Reorganisation of primary care services during COVID-19 in the Western Cape, South Africa: Perspectives of primary care nurses

Background Primary care nurses play a pivotal role in the response to disasters and pandemics. The coronavirus diseases 2019 (COVID-19) pandemic required preventative, diagnostic, and curative measures for persons presenting with symptoms of COVID-19 by healthcare providers, whilst continuing other essential services. We aimed to investigate the reorganisation of primary care services during COVID-19 from the perspectives of primary care nurses in the Western Cape province of South Africa. Methods We administered an online survey with closed and open-ended questions to professional nurses enrolled for a Postgraduate Diploma in Primary Care Nursing at Stellenbosch University (2020) and alumni (2017–2019) working in the Western Cape. Eighty-three participants completed the questionnaire. Results The majority of the participants (74.4%) reported that they were reorganising services using a multitude of initiatives in response to the diverse infrastructure, logistics and services of the various healthcare facilities. Despite this, 48.2% of the participants expressed concerns, which mainly related to possible non-adherence of patients with chronic conditions, the lack of promotive and preventative services, challenges with facility infrastructure, and staff time devoted to triage and screening. More than half of the participants (57.8%) indicated that other services were affected by COVID-19, whilst 44.6% indicated that these services were worse than before. Conclusion Our findings suggest that the very necessary reorganisation of services that took place at the start of the COVID-19 pandemic in South Africa enabled effective management of patients infected with COVID-19. However, the reorganisation of services may have longer-term consequences for primary care services in terms of lack of care for patients with other conditions, as well as preventive and promotive care.


Introduction
and treatment of common conditions, provision of ongoing management of patients with chronic illness, and the provision of support to community health workers, in line with trends in many other countries. 8 Ideally, PC nurses should function within an effective PC team, 9 but challenges in alignment between the PHC strategy and human resources for health lead to a very uneven realisation of that goal across the country. 10,11 Furthermore, a disjuncture between the South African 'Ideal Clinic' and the Office of Health Standards Compliance's criteria, two separate national quality care initiatives, puts strain on the resources of the provinces and the frontline staff because of diffused accountability and their lack of involvement in decision-making. 6 Of relevance to the current context, PC nurses play a key role in the response to and management of infectious diseases, being the first point of entry into the healthcare system. 12 This has resulted in PC nurses being increasingly expected to work long hours, with suboptimal nurse-patient ratios, and to upskill on very short notice to manage new types of diseases. 13 The South African healthcare system is committed to the provision of various preventative and curative services, including chronic care. These important services had to continue, while PC staff managed additional workloads because of the COVID-19 pandemic. 14 The Western Cape Department of Health advised that healthcare services should be reorganised to ensure that healthcare facilities could attend to people in need of urgent attention. For PHC services, the recommendations for reorganisation included: postponement of non-urgent outpatient appointments; stable chronic patients issued with two months' supply of medication; reduced outreach support; and suspension of 'Chronic Club' activities. 15 However, research on how the recommendations were applied in various PHC settings has not yet been published.
COVID-19 related reorganisation strategies include screening of the patients on arrival at a clinic. Patients are provided with a facemask and taught cough etiquette, whilst surface decontamination and hand hygiene are promoted. Suspected cases of COVID-19 should be rapidly triaged and placed in a separate waiting room, ideally in a well-ventilated space. 15,16 However, PHC facilities are often overcrowded with limited space. Given the critical role of PC nurses in this context, there is also an urgent and clear need for strategies to protect, support and manage exposed and infected healthcare workers. 17,18 In addition to the reorganisation of the clinical health services, COVID-19 also demanded strategies to reorganise management and leadership. Nurse leaders have commented on three missing aspects noticed in nursing leadership during the COVID-19 pandemic, namely the non-visibility of nurse leaders, a lack of collaboration amongst nurse leadership, and a failure to advocate for person-centred decision-making. 19 The COVID-19 pandemic necessitated the development of innovative strategies on how to prevent and manage this new illness and continue with essential PC health services, especially in low resource settings where many people depend on public health services for treatment and care. In this testing and strenuous environment, a lack of leadership may negatively influence work performance, with ultimate poor mental health and increased anxiety about COVID-19-related issues. 20 Reorganisation is therefore necessary to support staff as well as patients, and to ensure that the quality of services are maintained or improved, instead of being neglected.
It is unclear how the COVID-19 pandemic affected PC services in the Western Cape and what reorganisation strategies were employed. The aim of this study was thus to investigate the reorganisation of PC services in the Western Cape from the perspectives of PC nurses, to make contextappropriate recommendations for improving such processes during pandemics or other public health disasters.

