Introduction

Staff at organizations supporting violence against women (VAW) survivors provide essential and lifesaving services for women experiencing violence, including shelter and housing support, mental health and crisis support, case management, and legal advocacy. At the same time, VAW staff are at risk of experiencing emotional and psychological distress and vicarious trauma because of their work (Brend et al., 2020; Crivatu et al., 2023; Wies & Coy, 2013). This occupational stress is compounded by chronic issues of low pay, burnout, and high rates of staff turnover across a chronically underfunded sector (Beres et al., 2009; Dworkin et al., 2016; Slattery & Goodman, 2009; Wood et al., 2019). Ensuring that the mental health and well-being of staff working with VAW survivors (or VAW staff) does not suffer is paramount to effectively meeting the needs of VAW survivors.

During the COVID-19 pandemic, rates of VAW increased along with the demand for VAW support services (Piquero et al., 2021; Wathen et al., 2022; Yakubovich et al., 2023). Simultaneously, VAW organizations needed to adapt modes of service provision (e.g. switch to virtual services) to meet public health requirements, all while VAW staff were coping with new personal stressors related to the pandemic and its attendant restrictions (Wood et al., 2022; Yakubovich et al., 2023). In Canada, COVID-19 response protocols were mandated at the provincial level and changed throughout the course of the pandemic. In Ontario, the province with the most COVID-19 cases in Canada, restrictions and mandates included lockdowns or stay at home orders (including school closures), social distancing requirements, vaccine mandates, and the use of personal protective equipment (Chum et al., 2021; Shillington et al., 2021, 2022). VAW organizations had to manage and implement these rapidly evolving mandates, which, lacking the training and support of being situated within the health system, had the potential to exacerbate the impact that VAW work has on staff mental health (Garcia et al., 2021; Wood et al., 2022).

In Canada, where 44% of women over the age of 15 have experienced intimate partner violence (the most common form of VAW) in their lifetime, and where a woman or girl is murdered every 1.5 days, there has been recent increased funding for and political attention paid to preventing and responding to VAW (Cotter, 2021; Yakubovich et al., 2023). In 2022, the federal government announced CAD $601.3 million over 5 years to invest in a national action plan (NAP) to end gender-based violence, and in 2023, the NAP was released, offering provinces and territories a set of opportunities for action (Yakubovich et al., 2023). The NAP proposes that sustained funding in the sector could help with hiring and retaining qualified staff and increasing occupational health, mental health, training opportunities, and safety supports for staff. Given the increased federal and provincial funding and attention towards VAW prevention and response, identifying recommendations to improve and protect the mental health of VAW staff that address their realities is crucial to a responsive VAW service system in Canada.

Research from Australia (Carrington et al., 2021) and the United States (Wood et al., 2022) has reported on the detrimental effects of the pandemic on the VAW sector, including VAW staff mental health and well-being. In Canada, several studies have explored how VAW services were impacted by COVID-19, finding that staff at VAW organizations consistently reported increased workload and isolation (Michaelsen et al., 2022), exhaustion and burnout (Wathen et al., 2022), and difficulty separating work from home life (Mantler et al., 2023; Trudell & Whitmore, 2020). However, only two peer-reviewed studies in Canada have specifically explored staff mental health during this period. The first reported on the results of an online survey of 564 victim service providers across Canada (Roebuck et al., 2022). The authors found that 32% of participants reported a decrease in work-life balance, 42% reported that their mental health had deteriorated, and 72% reported that their level of stress had increased. The second study qualitatively examined experiences of staff working at VAW shelters and executive directors at VAW organizations during the pandemic in Ontario, Canada, and found that staff reported an increase in the emotional toll of the work, including distress, guilt, and feelings of helplessness and hopelessness with regard to meeting the needs of clients (Burd et al., 2023).

Objectives

We aimed to understand the impacts of the pandemic on the mental health of VAW staff in the Greater Toronto Area (GTA) to inform recommendations for policy and practice. Filling the gaps in the existing evidence, we conducted the first mixed-methods study in Canada that examines the mental health of both residential and non-residential direct support and leadership VAW staff during the COVID-19 pandemic. This included the first quantitative estimates of VAW staff mental health during the COVID-19 pandemic using validated scales to assess anxiety, depressive symptoms, and vicarious trauma, which we then contextualized using a rich and novel dataset of interviews with VAW staff.

