthcare concerns confronting persons with multiple disabilities and their care providers (Luiselli, 2016) and highlights service implications posed by the unique circumstances at the early stage of the COVID-19 pandemic and beyond.

Phase 1

Method

Participants

The setting for phase 1 of the study was a private human services organization within the northeast USA serving several hundred children and adults with intellectual, developmental, and neurological disabilities. Participants were 54 employees from one division of the organization that supported 28 adults (22 + years old) with ID and ABI who lived in seven community-based group homes. Among the participants, 56.6% identified as female and 44.4% identified as male with an average age of 44.8 years and an average of 6.8 years employment tenure. Within this convenience sample, 90.7% of the participants were employed as direct care providers, and 9.3% of the participants were employed as group home managers. They were recruited for the study based on their availability to attend focus group meetings (described below), voluntary participation, and approval of a group home supervisor.

Procedures

Four of the authors were focus group leaders and, in that role, conducted interviews with four to six participants in attendance at a single meeting scheduled in each of the seven group homes. Meetings began with the focus group leader explaining that the participants would be asked questions about their experiences working in the group homes during the first 4 months (March–June 2020) of the COVID-19 pandemic. They were encouraged to speak honestly, informed that confidentiality would be maintained by not revealing their identity, and advised that what they said would not affect employment at the human services organization.

Focus group interviews lasted between 45 and 60 min and were conducted virtually and video-audio recorded for later analysis. All of the participants consented to these conditions. The focus group leaders followed a written script that specified nine interview questions: (1) What was it like working here in the first few months of the pandemic, (2) What worked well during this time, (3) What did not work well, (4) What could we have done better as an organization to support staff, (5) What, if anything, could we put in place in response to the crisis that we should have been doing all along, (6) What things would you still like to see the organization do in response to the pandemic, (7) How did you feel about your job before COVID-19, (8) How do you feel about your job now, and (9) What lessons or takeaways should the organization learn from this crisis?

The interview script also included guidelines for eliciting responses from participants, clarifying information, and answering questions. For example, if participant responses to interview questions were unclear, focus group leaders were instructed to comment, “Could you please be more specific,” and “What other details could you add?” The guidelines also specified that focus group leaders ensure that participants fully understood all of the questions presented to them by re-phrasing inquiries as necessary. Focus group leaders practiced the interview protocol several times before meeting formally with the participants.

Measures

Each recorded focus group meeting (N = 7) was observed and scored independently by two randomly assigned group leaders using a standardized form. Group leaders never scored the meetings they had conducted. During observation, group leaders followed a guide that instructed them to document words and phrases they thought properly addressed each question specified by the interview script. They wrote as many actual quotes from focus group participants as possible on the form with the words and phrases time-stamped for later comparison scoring. In illustration, group leaders would write the full comments from participants such as “I think the assistant directors really communicated well with us about what was going on” and “Yeah, I definitely felt kept in the loop” in response to questions about communication within the organization. Documenting these and similar comments as simply “communication” would not represent acceptable and correct scoring.

Data Analyses

Following the principles of grounded theory coding (Kenealy, 2012), the first author identified codes from the common words and phrases the focus group leaders documented in the recorded meetings. Similar and related codes were later combined into larger categories that formed themes from responses to the interview questions (Saldana, 2009). In a final step of qualitative analysis, the research team reviewed the derived themes to confirm accurate representation of focus group content. The codes and themes are summarized in the “8” section.

Using the qualitative method of triangulation for “comparing and cross-checking data collected through observations” (Merriam & Tisdell, 2016, p. 245), the first author also compared the paired focus group recordings completed by group leaders. An agreement was defined as both group leaders documenting the same words and phrases from participant responses to interview questions. The comparison score across all of the paired focus group recordings was 78.9% (SD = 6.09).

