Disruption caused by the COVID-19 pandemic response from a Western Australian metropolitan general practice perspective: a qualitative descriptive study

Keywords: COVID-19 disruption, COVID-19 pandemic, general practice, general practitioner, practice manager, practice nurse, primary care, qualitative descriptive study.

The unique presentation of the recent novel coronavirus disease 2019 (COVID-19) in terms of contagion, novelty of associated clinical manifestations and ability to mutate rapidly within a short space of time has created challenges for health systems around the world (World Health Organisation 2022). Impact has been both direct and indirect, including that on health services (Australian Institute for Health and Welfare 2021).

In Australia, general practice serves to provide the first point of contact for most patients’ health needs (Australian Government Department of Health 2021). General practice services are subsidised through the national health insurance scheme, Medicare (Australian Government Department of Health 2022). Primary health care in Australia is delivered predominantly through general practice, with 85–90% of the national population seeing a GP at least once over a 12-month period; see reports 2017–22 (Royal Australian College of General Practice 2022). One strategy in the Australian Government response to dealing with the evolving COVID-19 pandemic was therefore to optimise services already offered, augmented with additional measures (e.g. telehealth consultations) that were also accessible through these general practice services (Desborough et al. 2020; Kidd 2020).

Through most of 2020 and 2021, Western Australia (WA) was uniquely placed in the Australian response to the COVID-19 pandemic by adopting a strict ‘COVID zero’ policy early and eliminating community transmission of the COVID-19 virus (Government of Western Australia Department of Health 2022). This resulted from various State Government measures to reduce the possibility of viral transmission, including strict border control, quarantine (McGowan 2020), sudden, brief and strict lockdowns (McGowan and Cook 2021a) and continual and vigilant infection control (McGowan et al. 2020; McGowan and Sanderson 2022a, 2022b). Combined with enviably high immunisation rates in the local community (Department of Health 2022) and the global development of treatments and better understanding of the disease over time, WA was able to brace for a ‘soft landing’ once COVID-19 finally infiltrated the community after border control measures were relaxed in early 2022 (McGowan and Cook 2021b).

Public health measures were crucial in achieving these goals in WA, with communication an important element. New measures were announced day-by-day as new information emerged (Desborough et al. 2020; Kidd 2020). Though general practice service delivery was much affected by the restrictions, sudden disruption to lives and enforced home isolation, the on-going health needs of the community needed to be served. Like that of many countries (Lim et al. 2021), general practice services in WA remained accessible to the community throughout, with modifications needing to be implemented quickly.

This study set out to explore how WA general practice responded to the disruption caused by the threat of COVID-19, the impact of the public health measures enforced to achieve the goal of ‘COVID zero’ and the role in preparing the community for the ‘soft landing’. The study objectives were to: (1) gain insights on how general practices prepared and adapted service provision to meet the disruption and challenges faced (including insights into preparedness and adaptability vaccination implementation and rollout); (2) explore how and where support and information was resourced and the usefulness of what was received; (3) identify communication strategies used between staff and with patients in regard to healthcare delivery; and (4) identify lessons learned from what was implemented.

We included the impact of the immunisation roll out as it added to the ‘disruption’ of service delivery.

A qualitative descriptive (QD) methodology using semi-structured interviews was employed. QD methodology allows the researcher to ‘stay closer to the surface of the data’ and to ‘describe’ events instead of applying their own interpretation to phenomena, as with other qualitative methodologies (Colorafi and Evans 2016). In keeping with this, the study objectives informed the context of the interview prompt questions (Table 1).

Table 1.  Interview prompt questions.

A purposive sampling approach was used to invite general practice teams (GPs, practice managers (PMs), practice nurses (PNs)), ensuring maximum participant experience and knowledge (Bryman 2012; Walter 2013).

Two strategies were used to recruit participants. The GP practice owner, clinical leads for multisite practices or PM from practices in our research and clinical networks were contacted via email and/or telephone by the researchers with information about the study and asked to disseminate the information to their practice staff. Fourteen practices were contacted by this method (13 metropolitan and one rural/remote). Information about the study was also disseminated through rural clinical network distribution lists independent of the study researchers. Interested participants within a practice self-selected to participate by contacting the researchers. Each participant provided verbal informed consent to participate and have the interview audio recorded prior to data collection.

Interviews were conducted from March to June 2021 in WA by two of the authors who are experienced in general practice research but are not GPs or involved in the delivery of general practice services. Interviews (45 min to 1 h in duration) were undertaken according to participant’s preference – face-to-face, online video conferencing or telephone either as a practice group or individually.

