On March 11, 2020, the World Health Organization (WHO) declared the coronavirus disease 2019 (Covid-19) a global pandemic. This pandemic has resulted in unprecedented global, societal and economic disruption and has challenged healthcare services and workers across the globe, unlike anything most of us have ever witnessed before.

Recently, Irish health services have been struggling to deal with the tsunami of post-Christmas cases, which marked the third wave of this disease in Ireland. Significantly, confirmed cases in the first three weeks of January surpassed those confirmed throughout the entire year of 2020. In general practice, the past year has been particularly challenging. The important role general practice plays in shielding and supporting secondary care services has been evident throughout the crisis.

Within Irish general practice, 90% of an estimated 20 million episodes of patient care are completed and managed annually without requiring onward referral.^1,2 General practice teams have demonstrated flexibility, dedication and innovation in maintaining day-to-day activities during the pandemic, including continuing immunisations, cervical screening, chronic disease, acute and minor illness management, while also providing care to over 80% of Covid presentations.

In the early days of the pandemic, general practice responded swiftly, changing work practices almost overnight. The health and safety of our practice teams and patients became a top priority as we worked together to ensure all health protection measures, such as PPE and public health guidelines on Covid-19, were implemented. To reduce footfall, a large part of our work moved to virtual platforms via video or teleconsultations, electronic prescribing, online triage and management of care. These changes were made possible by adopting a team approach to problem-solving, collaborative practice and flexibility.

As part of the team, general practice nurses (GPNs) have remained at the forefront and on the frontline throughout the pandemic. It is estimated that nurses make up 37% of clinicians delivering healthcare services in general practice.^3,5 While it is difficult to confirm the actual figure as there is no conclusive dataset, it is reasonable to assume this is an underestimate, as numbers have grown exponentially in response to increased demands on general practice.⁵

As colleagues in clinical practice, the experience of Covid-19 from a GPN perspective mirrors most of that experienced by GPs. The nursing role has adapted and continues to work in collaboration with GPs to maintain vital services and healthcare provision, including face-to-face and direct contact for patients who still need to be seen in practice.

Disruptions in care for non-Covid-related health conditions have been and continue to be a major concern, especially among our elderly and more vulnerable patients. We are juggling Covid-19 while maintaining a non-Covid service and implementing chronic disease management in practice, additions to immunisation programmes, delivery of new treatments and the reintroduction of the cervical screening programme. GPNs have also been managing requests for extra work from hospitals in terms of bloods and patient monitoring, while also under pressure to manage the administration of influenza vaccines, which were complicated by the shortfalls in QIV supplies in practice.⁴

There was consensus that all frontline general practice staff had to be vaccinated as quickly as possible to ensure protection against Covid-19, prevent the spread of the virus and enable continuity of vital health services for our general practice patients. Many GPs and GPNs were relieved to receive their first Covid-19 vaccine at mass vaccine clinics in Dublin, Portlaoise and Galway in January, while others were grateful to be facilitated at local nursing homes. At the time of writing, further members of GP teams were scheduled to receive their vaccines. The anxious wait for immunisation that many of us experienced has served to strengthen our resolve to ensure the rollout of the vaccine to our patient populations will be swift and equitable.

GPNs all over Ireland are eagerly awaiting the rollout of the Covid-19 vaccine in practices for our patients. GPNs are acknowledged by the HSE National Immunisation Office as experts in the delivery of immunisations; however, this has often been omitted and is often not reflected in media coverage when referring to the rollout of the Covid-19 vaccine in primary care.

Delivery of all national vaccine programmes within general practice is mainly nurse-led, with GPNs constituting the largest and most experienced group of vaccinators in the country.^5,6 As highly skilled clinicians in this area, we have been following Covid-19 vaccine technology developments with great interest. The educational programme for registered nurses and midwives under medicine protocol to administer the Covid-19 vaccine and the vaccines webinar series is available at www.hseland.ie

GPNs have been actively completing this training and ensuring we are updated with the necessary skills, knowledge and understanding to competently administer the new vaccines.⁶ The Irish Practice Nurses Association (IPNA), which is the representative professional organisation for GPNs, hosted a webinar to address concerns and questions regarding Covid-19 vaccines and the logistics involved in putting the programme into action in our surgeries. More than 440 GPNs attended this inaugural online event. 

According to the National Immunisation Office:“The objective of the vaccination programme for SARS CoV-2 is to ensure equitable access to a safe and effective vaccine with the goals of limiting mortality and morbidity from Covid-19, protecting healthcare capacity and enabling social and economic activity.”⁷

Following agreement on the programme details, GPNs and practice teams around the country are busy planning and preparing for the implementation and smooth running of vaccine delivery and administration as the rollout continues. The programme has begun with patients aged over 85 and then is moving sequentially until all patients over 70 years of age are vaccinated. Approximately 490,000 patients over 70 currently live in Ireland, 72,000 of whom are over the age of 85.⁸ Once the entire over-70s practice population is vaccinated, the vaccine will be offered in the order scheduled to all other groups.

