Primary care nurses’ preparedness for COVID-19 in the Western Cape province, South Africa

Introduction The novel coronavirus 2019 or COVID-19 pandemic has brought about a global public health crisis. Primary care (PC) nurses render first line care, or refer for more specialised services. Aim To investigate the preparedness of PC nurses for COVID-19 in the Western Cape. Setting The Western Cape province of South Africa. Methods We administered an online survey, with closed and open-ended questions, to 83 Stellenbosch University postgraduate PC nursing students and alumni working in the Western Cape, between 03 July and 01 September 2020. Results The results indicated that 43.3% of participants were confident about the infection, prevention, and control (IPC) training they received and 56.7% felt prepared to provide direct care to suspected cases of COVID-19. Primary care nurses were more comfortable to triage (78.3%) than to manage persons with COVID-19 (42.2%), indicating that they may not be functioning to the full capacity of their education and training. Adequate infrastructure was reported by less than a third of the participants (30.1%) and 59.1% reported that personal protective equipment (PPE) was always available. Primary care nurses needed support in coping with stress (57.8%) although few (14.5%) reported access to mental health services. Conclusion Primary care nurses were not prepared optimally for the COVID-19 pandemic. Challenges included adequate training, infrastructure, the availability of personal protective equipment, COVID-19 testing of health care workers and management support. Primary care nurses need comprehensive support to manage stress and anxiety.


Introduction
The novel coronavirus (Severe Acute Respiratory Syndrome [SARS]-Cov-2) or coronavirus disease 2019 (COVID- 19) pandemic has brought about a global public health crisis. 1 Primary care (PC) is the first point of entry into the healthcare system for many people and it is here where PC workers play a pivotal role in the response to and management of infectious diseases to ensure early identification and prevent the spread thereof. Primary care nurses are the leading frontline healthcare providers in community settings and are central to ensuring universal health access and achieving the sustainable developmental goals. 2 The South African healthcare system offers a range of preventative and curative services at PC level, including chronic care to address the quadruple burden of disease. 3 Not only have PC workers continued to provide these services during the pandemic, they have also needed to conduct COVID-19 screening and testing. Managing these additional workloads because of an increased number of people accessing the services and managing their own infection risk may be very stressful. 1,4 To minimise the spread of COVID-19, routine droplet and contact precautions, environmental hygiene and overall infection prevention and control precautions are needed. Recommendations on workplace preparedness state that healthcare workers who are exposed to possible or known COVID-19 cases are classified as having a high exposure risk. 5 Healthcare workers must assess their own risk, self-monitor and report if they experience symptoms. Those with unacceptably high risk because of other conditions should be redeployed. Strict adherence to guidelines and precautions is central to the protection of healthcare workers. 1 In April 2020, the Infectious Diseases Society of South Africa published a COVID-19 Primary Care Preparedness Guide. 6 The guide specifies the requisite equipment and consumables, required training, triage, management and referral procedures needed for the COVID-19 response. 6 Despite these guidelines, PC workers may not have access to the required facilities, equipment, consumables and training. Even internationally in high-income countries, there is limited availability of personal protective equipment (PPE) and respiratory isolation rooms to adequately evaluate patients. 1 To ensure nurses' protection during the COVID-19 pandemic, the following is advised: intense education and training; reasonable shift schedules; making full use of existing infection, prevention and control (IPC) systems; providing psychological counselling; and avoiding unnecessary contact. 7 It is likely that nursing curricula do not cover pandemic preparedness adequately, as this pandemic is the first experienced on such a scale, the previous ones (e.g. Middle East Respiratory Syndrome [MERS] and SARS) not reaching such global proportions. Although general disaster management is addressed in all postgraduate diploma in nursing programmes at Stellenbosch University, existing general guidelines, and those discussed in curricula for the safety of healthcare workers during a pandemic, are not comprehensive and precise. 4 Nurses thus need to attend additional training to provide COVID-19 services. There is still a lack of definitive evidence supporting which knowledge and skills are required to ensure that nurses perform competently during pandemics. 8 The competencies may also be different depending on the setting and the services provided.
Research on the experiences of frontline healthcare workers, such as PC nurses, in the early phases of a pandemic is crucial to inform strategies to ensure better support and future planning. For example, during the early phases of the 2009 H1N1 pandemic, a quantitative study in England found that some healthcare workers had negative attitudes towards taking antivirals and receiving influenza vaccinations. 9 The same study also found that the main source of information about infection control and risk was local guidance. In addition to work stressors, healthcare workers may be concerned about the risk of infecting family members, necessitating measures to prevent transmission when arriving at home or for selfquarantine when they are persons under investigation (PUI). 1,9 Other concerns include childcare responsibilities and dependents requiring their care and support. 10 It is therefore important to determine the COVID-19 workplacebased preparedness as well as psychological preparedness of PC workers.
The impact of COVID-19 on the Nursing and Midwifery workforce study (ICON) in the United Kingdom found that of 2600 nurses who responded, 92% were worried about risks to family members and 74% felt their own health was at risk. 11 More than half (52%) of the participants did not have sufficient confidence or training about COVID-19 infection and onethird (33%) reported severe or extremely severe anxiety, depression or stress. Almost two-thirds of participants (62%) had inadequate or no redeployment training. 11 These findings indicate a need for context-specific research to investigate the preparedness of PC nurses for COVID-19.
The aim of this study was to investigate the preparedness of PC nurses for COVID-19 in the Western Cape province, South Africa.