Design
An exploratory-descriptive quantitative study was undertaken. The online survey was sent to Stellenbosch University's Postgraduate Diploma in Primary Care Nursing students and alumni. This postgraduate diploma in Primary Care Nursing prepares nurses to assess, diagnose and manage a range of conditions in PHC settings. Admission criteria for a postgraduate diploma include at least two years of experience as a professional nurse. Students from various geographical locations in the Western Cape attend training at Stellenbosch University. The researchers had access to the contact details of these students and alumni, and they were therefore the accessible population for a rapid assessment at the time of the study which was conducted during the peak of the first wave of COVID-19 pandemic.

Setting
The Western Cape province of South Africa is one of nine provinces and has a population of about 6.6 million people of which 64% reside in the City of Cape Town urban district. Three quarters (75.2%) of people in the province utilise PHC services. 21 During 2019/2020, the Western Cape Department of Health reported 14.3 million PC encounters. 21 The Western Cape has the highest life expectancy (68 years vs. 64 years on average for South Africa) and lowest maternal mortality rate (68.3 per 100 000 live births vs an average of 119 per 100 000 live births in South Africa) in the country. 21 The three core services of the PHC platform in the Western Cape include: community-based care (via non-profit organisations and community health workers), PC (in 266 fixed and non-fixed facilities) and intermediate care. Primary care is driven by PC nurses and includes a range of services, including child and adult curative services, preventative services, women's health, mental health, human immunodeficiency virus (HIV), tuberculosis (TB), and chronic disease management. 21 The Postgraduate Diploma in Primary Care Nursing students and alumni that was the target population for this study also provide these services.
Primary care nurses include professional nurses with undergraduate diplomas and degrees working in PHC settings as well as those who have completed an additional Postgraduate Diploma in Primary Care Nursing (Clinical Nurse Practitioners) that enables them to assess, diagnose, prescribe treatment for, and manage persons according to the PC guidelines. 21

Instrument
We developed a questionnaire based on the Impact of COVID-19 on the Nursing and Midwifery Workforce study (ICON) questions 22 and other relevant literature. The questionnaire was based on the structures and processes needed for preparedness for COVID-19 and included: demographic information, COVID-19 training and attitudes, access to guidelines, facilities and equipment, services reorganisation, information, and training needs and personal or self-care needs. The questionnaire was reviewed by four external experts, including two nursing health services managers, one academic involved in the COVID-19 response in the Western Cape, and one expert working for a nongovernmental organisation involved in community education and testing in relation to COVID-19. The experts suggested some changes to a few questions, as well as some additional questions, but were overall happy with the content of the questionnaire. The final questionnaire comprised of 48 questions, both closed-and open-ended. Open-ended questions allowed for participants to provide explanations or comments regarding their context that may have not been captured by closed-ended questions. For this article, we focused on the questions related to services reorganisation.
Validity was ensured by developing the questionnaire from the literature and subjecting it to expert review. Reliability analysis could only be performed on the questions that measured similar concepts on a Likert-type scale. These questions related to confidence and preparedness (Cronbach alpha 0.7) and personal and self-care needs, specifically worry and anxiety (Cronbach alpha 0.75).

Population and sample selection
Professional nurses enrolled for the Postgraduate Diploma in Primary Care Nursing (year 2020) and alumni from the years 2017-2019 were included (n = 251). We excluded nurses who were not working in PHC practice at the time of the study or who did not have working emails (n = 37). The total number of eligible participants was 214. We included the total population in the sample to account for non-responders. A minimum sample size 136 was needed for representativeness. 23

Pilot survey
A pilot survey was conducted to assess whether the questions were clear for participants and if they could easily follow the electronic link and complete the online questionnaire. We selected 20 students from the 2016 cohort of which 12 completed the questionnaire. We made a few adjustments to some questions and did not include the pilot data in the main study.

Data collection
An email was sent to participants with a link to complete the questionnaire. Reminders were sent to participants who did not complete the questionnaire. Participants completed the questionnaires during the peak of the first wave of the pandemic, between 30 June 2020 and 01 September 2020. We sent a total of five reminders. Most participants completed the questionnaire in July, with few responses received thereafter. There was therefore only one wave of responses. We did not perform non-response analysis as we did not have access to the demographic details of the participants who did not respond.