Audio recorded interviews were transcribed verbatim by a secure transcribing service provider and de-identified prior to analysis. QSR NVivo™ ver. 12 (QSR, Burlington, MA, USA) was used to manage coding and analysis of the data. The context of the interview prompt questions (Table 1) guided the preliminary analysis framework within which emerging themes were identified. Template thematic analysis (TTA) was employed using an initial skeleton deductive code frame, which was derived from the interview questions forming a priori codes followed by inductive coding process throughout the interviews (Brooks et al. 2015). This approach is acceptable when conducting TTA, as a priori codes are usually taken from interview or focus group questions as a way of initially organising the data (King 2012).

Consensus between three researchers was used as follows; one author (a qualitative researcher not involved in general practice service delivery) coded all interviews independently. The other two authors (a GP in practice and a non-clinician general practice researcher), also independently coded a selection of the transcripts. This ensured reliability and consistency in interpretation of the emergent themes.

The University of Notre Dame Human Research Ethics Committee granted approval (ID 2020-195F) for the research to be undertaken. All participants provided informed consent to participate and to have the interviews recorded.

Thirteen participant interviews from six metropolitan practices were undertaken. No rural practices responded to the invitation to participate. Teams (GP, PN and/or PM) from four practices and GP only (two practices) were interviewed. Practice and participant descriptors and interview formats are summarised in Table 2.

Table 2.  Details of participating practices and formats used for interviews.

The key themes that emerged from the analysis framework are explored in depth below, with additional quotes presented in Table 3.

Table 3.  Additional exemplar quotes.

The threat of COVID-19 presented practices with a unique set of challenges within a short space of time. Practices moved quickly to put precautionary measures in place. The sense of urgency and the degree of the ‘unknown’ in terms of the extent of the COVID-19 pandemic was a common theme among participants.

So, it was really stressful. We were trying to show clinical leadership, both myself and one of the GP clinical leads, along with the other two clinical leads and a head nurse, we were trying to set new protocols in place very quickly. (GP – Practice B)

For some, this entailed additional workload to reorganise the practice in order to meet the changing public health directives regarding physical distancing and reducing non-essential movement within the community. For example, considering the physical structure and workflow, such as preventing patients from entering directly by re-purposing carparks and practice front entrances for use as triaging sites.

So, at the lockdown, people were not allowed in the building until we had vetted them at the front, outside. They were made to clean their hands, put gloves on, have a mask, asked umpteen questions. (PN – Practice C)

In regard to vaccination roll out, once again, most practices rapidly adapted their ways of operation to meet the requirements and challenges. Practices were organised and managed the logistics of the process with relative ease and thoughtful planning. Larger multisite practices received guidance from their management, whereas smaller practices received support from other avenues.

Even with the documentation, I’ve got alerts on my phone where an email they [Health Department] send me just to say, you need to do the stock management at the end of this week. You need to order by the end of this week. So, yeah, we’re very happy on our side. (PN – Practice D)

Also, the Australian Practice Nurse Association that all the nurses here are members of, they actually run a Facebook page and so there’s nurses posting things on there about, ‘what is your practice doing about, for example, what are you saying to patients about the COVID vaccine today?’ And everyone’s giving their ideas. (PN – Practice A)

Managing staff anxiety was a key challenge in the early days for most participants. Some doctors and practice staff took stress leave during that period.

In the initial phases there was a lot of fear, and we didn’t know what to wear, and a lot of the information wasn’t very specific to general practice. It’s about managing fear to me, but you’ve got to make sure your staff feel that they’re being protected, and if PPE is what provides that comfort then just go for it. (PM – Practice A)

There were work–life impacts on the workforce, such as the stress of having to manage family commitments during their usual working day with schools and day-care being closed for some periods.

… we had doctors that wanted to work, who couldn’t work, because they had school-aged or kids … they were trying to home school their kids. So, it got really quite messy, sort of having provision of the roster. (GP – Practice B)

Frontline staff (PNs, reception and GPs) often had to deal with the frustrations of the patients themselves due to perceived inconvenience and anxiety about the change in practice mandated by the public health measures.

There’s so many patients that just abused the signs or verbally abused the staff for having the rules in place. And the patients would get really angry about it and saying, ‘I’m sick. I need help.’ (GP – Practice B)

Implementation of vaccination roll out at the individual practice level took its own toll on staff.

