Table 2 Themes Developed from Health Care Provider Qualitative Evaluation

1. Successful Program Characteristic

Flexibility of scheduling and clinical care

“I’ve taken on what I could, given caseloads…the flexibility to be able to schedule when I can, and when that individual's needed… and the clinical flexibility to decide, even though it designed, or intended to be fairly brief, but if individuals needed something additional, the flexibility in the decision for myself just to say, okay, I’ll continue to see them until things have improved, or until there's, you know, somewhere else they can access.” PR-interview-9 (Psychologist)

“Because I felt I was in a situation of flexibility and availability, I saw patients often later in the evening…Which was highly appreciated by patients. So, you know, for the sheer fact that they were typically working shifts, or they were working during the day, to be able to see a psychiatrist out of hours was really, really appreciated… If you're really focusing on mental health and not just wellbeing, I think there needs to be enough flexibility to offer this kind of care when the employees need it and not just when we are available.” PR-interview-3 (Psychiatrist)

“The good thing about UHN Cares and doing it from home is that I talked to people sometimes after 5:00 or I talked to them on the weekend, and that is very helpful for people who work full-time. So, I think that that was a good thing, that we were able to be flexible about that.” PR-reinterview-7 (Psychologist)

Healthcare record keeping and confidentiality

“People were definitely concerned about confidentiality. And they were very relieved to know that our process in the Cares program was set up so that… their clinical charts was completely separate from any kind of documentation within UHN… I think that was something that almost everyone had said that they felt reassured by…I don't think anyone was worried so much about the one-on-one, interpersonal component of confidentiality. It was more, like, where was their information being housed? Who could have access to it? And that being very separate from, like, the hospital's electronic medical record system, I think, was something that most people found very reassuring.” PR-reinterview-1 (Psychiatrist)

“There was some question as to who sees it, who has access to the documentation, does it go into EPR, and you know, all of the answers to that were no, it does not, and it's only seen by the UHN Cares team.” PR-interview-9 (Psychologist)

High quality administrative support

“…then being able to just email the [template] PDF so that [the admin] could file them was really useful. And having the admin support for booking, which I haven't historically always had was really helpful. The people running the program are excellent…The billing was good… And then if I wanted to refer, like when the one person I’m working with now I did want her to be able to access more intensive therapy and [the admin] just said, oh, sure, we can, you know, refer to the psychology team, and I was like, oh, that's easy. So, it was just, you know, it was great!”PR-interview-4 (Psychiatrist)

“The templates were really helpful to use, like everything was sort of set up, I didn't really have to wonder, or worry was my record keeping good enough? Where was I going to keep the charts? Like, all of those kinds of things that you need to make sure that you're doing to be in good medical-legal compliance, it was taken care of, especially because I don't actually typically see outpatients, and I don't have a process for any of that sort of thing. It was very helpful to have it all set up for me. It made me much more comfortable and confident in doing the work and felt very good about doing it. I knew I wasn't going to get either bogged down in something, like paperwork, but I also knew I wasn't going to inadvertently make some kind of mistake, because again, I'm not used to following outpatients. So, I didn't have to worry about that.” PR-interview-1 (Psychiatrist)

2. Challenges within Program/ Recommendations for Change

Increase opportunities for peer supervision

“I think I’m in a special position because I have a supervisor. I guess peer supervision would be nice, because sometimes I ask my supervisor what types of cases she has been dealing with and whether there are any similarities. How does she deal with this particular type of issue? So, I feel like maybe some type of group discussion can be quite helpful because there might be recurring themes, or you could get ideas from what other people are doing. And obviously, most of the people are more senior than me so I’m going to be learning from them as well.” PR-interview-2 (Psychologist)

Enhanced triaging of CARES Users

“I don't think [I felt pressured to see people really quickly]…I think the idea at the beginning was that we would see them within a certain period of time. So, that's okay, I mean, if I was available, I could do it. But I think if I knew it was somebody who was less urgent, I would schedule them in my clinical time, I wouldn't have seen them on a weekend, or on my research day. Like, I would have scheduled them like a few weeks out, into a clinical spot.” PR-interview-4 (Psychiatrist)

