Impact of coronavirus on professional life – how GPNs are coping

Everybody is working flat-out, and getting to grips with new ways of working. But while we battle a common enemy, every practice is different and you may learn from the insights of other general practice nurses

THE GENERAL PRACTICE NURSE

KATHERINE ELLERBY, NURSE PRESCRIBER AND RESEARCH NURSE, SUFFOLK

So much has happened in such a short space of time and the global impact of COVID-19 has been immense. Since the first patient was diagnosed with coronavirus in the UK on the 31 January 2020, the daily life for everyone has changed beyond recognition as a result of this public health crisis, which has not yet reached its peak. In primary care we are being bombarded, rightly so, with information to ensure that we take appropriate action to keep the population and our colleagues safe.

While we have a plethora of guidance advising us how to respond to and make preparations for the impact of coronavirus from Public Health England (PHE) and other national sources, how has this actually been working in practice? In the early days, nurses in some practices were responsible for the environmental cleaning after potential cases had appeared in surgery whereas other surgeries were enlisting specific cleaning companies to carry out this procedure. I’ve never seen our clinic rooms looking so immaculately clean and sparse. But actually, shouldn’t they be like that all time, pandemic or not? Furthermore, we also experienced patients who were withholding information about travel or failing to admit to symptoms so they could cross the threshold at the local surgery to be seen by their own GP rather than following the very well advertised NHS procedure at that time. Clearly the advice has been subsequently updated to focus on symptoms rather than travel.

Pressure was placed upon staff not to order PPE too early due to the cost in case it wasn’t used, only now to be desperate to get hold of stock but with supplies not readily available. And for some, there were different rules for different members of clinical staff. GPs were protected, ensuring that face-to-face contact was only for very specific cases and the very large majority of patients were dealt with by telephone. For many GPNs and their teams it was, during the same period, business as usual – a discrepancy which was difficult to accept and one which didn’t make sense. But to give the benefit of the doubt, everyone was just trying to come to grips with the reality of it all.

However, it is true to say that within the past week or so practices have definitely upped the ante as the enormity of the situation has hit hime across the whole country. As we are far too acutely aware, the absolute priority – beyond anything else – is to identify all potential cases and prevent potential transmission of the virus to staff and any patients who do have to come into the surgery.

Locally there has been a very welcome surge of newsletters and communications offering practical solutions to how we manage things in primary care. With all non-urgent work postponed, we’re all looking at how to do our everyday things differently. Out go travel consultations, face to face LTC reviews, non-essential phlebotomy (in theory at least!), medication reviews and new patient checks. And many consultations, previously conducted face-to-face, are being carried out by telephone or postponed as necessary. Clinical research activities in primary care are also currently suspended.

An example of where we are adapting our practice: routine childhood immunisation is continuing where we are clear that both infant and parent are well and symptom-free (of coronavirus and other infections), in line with PHE recommendations.¹ Our practice has two sites, so all childhood immunisations can be directed to the smaller surgery, where staff numbers are lower, and very few patients will be present, keeping everyone as safe as possible. It’s adapting as best we can to the times.

As someone who specialises in contraceptive services within Primary Care, the Faculty of Sexual and Reproductive Health guidelines on essential SRH services during Covid-19 has been absolutely invaluable.² There is a plan for patients who are concerned that their Intrauterine systems and devices need replacing, or their sub-dermal implants are due for renewal, and we can ring and advise them accordingly with hot off the press guidance. The FSRH COVID-19 contraception contingency plan flow chart is indispensable whilst telephone triaging all the patients who need contraceptive advice and care.

So while prioritising what we must do in view of this pandemic, by following national guidance and to keep people safe we can also ensure that we can give the most appropriate advice and manage our work in primary care under these exceptional circumstances for people who are still worried about their everyday health needs.

References

1. Public Health England. Vaccine update. Issue 306. March 2020.

2. The Faculty of Sexual and Reproductive Healthcare. COVID-19 Resources and information for SRH Professionals. March 2020. Available at: www.fsrh.org/fsrh-and-covid-19-resources-and-information-for-srh/

THE PRACTICE NURSE MANAGER

JENNY GREENFIELD, PRACTICE NURSE MANAGER, PATCHAM, EAST SUSSEX

While discussing COVID-19 with my 86 year old mother, her comment was, ‘we survived the war, so we will survive this!’

The difference is, now we are not allowed to be less than 2 metres away from people, so no hugs or touching.

Yesterday I was back at my surgery, after having spent a weekend of messaging and emailing staff as to how we should be managing primary care. We are already stopping patients from coming through the surgery doors. Our GPs, paramedic and ANP/NPs are triaging, either from home, if they are self isolating or coming into the surgery to triage. Our reception staff are doing a sterling job of manning the phones, doing prescriptions for patients who think the world is going to end and much more sifting and sorting of patients. What is it with patients, that despite the fact we have big signs on the surgery doors, telling patients to go away and phone in, the still want to insist on talking to one of the reception staff, who are at the reception desk, with gloves, aprons and masks on – is this not enough of a deterrent to make patients realise they need to go away?

