Discussion

This study is the first attempt to specifically explore the experiences of PHC nurses during the COVID-19 pandemic. The findings highlight the significant impact that the pandemic has had on the employment of PHC nurses, their role and caseload, and the potential negative impact on the quality of care delivered. It has also revealed the significant lack of PPE within the PHC setting in Australia. Understanding these experiences is vital to ensuring workforce support during and following the pandemic to optimise workforce retention, sustainability and care quality.
A key finding of the study was that the PHC nurses held significant concerns for their job security and many reported lost work hours. This seems somewhat paradoxical given the increased health needs of the community, in terms of pandemic screening and management, and ongoing health care. While health emergencies require a responsive workforce (Hope et al. , 2011), the current funding of Australian PHC does not support nursing workforce flexibility to adapt to changing circumstances (Halcomb et al., 2018, Australian College of Nursing, 2020). Despite block funding, bulk and private billing arrangements (Victoria State Government, 2017, Australian Government Services Australia, 2020), vulnerabilities exist in job security for nurses working outside acute care. Changes to funding made by the Australian Government in response to COVID-19 allowing GPs to deliver services via telehealth, were not initially extended to nurses. This had a negative effect by reducing nurse ability to gain reimbursement for services, as face-to-face consultations were reduced and nurses were not included in funding mechanisms to deliver telehealth. The impact of funding models on PHC nurses delivering services to the extent of their practice scope has been previously identified (Halcomb et al., 2008). This highlights the complexity of the political environment of health care outside the acute care system and the medical dominance of this landscape (Mills & Hallinan, 2009). Since this survey, the Australian Government announced temporary funding for COVID-19 telehealth consultations by nurses to provide services including antenatal care and chronic disease management (Australian Government Department of Health, 2020a). Monitoring funding impacts on workforce retention, clinical roles among PHC nurses and overall care quality will be required to ensure that this funding achieves the desired outcomes. It will also be important to monitor secondary morbidity and mortality during and following the pandemic to ensure that health services meet the needs of the community beyond those infected with COVID-19.
Findings revealed significant personal safety concerns driving many nurses to consider resigning from their place of employment. Heightened anxiety about the risks associated with acute care employment during pandemics has been previously reported (Lam and Hung, 2013, Holroyd and McNaught, 2008, Kang et al., 2018, Koh et al., 2012). Rapidly changing clinical practice, inadequate pandemic preparation, insufficient and limited resources and potential disease exposure all contribute to perceived threats to personal safety (Shiao et al. , 2007, Holroyd & McNaught, 2008). While deaths of colleagues have created uncertainty and anxiety in previous pandemics (Holroyd and McNaught, 2008, Koh et al., 2012), the high number of health care workers dying globally due to COVID-19 (Ehrlich et al. , 2020) are likely to have increased current concerns. Strategies to promote the dissemination of consistent and reliable information may be the key to ensuring that nurses are well informed and supported to manage these fears.
The shortage of PPE during the COVID-19 pandemic has been extensively reported across the world (Ranney et al. , 2020, Livingston et al. , 2020). Respondents in our study provided a stark picture of the insufficient PPE available to them in their workplaces. In Australia the shortage of some items, such as particulate masks, was made even more acute as the COVID-19 pandemic followed shortly after the devastating 2019/20 bushfire season (Surf Life Saving New South Wales, 2020). Like the respondents in our study who described using homemade PPE or repurposing other products, such as plastic bags, Shih et al. (2007) described nurses using plastic raincoats to protect themselves from SARs transmission. Given the supply of adequate PPE remains one of the largest issues of concern related to pandemics and epidemics (Huang et al. , 2020, Cohen & Casken, 2011, Jones et al. , 2017, Michaelis et al. , 2009, Speroni et al. , 2015), more needs to be done to ensure sufficient stockpiles are maintained and supply chains are reviewed to ensure health professionals and frontline workers are adequately protected. Additionally, ensuring clear and consistent communication of evidence-based principles and practice guidelines around the required PPE for specific types of exposures in diverse settings will ensure that available stock is used appropriately (Verbeek et al. , 2020).
Beyond their fears of personal physical safety, respondents in this study indicated a level of concern for the psychological impact of the pandemic. A combination of job insecurity, workplace stress, inadequate PPE, concern for personal, family and client safety places a significant toll on the mental health of nurses everywhere during a pandemic (Fernandez et al.). Additionally, high workloads and lockdowns related to social distancing are likely to separate some nurses from their usual social support networks (Huang & rong Liu, 2020). In order to ensure that PHC nurses remain healthy and able to provide PHC to the community throughout COVID-19 and beyond, it is vital that they are provided with short and long term, meaningful mental health support.
Previous research during pandemics has shown that routine service disruption has led to increased morbidity and mortality, in particular, for older people with complex chronic medical conditions and those in disadvantaged communities (Dempseyet al. , 2019). Consistent with reports by Hendrie (2020), who estimate that presentations to Australian hospitals and general practices is down by 50%, respondents in our study reported a decreased caseload. Reasons for this reduction vary from health professionals being reluctant to see patients face-to-face, people attempting to socially isolate themselves, and people being reluctant to present to what they perceive is an overburdened health system. This highlights a need for community education about service availability and the importance of ongoing management and care for complex conditions, and strategies to triage health services for those most in need.
Of concern in our study was a perception that the quality of care was significantly or slightly worse than before COVID-19. Pandemics typically cause disruption to services impacting on care quality (Hartmann-Boyce & Mahtani, 2020). Vulnerable populations at risk of chronic disease are especially susceptible to infectious illnesses, requiring ongoing support to prevent increased morbidity (Hartmann-Boyce & Mahtani, 2020). Nurses also face dilemmas during pandemics through inability to provide care in line with patient needs (Corley et al., 2010). Adequately resourcing and utilizing this group of nurses through appropriate funding, workplace organisation and PPE would better support workforce and patient care needs.