Background and Aims

General practice rapidly and extensively changed working practices and care delivery in response to the COVID-19 pandemic. There has been little exploration of the experiences of nurses working in general practice (GPN) and the impact on care delivery, job satisfaction, workload, stress, burnout and professional support. In this study, we intended to gain insight into GPN practice during the pandemic and considered how this may affect nursing in general practice  going forward.

Aims:

• To explore how nurses working in general practice experienced implementing change at pace and scale in delivering care during consecutive waves of the COVID-19 pandemic.

• To evaluate the impact of changes to nurses’ working practices on their professional wellbeing.

Specifically, we looked to:

• Identify changes to care delivery by nurses working in general practice  during consecutive waves of the COVID-19 pandemic.

• Identify barriers and facilitators to care delivery.

• Explore access to, and experience of, translating rapidly developed guidance/evidence-base into practice.

• Explore acceptability of new models of working.

• Explore effects of the development of rapid and significant workforce practices on the welfare and working conditions of GPNs

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Approvals

The study received a favourable opinion from the University of York Health Sciences Research Governance Committee (HSRGC/2021/458/I). Health Research Authority Approval was also gained (IRAS:303536; Protocol Number: R23982). The study was accepted for NIHR Clinical Research Network support and registered on the NIHR CRN Portfolio (CPMS ID 51834).

Recruitment and Participants

Data were collected between April-August  2022. A total of 40 participants took part, ranging in experience from newly qualified nurses to those with over 40 years’ experience, as well as one student nurse and one GP. Most participants had worked in general practice for a number of years. N=3/40 participants were male and the rest were female. Interviews were conducted remotely via Zoom, MS Teams or by telephone, or in-person at the case sites.

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Case study participants were also recruited from three general practice locality sites within one overarching organisation across the north of England. The overarching organisation was given the pseudonym “Woodlands”, with the individual sites  “Yew”, “Sycamore” and “Hawthorn”.  13 individuals took part in either an interview/focus group, observation of meetings or both.

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Findings

At the beginning of the pandemic, General practice was required, at pace, to rethink how care would be delivered. This was generally led by GP partners and practice managers, although some nurses in the study had involvement in this, ranging from nominal to significant. Some nurses in the study were told what their clinics/consultations would look like and how care was expected to be delivered. Remote working mainly consisted of telephone consultations, but in reality the majority of nursing work continued to be carried out in-person. Technology was used as an adjunct, rather than replacement for, face-to-face care. In the experience of many participants, nursing was considered to be somewhat of an afterthought, both strategically and practically, during the pandemic. Nurses made a major contribution to setting up covid vaccination centres and delivering the bulk of vaccinations, although this, and the wider work of nurses in general practice, was often not recognised by colleagues or the public more broadly.

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Nurses in this study experienced significant challenges to their working life, their nursing practice and their personal and professional wellbeing. While some nurses thrived on the opportunities that workplace changes associated with the pandemic offered, the majority experienced challenges and some participants displayed symptoms of burnout and stress. Many of the experiences nurses talked about in the study pre-dated the pandemic, sometimes by years and decades, but these issues had been exacerbated and laid bare by the pandemic. Consequently, this had implications for retention of both newly qualified and experienced nurses with several revaluating whether they wanted to continue working in general practice and in what capacity, while some had already left general practice, taken early retirement or had reduced their working hours. This has implications for the future of  nursing in general practice.

Implications for Future  Practice: Key Factors to Consider Post Pandemic

Drawing on the key findings from the study, underpinned by the understanding that autonomy, a feeling of belonging (fairness and feeling valued) and making a positive contribution all support the positive wellbeing of nurses (West et al, 2020), the following factors to consider post pandemic have been developed:

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• Nurses working in general practice should be involved in key decision-making at senior levels (at practice, local and national levels) about adapting and developing new ways of working. Nurses themselves understand how their work is done, rather than their work as imagined by others who make decisions (Leary, 2016). This shift towards embracing nurses as decision-makers will require structural and cultural shifts in general practice relationships and support for nurses to work confidently at this level.

• The role and value of nursing in general practice should be recognised by colleagues and employers, as well as by the media and public more generally. General practice nursing is essentially isolated and the nursing profession, and its professional organisations and associations, have a role to play in promoting and supporting nursing in general practice and strengthening the voice of nurses.

• Nurses working in general practice should be provided with the technological equipment and training to further develop ways of working established during the covid pandemic on an equal basis to others in the practice. This means they would have access to the means to conduct consultations in ways which are effective for their patients and support their own personal and professional circumstances.

• Opportunities for nurses to work differently, for example, consulting with patients remotely  from home or offering retired nurses flexible contracts, can be further developed in order to promote positive working experiences for nurses and improve access for patients. Such initiatives may support nurses to continue working in general practice.

• Recruitment and retention need to be strategically addressed. Pay, conditions and pensions equitable to, and competitive with, nurses directly employed by the NHS may address some recruitment and retention issues. Addressing pension abatement issues may also help retain some nurses in some capacity within general practice. Innovative ways of retaining  experienced nurses in general practice at some level (e.g. in supporting and mentoring nurses new to general practice, focusing on a single aspect of care provision, flexible contracts) may all contribute to retention.

• Support from practices, and other groups such as primary care networks, as well as nursing’s professional associations/leadership to develop strategies to prevent and reduce stress and burnout among practice nurses is necessary in order to retain the skills, longer term, of this highly qualified professional group.

• HEIs and educational institutions will need to adapt clinical teaching to reflect new and hybrid ways of working

References

Leary, A. (2016)Hope is not a plan: Can healthcare in the UK learn from other safety critical industries?: A reflection on visiting safety critical, high reliability organisations. Medical & Health 2016

West, M., Bailey, S., Williams, E. (2020) The courage of compassion. Supporting nurses and midwives to deliver high-quality care. The King’s fund https://www.kingsfund.org.uk/publications/courage-compassion-supporting-nurses-midwives