The pressure – pressure! And you end up with anxiety, you can’t sleep, because it’s a funny feeling. You feel so responsible to get these vaccines out…But the day it was released, that we were one of the clinics that was selected, the phone calls; we took something like 240 phone calls. (PM – Practice C)

Overall, preparedness was a shared responsibility among all practice staff.

This is not something that individual doctors can synchronise on, you need a whole practice team structure approach, and often it’s the reception staff and the nursing staff who keep things uniform throughout the practice. (GP – Practice A)

There was an overarching sense of teamwork and ‘working together’ to address the challenges in the early days of lockdown. Information sharing among colleagues and other practices was vital to managing workload, patient load and supporting staff.

But we’ve understood each other better and we’re working more as a team… think support each other …. We are – I think we’re a very good team. (GP, PN and PM – Practice E)

Team support from the practice was integral in addressing the personal toll of changes to service provision, disruptions and challenges. In addition, some practices utilised the Employee Assistance Program (EAP) provided through the WA Primary Health Alliance (WAPHA).

We just need to reassure our staff as well, because they actually overwork and a lot of us working also – work and a lot of stress, so we each had to stay calm at the same time. (PM – Practice D)

Participants also spoke of staff working together to implement the vaccination roll out during 2020 and 2021. Most practices perceived that they had handled the strategy well, although there were the inevitable challenges largely around patient flow, patient demand for information about the vaccine and management, as well as the delivery of doses during flu season.

So, it’s obviously challenging, we’re going to have the flu vaccine coming around about the same time and we have to make sure we’ve got it spaced. So, just managing patient flow safely and being able to observe people safely in the waiting room considering there’s an increased risk of anaphylaxis and side effects. So, it’s challenging. (PN – Practice A)

Some of the negative press that the vaccine has received has not been very helpful. But we try and talk to our patients. We counsel them, saying that it is safe. And, touch wood, so far, we have not had any issues apart from minor side effects that patients do. (GP – Practice E)

Personal protective equipment (PPE) was required to ensure that virus transmission did not occur; however, practices described practical issues in regard to availability and ‘knowing how much to order ahead’. Mask supplies were extremely limited in early 2020, although some practices did describe using previous stocks that had been sourced before the COVID-19 pandemic started.

Yeah, despite having the stockpiles we were still worried about PPE availability because if it was to be a big thing – we were saved by the fact that in WA we don’t see COVID patients, but if we were you could see that in reality our PPE could run out quite quickly. (GP – Practice A)

Overall, practices often sourced their supplies independently. Although smaller practices relied on the experience of their practice principals and personal contacts, larger practices were supported by their management teams.

It all just depends on what the situation is…… it’s all that kind of who you know type process. … I think it helped we were part of a larger network that puts a lot of effort into securing supplies, and if we ourselves had to go out and each individual practice and try and secure supplies, it was difficult. (GP – Practice C)

With the rapidly evolving situation of the COVID-19 pandemic, GPs needed to keep up-to-date with the nature of COVID-19, the public health rule changes and the recommendations from peak bodies regarding implementing public health measures in general practice. GPs relied heavily on reliable sources of information during this time. Avenues of information mentioned were: Department of Health WA (DOHWA) and the Royal Australian College of General Practitioners (RACGP) websites, DOHWA Health Pathways, Australian Medical Association (AMA), WA Primary Health Alliance (WAPHA) Practice Assist, Australian College of Rural and Remote Medicine (ACRRM), Australian Practice Nurse Association and interest groups on social media. Larger multisite practices received more directed guidance through their management.

So, she [management] was also sending excellent advice through… but because we were still the doctors on the ground … we had to adapt the advice suitable to our particular practice circumstances. (GP – Practice B)

Daily information sharing was a key strategy. Aside from the formal daily meetings, informal information sharing was widely used through social media conversations, within practices and through interest groups. Encouraging autonomy among PMs and PNs was important in assisting and reassuring staff that the response was being adequately managed.

We have a reception lead and a nursing lead, and they tend to be the governors that keep things consistent across the practice. I think it’s good to give these people their independence to run things to some extent… The nurses have been keeping up much more with the information, the public health measures than the doctors, and are best placed to institute measures. (GP – Practice A)

Communication with patients centred on two key aspects: reassurance and care for vulnerable patients, and clear guidelines around COVID-19 restrictions for all patients seeking care. Practices spoke of issues around dealing with misinformation among patients.