At the time of writing, we have now set up video consultations. Every day we are having a surgery huddle to discuss new implementations, which are slow to come down from CCGs and Government and continually seem to change with new and different guidance. We have set up a COVID-19 leads WhatsApp group so are sharing latest information and ideas here also.

The nursing team have cleaned and cleared two rooms to use as isolation rooms. Getting hold of PPE equipment has been difficult and what we were originally sent was not fit for purpose. Hand sanitiser is at a premium and we are in desperate need of hand cream with all the hand washing being undertaken! We are now setting up clinics in the morning to see our Childhood immunisations, B12, necessary injections, cervical screens and dressings. We have agreed that in the morning we can bring patients down to the surgery who are ‘not at risk’, under 70 years and who wish to come in to our clinics. Obviously we are taking precautions of hand washing, wearing gloves and aprons and if necessary face masks.

We have already identified our frail/vulnerable and immunosuppressed and are visiting these patients at home for INR, blood tests and dressings.

We have arranged for the afternoon to be free from clinics, so that if the clinicians who are triaging, need to bring anybody down the surgery then, if necessary they can be put into an isolation room, so that we can after use clean the room, to stop any spread of infection.

However, in the light of all the doom and gloom, we try and keep cheerful by sending each other messages on the nurses’ WhatsApp group of comical scenarios. The whole atmosphere in the building has changed from one of happiness and just about coping with our workload, to overnight, a feeling of scariness and not knowing or understanding where we will be this time next week.

We are all on the front line, but we are still a team and are trying our hardest to work together. The majority of patients are very grateful and fully understand, but there always has to be a few who will always rock the boat!

From a knackered practice nurse manager

PS. COVID-19 could make primary care work very differently and possibly for the better. More video consultations and telephone triage to stop the pressure of face to face. If it’s working now we should continue with this way of working

THE NURSE PRACTITIONER

LIZ BRYANT, NURSE PRACTITIONER, GATESHEAD, TYNE AND WEAR

Our practice – with over 16,000 patients – is trying to maintain contact with patients online and by telephone. All booked appointments have been changed to telephone appointments, and patients can only book new appointments on the day. Every patient is triaged for symptoms of, or contact with, COVID-19 on the phone before the core consultation; some patients are subsequently invited in to see the nurse practitioner, GP or practice nurse and their temperature is taken when they come into reception. They can only get into the building by ringing the doorbell. This is clearly for the protection of patients and staff but, because the response has had to be rapid, some of the detail has not been thought through, and the notices might be seen as forbidding rather than supportive. There is information on how to get advice and assistance, but it is rather submerged by warning signs. 

There is washing hands, gel, cleaning between patients, and a ‘quarantine’ area for suspected cases.

We are actively seeking out those patients who need particular help. The nursing team and the link workers are telephoning patients one by one, starting at the eldest (anyone over 90), finding out their support network, their worries, and anything we as a practice can do, such as improving their access to medication, or linking them to the local voluntary projects.

We have decided to continue with long term condition reviews. People are invited in for the necessary data gathering – BP, blood tests and so on – but we have postponed spirometry for the moment. When the results are back, the key information is sent to the patient (as part of the Care and Support planning that we have in place already – see Practice Nurse, March 2020;50(3):20-24) and the review is then conducted over the telephone, with both parties having access to the data. There are problems with this situation; it is not always easy to tell how someone is coping with their asthma or heart failure over the phone, and it is nigh on impossible if they are hard of hearing. For patients with hearing problems, the isolation is – of course – far worse then anyway.

Repeat pill reviews are done online, with the patients supplying their data. Clearly people are still attending for immunisations, Zoladex injections, dressings and suture removal for example, but booking in is more complex and done on the day.

Sometimes the changes are so quick that communication is muddled, and there is confusion. Local pharmacies are very stressed, and so are patients who do not yet order their repeat prescriptions online, because we are no longer accepting paper requests or telephone requests. We are short of staff because people are self- isolating, but we are trying to keep spirits up with flowers, cake, and gratitude. There is significant misinformation in the environment, and one of our jobs is to ensure that the well-validated facts are understood.

THE NURSE ADVISOR

ANN GREGORY, CLINICAL NURSE ADVISOR, NHS X

In March I attended the CNO summit in Birmingham. The onset of COVID-19 rewrote much of the agenda. The impact of this unknown disease on the population and the ability of our NHS to cope was frightening to hear. Incredible to believe the nearby Birmingham NEC is currently being fitted out to be a hospital to care for those affected.