Managing Expectations of CARES Users

“Where it's been really challenging, and then they also feel, I’ve had to deal with a fair number of calls with people who'd hoped that we would help their family members… particularly adolescents with eating disorders and anxiety… that couldn't access resources in other places, or husbands or wives. So, needing to be able to say, no, no, we can't.” PR-interview-11 (Psychiatrist)

"I think as the discussion progressed, my sense was that there was a hope that UHN would be able to provide a regular therapist that this individual could see weekly…it went sort of badly in that situation then having to sort of set the boundary and say, well, actually, you know, weekly therapy is outside of the scope of what this program is intended to provide. So, here's what I’ll be able to do, and you know, in the circumstance, whether it was in the context of the Cares program or our regular outpatient psychiatry clinics, as you probably know, securing long-term psychotherapy is not an easy thing to do. So, it was also managing expectations in that regard to say I can see what I can do, to see if my colleagues have any names that they would recommend. It would be up to you, as the individual, to reach out. And essentially, there are no guarantees in this process, it often takes a lot of effort and work to secure that.” PR-interview-10 (Psychiatrist)

3. Positive Aspects of Provider Experience

Finding meaning, purpose, and motivation in clinical work during the pandemic

“It's a good feeling that I'm part of this, that I'm helping out in some way, other than my regular work, like this is kind of getting my feet and hands kind of wet, or whatever the saying is, like right in there, right? With them. It's a good feeling, a camaraderie, that we're all working towards something. I guess it's kind of stretching a bit, which was nice, even though it wasn't in my comfort zone to get a little bit of a new skill set of working with health care providers and seeing what that's like. And yeah, I think, maybe because I could identify a little bit, especially with the last one that I got to know a little bit more over time, I think I could identify with her because we were both… it felt more like we were parallel, like on equal ground rather than I was, like, her… even though I was there, kind of, doing psychotherapy, it felt a little bit more equal in this role of the Care program. And I think that I, you know, even though we were only there for a few sessions together, I felt really touched at the end, you know, that I was working with her to get her somewhere professionally and also personally, and that was helping others… I don't know. It just felt like a really touching, important feeling for me.” PR-interview-6 (Psychiatrist)

Familiar clinical care issues within scope of expertise

“I see, you know, a wide range of people in my private practice, you know, and I'm also a neuropsychologist, so I've worked with people, you know, with a really wide range of brain injury for a long, long time. So, you know, as much as it's different, it's also the same, you know, it's people who have lived through something traumatic, life changing, that has really impacted. So, yeah, I would say that, you know, working with these people, I would definitely be drawing on similar kinds of skills that probably I would be, that I've also used with private clients or even patients on the brain injury program too.” PR-reinterview-5 (Psychologist)

4. Challenges within Provider Experience

Providing care in virtual settings

“I hadn't been used to the virtual environment, but I’ve got to like it. At first, I found it quite hard, I don't know, because it doesn't feel, it doesn't feel… you don't get the sort of same affective cues necessarily that you get with being somebody. I can't really feel whether they're anxious or depressed, like it's quite hard to tell. And I probably have a touch of ADHD, so I found it a bit harder to, like as I’m talking to you now, I’m trying to sort of, because of the way that the devices are positioned, my eyes are drawn to you, but I should be looking up at the camera…The first two or three months, i just found it exhausting, I would just go home and go to bed.” PR-interview-11 (Psychiatrist)

Navigating and maintaining boundaries in shared work setting

“Yeah, we're colleagues, we're peers, but they're also coming to me in a role where it's kinda, I don't want to say they're beneath me, but it's kind of like I’m there to help them more of an authority on how I can be helpful. I'm not used to that. And yeah, I guess that did come up once or twice, where what if we do, you know, they're changing locations, what if we do, at some point, meet in a professional realm, yeah. That might be a bit messy too, potentially.” PR-interview-6 (Psychiatrist)