Methods

The data used were collected as part of a community-based, mixed-methods study on the processes, experiences, and outcomes of adapting VAW programming during the COVID-19 pandemic, in collaboration with 42 VAW organizations across the GTA (the MARCO-VAW Study) (Yakubovich et al., 2023). The Unity Health Toronto Research Ethics Board (REB#20–124) and the Dalhousie University Research Ethics Board (REB# 2022–6275) approved this study.

Quantitative data collection

Quantitative data were collected through online surveys (via REDCap) from February to April 2021. We recruited participants in partnership with VAW organizations and networks in the GTA, including through mailing lists, emails, and engagement events. All direct support and leadership staff who had been working since 11 March 2020 at an organization in the GTA with at least one VAW service were eligible to participate in the study. Survey participants had to be 18 years of age or older and able to provide informed consent. Participants received a $10 honorarium for participating in the survey.

In this study, we used participant data from the Vicarious Trauma Scale (VTS) (McCann & Pearlman, 1990; Vrklevski & Franklin, 2008), a psychometrically valid, eight-item screening tool to assess exposure to traumatic material or distressed clients, and the impact of the exposure (Aparicio et al., 2013) and we used participant data from the Patient Health Questionnaire (PHQ)–4 to assess symptoms of depression and anxiety among staff participants (Kroenke et al., 2009). We also report on whether or not staff found their work to be more upsetting or distressing during the pandemic compared to before.

Qualitative data collection

Qualitative data were collected from April to September 2021. We purposively recruited direct support and leadership staff from the pool of survey participants who agreed to be contacted for follow-up, to broadly reflect the sample’s demographic characteristics, types of VAW services where participants worked, and the populations served. The study’s co-leads (ARY, an academic VAW researcher, and PS, a community-based VAW researcher) and three peer researchers (women with lived experience of gender-based violence who received (further) training on VAW research methods) conducted semi-structured interviews ranging from 1.5 to 2 h in length. The interview guides asked staff about their experiences delivering VAW services during the pandemic, with a specific section on their mental health. Participants provided informed consent by email prior to being interviewed and were provided with a $40 honorarium following their interviews. Interviews were conducted and recorded over Zoom (Zoom Video Communications, Inc., San Jose, CA, USA) and transcribed verbatim using Trint (Trint Ltd., Toronto, ON, Canada). BS and ARY de-identified and checked the accuracy of the transcripts to the original recordings.

Analysis

We descriptively analyzed participant responses to the survey questions related to their mental health using Stata (StataCorp, 2017). The results of the quantitative analysis were used to inform the development of questions around vicarious trauma and mental health used in the qualitative interview guide. For the qualitative data, we used a reflexive thematic analysis methodology that recognizes and embraces the subjectivity and positionality of the research team, allows for flexible coding practices, and emphasizes iterative, in-depth engagement with the data, to identify themes related to staff mental health throughout participants’ entire transcripts (Braun & Clarke, 2019). Our analysis was informed by a critical feminist lens, accounting for systemic, societal undervaluing of work in fields that are predominately comprised of women and aiming to identify the ways in which participants’ self-reported experiences can be used to identify structural gaps in the VAW support sector and to inform policy and practice (Grimshaw & Rubery, 2007; McPhail et al., 2007).

A team of four trained researchers, three of whom participated in interviews, and two peer researchers with lived experience of violence collaborated on the qualitative data analysis. The analysis team first conducted open coding on the same two interview transcripts to obtain a fulsome picture of the dataset and then the research team collaboratively compared and consolidated codes into a framework to apply to the remaining dataset. Next, each analyst was assigned a subset of transcripts for coding. Once all transcript data were initially coded, each transcript was double coded by another analyst to identify opportunities to add codes and integrate perspectives. Then, the research team met to discuss additions and changes to the coding framework.

For this analysis on VAW staff mental health, two researchers read through the data assigned to codes on mental health. We then integrated the results of the qualitative and quantitative data (Ivankova et al., 2006). We used the codes identified in the qualitative analysis to explore contributing elements to staff vicarious trauma and anxiety and stress to unpack the quantitative findings. Embedded within this analysis was an investigation of how mental health varied across direct support and leadership staff. We then identified and developed an initial summary of the most salient data on staff mental health and generated themes based on patterns of ideas we identified across these data. Finally, we developed a thematic framework to summarize the relationships between these patterns.