Results

Several themes emerged from the focus group meetings during phase 1 of the study and are summarized with direct quotes in Table 1. First, a general response from participants was that they “loved” their jobs before the pandemic despite the sense that they received low pay and insufficient compensation. Participants also believed that they were prepared and comfortable prior to the pandemic and had purpose and connection to the work. Next, participants indicated even greater job importance following onset of the pandemic, appreciated that they had a job when so many people were unemployed, yet described fear and anxiety about their physical health and safety as well as the lives of family and the adults they supported. Participants commented further that the restrictions necessitated by the pandemic made their jobs more demanding. Other consistent themes from focus groups were uncertainty about virus transmission, availability of essential PPE, and financial stress imposed by lost income.

Table 1 Focus group responses to changes in work experience during the COVID-19 pandemic
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Participant responses to organizational leadership actions during the pandemic are summarized in Table 2. Positive themes that emerged were implementation of comprehensive protocols to mitigate risks and promote safety, the “Stay Healthy in Place” (SHIP) program in which employees remained on shift without leaving a group home for more than 72 h, and incentive pay for employees who were willing and able to work during the early months of the pandemic. A theme of “what did not work well” during the pandemic revealed that participants were frustrated with having to use accrued benefit time if not working, dissatisfied with seemingly rapid shift changes at the group homes, and sometimes confused about inconsistent communications from leadership to direct care personnel. Additionally, the eventual termination of incentive pay was generally criticized. Beyond leadership actions in response to the pandemic, participants responded consistently about support strategies that group home managers and supervisors put in place. This theme involved assistance such as scheduling additional staff coverage, dropping off groceries and PPE, delivering “care packages” of favorite foods, writing thank you notes, and fostering teamwork.

Table 2 Focus group responses to leadership actions during the COVID-19 pandemic
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A final theme, illustrated in Table 3, was participant recommendations for continued strategies during the pandemic and in preparation for future health crises. There were suggestions that the organization reinstate incentive pay and reimburse benefit time for employees who had to use earned vacation hours during shifts. Other points of emphasis were providing employees with an ongoing supply of PPE on the job and to take home for personal use, disseminating guidelines that inform employees about safety measures on and away from the job, and continuing with environmental cleaning and hygiene practices at group homes. Finally, participants urged the organization to maintain a “hands-on approach” to program support, engage employees with strategic planning, and formally recognize performance accomplishments.

Table 3 Focus group recommendations to organization leadership
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Phase 2

Method

Participants

Participants were 498 care providers, 68% identified as female, 30% identified as male, and 2% without identification employed at the same human services organization described in phase 1 as of March 15, 2020. From this sample, 62% of participants had direct care positions in group homes, 21% were residence directors, 11% were assistant residence directors, 3% were shift nurses, and 3% were undefined. Within the organization’s network of programs, 74% of participants provided care to adults with ID, 12% supported adults with ABI, and 14% transitioned between service-recipient populations. Participants had been employed at the human services organization for less than 6 months (8%), 6 months–1 year (10%), 1–5 years (35%), 5–10 years (25%), and more than 10 years (23%). During the period of March–June 2020, 56% of participants had been involved in the SHIP program, 43% had not, and 1% were unsure; 29% of participants had to quarantine on at least one occasion during the same period.

Procedures

Based on the findings from phase 1 and discussion with organization vice presidents, the research team constructed a list of leadership actions in response to the COVID-19 pandemic (Table 4) according to six categories: (1) changes in schedules and work assignments, (2) delivering services remotely, (3) changes in administrative activities, (4) adding new safety practices, (5) enhancing existing supports, and (6) improving technology resources. The leadership actions were subsequently converted to a 31-item questionnaire that was sent to the participants via online survey platform. Other than requested demographic information, the questionnaire was completed anonymously and returned on or before a deadline date.

Table 4 Leadership actions in response to the COVID-19 pandemic
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Measures

Each item on the questionnaire represented one leadership action. Participants were requested to rate the impact of these actions during the period of March–June 2020 on a five-point scale: 1 (very positive impact), 2 (somewhat positive impact), 3 (no impact), 4 (somewhat negative impact), and 5 (very negative impact). The ratings produced quantified measures by which to evaluate organizational effectiveness in response to the pandemic. Participants could also rate items with “I am unable to evaluate the impact of this item.”