Data analysis
Data were analysed descriptively and summarised in frequency tables. Comparisons between participant responses and whether they were working in an urban or rural area were made using cross-tabulations and the Chi-square or Fisher's exact statistics. Content analysis 24 was used to analyse the open-ended questions and the frequencies of themes identified. The process involved at least two of the authors reading the responses, dividing the text into meaning units and formulating codes. The codes were then grouped into categories and overarching themes. Once all the responses were coded and linked to a theme, the frequencies of the themes for each response were calculated. Verbatim quotes were added to support each theme. All the authors reviewed the themes and quotes for meaningfulness and credibility. Quotes were labelled as follows: female or male (F/M), age and rural or urban district (R/U).

Ethical considerations
We obtained ethical approval from the Health Research Ethics Committee at Stellenbosch University (N20/04/015_ COVID-19) on 15 March 2020. Institutional approval from Stellenbosch University was provided to access the email addresses of students and alumni after signing an agreement outlining the Protection of Personal Information Act 4 of 2013 requirements. Participants could read the online information leaflet and voluntarily decide to participate. Responses were anonymous and not linked to participants' information.

Participants
Eighty-three participants completed questionnaires, a response rate of 38.8%. The mean age of participants was 37.8 years (range 27-55 years) and the mean number of years of working in PHC was 5

Figure 1 indicates the health districts in the Western
Cape where the participants were working.

Reorganisation strategies
A substantial majority of participants reported that they were reorganising services (n = 61; 74.4%), with half expressing concern about the reorganisation (n = 40; 48.2%). The most common service reorganisation strategy, based on the options provided in the survey, was issuing multiple months of supply of medication for those with chronic illnesses (n = 44, 53.0%), followed by postponement of non-urgent appointments (n = 37; 44.6%), and reduction of outreach support (30; 36.1%) (see Table 1). A minority of the participants (n = 24; 28.9%) indicated that they were continuing to provide non-COVID-19 acute care. Other initiatives being undertaken as reported by participants. Nine participants (10.8%) reported other initiatives. These initiatives included: (1) Chronic medication related such as electronic scripting before appointments, telephonic scripts, medication dispensing outside facilities, teaming up with an non-government organisations to do home deliveries of medications; (2) Patient appointments/flow improvements such as drawing patient files that allowed patients to leave earlier, telephonic consultations with healthcare providers prior to visiting the facilities, facilities divided to see sick  Some concerning strategies were also mentioned, which included minimising HIV testing services and stopping monthly weighing of babies.
There was a significant difference between the number of persons under investigations (PUIs) that participants in this study had direct contact with in rural versus urban areas, with participants in urban areas indicating higher numbers (Fishers Exact, p = 0.037) (see Table 1). No other variables related to services reorganisation showed significant differences between urban and rural areas.  'We are trying to give the message that those with co-morbidities to stay home and come to clinic when it is really necessary.' (Female, 29 years old, rural) The service restructuring was dependent on the facility. Table 3 indicates the services and procedures at primary and secondary levels of care that were stopped during the first wave of the pandemic.

Consequences of and concerns related to service restructuring
In the open-ended questions, participants were asked about their concerns related to the reorganisation of services. Table 4 depicts the most common themes related to these concerns. The greatest concerns were related to possible nonadherence of patients with chronic conditions, challenges In response to service restructuring, patients experienced emotional distress. They were also afraid that they will not be helped, and this resulted in them being dishonest during the screening process: 'We have a dedicated COVID [coronavirus disease] screening site and a COVID ward for stable COVID positive patients. However, this has greatly impacted the stable and unstable chronic patients and they are being given long term follow up dates. Thus, has caused some patients emotional stress.' (Female, 51 years old, urban) 'Screening not reliable as clients lie about being contacts because of the stigma and they are afraid that they will not be helped if they tell the truth that they were contacts of positive cases.' (Female, 29 years old, urban) The changes made during the pandemic affected the staff in many ways. Staff experienced burnout as a result of heavy workloads and a shortage of staff. Some facilities had to close temporarily because of all of the staff testing positive for COVID-19. Some participants felt that their working conditions were not safe and experienced increased levels of stress and anxiety:  The restructuring in some instances influenced the quality of care rendered. While some patients experienced longer waiting times, others were fast tracked to minimise the risk to staff. At times, the lack of equipment and PPE compromised the care provided: 'Triaging of patients is not done well, because patients will pass the gate to come into the clinic with no possible signs of COVID

Redeployment
Healthcare workers who may be at high-risk should be identified and provided with the option for redeployment. In our sample, no risk score was calculated for 19 participants (23.2%). Of those who had a high-risk score, 22 participants (26.8%) were not provided with the option of redeployment (see Table 5).

