General Practice Nurses' experiences of changing care delivery during COVID‐19. Implications for future practice: Qualitative study protocol

Abstract Aim To explore how General Practice Nurses experience implementing change at pace and scale in delivering care during consecutive waves of the COVID‐19 pandemic. To evaluate the impact of changes to general practice nurses' working practices on professional wellbeing. Background In response to the COVID‐19 pandemic, general practice rapidly and extensively changed care delivery. There has been little exploration of the experiences of General Practice Nurses and care delivery, job satisfaction, workload, stress and professional support. Design A qualitative case study design of three to five general practice case sites will explore General Practice Nurses' experiences during the Covid‐19 pandemic. The study was funded and approved by the General Nursing Council Trust in June 2021. University ethics approval was gained in July 2021. Health Research Authority approval has been obtained [IRAS:30353. Protocol number: R23982. Ref 21/HRA/5132. CPMS: 51834]. Methods Data will consist of focus groups and/or semi‐structured interviews with General Practice Nurses, primary healthcare team members and other key informants. Business/strategy and nurse team meetings relating to workforce planning/review will be observed. Documents will be analysed and routinely collected general practice data will provide descriptive contextualisation at each site. The study will be theoretically underpinned by the Non‐adoption, Abandonment, Scale‐up, Spread and Sustainability Framework and data analysed using framework analysis. Discussion General Practice Nurses have a unique sphere of knowledge and undertake specific work in primary care. This workforce is challenged by recruitment, retention and retirement issues, leading to the loss of highly experienced and knowledgeable professionals. It is important to explore how working practices brought about by Covid‐19 affect General Practice Nurses. Impact This study will explore working practices brought about by the Covid‐19 pandemic to inform care delivery, patient care and support General Practice Nursing workforce wellbeing and will highlight and mitigate negative aspects of novel and changing care delivery. Key factors in implementing and supporting future practice and change implementation will be developed. Trial registration: CPMS: 51834.


| INTRODUC TI ON
Delivery of primary care has changed significantly since the start of the COVID-19 pandemic in early 2020, both in England (Mroz et al., 2020) and internationally (Rawaf et al., 2020;Verhoeven et al., 2020;Wherton et al., 2020). Changing care delivery and implementing new ways of working have the potential to enhance and improve patient care and healthcare delivery in general practice.
However, such implementation requires a robust evidence base and little attention has been focused on the work and experiences of General Practice Nurses [GPN] throughout this time. This is significant as GPNs make a distinct and significant contribution to patient care. The GPN workforce is central to general practice healthcare delivery, provides an interface between health and social care and provides specific care not delivered by others.
This study will identify aspects of patient care and workforce practices brought about by the pandemic to inform and enhance future practice, GPN education and patient care. It is also intended to highlight potential difficulties and negative aspects of implementation. Key factors for success in implementing and supporting different ways of working for GPNs will be identified. Working practices and systems which develop and streamline care delivery, improve patient care and support the wellbeing of the primary care workforce will be highlighted. The study will also identify the scope for the development of GPN education through identifying skills and knowledge required to deliver new and changing ways of working.
Identifying factors which may support the GPN workforce has the potential to positively impact on patient care.
However, while novel consultation methods have been demonstrated to be safe and effective , studies were often underpowered and not designed to evaluate the management of acute/ serious illness . Potential wider consequences of remote working on practice populations are also unclear. However, the pandemic has also provided a catalyst for changes which, while identified as potentially beneficial to patients, were previously considered difficult to implement and upscale . It has also allowed more flexible working for healthcare professionals (Khan et al., 2020) and improved access for some patients.
General Practice in England, and in other countries, has responded to the pandemic in other ways. Triage has been expanded, work deemed non-essential postponed and essential work carried out differently (Verhoeven et al., 2020). In England, General Practices (and staff) also underwent rapid reorganization to operate hubs across Primary Care Networks (PCNs) separating those suspected of having COVID-19 from non-COVID-19 care (Khan et al., 2020). Suspended non-urgent secondary care provision also impacted on primary care providers (Verhoeven et al., 2020). Furthermore, only a small proportion of those diagnosed with COVID-19 are managed in secondary care, with primary care delivering the bulk of service provision and dealing with 'collateral damage' (Rawaf et al., 2020;p. 130) caused by resource diversion and reduced access (Khan et al., 2020). Face-to-face primary care access was also initially impacted by lack of personal protective equipment (PPE) (Rawaf et al., 2020). Latterly, general practices have responded at speed to the large-scale roll out of COVID-19 vaccinations. While the longstanding effects of COVID-19 remain unclear, it is anticipated primary care will be central in managing long-term sequelae.
However, there has been little exploration of the experiences of General Practice Nurses (GPNs) in adapting their practice, or consideration of how such rapid and extensive change has impacted on care delivery, job satisfaction, workload, stress, burnout and professional support. A Queen's Nursing Institute (QNI, 2020) survey indicated that, exacerbated professionals. It is important to explore how working practices brought about by Covid-19 affect General Practice Nurses. Impact: This study will explore working practices brought about by the Covid-19 pandemic to inform care delivery, patient care and support General Practice Nursing workforce wellbeing and will highlight and mitigate negative aspects of novel and changing care delivery. Key factors in implementing and supporting future practice and change implementation will be developed.