As part of our integrated knowledge translation approach, VAW knowledge users (including advocates, organizational leaders, direct support staff, and women with lived experience of VAW) were engaged as active participants throughout the research process, as co-lead, team members, or advisory group members. In addition, the team regularly presented and discussed progress and preliminary findings with knowledge users across the VAW and allied sectors in the GTA through knowledge sharing events. Attendees provided input and feedback on the direction of the research and offered contextual insights to inform and nuance our data collection and analysis.

Results

Participants

Table 1 summarizes the sociodemographic data of the survey sample and the interview participants. Of the 127 staff respondents to the survey, 104 responded to a question on mental health. Of these participants, 71 were direct support workers and 33 held leadership roles. The average age of participants was 42 and most participants identified as a ciswoman (92%) and as heterosexual (83%). Just over half of the sample (51%) identified as an ethnic or racial minority and 42% were born outside of Canada. Over half (55%) of staff worked in residential VAW services (i.e. shelter). Half of the direct support participants and most leadership (82%) participants conducted some in-person work during the pandemic, with staff at residential organizations conducting more in-person work than staff at non-residential organizations. The supplementary material describes the diversity of programs, services, and organizations where staff participants worked.

Table 1 Sociodemographic characteristics of the sample
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The interview sample (n = 18) had a similar composition to the survey sample. The average age of participants was 47 and most participants identified as a ciswoman (95%) and as heterosexual (79%). Two thirds identified as an ethnic or racial minority and 52% were born outside of Canada. Slightly less than half the staff (42%) worked in residential VAW services. As with the survey sample, there was a diversity in VAW programming delivered by VAW staff.

Quantitative findings

Both direct support and leadership VAW staff participants reported moderate vicarious trauma symptoms on the VTS as assessed by a cut-off score of 19–42 (Table 2). The mean score was 37.5 (9.8) for direct support staff and 33.2 (9.6) for leadership. Both direct support staff and leadership faced similar levels of anxiety and depression, with participants reporting on average mild symptoms of anxiety and depression on the PHQ-4 (Table 2). Direct support staff reported a mean score of 3.6 (SD = 2.7) and leadership reported a mean score of 3.4 (SD = 2.5). Most VAW staff reported that their work was more distressing during the pandemic compared to pre-pandemic (61% of direct support staff and 81% of leadership).

Table 2 Staff self-reported mental health
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Qualitative findings and data integration

We found that all participants, throughout the qualitative interviews, discussed mental health, not just in response to the direct interview questions on mental health. We identified three themes across direct support and leadership staff data that described how staff mental health was impacted during the pandemic: (1) challenges related to changing work environments; (2) distress over not meeting client needs; (3) difficulties adapting self-care strategies during the pandemic.

Challenges related to changing work environments

The pandemic altered the work environment for both direct support and leadership VAW staff. For some staff, pandemic restrictions meant that they needed to work from home, and as a result, they lost a sense of connection and community with their colleagues. Often, this left staff to cope with challenging work situations in isolation, exacerbating experiences of vicarious trauma. This was exemplified by leadership participant P68, from a large non-residential organization, who shared that while vicarious trauma “is always an issue”, historically, a common strategy used by VAW staff to cope with it was to drop into colleagues’ offices to discuss difficult cases (e.g. subtheme A in Table 3, [hereafter referred to as “Table 3 A”], leadership P68). These in-person debriefs were vital opportunities for feedback and an emotional outlet. Staff working in person also reported a loss of connection and community throughout the pandemic. For example, P43, a direct support staff, described how, because of pandemic protocols, staff no longer went in pairs to visit clients, which made debriefs “less meaningful” due to a lack of shared experiences. P115, another direct support staff, also shared how working alone during the pandemic meant that the only chances she had for in-person interactions with colleagues were during “handovers” at shift changes.