Influence on the other healthcare services and quality of healthcare
The majority of the participants (n = 48; 57.8%) indicated that other services were affected by COVID-19, whilst more than half (n 51; 61.4%) reported that there were fewer patients at the facility. Almost half of the participants (n = 37; 44.6%) indicated that the services were worse than before for other patients (Table 6).
Suggestions provided by the participants on how to improve the circumstances created by the pandemic and the restructuring are depicted in Table 7.

Discussion
In alignment with what is happening internationally, healthcare workers and PC nurses demonstrated resilience to adapt and manage COVID-19 whilst continuing essential services. 25,26 The required reorganisation of services mandated provincially was differentially applied at a local level, and this came at a cost to both patients and PC nurses. A study from Australia 27 reported that PC reorganisation efforts for COVID-19 resulted in fewer face-to-face consultations but an increase in additional tasks incorporated in the nursing role. Furthermore, a similarity was seen with the increase in work hours as reported by 8.4% of the participants and fewer breaks by 20.5% in this study.
Although almost half of the sample (43.9%) had seen 'too many COVID-19 patients to count' the majority reported seeing fewer patients at the facility, which could be related to the necessary reorganisation of services. While reorganisation allows for effective triaging, and keeping vulnerable patients out of harm's way, the effects on patients, and other people needing care, is not known. Despite participants' concern for the way that services were reorganised, individual creativity to provide care to those in need of it was described. Nyasulu and Pandya 14 raised concerns about the impact of the pandemic on HIV care, the Expanded Programme on Immunization (EPI) and other essential services in the South African healthcare system. Blanchett et al. 18 mentioned that a decline in essential services across lower-and middle-income countries may reverse health gains. Nyasulu and Pandya 14 offered the building blocks of the World Health Organization's (WHO) Two major issues mentioned by PC nurses were poor infrastructure in which to provide care and the difficulty to perform screening and triaging because of staff shortages. While the intention was for reorganisation to allow two streams of patients (PUIs versus those thought not to be affected by  in order to still provide essential services, 28 in practice this was often suboptimal. Good communication and visible frontline support by managers and supervisors are needed. 29 Butts and Rich 30 mentioned that it is the responsibility of ethical leaders and governments to maximise preparedness in order to minimise the need to make allocation decisions later during a pandemic. Investment in robust public health infrastructures and health equity are the best preparation for dealing with a health disaster, such as a pandemic. 30 Leaders therefore need to be organised, creative and adequate in their leading, and influence their employees as followers, as well as the public, to be involved with improving people's health.  In response to addressing their own needs for safety and self-care, with a proportion of the participants having to perform risk-scoring themselves, some not checked at all, and for a number of participants not being given the choice to be redeployed was a concern. Clear strategies are needed to support and manage exposed and infected healthcare workers to ensure effective staff management and to foster trusting relationships in the workplace. 17 Chersich et al. 29 mentioned the importance of prioritising support for healthcare workers, suggesting 10 key interventions based on the literature that can make a difference in securing the health and mental well-being of frontline healthcare workers in the COVID-19 response in Africa. It is therefore important that the health and mental well-being of frontline workers form an integral part of reorganisation strategies amidst a pandemic.

Strengths and limitations
Targeting only the Postgraduate Diploma in Primary Care Nursing students and alumni, the low response rate and possible response bias limits the generalisability of the findings. The demographic profile of the participants reflects the vast age profile of healthcare workers in the province (85% of healthcare workers in the Western Cape province are between the ages of 25 years and 55 years). 21 Further, there were no differences across subgroups and the results were in accord with our own experiences and anecdotal reports, which suggest validity and credibility. In addition, qualitative data provided by participants and the similarities between our study findings and what was found in other settings enhances the credibility of the results.

Conclusion
Primary care services are pivotal in the pandemic response. Our findings suggest that the very necessary reorganisation of services that took place at the start of the COVID-19 pandemic in South Africa enabled effective management of persons infected with COVID-19. However, the reorganisation of services may have longer-term consequences for PC services in terms of lack of care for patients with other conditions, as well as preventive and promotive care, that will only be seen in time. It is encouraging that the PC nurses are aware of this issue and will thus hopefully act to address it going forward, but it is possible that the damage has been done and cannot be reversed. Similarly, the resilience and goodwill that seem to exist, need to be strengthened and harnessed going forward, which requires implementation of some of the interventions we have described, both in terms of human resource management and system restructuring. The study highlights leadership, management, staff support, infrastructural and equipment deficits in PHC settings that should be addressed to realise the vision of universal health coverage.