K E Y W O R D S
Covid-19, general practice, general practice, NASSS framework, nursing, nursing change implementation, primary care, qualitative research, remote consultations, study protocol by the pandemic, GPNs felt undervalued and this was reflected in poor employment terms and conditions, including remuneration. They also felt GP colleagues deflected face-to-face consultations onto GPNs.
Indeed, Murphy et al. (2021) showed that 90% of GP consultations were held remotely between April-July 2020, compared with 46% for GPNs. Crucially, the QNI survey showed lack of respect, support and poor employment conditions led some GPNs to consider leaving their position. This is significant because the GPN workforce has experienced recruitment and retention issues long before the pandemic, with a significant 'retirement bubble' leading to loss of a highly experienced and knowledgeable workforce which are difficult to replace (HEE, 2017).
GPNs have a unique sphere of knowledge and undertake specific work different to that of other primary healthcare professionals. For example, GPNs deliver the bulk of long-term condition management, essential care which cannot be delayed, public health interventions such as childhood immunization and other vaccination programmes (PHE, 2020), mental health support and procedures requiring face-to-face consultations (e.g. complex dressings and cervical cytology).  (Massey, 2020). However, experiences of GPNs throughout COVID-19 have not been explicitly researched in-depth. By gaining insight into the development of GPN practice triggered by the pandemic, new ways of working can be identified and evaluated, and barriers and facilitators highlighted. The current study asks how GPNs enact, experience and perceive their roles during the Covid-19 pandemic to: • explore changes to GPN practice and care delivery, including technology-medicated working, • find out what works well and how practice could be improved, and • gain insight into how changes in care delivery during the pandemic may affect GPN wellbeing.

| Aims
Primary aim: This study aims to explore how GPNs working in general practices in England experience implementing change at pace and scale in delivering care during consecutive waves of the COVID-19 pandemic.
Secondary Aim: To evaluate the impact of changes to general practice nurses' working practices on their professional wellbeing.
More specifically, we aim to: • Identify changes to care delivery by GPNs during consecutive waves of the COVID-19 pandemic.
• Identify barriers and facilitators to care delivery.
• Explore access to, and experience of translating into practice, rapidly developed guidance/evidence-base, brought about as a response to the Covid-19 pandemic.
• Explore acceptability of new models of working.
• Explore effects of the development of rapid and significant workforce practices on the welfare and working conditions of GPNs.

