Table 1 Meso and Macro Snakes and Ladders

Team connection and contact

Ladder if frequent/consistent virtual means of contact maintained or initiated

• Therapists whose teams were physically co-located prior to the pandemic described feeling connected to their teams, and vice versa, as they entered the pandemic.

• Regardless of pre-pandemic connectedness, therapists’ sense of connection with their team was influenced by the development, or lack thereof, of technology-mediated forms of contact.

• Both informal and formal means of virtual contact helped with adaptation, from teams’ social What’s App chat groups, to regularly scheduled formal team meetings.

• Exception: certain forms of informal/spontaneous in-person interactions that had previously helped with communication of role clarity and prompted referrals from the team were difficult to replicate with technology.

Immediate supervisor support

Either, dependent on level of support of supervisor

• Supervisors were perceived to remain consistent in their pre-pandemic management style.

• Supervisory support was important during the pandemic as policies and procedures changed continually, having a direct impact on the therapists everyday work in predictable and unpredictable ways.

• Supportive supervisors ensured that there was transparent two-way communication between themselves and the team and provided reassurance and support.

• Early in the first year of the pandemic, therapists appreciated immediate supervisors who were directive, but who transitioned into a more supportive role as time brought more stability.

• Leadership changes and inaccessible immediate supervisors left the therapists feeling alone in navigating day-to-day procedural changes.

Access to resources

Either, depending on access or lack thereof

• PPE: a particular concern in the first months of the pandemic, where pathogen transmission method was unclear. At this point, PPE was scarce in primary care, and some were asked to reuse PPE, creating fear and anxiety.

• Computer hardware and software: the speed of access to computers, and software needed to meet privacy standards, influenced adaptation.

• Clerical support: new clerical demands included setting up virtual appointments, ensure patients knew how to use the technology, mailing out information to patients, screening patients for in-person appointments, room cleaning after in-person appointments.

Mainly a snake for therapists because there was no or limited clerical support. Therapists did these tasks themselves, reducing time for patient care.

Within-profession colleagues

Ladder

• Therapists who sought support from other members of their profession working in primary care found that helped adaptation.

Support for virtual care

Either, dependent on setting/organization

• Most organizations pre-pandemic had policies and procedures that limited the use of virtual care due to concerns of privacy. How quickly these polices changed, and the therapists degree of access to the needed computer hardware and software, affected adaptation.

Organizational Leadership and Meso/Macro Coordination

Snake

• Almost all therapists described the leadership above their immediate supervisor to be a source of frustration that impeded role adaptation. They reported a lack of communication and coordination from upper-level administration, and between macro and meso structures. This resulted in uncoordinated information from varied sources that they had to work to interpret.

• Therapists they felt higher levels of management had little understanding of their work and work context, and did not value their contributions and sacrifices made, while other professions received kudos and financial bonuses.

• There were a lack of feedback channels with the higher levels, and thus little opportunity for input into planning or decision-making.

• In Manitoba, this dissatisfaction intensified over time. After a very limited first wave during spring 2020 and a long period of few cases in summer, the Manitoban therapists were frustrated at the persistence of earlier patterns of poor communication and disorganization. They interpreted this as minimal planning or preparation for the second wave, despite signs from other places showing its eventuality. This disorganization was especially evident in second wave redeployment.

Redeployment

Either, dependent on personal and organizational factors, but mostly a snake.

• Redeployment was the most stressful factor influencing role adaptation.

• Most therapists were redeployed to activities outside of usual scope, and many outside their usual primary care organization.

• Redeployment was an opportunity to do something concrete and that felt helpful during early weeks, when the therapists were disoriented and struggling with uncertain and daily changes.

• However, therapists were overqualified for some redeployments, which when sustained, led them to feel that their expertise was not understood or respected, and created a lack of meaningfulness in their work.

• This work took away from work that would have a bigger impact on the pandemic response.

• In Manitoba in particular, a major snake was the lack of communication and coordination regarding redeployment. Some were told they were going to be redeployed for the second wave of the pandemic, but not when or where, which left them in limbo for weeks regarding taking on new patients, scheduling follow-up visits, or prematurely wrapping up patient care in preparation for redeployment.

• Redeployment was positive for some therapists. Positive aspects included creating in-person connections with known and new colleagues, learning more about other programs in primary and public care, and creating new opportunities for skill development.

Regulatory bodies

Snake early on, then ladder for some when they developed and released virtual practice guidelines

• Initially, pre-pandemic regulatory body guidelines for topics such as consent processes prevented virtual care, slowing adaptation.

• When regulatory bodies did release virtual care guidelines, they were welcomed for their guidance.