My role as a Clinical Nurse Advisor at NHSX is to help implement the digital elements of the long term plan, particularly around primary care. Within my team, Helen Crowther and Jennie Smith, I have attended conferences and meetings both locally and nationally to spread the word about the benefits of digital technology, for our profession and our patients.

Leaning and sharing expertise in video and group consultations, promoting use of the NHS app, as well as encouraging staff to enable their patients to order prescriptions, book appointments and view their medical record, all online. The interest is there, but among staff, degrees of enthusiasm and suspicion are variable!

We also set up the free to join Digital Nurse Network, up and running for over 12 months now, offering a monthly live webinar on topics related to the digital transformation programme. With over 500 members, our community has grown.

The COVID-19 pandemic has ensured the digital transformation programme has to happen now. Practices around the country are realising the need to get patients and practices online, but the process is often frustrating and complex.

I have returned to my practice at Page Hall Medical Centre, Sheffield, to support this as well as offering my clinical experience.

Page hall is a busy inner city practice that cares for 8,000 patients. Approximately 40% of consultations require an interpreter. Digital transformation has not been a priority before now, mainly due to a large cut in funding during the equalisation process in Sheffield, staff shortages and the patient demographic.

Over the last 10 days I have witnessed the difficulties and frustrations of clinicians and admin staff trying to work with old technology, systems that don’t link together, and the plethora of new IT companies involved, adding to the complete confusion in general practice.

All the time those same staff are frantically preparing for the medical emergency that is the COVID pandemic. Sheffield University Medical Society has set up a volunteer student group, three fantastic students have been recruited and are assisting the practice in this planning.

The practice has whole staff meetings daily for those in practice and those at home, currently six clinicians, who are self-isolating either with symptoms or in contact of those with symptoms, as currently no testing available. These meetings are essential to keep in touch, keep motivated and share the daily changes in practice.

Each time approximately 15-20 minutes of time is wasted in trying to enable a conference /remote meeting facility. In the last few days we have tried Facetime, Google Hangouts and Zoom. Systems failed due to technology, such as no mic or camera on the computer. Great that I am here to sort this out, but I am well aware that over 8,000 practices in England are probably having to cope with these challenges.

Staff remain stoic and keep trying. My colleague Blerta Ilazi, an advanced nurse practitioner, today described the benefits of her first ever video consultation with a small child and his mother using accuRx, and highly recommended using this system, but she is also cautious as two elderly patients who would have benefited from video consultation informed her that they are unable to use the technology over the phone.

Obviously, this is an extraordinary situation, new ground for us all, and in my view once this pandemic is over digital technology will be here to stay and the NHS will have transformed as per the long term plan.

Thanks to digital, some meetings have been able to remain in my diary. My planned teaching session for 3rd year student nurses in Sheffield went ahead. I was at Page Hall and was able to deliver a 1 hour session on the digital transformation programme to a cohort of nurses from across Sheffield, via Google Hangouts – although I needed to connect to my 4G network on my mobile as the practice WIFI signal was too weak. Again, an example of the technology not being fit for purpose.

Our digital nurse network launched on the future hub platform last week and is updated daily with detail on COVID-19 and other content related to the digital transformation programme. It’s is a free network open to any member of the nursing, midwifery, and social care professions. As all of us have had our instructions to work from home, our work has been able to continue. We had our monthly webinar last week, I was in Sheffield, Helen in county Durham, Jennie in Stroud. Members tuned in from all over the country to join and contribute.

In this year of the Nurse and Midwife, I believe will be more than ever our roles, expertise and dedication will be understood more now than at any other time.

So surely this is also the moment to plan for the terms and conditions of the GPN to be finally resolved. At a time of national crisis, when GPNs are working under immense pressure, it feels abhorrent to continue to hear of nurses being refused sick pay by their GP employers.

General practice nurses are a branch of the profession where nurses can and do make a real difference to their patients' lives. Their terms and conditions should reflect their contribution, proficiency and dedication to their career and the patients they care for.

THE NEWLY QUALIFIED NURSE

CLAIRE CARMICHAEL, RN, BSc(Hons), GPN, PORTSMOUTH

As a newly qualified nurse (NQN) I was excited to be going into my dream job as a GP nurse. My year 2020 started amazingly and I couldn’t of been happier – and I’m still happy, don’t worry! However, it’s now turned into a time of uncertainty. That’s not just for me, I think I can safely say I speak for the whole nation of healthcare professionals and ‘keyworkers’ right now out there. We are all risking our own lives and our families’ lives (or health) to care for others.