What they see on television is completely different to what they get in terms of email [from the

practice]. So, we were able to inform them, keep them up to date just to help decrease their anxiety, and not in a panic state as well. (GP – Practice D)

Telehealth service item numbers were initiated early in the COVID-19 pandemic by Medicare Australia following advocacy by peak GP bodies. GP practices and their patients were quick to take up telehealth services. As a result, practices described only a transient drop in income and patient services.

…quite quickly patients sort of got used to the idea of telehealth and telephone consults, and even if they wanted to stay away, they kind of embraced the contact that they have through that medium. (GP – Practice F)

Practices took responsibility for enabling telehealth consultations. Multisite practices received assistance from their management. Telephone consultations were important and most used in practices because of patient and doctor preferences. Video telehealth consultations, however, were also considered to have their merits.

Well, the management set it all up in the computers. They have our best practice team do all that. They’re very, very proactive, they love technology, this company. (PM – Practice C)

Some felt that although Government focus on reimbursement through Medicare was important, more could have been done to support the logistics of implementing telehealth.

There are these Medicare item numbers, but in terms of the logistics of developing it we had to quickly buy more speakers and headsets, microphones… (GP – Practice B)

So, at that time all the telehealth gear was sold out already and my IT can’t access any… (GP – Practice D)

Participants highlighted the adaptability of all staff in managing the practice during the disruption. Although acknowledged that in 2020–21, WA had relatively few lockdowns and cases, nonetheless preparedness was always to the fore for participants in this study. Most participants commented on how the practices that were initiated in the early days of the COVID-19 pandemic lockdown ensured a smoother and less stressful transition during subsequent ‘mini’ lockdowns over 2020 and 2021, which occurred sometimes within hours of notification of an isolated case of COVID-19 detected in the community.

Again, I think it was much smoother. I think because we’ve got policies and procedures in place from the early days. And it didn’t seem to have the same sort of impact as it did early on… patients have gotten used to, now, the idea of telehealth. (GP – Practice F)

The new normal, that’s right. We’re all getting used to it at the moment. (GP – Pratice A)

Participants reflected on some of the benefits of what was implemented in early COVID-19 days. Many wanted to see the retention of practices such as telehealth appointments.

I feel the telehealth item numbers definitely should stay. Even from just the sustainability thing. There are a lot of patients, particularly elderly, where it’s difficult to get to the doctors. And a lot of it you can do by telephone. (GP – Practice B)

Furthermore, participants acknowledged the transition of these processes to dealing with all patients with communicable respiratory illnesses.

I think masks for respiratory patients is something important going forward. … It’s much simpler and easier – now that masks have got more acceptability you can make respiratory precautions much more universal and matter of fact and standard. (GP – Practice A)

This study explored the views of general practice teams (GP, PN and PM) regarding their experiences of having to respond to changes implemented in WA in response to the public health emergency of the COVID-19 pandemic. The overall response of the community was unique in that a major health crisis (COVID-19) was avoided for much of 2020–21, with the achievement of ‘COVID Zero’.

Literature on community response to public health disasters describes the importance of health systems resilience, with adaptability, resistance and quick recovery from external disturbances seen as the key abilities required for resilience (Chen et al. 2020). Our participants exhibited these qualities in describing an overall ability to swiftly adapt and modify the delivery of health care, like their primary care counterparts in Australia and internationally (Krist et al. 2020; Ashley et al. 2021; Lim et al. 2021; Mughal et al. 2021; Ashley et al. 2022). Collectively through these practices, GPs were able to continue to provide healthcare services for all conditions, although initially there were some concerns regarding loss of income and financial security. Key features of this adaptability included: accessing and disseminating health information in regard to COVID-19 information and vaccine roll out from numerous sources within and between practices. Multisite practices were able to assimilate and disseminate information, and design and implement policy to a large number of practices. Those interviewed from these practices recognised that this helped to reduce their own stress and workload. Single site practices each had to take on this role themselves, in addition to procuring essential equipment. All practices demonstrated they were able to communicate what was required effectively. Teamwork was an important theme that emerged in ensuring this occurred.

Communication between practice staff members and leadership shown by GPs was also highlighted as crucial to allaying anxiety amongstaff, especially in the early stages of the COVID-19 pandemic. Similar themes of leadership and trust have emerged in previous studies in response to other pandemics (Shaw et al. 2006; Murton 2021). Communication between practice staff and patients showed clearly the unique position of trust between practices and their patients. GPs and PNs took time to communicate with patients in many matters, including changes to the practice aimed at protecting patients from COVID-19 such as triage, telehealth and infection control practices, and information regarding vaccinations; the latter likely an important facilitator in vaccination uptake success (Murton 2021).