Table 3 Subthemes and example data under Theme 1, Changes in workplace environment
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Staff participants reported that they did not find the virtual environment was able to replicate what leadership participant P38 from a large non-residential organization described as “informal debriefing” (Table 3 A). For example, direct support staff P23, P43, and P68 who typically relied on support from colleagues and team members to process cases to mitigate vicarious trauma felt that this was a major missing piece resulting from the switch to virtual work. The loss of social interaction, collegial support, and community was also felt by staff who relied on in-person interactions with colleagues to help process difficult aspects of home life. Direct support staff P140 described a challenging home environment with complex care responsibilities; prior to the pandemic, she valued the in-person support and perspective she received from her colleagues in processing her home circumstances, but this stress was compounded when working from home (Table 3 A).

Many staff, like P140, indicated that an additional challenge to working from home was keeping work and home life separate. Prior to the pandemic, having separate spaces for work and home meant they were able to set healthy boundaries for when to think about work and when to disengage, as a way to manage vicarious trauma as well as symptoms of anxiety and depression. For example, direct support staff P43 shared that the lack of physical separation between home and work made it hard to decompress and detach from challenging work situations, making work all-consuming (Table 3 B). Another participant, direct support staff P37, reported feeling “disturbed” by having to see work-related files and equipment on her table. Working from home also created stressors related to client confidentiality (Table 3 B). By working in more personal spaces, oftentimes with children or family members also at home, staff experienced worry in trying to ensure that they could maintain the privacy of the clients they worked with. The consequence of not being able to have a physical separation between work and home was detrimental to staff well-being. For instance, direct support staff P92 explained that since working from home, client cases were stuck in her mind all day and night, impacting her sleep and ability to relax after work (Table 3 B).

Working from home was not the only change occurring for staff at VAW organizations. For participants whose roles required in-person work (e.g. shelter staff), the stress of managing infection prevention and control procedures, combined with fears about contracting the virus and staffing shortages, brought about anxiety. Direct support participants from residential organizations, e.g. P15 and P103, felt anxious about the possibility of being exposed to the virus in a work setting and bringing it home to their families (Table 3 C). P103 described emotional stress from worrying about infecting people close to her who had underlying health conditions while also knowing that if she did not attend work, she could lose her job.

Distress over not meeting client needs

VAW staff reported hopelessness and distress over feeling that they could not meet the needs of their clients. Pandemic restrictions limited their ability to support their clients in addressing their safety. Early in the pandemic, many wraparound support services for survivors (e.g. housing and legal support) reduced service capacity or temporarily shut down, leaving staff uncertain of where to refer clients and worried that clients may not receive certain timely help. For example, P5 (leadership) and P140 (direct support) felt increased stress in their jobs knowing that if they referred a client to a certain support, they might not be able to reach anyone by phone or email or receive adequate help when it was needed (Table 4 A).

Table 4 Subthemes and example data under Theme 2, Distress over not meeting client needs
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Increased workload and staffing challenges during the pandemic also contributed to staff feeling that they were not meeting client needs. Increased caseloads and complexity, in addition to staffing shortages, meant that some clients were not able to receive timely access to services. Staff were left overwhelmed with guilt and concern for their clients, often extending themselves to meet client need at the expense of their own mental health. Many staff reported feelings of stress and burnout due to increases in caseloads combined with understaffing. This stress was compounded for staff working at organizations that service specific communities (i.e. based on language, culture, religion, or nationality). P136, a leadership participant from a community-specific organization, described how waitlists went from 2 to 3 weeks to 6 months due to the volume of cases, and because they were the only resource in the community, they could not refer clients to any other organization, leaving client needs unmet (Table 4 B).

The relationship between increased caseload and complexity with staffing issues proved to be a vicious cycle. Aptly depicted by P115, unmanageable workloads left staff feeling exhausted and hopeless, and in some cases caused them to quit. However, these staffing shortages and turnover left an additional burden on the remaining staff to work more to try and meet client demand (Table 4 B). Ultimately, as P115 described, this cycle “takes a toll” on staff mental health and leadership participant P38 described staff morale as “super, super, super low” as a result of a deep sense of guilt and despair due to workload and burnout (Table 4 B).