Data Analyses

An exploratory factor analysis (EFA) using principal component analysis of the questionnaire showed support for a one-factor solution based on a flattening point on the scree plot following the first factor. Additionally, the one-factor explained almost 38% of the total variance, whereas the next factor explained only 8% of the total variance. The EFA revealed that 30 of the 31 items on the questionnaire were associated with the one-factor scale at reasonable level as demonstrated by factor loadings above 0.3 (Furr & Bacharach, 2014). The one item that did not meet this threshold, “temporary incentive pay for direct support staff,” had a factor loading of 0.264.

Outcome measures were first determined by identifying participants who rated a minimum of 10 questionnaire items. Participants who did not meet this criterion were excluded from the analysis. A mean rating per item was computed by summing the ratings on each item and dividing by the respective number of participants (not all participants rated every item).

Results

The mean rating across all items on the questionnaire was 1.71 (SD = 0.58) for participants who rated a minimum of ten items or average impression that leadership responsiveness to the COVID-19 pandemic had a “somewhat positive impact.” Table 5 presents the rank-ordered mean ratings for every item on the questionnaire (none of the participants rated every item). Items with the strongest endorsements from participants were “Mobile COVID-19 testing at the group home” (M = 1.31, SD = 0.68), “temporary incentive pay for direct support staff” (M = 1.31, SD = 0.66), and “providing masks to programs” (M = 1.33, SD = 0.81). The weakest endorsed items from the participants were “redeploying day services staff to group homes” (M = 2.20, SD = 1.16), “conducting hiring interviews remotely” (M = 2.19, SD = 1.14), and “adding remote cameras to residence computers” (M = 2.03, SD = 1.21). Finally, five items on the questionnaire were scored “I am unable to evaluate the impact of this item” by more than 25% of participants, specifically “adding remote cameras to residence computers” (35%), “conducting hiring interviews remotely” (29%), “remote day program services for residents by vocational training staff” (29%), “remote referral screenings” (26%), and “redeploying clinicians for operational support” (25%).

Table 5 Mean and rank-ordered questionnaire ratings
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Discussion

We conducted a mixed methods study that assessed the opinions of direct care providers about leadership responsiveness to the COVID-19 pandemic at a human services organization for adults with ID and ABI. The reasons for conducting workforce assessment are many, including evaluation of organizational effectiveness, identification of areas in need of improvement, and solicitation of program recommendations from employees (Eisenberger & Stinglhamber, 2011; Eisenberger et al., 1986). Demonstrating sensitivity to the attitudes of employees also shows commitment to valued services and client care that most employees would perceive as meaningful POS (Kurtessis et al., 2017). Discussed below, there were several key findings from the study specific to issues raised by the COVID-19 pandemic, results of prior research, and mixed methods inquiry targeting health topics.

Within focus groups, the responses from participants suggested they were capable of working through fear, uncertainty, and doubt at the start of the pandemic and emerge with a stronger sense of the importance of their jobs. Their apparent resilience may have been the result of the rapid response to safety concerns, distribution of PPE, and SHIP program which were perceived as critical risk mitigation strategies within group homes. Also, the positive experiences reported by participants may have been nurtured by group home managers and supervisors who promoted collaborative teamwork, acknowledged exemplary performance, and added supports that relieved day-to-day burdens. Importantly, these findings suggest that human services care providers are keen observers of how their leaders react to crises and will form lasting judgments about an organization on this basis.

The recommendations from focus group participants further reflected the desire to prepare for future health crises. For example, participants suggested that the human services organization could improve its training and emergency response guidelines. While programs were eventually able to meet PPE needs, participants recommended rapid availability and storage of a broader range of equipment. And many participants enthusiastically endorsed continued recognition and positive support of employees from organizational leaders and program managers that was evident during the early months of the pandemic.