The NIAC (February 2021) updated guidelines recommend that “any currently authorised Covid-19 vaccine, including Covid-19 Vaccine AstraZeneca, can be given to adults of all ages, including those aged 70 and older. Where practicable and timely, those aged 70 and older should be given an mRNA vaccine”. Based on the recommendations of NIAC, the Department of Health’s policy is that people aged 70 years and older will be offered mRNA vaccines, ie. Comirnaty and Covid-19 vaccine Moderna.⁹ It is anticipated that the AstraZeneca vaccine will be administered to those under the age of 70 and other people in priority groups such as healthcare workers.⁹ GPNs are well informed and eager to offer the vaccines to patients who have been contacting surgeries in unprecedented numbers to enquire as to when it will be available.

Vaccines are among the greatest public health achievements of modern times. However, concern about vaccine safety continues to be an important driver of decreased vaccine uptake in most contexts.¹⁰ This concern is often fuelled by misinformation and propagated by organised anti-vaccine groups, social media and celebrity endorsements. 

The WHO listed vaccine hesitancy as one of the top 10 threats to global health in 2019. The reasons why people choose not to vaccinate are complex but lack of confidence in vaccine safety, driven by concerns about adverse events, has been identified as one of the key factors.¹¹ Healthcare workers, especially those in primary care, remain key influencers on vaccine decisions. GPNs play a crucial role in increasing vaccination uptake among the general practice population through evidence-based information and patient education, therefore reducing vaccine hesitancy and health inequalities caused by misinformation and ill-informed concerns.¹² GPNs are particularly aware of the responsibility we have regarding Covid-19 immunisation. Following the impact of the third wave of the virus, we understand that it is impossible to overstate the importance of enlisting public confidence in the safety and efficacy of these new vaccines.

The rollout of Covid-19 vaccines in general practice will be challenging, especially on top of an already busy workload for the more than 2,000 GPNs in practice, but we are knowledgeable, skilled and competent at managing and delivering vaccination programmes. We are at the heart of every community and vaccinating our practice populations is a major part of what we do every day. We know our patients and we have gained their trust, so we are well placed to be main players in partnership with GPs to accelerate the rollout of the Covid-19 vaccines nationally.⁶

Nationally, we face an uncertain future, finely balancing health and illness, economic contraction and recovery. The stakes remain high as we look with hope to the rollout of vaccines in the suppression of Covid-19. Nurses in general practice are eager to be part of the solution. 

References

1. Irish College of General Practitioners. (2016). ICGP submission to the Oireachtas Committee on Future Healthcare. [Online].  https://www.google.ie/search?q=slainte+care+submissions+ICGP&oq=slainte+care+submissions+ICGP&aqs=chrome..69i57.10431j0j8&sourceid=chrome&ie=UTF-8
2. Crosbie B, et al. A real-time measurement of general practice workload in the Republic of Ireland: a prospective study. British Journal of General Practice, 2020; 70: e489-e496
3. Bury, G, Twomey, L and Egan, M. General practice nursing: the views and experience of practice nurses and GPs in one county. Irish Journal of Medical Science. 2020 Dublin
4. Lowry Lehnen, T. The IPNA and Future of General Practice Nursing in Ireland. Nursing in General Practice Journal 2020; 13(6); 14-19. Nov/Dec 2020
5. Loftus Moran O. 2020 Vision- future focus for general practice nursing. Nursing in General Practice, 2019; 12(6); 19-22. Nov/Dec 2019
6. Lynch, P. General Practice Nurses and Covid-19 Vaccination. Nursing in General Practice Journal, 2021; 14(1); 4-5. Jan/Feb 2021
7. HSE NIO (2021). Chapter 5a Covid-19. Severe acute respiratory syndrome coronavirus 2, SARS-COV-2. HSE, National Immunisation Office. Dublin
8. IMT (2021).  Three delivery systems for revised vaccination plan in general practice. Irish Medical Times. 6th February 2021
9. HSE NIO (2021a). COVID-19 VACCINE BULLETIN 5. Health Service Executive, National Immunisation Office. Dublin
10. Larson H, Jarrett C, Eckersberger E, Smith D, Paterson P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature, 2007-2012. Vaccine 2014; 32: 2150-2159. 10.1016/j.vaccine.2014.01.081
11. Ahmed F, et al. Why inequality could spread COVID-19. The Lancet Public Health; 2020; 2667: 20, 30085
12. Hemingway, A., Bosanquet, J. Role of nurses in tackling health inequalities, Journal of Community Nursing; 2018; 32(6): 62-64