Difficulties adapting self-care strategies during the pandemic

Having the space and capacity for VAW staff to develop and use self-care strategies is paramount for maintaining positive mental health and managing vicarious trauma. However, many VAW staff shared that because of the pandemic, they could no longer rely on the self-care strategies they typically used. P37 explained that during the pandemic, for the first time in her life, she experienced anxiety. She shared that prior to the pandemic she was effective in implementing self-care strategies (e.g. swimming) but since the pandemic she had struggled to find something equally helpful to de-stress (e.g. when pools were closed) (Table 5 A). Staff were limited in their ability to practice self-care, partly because restrictions and lockdowns prevented people from doing things that would normally provide them with breaks from work, including exercise (P37) or travelling (P115). P103 described how during the height of the pandemic, the thought of taking a vacation was unappealing, given that there was nowhere to go due to travel restrictions and very few activities open (Table 5 A).

Table 5 Subthemes and example data under Theme 3, Barriers to implementing self-care strategies
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Other staff relied on social interaction as a form of self-care, but due to working from home and pandemic restrictions, many staff experienced social isolation. P95, a direct support staff, explains how this was particularly true for people living alone, reporting that for staff who were newcomers to Canada, this loneliness was particularly challenging due to separation from family and other established support networks (Table 5 A).

Across the dataset, participants discussed how in many cases direct support staff were facing similar challenges to clients during the pandemic. P137 (leadership) described how VAW staff themselves, many of whom were on part-time or casual contracts without access to benefits, often faced increased care responsibilities, economic impacts, loneliness and isolation, and increased stress, which compounded a sense of “hopelessness and helplessness”. P137 witnessed her staff enter a “valley of despair with the clients” due to a lack of control and ability to fix the challenges facing both their clients and themselves. Leadership participant P68 similarly discussed the challenges of trying to support VAW staff with their self-care during the pandemic, sharing that there was only so much that could be done when the reality of the situation was that staff were working in isolation, in front of screens every day, and in addition to experiencing social isolation in their personal lives (Table 5 B).

Discussion

Our mixed-methods study assessed the mental health of VAW staff in Canada’s largest city during the COVID-19 pandemic. To start, we offer the first quantitative analysis of Canadian VAW staff mental health and vicarious trauma using validated and standardized measures and previously established cut offs. First, we found that staff showed moderate vicarious trauma symptoms. The mean total scores were slightly higher than what was found in a pre-pandemic study on vicarious trauma among a sample of victim advocates working in the USA (Benuto et al., 2018) and significantly higher than a pre-pandemic study on vicarious trauma among US social workers (Aparicio et al., 2013). Second, we found that both direct support and leadership staff had mild symptoms of anxiety and depression. The total mean score from our sample was larger than the total mean scores found in general population studies before the pandemic (Kroenke et al., 2009; Löwe et al., 2010) but comparable with the mean estimate using a Canadian general population sample during pandemic times (Emodi-Perlman et al., 2021). We also found that most staff reported that their work was more distressing during the pandemic compared to prior to the pandemic.

We found that both direct support and leadership staff reported similar levels of vicarious trauma, and anxiety and depression and that more leadership staff, when compared to direct support staff, found their work more distressing during the pandemic. This analysis provides a novel contribution to research on staff in the VAW sector. Based on previous studies using samples of health care staff, we could have expected an additional burden placed on direct support staff (and not leadership), due to their direct relationships with survivors, and other job-related factors such as increased workload and lower pay (Oğlak & Obut, 2020; Trumello et al., 2020). Our qualitative data help explain this finding: many leadership staff described the feelings of responsibility, guilt, and hopelessness they experienced in being unable to offer effective solutions to the challenges faced by direct support staff in supporting survivors or managing the trauma they were experiencing from service adaptations due to the pandemic. In many ways, leadership staff felt the weight of both their organization’s clients’ increased needs and those of their staff as a result of the pandemic.

Using the qualitative data to further unpack the quantitative results, we found that staff repeatedly and consistently discussed the impact of their work during the pandemic on their mental health, providing a deeper understanding of factors contributing to mental health challenges. We identified the following three themes to describe how staff mental health was impacted during the pandemic: (1) challenges related to changing work environments, including loss of collegial support, lack of boundaries between home and work life, and fears over contracting COVID-19; (2) distress over not meeting client needs due to reduced availability of services, increased workload, and staffing shortages; and (3) barriers to implementing self-care strategies, including challenges adapting self-care strategies during the pandemic and staff facing similar personal challenges as clients.