Methodology Design
A quantitative descriptive research design was used. We conducted an online survey using RedCap that was sent to Stellenbosch University's postgraduate diploma in PC nursing students and alumni.

Setting
The Department of Nursing and Midwifery at Stellenbosch University is responsible for the postgraduate training of PC nurses. The students come from various urban and rural districts in the Western Cape. These students and alumni were the most accessible population to perform a rapid assessment of the current situation.

Instrument
The questionnaire was developed by the research team and was based on the literature, 'The impact of COVID-19 on the nursing and midwifery workforce study (ICON)', questions for this specific category of healthcare worker 11 and the team's own experience. The questionnaire consisted of 48 questions, both closed-and open-ended, in seven sections. Section A consisted of demographic information such as age, sex, qualification, position and district where working. Section B required information about COVID-19 training and attitudes. Section C required information about access to guidelines. Section D related to facilities and equipment. Section E enquired about services reorganisation. Section F consisted of information and training needs. Section G enquired about personal and self-care needs. Open-ended questions allowed the participants to explain their answers to certain responses and provided an opportunity to elicit complementary information. For the purpose of this article, we focused on the sections related to the preparedness of PC nurses. The questionnaire is available on request from the authors.
Four experts, including health service managers and academics involved in planning for the COVID-19 pandemic in the Western Cape, reviewed the questionnaire to establish face validity and assessed the alignment between the research objectives and the questions. Reliability analysis of the two Likert-scale questions related to confidence in training and preparedness indicated a Cronbach's alpha of 0.7. The three Likert-scale questions related to stress and worry about COVID-19 had a Cronbach's alpha of 0.75, indicating an acceptable reliability.

Population and sample selection
Current PC nursing students (year 2020) and students from the years 2017-2019 were included (N = 251) in the study. Figure 1 depicts the study sample.

Pilot test
We conducted a pilot test of the questionnaire on 12 conveniently selected PC nurses of the 2016 student cohort. The purpose of the pilot test was to determine if the questions were clear. We contacted the participants after they completed the questionnaire online via WhatsApp to enquire if they experienced any difficulty completing the questionnaire and to obtain feedback. Minor changes were made following the pilot test and the responses from the pilot test were not included in the main study.

Data collection
Once institutional permission was obtained, an email with a link to the online consent form and questionnaire was sent to all the eligible students and alumni. Follow-up emails were sent via RedCap to remind participants to complete the questionnaires. Participants who did not respond after several reminders received a courtesy WhatsApp message to ask them if they were aware of the survey, in an attempt to increase the response rate and representativeness of the study results. This did not compromise confidentiality, as RedCap only indicated which respondents did not respond; the participants' identities are not linked to their responses. The electronic link was open from 03 July 2020 to 01 September 2020, although the majority of the participants completed the questionnaires between 03 July 2020 and 31 July 2020.
Participants who completed the questionnaire were entered into a lucky draw to win a gift voucher to the value of R1000.00. This incentive was introduced in an attempt to increase the participant response rate.