“I think what was complex, again, going back maybe to this we're all in this together experience, was I was taking care of highly, highly, at times, not all of my patients, but some, three examples come to mind, of highly distressed, dysregulated, desperate colleagues, who were very close to my own identity. And were expressing concerns that were close to my own experiences, only the amplitude was different. And so, I think what made it more difficult, if I reflect upon it, was the level of identification and the degree of identification, and projection, that was going on.” PR-reinterview-3 (Psychiatrist)

“I was happy to be able to help people who work at UHN as well. More just having to be a little more careful around boundaries and just thinking about, you know, not disclosing a lot more of my own experiences than I maybe normally would for seeing patients, just because I do have more in common with the people I was seeing through the Cares program. And especially for ones who maybe worked where I would come across them, just talking about, well, what would you like me to do if I see you at the hospital? So, just being a little bit more mindful of that.” PR-interview-4 (Psychiatrist)

“I think we did a pretty good job because there were times, for example, where [admin1] or someone, I worked at, you know, if anyone from my location was looking for care, which happened several times, I wouldn't, you know, [admin1] would make that clear when she sent the message out to the psychologists to say, you know, nobody from here. So, I would always know, okay, that person, you know, that would be someone I know. I think because UHN is so big, you know, it really is, like, separate, with the different hospitals and things. So, it really did quite separate and pretty unlikely that I'm going to, you know, be bumping into any of these people in the halls. So, it actually worked fine.” PR-reinterview-5 (Psychologist)

“There was some concern in close proximity to my clinical role, versus the people I was seeing, but we were able to manage that well. So, knowing that we are in close proximity, potentially could see each other, potentially, if there's any sort of inter-program movement with patients, that we could potentially work with each other in that capacity. So, that was discussed in the first session, and had a plan confirmed and the person was comfortable with continuing. Had they not been, I would have just said, okay, let's find you someone else. But they were comfortable with that. So, we sort of set the ground rules and moved forward with that.” PR-interview-9 (Psychologist)

Managing requests, referrals, follow-up care outside of the workplace program

“It was initial validation, support, normalization of this experience, talking about problem solving versus navigating things with the workplace and with their partner and some hygiene kinds of interventions, self-care kinds of interventions… I think they were somebody who had had a lot of experience of actually doing psychotherapy or psychodynamic types of therapies but had never fully explored this before, and then all of the pandemic-related stressors really brought things to the forefront. And sort of compelled this individual to think about doing that on a regular basis, and so had asked for some recommendations or names, whether or not they reached out, I don't know. But I contacted some of my colleagues to get a name or two to provide to this individual, and they seemed to be very satisfied with that.” PR-interview-10 (Psychiatrist)

“I think it’s quite challenging because one, it’s remote therapy and then two, often they don’t have much capacity to do a lot of stuff outside of their work. I think often people are exhausted or it’s like their life has been all consumed by work and by COVID. I think CBT, especially, is like a type of therapy that can involve a of homework, a lot of them going away and doing exercises, trying out strategies. And I think, sometimes that’s just not practical for some people, so sometimes the sessions have been more maybe helping them understand. Or helping them have a place to ventilate and express their feelings and to understand things maybe within a CBT framework, or trying some really simple stuff like mindfulness and sleep strategies. So, nothing really very involved in terms of the CBT. And obviously with COVID it’s just hard to do a lot of the stuff that we would usually recommend, which is like, go socialise or do hobbies. There’s a lot of stuff that you would normally suggest in therapy that is not possible because of their job, but as well because of all the lockdowns and restrictions. So, I think we’ve had to adapt a lot and be really, obviously, flexible, and also be really clear about what’s achievable and what could help the most in this situation. But it might not be a goal normally in therapy, it might be setting different goals for this situation and you adapted to the person.” PR-interview-2 (Psychologist)