Now, I am a GPN in the middle of this pandemic. We have cut our clinics right down and only seeing a list of ‘urgent’ appointments only, which may differ from those working in the acute sector. Our urgent list includes things such as wound management, leg ulcers, compression bandaging (as patients are at risk of infection and sepsis), then we have our baby immunisations, urgent ‘at risk’ smears tests, ECG’s for chest pain, blood tests for medication monitoring. All other services have been moved to telephone and video consultations where possible and only seen if absolutely needed in clinic to reduce the risk of spreading COVID-19.

I was due to go on my fundamentals of Primary Care course in May, which has now been put on hold until September. My clinics have reduced massively – I only have around 3 patients a day now in a 10-hour shift.

But the good news is that I have more time to see each person and make sure they are OK and have the right support during this tough time. There’s plenty of time for me to stock up all the rooms and do a thorough clean down as well. I am now ringing patients and making sure they are alright, that they have enough support and giving out telephones numbers of helplines if needed. We are all being reduced greatly at the minute, as managers want us well rested and well, ready for when this virus peaks because that’s when we will be called to help much more, for example on the home visits will be put into place for those patients who can’t get into hospital.

We need to be the ones helping those patients at that time. I’ve seen many comments from ward nurses on social media recently asking ‘why can’t you get the community and GP nurses in to the wards?’ But then who would look after the patients who can’t get in to hospital? Those patients who have been told ‘sorry we are prioritising someone else over you right now as they have more chance of survival’ – sorry that is so blunt but that is exactly what is happening – there needs to be A LOT of nurses out in the community for those patients too and this is what my role will eventually involve.

One of my friends said recently, ‘Covid Compassion is needed the most right now, not just your clinical nursing skills’ and they were right.

There needs to be far more kindness and compassion at times like these and I’m glad to be doing my bit for our patients right now. It is so lovely to see people coming together right now out there. I have seen people take to social media and share their stories of how they have been helped by someone or they have helped their neighbours out.

I have witnessed the kindness of shops, supermarkets and companies giving freebies to healthcare staff across the country. Thursday 26 March at 8pm was the first time everyone stood outside their doors or hung outside their windows to give a huge round of applause to healthcare workers. I didn’t expect my street to be doing this, but I went to have a look and was so shocked to see everyone clapping, cheering, car horns beeping, boat horns going off and even a firework set off! It was amazing!

I can’t explain the feeling this brought, not only to me but I imagine everyone out there right now doing their bit to help in this crisis and I imagine it was a lovely morale booster for many people out there struggling right now.

It’s times like this when communities really come together and share their kindness for one another, it’s beautiful to see. My clap and cheer didn’t go out to just healthcare staff but to those we don’t hear so much about in the news – police, firefighters, military, supermarket and shop workers, transport staff, carers, support workers, and many, many, more. To everyone out there, whatever your role in this – thank you! Keep being amazing, keep going – you’ve got this!

THE STUDENT NURSE

KATIE DIXON, STUDENT NURSE, BIRMINGHAM

A nursing student from Birmingham City University has set up a volunteering group to help vulnerable members of her south Birmingham community during the COVID-19 outbreak.

Katie Dixon, who is studying adult nursing at Birmingham City University, has since recruited nearly 1,000 people to help in the Kings Heath community, with another 250 kind hearted residents awaiting approval to join the ranks.

This comes as the government called for 250,000 volunteers to support people who have been asked to shield themselves from the virus by staying at home for 12 weeks.

As a student nurse, Katie says she was inspired to help by a desire to help people in her community.

She started out by dropping flyers off to neighbours on her road offering to help with essentials like shopping, but soon discovered that others would like to offer their help and that more residents could benefit from it.

Katie said: ‘It’s my goal to work within the community when I qualify as a nurse, as this is where my heart is, both personally and professionally.

‘We have a real sense of community where I live, which is so lovely, especially at a time like this when so many are worried. This is what prompted the idea to start a volunteering group at our local neighbourhood watch group.

‘I mentioned that I had created a flyer to help the elderly and vulnerable on the road I live on. It quickly became apparent that others wanted to do the same, so it made sense to create a group specifically for this purpose. I knew that in order to be effective, it was going to require a lot of organisation and structure.

‘Organising and leading a mutual aid group of nearly 1,000 volunteers – with another 250 awaiting approval – has been a huge learning curve. But it’s also been an amazing opportunity to put my leadership skills into practise.

‘I never realised just how transferable they would be, particularly extending them to a context like this. I’m finding myself using skills including time-management, team-working and delegation. I’ve written mutual aid safeguarding and GDPR guidance for volunteers – with some help from the professionals, of course.

‘It’s been a whirlwind, but we are making a difference and that’s what it’s all about.

‘We’re still being inundated with offers of help and now the elderly and vulnerable in our local area are getting in touch for support. It’s been hard work, but to know we are making a difference, even if only at a local postcode level, is everything.

‘Everyone has pulled together to make this a remarkable safe network and I know over the coming weeks and months we will continue to do everything we can to support those in need during the uncertain times ahead.’