Data analysis
Data were analysed descriptively and summarised in frequency tables or graphs. Inferential statistics included differences between urban and rural districts and participant responses, using the chi-square test. Content analysis 12 was used to analyse the open-ended questions. Themes were identified and quantified.

Ethical considerations
We considered the ethics and practicalities of duty of care during pandemics. 13 Duty of care also drove this research as we aimed to determine the preparedness of PC nurses for the COVID-19 pandemic in order to make recommendations on how to improve support.
Ethical approval was obtained from the Health Research Ethics Committee at Stellenbosch University (clearance no. N20/04/015_COVID-19) and institutional permission was obtained to access the students' contact details. This research was of minimal risk as all data collection occurred online and did not compromise the health of any participants or researchers. We specifically kept the questionnaire short so that it did not require too much time from the participants who may be providing essential services. Participants agreed to participate after reading an online participant information leaflet.

Demographic information
The final sample included 83 participants (83/214, 38.7%). The mean age of the participants was 37.

Training and attitudes
In response to questions on training to triage and manage COVID-19, some participants indicated that they received no training (n = 10, 12.0%). The most common training method was an instructional video (n = 28, 33.7%) (see Table  2). Less than half of the participants (n = 36, 43.3%) felt confident or very confident about the IPC training received in relation to COVID-19 and just more than half (n = 47, 56.7%) felt somewhat or very prepared to provide care. More participants indicated having the necessary expertise We used two open-ended questions to ask participants about their information and training needs. Table 3 summarises the themes identified.

Guidelines
The majority of participants had access to guidelines on triaging and managing COVID-19 (n = 71, 5.5%) and access to the use of PPE (n = 72, 86.7%). Guidelines that were the most often used were the Practical Approach to Care Kit (n = 56, 67.5%) and the Western Cape Department of Health guidelines (n = 44, 53%). A large majority of participants reported that they followed the guidelines (n = 76, 91.6%) and 84.3% (n = 70) found the guidelines helpful.
In the open-ended question, participants reported reasons for not finding the guidelines helpful, such as lack of clarity about what PPE to wear in certain situations, especially in emergency units because of uncertainty of whether a patient might have COVID-19, continuous changes in the guidelines or a lack of training on guidelines. One participant commented: 'The guidelines don't take appropriate infrastructure of facility in mind … still don't take health care practitioners' expertise or the amount of patients in mind for effective triage and management.' (Male, 31 years, community health centre)

Personal protective equipment and infrastructure
Less than one-third of the participants (25, 30.1%) indicated that there was adequate infrastructure in their facility to triage and manage COVID-19 cases and almost two-thirds of the participants (n = 49, 59.1%) agreed or strongly agreed that PPE was always available.
In the open-ended question, participants indicated several infrastructure and equipment needs including full PPE packs for testing, dedicated space for COVID-19 triage and testing, isolation rooms, patient flow challenges such as the inability to effectively separate patients because of load and small spaces with a lack of ventilation. In most facilities, COVID-19 screening and triaging was performed outside, for example, in gazebos or tents. These spaces were not always suitable because of windy and rainy weather conditions. Many participants reported a lack of equipment that was fully functional and sharing equipment between COVID-19 and non-COVID-19 patients.
Mobile clinics experienced particular challenges as shown in the below quote:

Personal and self-care needs
More than half of the participants indicated that they needed support for coping with stress (n = 48, 57.8%), whilst 41% (n = 34) frequently or very frequently experienced feelings of distress related to COVID-19; however, only 33.7% (n = 28) were concerned about their self-care needs (see Table 4). Participants made suggestions for improving their work life and these are depicted in Table 5.
Inferential statistics did not indicate any significant differences between rural and urban areas and the responses provided by the participants.