Many of the qualitative themes we identified in our analysis, including increased workloads, reduced support between colleagues, challenges separating work from home life, and limitations to self-care strategies, were consistent with findings from similar studies on the well-being of staff working at VAW organizations (Burd et al., 2023; Nnawulezi & Hacskaylo, 2022; Roebuck et al., 2022). These parallel findings help to strengthen the evidence base on mental health among VAW staff. A unique strength to our study, however, was the diversity of our sample. In having a diverse sample, we identified novel factors influencing VAW staff mental health, including challenges faced by staff working at culturally specific VAW organizations, loneliness felt by staff who had no family living in Canada, and challenges staff faced when working from home in multigenerational households where they had care responsibilities.

While we were committed to capturing experiences from staff with a diversity of personal and social identities, most of our sample identified as heterosexual ciswomen and may not capture the unique experiences of gender and sexual minorities working at VAW organizations during the pandemic. Our study also only focuses on VAW staff from Toronto, Canada’s largest and most diverse city, with expansive health and social services. While we provide an in-depth snapshot of Toronto-based perspectives, it is necessary to replicate this research in other Canadian regions (including rural and remote areas) and in Indigenous communities.

The combination of public health restrictions and increased VAW during the pandemic created new and exacerbated existing strains on a support sector that was already at capacity and contending with what Mantler et al. (2023) aptly described as multiple pandemics (including systemic racism, poverty, and opioid-related overdoses). For decades, scholars and activists have written on how women’s organizations, including VAW organizations, have been chronically underfunded due to societal misogyny, which devalues women’s work, health, and safety (Beres et al., 2009; Knight & Rodgers, 2012; Quinlan & Singh, 2020). The creation and continued existence of VAW organizations—in the face of enormously inadequate resources—is a testament to the resilience of feminist and VAW advocacy movements. The staffing shortages, burnout, exhaustion, and vicarious trauma described in our study have plagued the sector long before the COVID-19 pandemic began (Beres et al., 2009). The new challenges posed during the COVID-19 pandemic, however, made it even more difficult for VAW staff to meet the diverse needs of clients and, ultimately, their own health and well-being needs.

VAW organizations require a substantial increase in resources and flexible funding to hire and retain additional staff to respond to increased caseloads and complexity of cases during public health emergencies, to increase the wages of staff to reduce staff turnover, to increase programmatic capacity, and to establish stronger pandemic preparedness and infection prevention and control strategies so that VAW staff can establish more robust work-life boundaries, and respond to PHE conditions with adequate training and equipment. With more structural support in place, VAW organizations could create more time and space to work with staff to develop their trauma-informed organizational practices that establish a culture of connection and learning among staff virtually and in-person and facilitate a range of self-care opportunities to prevent further trauma during emergencies (Nnawulezi & Hacskaylo, 2022).

Conclusion

Making meaningful how the VAW sector is resourced necessitates a shift in how direct support work for VAW survivors is valued and prioritized by government and policymakers. The federal, provincial, and territorial commitments to a National Action Plan to end gender-based violence is a promising first step, but it is necessary that this funding is used to address the structural deficiencies across the VAW sector to ensure organizations and staff are prepared for success in responding to survivors’ needs while also maintaining their own health, well-being, and safety.

Contributions to knowledge

What does this study add to existing knowledge?

  • We conducted the first mixed-methods study in Canada that examines the mental health of both residential and non-residential direct support and leadership staff working at violence against women (VAW) organizations during the COVID-19 pandemic.

  • We offer the first quantitative estimates of staff mental health during the COVID-19 pandemic using validated scales to assess anxiety, depressive symptoms, and vicarious trauma, which we then contextualized using a rich and novel dataset of interviews with VAW staff.

What are the key implications for public health interventions, practice, or policy?

  • Direct support work for VAW survivors must be valued and prioritized by government and policy makers due to the increasing number of and severity in cases of violence against women, the critical lifesaving role staff play in the lives of survivors, and the impact of the work on staff mental health.

  • This study highlights the need for VAW organizations to receive significantly increased financial and staffing resources so staff can effectively and safely respond to higher and more complex caseloads during public health emergencies.