Anticipation of support required

“Initially, recognizing that this is overall, a relatively healthy, well population. And thinking about, like, I didn't have to worry so much about all the worst-case scenarios that could be going on. So, I think getting used to that was… well, one area of challenge that, like, there might be a crisis happening right now for this person but overall, they have ways of coping. And it's not on me to have to do these big interventions, that we can just help them get through, help them reconnect with their own ways of coping and I think being able to get used to that was… to some degree, I guess, a challenge, that I didn't have to react and respond in the way that I might react or respond to an acute situation with, say, an inpatient, that kind of thing. That it was a different ballgame altogether. And I think that was probably… And that, again, it felt like this sort of thing that it was a benefit to me too, because it sort of stretched me and stretched my skills in different kinds of ways. So, what maybe started as a challenge, I think, ultimately, was very beneficial.” PR-interview-1 (Psychiatrist)

“It was a bit frustrating but more… frustration comes from when you have expectations that aren't met, and I think it's kind of like I'm not sure what to expect but yeah, it was a bit frustrating because I guess what I wanted was to be helpful and I wasn't sure if I was being helpful, right? So, it's kind of like, here's a bunch of things I'm throwing at you, and you're not really giving me much feedback. So, this doesn't feel so great, I don't know…I could imagine a lot of people don't really know exactly what they're wanting, they're just suffering, right? They're stressed.” PR-interview-6 (Psychiatrist)

5. Strategies for Providing High-Quality Care

Skills and tools for patient-centredness

“And I think that for a lot of people, my experience was that even when there was what had felt to them to be more distress and more of a crisis, knowing that they had someone to connect with and that they were going to be connecting with them quickly and in my case, I told people that they could set the pace of how often they wanted to be seen, and how many follow ups they would have. I think that for a lot of people, that sort of helped settle, like they knew that someone was there to coach them. And that's really what a lot of the work, I think, that I was doing was. I would sort of conceptualize it much more in a kind of coaching frame, more than the high acuity psychiatric patients who I typically see on the inpatient unit. This is a lot more coaching and sort of helping people see the kinds of coping skills and see their own resiliency that they had, that they just weren't really as in tune within the present moment.” PR-interview-1 (Psychiatrist) 

Personal coping strategies

“We were all going through this. All of us. This is not a situation where I'm treating someone because I studied it, because I'm a resident, I learn how to deal with it, I’m a staff, I keep developing skills and then I'm taking care of a disorder. No, this was a situation where we were all going through the same anxieties and the same uncertainties, and the same sense of overwhelm, exhaustion and sense of loss of safety and orientation. And I remember that it was sometimes hard to be the containing, holding space for distressed people when my own distress wasn't insignificant. And yet, at the same time, this sense of being able to provide help to others was also, of course, a way of stabilizing my own self-esteem and my own sense of integrity.” PR-reinterview-3 (Psychiatrist)

“I try and have a routine. So, I think it's quite important—like, I haven't been doing it that well, but trying to have good boundaries around working and not working because for me, like, I’m working mostly from home. So, so I think it's easy to not have that division. So, you know, like, checking email at all hours and then I work in research as well, so research literally people are on like 24/7, they're answering emails 24/7. So, I try and like not do that. So, I make sure that I have the downtime and then, like, obviously, try and get enough sleep. I think sleep is really important. Try and get some physical activity in. And then also, like, take a bit of time off. So, recently, we travelled for the first time. So, I think that that really helps, so kind of change of setting, yeah.” PR-reinterview-2 (Psychologist)

“I think in the beginning it was sort of a sense of guilt that, you know, some questioning of was I doing enough? Was I doing enough for the Team Cares program? Could I be making more of an effort in this sphere or that sphere? So, there was a little bit of room through there. You know, it also was, as with any time we set a boundary that's important for one's own time and sanity, there's that doubt sort of intertwined with relief of having set a boundary. It helped that it felt like I was contributing in other ways…You know, where I left things was if you're ever in a pickle and there aren't enough providers or things like that, please don't hesitate to reach out. But if you've got a good crew and they're able to meet the needs of the patients that are coming, then that freed me up to do some other things that were also important.” PR-interview-10 (Psychiatrist)