Towards a liquid healthcare: primary care organisational and management strategies during the COVID-19 pandemic - a qualitative study

The aim of this study is to explore the management, organisational strategies, and response capacity of primary healthcare centres in two different Spanish health regions to cope with and adapt to the pressure of the COVID-19 pandemic, from the viewpoint of frontline healthcare workers.

We designed a qualitative, exploratory study [35, 36] under a phenomenological paradigm that follows hermeneutic approach. It focuses on the relationship between an individual and their life trajectory and culture, which influences the conscious way in which they experience a phenomenon. Hermeneutic phenomenology must go beyond describing a phenomenon – it must interpret it, exploring the person's consciousness and understanding how they give meaning to aspects of their life [37] to explore personal perceptions of the phenomenon studied. An inductive thematic analysis of semi-structured interviews [38] and focus groups [39, 40] was conducted. This approach allowed us to explore the significance that participants attributed to their personal experiences and perceptions of institutional organisation during the COVID-19 pandemic.

Study subjects were primary care workers of the Castilla-La Mancha Healthcare Service (SESCAM) and the Madrid Region Healthcare Service (SERMAS). These regions were selected for the study due to the similarity of their profiles in terms of incidence during the first surge of the COVID-19 pandemic, management of healthcare resources, restrictions in access to the healthcare system, and economic and socio-demographic factors [41, 42]. Purposive sampling was used to increase diversity in participants and results. To maximise variability in the experiences collected, sampling was based on the following criteria: demographic profiles (gender and age), professional roles (practice managers, general practitioners, pediatricians), employment status (permanent, temporary, zero-hours), and years of experience (under or over ten years of experience) ensuring there were at least two subjects each with different profiles. We also considered whether these workers had dependent family members (Table 1). Invitations to participate in the study were sent via institutional e-mails to more than 600 healthcare professionals working in the regional healthcare system where the study was conducted (convenience sampling). Participants answered questions regarding their health status, job characteristics, socio-demographic profiles, and the Burnout Clinical Subtype Questionnaire (BCSQ-36). Once the survey was completed, participants were asked whether they wanted to join the qualitative research phase, either via individual interviews or focus group discussions. A total of 677 invitations were sent, of which only 37% resulted in acceptance to join the project. From this 37% (n = 252), only 22% (n = 56) agreed to participate in the qualitative phase. We also used snowball sampling, with initial participants identifying additional subjects among their contacts. Those who expressed their willingness to participate in an individual interview or focus group and fitted the target profile were sent an e-mail with information on the study’s aims, anonymisation, and personal data processing procedures. The research team responded to queries from the participants via e-mail or telephone calls.

Data were collected through in-depth, semi-structured interviews [38, 43] and focus groups [39, 40], which were conducted between July and December 2020.

Most individual interviews were completed in-person, in venues selected by the participants themselves, although some took place via telephone or video calls. A total of 38 individual interviews were conducted, with durations of between 45–70 minutes each. Interview guides (Table 2) were developed by the same researchers who conducted the interviews, all of whom were experienced in qualitative research.

Focus groups were conducted in rooms that were comfortable and guaranteed confidentiality while adhering to COVID-19 health guidelines, allowing healthcare workers to engage in a candid discussion of their experiences. A total of 15 professionals took part in three focus groups, with durations of around 120 minutes each. Focus groups followed a discussion guide (Table 3) that the research team prepared after a preliminary analysis of questionnaires and interviews. They were attended by professionals who indicated their willingness to participate in the qualitative research stage. Discussions were led by different research team members, with help from another researcher in their preparation and planning.

Interviews and focus groups were audio-recorded [38], and a fieldwork diary was used to record contextual issues and the researchers’ observations and thoughts [44, 45]. Only members of the research team had access to data collected throughout the study. None of the researchers involved in data collection had any work relationship with the study subjects.

Interviews and focus group discussions were transcribed verbatim. All members of the research team read the transcriptions to familiarise themselves with the accounts. A thematic map was prepared with themes and subthemes, illustrated with relevant quotations from the participants’ accounts. Following an inductive thematic analysis approach [46], a phenomenological perspective was used for a more descriptive analysis of the participants’ responses, identifying significant meaning units. Texts were compared and analysed to identify emerging categories [47]. During a second stage, a more in-depth analysis was performed to identify common categories.

This procedure was repeated by each member of the research team for each interview, focus group discussion, and field notes and observations – all of which were independently coded. The results of their individual analyses were discussed in team meetings, where significance units were agreed upon through consensus between all researchers. Each participant was allocated an alphanumeric code for data logging, category creation, and as a reference for literal quotations from the participants’ accounts.

All participants were offered the opportunity to review the audio or written records as well as the subsequent analysis to confirm the interpretation of their narratives by the researchers

The study followed the COREQ guidelines for reporting qualitative research [48], as well as Lincoln and Guba’s quality criteria for qualitative research [49] (Table 4).