Our current study reports mirrored the shortage in PPE availability noted in other studies during previous pandemics (Shaw et al. 2006; Tomizuka et al. 2013; Kunin et al. 2015) and internationally during COVID-19 (Haldane et al. 2020; Lau et al. 2021). Concerns regarding difficulty in accessing PPE and uncertainty about supply of PPE were identified as major stressors, with GPs unable to access PPE from the national stockpile in 2020 and limited opportunity for procurement in the private sector. However, despite the risks and in keeping with the primary care response to pandemics (Shaw et al. 2006; Haldane et al. 2021), GPs largely expressed the need to continue to provide care for patients throughout the lockdowns, particularly the vulnerable patients within their practice.

Some procedures and practices were perceived by practice staff as valuable and they desired for them to remain post pandemic. One such practice was telehealth (mainly telephone) consultations. Though like the international experience (Haldane et al. 2020), when telehealth was initially not an easy option for most practices given procurement problems, poor or no infrastructure support, and limited clinical experience using telehealth, practices were able to transition to this modality in delivering care and hoped that it would persist beyond the COVID-19 pandemic.

An important theme was the personal toll of the threat of the COVID-19 pandemic on staff at all levels. Staff anxiety and fear of exposure to risks have been reported previously (Ashley et al. 2021; Lau et al. 2021; Ashley et al. 2022), but in our study, staff also faced the frustrations of patients and the added stress of balancing work and family life, with family life also significantly affected by the COVID-19 pandemic.

In summary, our study showed that in preparing and adapting service provision in meeting the disruption, general practice staff at all levels responded rapidly amid uncertainty and workload challenges, with a personal toll. Self-reliance at practice and multisite management levels in the sourcing of support and information was important and relied on teamwork. In communicating between staff and with patients, inclusivity, autonomy and support were important elements, as was the need to respond to changes in general patient behaviour. Practices adapted to the use of telehealth for consultations.

In terms of lessons learned from what was implemented, it provided practices with preparedness for the future. In 2020–21, WA was in a unique position in that general practice prepared for a situation that was averted through effective public health measures. However, what was learnt will have helped general practice in WA adapt to the 2022 situation readily, as case numbers increased once restrictions were eased.

The sample number was low and participating practices were recruited via an email by the researcher, and participants self-selected to be interviewed. It is therefore possible that only those who had a particular view responded to the recruitment email. Different approaches (individual and group) to the interviews were also vulnerable to some bias, as in-group interview employees of the practice may have felt the need to provide an accepted response rather than their view. Sampling was conducted purposively from one single state (WA) in Australia;however, given the distinct experience of the COVID-19 pandemic in WA, where fewer COVID-19-positive cases were recorded compared to the rest of Australia, the sampling of one state enabled the researchers to describe the experiences of a relatively homogenous smaller group of practices. Views may not be representative of all GPs, PMs and PNs in other socio-economic or rural/regional areas. The authors acknowledge that there are differences in the impact on general practice to the COVID-19 pandemic in these areas (O’Sullivan et al. 2020). Malatzky et al. (2020) suggest the need for rural engagement to genuinely understand ‘place-sensitive’ issues. Given that there was no uptake from rural practices, we felt the rural response could not be adequately addressed. Patient perspectives were not included and this may be a topic to be explored in future studies.

In responding to a sudden and unexpected major disruption caused by the COVID-19 pandemic, those working in the general practice sector demonstrated self-reliance and teamwork. Adaptability to sudden change in practice, in order to meet ongoing health service provision, was also demonstrated on many levels; COVID-19-safe protocol implementation, transition to telehealth, vaccination roll out, assimilation and dissemination of rapidly updated information, and supporting staff and patient needs. Although the COVID-19 landscape has now changed with no isolation measures in place, a predominantly immunised population and effective treatments now available for COVID-19, the lessons learned and the planning that took place will help general practice in WA adapt easily to similar situations in the future more readily. Given that general practice serves to provide the first point of contact for most patients’ health needs, it is not an unlikely scenario.

Full interview data that support this study cannot be publicly shared.

The authors declare no conflicts of interest.

Research Incentive Scheme funding from the University of Notre Dame Australia supported study running costs.