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.