Our participants perceived that their working environments during the COVID-19 pandemic were increasingly imbalanced and conflicted – stressing the contrast between the day-to-day reality they experienced at work and the institutional protocols and guidelines defined by healthcare authorities. Their feelings of having been left to cope with whatever resources they already had, in a context of “liquid modernity”, suggested the following categories:

Healthcare professionals’ personal experience was based on a departure from their usual work routines – with the abrupt implementation of highly fluid organisational strategies. Different actors at different management levels – the Spanish Ministry of Health, regional healthcare authorities, and primary care centres – used varying criteria to define their action plans and protocols. The concatenation of sometimes contradictory guidelines was counterproductive and inadequate for solving the problems faced by healthcare professionals on their day-to-day practice. Our informants described these clashing criteria as “improvised”, “incoherent”, “uncertain”, “lacking coordination”, and “disorganised”. Moreover, their situation did not improve once the first wave of COVID-19 was over.

The lack of clear guidelines forced healthcare professionals to take responsibility for decision-making – which, in turn, caused anxiety and feelings of being abandoned, exposed, and unprotected. Each primary care setting had to self-organise and make their own decisions independently. Institutional, top-down decisions were not aligned with their real, day-to-day experiences and needs. The general perception was that healthcare authorities had been unable to respond effectively to the crisis. As a result, primary care workers had to become responsible for managing the response to the pandemic:

(...) it caught us with a management model that was not good, because there was uncertainty – nobody defined clear criteria and you had to improvise as you went along, because at the end of the day you are the one dealing with the patient, so you are the one improvising – on a clinical level we have improved, now we know what to do, but as for management it leaves much to be desired, well yes, of course – working conditions were inadequate because nobody sorted it out – I had to make decisions because nobody told us what to do and it had to be done, and by the time the regional healthcare authorities sent their guidelines we were already there. We would have preferred more horizontality, more sharing... (UM-23, medical coordinator)

According to our participants, the lack of a horizontal approach to decision-making and the top-down communications between different primary care levels complicated their adaptation to the new situation. Paradoxically, the increasing number of team meetings conveyed a subjective perception of chaos and disorganisation.

What I cannot understand is how we got to this point, now, with no organisation whatsoever – because the organisation, I’ll say it again, from my point of view – it was chaotic (nurse, focus group 2).

(...) everything was over the telephone and the solutions did not make any sense (nurse, focus group 1)

The lack of response to their demands and the perception of a sustained “administrative silence” filled primary care workers with indignation. It was also counterproductive for maintaining motivation in an already complicated context.

(...) what you felt sometimes was anger – you got annoyed because you did not get an answer to your demands (RN-15, nurse)

In addition, there was a subjective perception among primary care workers that they were not being treated the same as other healthcare professionals. This was partly because of poor communication between different care levels and the dysfunctional healthcare system organisation, as suggested by the Primary Care Physicians’ Forum [50]. Healthcare authorities never sought their opinion, and decision-making was not consensual.

I would like them to listen more to those of us that are on the frontline – I would really like that, because they do not listen to us, and that is the problem – perhaps if they listened a bit more we would feel better (UN-2, nursing manager)

Communication with regional authorities... It has remained more or less as it was. It was always poor – this should make us realise that there is a lot that needs to be changed and improved – for instance, communication with regional healthcare authorities (RN-24, nursing manager)

Parties across the political spectrum have touted, over the last decades, the enduring myth of the Spanish National Health System. Electoral pressures have made politicians exaggerate its successes and obfuscate, shifting attention from real problems in what has always been promoted as “the best healthcare system in the world”. In practice, these arguments have masked the consequences of years of far-reaching, repeated pseudo-privatisation policies and dismantling of public healthcare services. Structurally, there is a general lack of awareness and understanding of the role of primary care, which has been magnified during the current pandemic.

The problem is that regional healthcare authorities do not know how primary care works, they have no idea – even more so in this situation. And I think that, since they know nothing, they should delegate and seek the advice of those who are working in the sector – those are the people who can inform policies and guidelines for primary care, and they would be more useful than the ones in place now (UAUX9, nursing aide).

The perception that there is a lack of adequate leadership in primary care has been a constant in our participants’ accounts. This perception has been reinforced in the increasingly complex working environments required to deal with the challenges created by COVID-19. The assessment of primary care management strategies from the viewpoint of institutional analysis is revealing.

(...) we have been a bit adrift – primary care management is inadequate, we need it to change – we professionals try to make things work differently, to have that – to leave uncertainty behind and do things better, because we have the ideas (UN-12, nursing manager)

Inadequate leadership led some practice managers to step down from their roles. Other professionals applied for early retirement or were considering leaving their jobs after repeatedly denouncing their poor working conditions. During our study, it was observed that several primary care centres lacked medical and nursing managers. Although in some cases this situation pre-dated the pandemic, during its first few months it deteriorated further.