Discussion
We set out to determine the preparedness of PC nurses for the COVID-19 pandemic in the Western Cape province. Only 56.7% of the participants indicated that they were partly or fully prepared to provide care to patients with COVID-19. Primary care nurses were more confident to screen possible PUI than to manage individuals with COVID-19. In the United Kingdom, 52.0% of nurses reported confidence in their training about COVID-19. 11 In Iran, 56.5% of nurses reported good knowledge 14 compared to 71.9% of PC nurses in Australia who believed that they had sufficient knowledge of COVID-19. 15 The COVID-19 pandemic necessitated the training of PC workers, specifically nurses, to respond to patient care needs. 4,16,17 This should ideally also include simulation training to facilitate critical thinking skills unique to pandemics. 18 However, such training may be challenging because of rapid curriculum development and various social distancing restrictions on teaching and learning as well as staff being needed in the healthcare facilities and thus not able to attend training sessions. In line with this, the most often reported training platform was an instructional video, followed by written instruction. However, these methods were not sufficient, as indicated by the percentage of participants that either did not receive training or did not feel confident about the IPC training received (55.4%). Qualitative data indicated the need for further skills development and in-service training. Additional training will assist to ensure that PC nurses function to the full scope of their education and training, as research shows that they may provide equal or better care than doctors. 19 Guidelines appeared to be available and accessible to most participants. This is contrary to an Australian study where only 47.3% of participants reported access to COVID-19specific guidelines. 15 Although COVID-19 guidelines were available, the application of the guidelines was problematic, particularly in certain contexts such as small clinics and mobile clinics with poor infrastructure. Poor leadership from management hindered guideline implementation. Guidelines changed during the course of the pandemic, which were problematic for some participants. It is recommended that guidelines should be adapted based on the pandemic stage or interval. 20  Participants reported support needs such as childcare, home schooling and taking care of family members. Similar carer responsibilities were reported amongst Australian PC nurses. 15 Almost 60% of participants needed support with coping and stress management, yet only 14.5% reported access to mental healthcare at their workplaces.
Other studies also found that comprehensive assessment, support and management of anxiety during a pandemic are needed. 23,24 A lack of support from management was identified in this study. In Australia, only 54.8% of PC nurses reported feeling supported by management. 15 In our study, only 33.7% of the participants reported having access to COVID-19 testing at their workplace. This is concerning as clear strategies should be in place to manage exposed and infected PC workers. 25 The study participants indicated that effective management and staff wellness were the most pertinent needs. A study in the United States of America found that healthcare workers requested to be heard, protected, prepared, supported and cared for during a pandemic. 24 Investment in leadership and support for PC nurses are therefore essential. 17

Strengths and limitations
The limitations of the study include its cross-sectional nature, the relatively low response rate, the focus on the public health system and the dominance of respondents from urban areas. Furthermore, the fact that the questionnaire was administered online, and that the participants were all from the same university, could have introduced sampling or response bias. The inclusion of other universities within the Western Cape may have provided a more representative sample, but may have also delayed data collection during the peak of the pandemic. The findings, however, resonate with global literature. Further, the qualitative participant responses provide rich contextual information that increases the transferability of the findings.

Conclusion
Primary care nurses remain central to ensure 'health for all' and continuous quality healthcare. The findings of this study indicate that PC nurses were not optimally prepared for the COVID-19 pandemic. Challenges included adequate training, infrastructure, the availability of PPE, COVID-19 testing of healthcare workers and management support. Personal care nurses need comprehensive support to manage stress and anxiety. The findings of this study may be used to inform nursing curricula and future PC preparedness interventions.

Themes (n = 72) Example quote Frequency † Percentage
Effective leadership, management and support 'The main thing that is lacking from our employer is enough support instead, we are issued with circulars that are read to us. Many of our staff that have tested COVID-positive are people that declared that they have an underlying medical condition but the circular says they are not high risk so they ended up working in COVID area and some of them were even admitted to hospital. And that has left us feeling very worried and concerned but the employer is only concerned about what to be done for patients when we have staff shortage due to quarantine of the staff'. In-service training 'Provision of training and enabling environment for nurses to perform their duties without fear'. 'I want the training required to test patients at the facility I work at, instead of having to refer them to a primary health care facility and not only burdening the public health system but also putting employees at risk'. 10 13.8 PPE, personal protective equipment; COVID, coronavirus disease. †, Frequencies and percentages were calculated out of the number of participants who responded and represent the frequency of the themes in the participant narratives.