Phase 2 results were generally positive for many of the COVID-19 leadership actions rated by a large sample of direct care providers. Immediate and conspicuous initiatives such as performing mobile surveillance testing at group homes, offering temporary incentive pay, and supplying PPE were highly regarded among other directives toward risk mitigation and health promotion. The appeal of these leadership actions may have reflected positive regard for the immediate corrective plans that were put in place and the appreciation care providers felt for steps taken to guard their health and personal welfare. At the same time, participants viewed some initiatives as having less impact, or they were not able to endorse a rating, for example, adding remote cameras to computers, conducting hiring interviews remotely, and assigning day-services employees to group homes. It appears that the top-rated items on the questionnaire including other approved strategies (e.g., fluid communication, information sharing, delivering of materials to group homes) quantified the impressions of focus group participants. However, we propose that all of the items and respective ratings from the questionnaire provided the human services organization with meaningful measures to evaluate the scope and effectiveness of its COVID-19 pandemic responsiveness, decide about performance maintenance, and plan strategically. And, as referenced previously, the highly endorsed leadership actions from focus group and questionnaire participants were tangible contributions to job satisfaction that usually appeal to employees and heighten their opinions about POS (Kurtessis et al., 2017; Rhoades & Eisenberger, 2002).

Mixed methods research intentionally integrates and combines qualitative and quantitative data as a methodology to evaluate programs from multiple perspectives, build cooperative relationships with research participants, contextualize the questions being studied, and compare-contrast findings in the broadest context (Jason & Glenwick, 2016; Plano Clark, 2010; Tebbes, 2012). As illustrated in this study, initial qualitative analysis often has the purpose of designing an instrument for acquiring measures pertinent to health-related services and outcomes (Bowers et al., 2013; Fetters et al., 2013; Song et al., 2010. For example, Jason and Reed (2015) described mixed methods approaches toward myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS), starting with patient and illness support group interviews that addressed symptom presentation, access to treatment, negative encounters with medical professionals, and stigmatization. Qualitative analysis within a grounded theory framework was followed by quantitative measurement through several screening instruments and rating scales which refined demographic variables and diagnostic criteria among ME/CFS patients. The acquired measures also suggested alternative treatment modalities and sources of community support to help cope with the illness. Relative to the objectives and benefits of mixed methods research, Jason and Reed (2015) concluded that “Quantitative research provided us the data on the magnitude of this illness, whereas the qualitative methods allowed us to better understand the unique challenges and stigma that the patients had experienced from their families, friends, and treatment professionals” (p. 10).

In summary, the present study adds to the emerging literature on the effects of the COVID-19 pandemic with healthcare workers including service providers for adults with ID and ABI (Blake et al., 2020; Courtenay et al., 2020; Embregts et al.,, 2020; Giusti et al., 2020; Tan et al., 2020). Our focus was on human services care provider perceptions of the effectiveness of leadership actions and recommendations to prepare for future health crises. The research participants prioritized the impact of several leadership initiatives and emphasized other actions to institute organization-wide. This integrated assessment produced qualitative and quantitative measures that were merged as a comprehensive and socially valid performance evaluation.

Limitations and Future Research

Interpretation of our findings is limited on several levels. First, results are not easily generalizable because the study was conducted with a convenience sample at one human services organization. Also, circumstances at the time of the study dictated that the focus groups be interviewed remotely; thus, it may be questioned whether in-person meetings would have produced different responses from participants. And third, the study relied on self-report measures, none of the participants in phase 2 rated every item on the questionnaire, and our demographic data did not include educational level, SES, and racial/ethnic background of the participants.

Another potential limitation is that mixed methods evaluation may be too time- and labor-intensive for some human services organizations (Creswell & Plano Clark, 2011; Tashakkori & Teddlie, 2003). Yet, a scaled-back methodology could be the focus of future research by assembling a team of in-house professionals who have shared responsibilities and address organization-supported objectives as incorporated in this study. An additional research direction is determining how the work experiences of care providers, time on the job, and roles at a human services organization influence their perceptions of leadership responsibility and effectiveness.