Nearly twenty years on a temporary contract, almost five as a nursing manager, and when the pandemic hit we achieved the impossible, managing the practice – because nobody wanted to be in charge of medical coordination – and out of the blue, one day I was fired – with my family situation – the constant mistreatment... (UN-5, nurse).

As a collaborative exercise, our participants described a double situation of subordination: first, as workers with no participation in decision-making, with top-down orders dictated from higher management spheres; and besides that, they received different treatment from colleagues in specialist care.

For some of them this novel situation was more “relaxed” – compared with the previous, overburdened primary care, which was not delivering high-quality patient care. However, this perception was not widely shared – other participants described a situation of uncertainty with which they only coped by assuming individual responsibilities.

(...) not seeing so many people gives you a break, you do not see them – but telephone visits are chaotic, patients do not feel relieved, for people it is disastrous (UAD-6, administrative staff).

Healthcare workers with extensive professional experience, including in hospital settings, describe a scenario with a predominance of highly experienced staff, at the end of their long careers.

Yes, yes it is going to change... Regional healthcare authorities must organise their workers differently, too many professionals are high risk – we were the ones at risk, most of us over 55 years old – frontline workers cannot be a high-risk population – we need to rethink organisational strategies so we work better and with less risk (UN14, nurse).

These professionals demand a new primary care model that recognises the central role of healthcare professionals and the importance of the work they do, giving them back a sense of dignity and self-respect, and resourcing the healthcare system adequately.

Our participants pointed out that the COVID-19 pandemic has magnified structural deficiencies that pre-dated this global health crisis. This affected the healthcare professionals’ working conditions, hindering their capacity to respond to the crisis and putting both patients and workers at risk. For epidemiological reasons, primary care had to radically transform its traditional care delivery model – based on direct contact with patients and their close family – and implement a virtual patient care model. However, this new model caused conflict among primary care workers and their patients. It highlighted how under-resourced primary care was and the public’s resistance to changes in the traditional, personalised patient care model.

Our qualitative study provided an insight into personal narratives describing the dynamics and the logic underpinning the attitudes of certain population groups, i.e., older, rural adults.

(...) many people do not have access to a telephone, and they are very, very old, and they still operate under the conviction that if they phone you, they have to pay – so they prefer to come down here, because it is faster and they do not have to spend any money – some of them cannot read, they cannot use a phone, and it was difficult to stop them coming here – they were like “No, I am just coming down to ask you if I could be seen” (nurse, focus group 2).

In addition, physical facilities in some primary care centres were old and inadequate, making it difficult to adhere to safety regulations essential in a pandemic context. Primary care settings in ancient buildings, with large communal areas but small consultation rooms, complicated the division between “clean” and “contaminated” spaces required to examine patients with respiratory pathologies and/or suspected COVID-19 cases.

Primary care centres are in a dire state, some of them have never been renovated (nurse, focus group 2).

Regarding the allocation of human and material resources, the perception re-emerged that primary care and its workforce were not a priority within the Spanish healthcare system. Among other issues, this was related to the problem of overwork, with increased numbers of shifts.

(...) the feeling is that nobody cares – it is like, you go in and that’s it, whatever will happen will just happen and that’s all, come on – and on, and on, another day, doubling shifts, that’s it, who cares. It’s like this colleague who took medical leave early on because he developed symptoms, and he was away for two and a half months and another colleague took his shifts – nobody ever phoned him to ask how is it going, how are you doing (RT-3, emergency technician).

Professionals adapted to this novel situation but mentioned the increasing flexibility required from them as the months went by. Careful resource management during the most challenging stages, to alleviate the lack of resources, was crucial.

(...) I am not the same as I used to be, I am up for anything, I try to help, that is my role, to help as much as I can – if I have to give a hand in physio I do, if I have to help administrative staff I hand paperwork over, if I have to pass on a document I do it – so that the queue there does not reach … (UAE-7, nursing aide).

(...) they must think we are elastic chewing gum – the stress is not because of the virus, it is because of the situation – because I do not have enough people, because I cannot do this (UM-23, medical coordinator).

The main limitation of our study is its focus on primary care settings, whose activity has been dramatically reduced during the pandemic. Primary care professionals ensured the delivery of non-COVID care despite a rise in absence rates among their workforce due to COVID-19 infections. Over the course of the study, participants shared a perception of being overburdened. On the other hand, our research project was not the only one that took place at the time. This might have caused a certain degree of saturation and reluctance to participate among primary care professionals. It is also possible that those willing to participate were particularly sensitive to deficiencies in the primary care model. Finally, the representation of different healthcare professionals has been unequal – 49% of the participants were female nurses, which might have biased the results obtained. However, this could also be a positive factor since nurses have played a crucial role in the management of primary care settings. Thus, we believe their opinions are relevant in this moment of instability and might suggest new avenues for primary care provision.