| Study design
Using a qualitative case study approach, data will be collected from three to five general practices in England to gain a broad perspective of how GPNs enact, experience and perceive their roles during the COVID-19 pandemic. This will involve holding focus groups/individual interviews with GPNs and a range of primary healthcare team members, as well as key informants such as Primary Care Network leaders and general practice service commissioners (individual interviews may be conducted if it is a participant's preference or they are unable to participate in focus groups). Attendance (in-person or remote, dependent on participants' choice and contemporary pandemic guidance) at meetings such as GPN team meetings and relevant general practice business or strategy meetings will allow observation of discussions relating to the study aims. Documents such as practice protocols and local and national policy guidelines will be analysed. At case sites, routinely collected practice data (e.g. percentage of GPN and GP consultations face-to-face/telephone/ video/email before, during and after COVID waves) will be examined descriptively to identify changes in care delivery related to the pandemic and will be used to contextualize qualitative data. The study is funded for a 12-month period and data are expected to be collected over a 6-month period in this time.
Qualitative research's strengths are in gaining in-depth understanding of a particular context, exploring underpinning meanings and unpicking how experiences, interactions and behaviours are constructed (Pope & Mays, 2006). Because of these characteristics, qualitative research has a range of applications in applied healthcare research and the study of healthcare organizations (Bowling, 2014). Consequently, this approach will be taken to gain in-depth understanding of the effects of changing working practices during the COVID-19 pandemic on GPNs and the study will be underpinned by a social constructivist perspective.
Triangulation will be used to support comprehensiveness and consistency through the investigation of GPN working practices from a variety of perspectives (Holloway, 2008). That is we will compare several methods of data collection (observations, interviews/focus groups and document analysis) and will use more than one data source (several research sites and informants from different professional groups).

| Theoretical framework
We will explore new models of working including technologysupported forms of working and so the study will be underpinned by the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) Framework (Greenhalgh et al., 2017). This is an evidence-based, theory-informed pragmatic framework that was originally developed to predict and evaluate success of technologysupported healthcare. The framework's authors indicate it is not a checklist, but rather its strength lies in its adaptability to different cases and settings. NASSS has been extended to theorize and analyse service innovation and delivery more broadly in that it provides a complexity-informed approach in which to situate implementation of new ways of working beyond a direct technology focus (Hollick et al., 2019). NASS identifies seven domains of influence which can be used to explore the acceptability and success of introducing healthcare technologies/changes in service delivery: In this study, the NASS framework will be used to inform data generation and will allow exploration of technology-enhanced ways of working, such as remote consultations, as well as the broader rapid adaptation of GPNs to new and different ways of delivering healthcare, while also maintaining established aspects of care which continue to be required.

| Sampling and recruitment
The researchers' university has an established network of primary care stakeholders through research and education provision. We will work with them to publicize recruitment to the study of both and key informants such as practice managers, GPs, administration/reception team members, Primary Care Network leaders and service commissioners, to gain a wider perspective on the role of GPNs during consecutive waves of the pandemic. Informants will be purposively sampled based on a range of roles, knowledge and insight relevant to study aims and objectives (Bowling, 2014), and invited to take part. GPNs will be purposively identified based on variation, for example experience; gender; age; role; professional level (e.g. registered nurse/advanced nurse practitioner/ health care assistant/nursing associate). A snowballing strategy will also be employed with participants asked to identify other key informants.
The sampling strategy will be pragmatic, focusing on a balance between breadth and depth of data. This will enable the sample size and data generated to be manageable and comprehensive (Pope & Mays, 2006). We will not aim for saturation but instead will focus on ensuring a varied sample is represented (Braun & Clarke, 2019

| Data generation
Focus groups and semi-structured interviews with participants will be informed by a topic guide developed by the research team using a priori concepts based on an adapted NASSS framework (Greenhalgh et al., 2017), research aims and current literature. ing and support provision? Key ideas generated will be iteratively integrated throughout data collection into the topic guide, which will be adapted to allow contextual cross-site comparison and contrast. Key meetings, such as GPN team meetings and business/ strategy meetings will be observed and documented in field notes underpinned by research aims and NASSS framework (Greenhalgh et al., 2017).
Each case site will conduct IT searches on routinely collected data for the purposes of informing qualitative data collection. For example, we will find out the percentage of remote GPN consultations pre-pandemic, compared with current working practices. We will also compare this to general practitioners' pre-pandemic and current working practices. We will use these data descriptively to illustrate patterns of working of professional groups in and across case sites. We will also use these data to inform and generate focus group/interview discussion. For example, we will ask participants to comment on any differences in working practices between professional groups and explore reasons for any differences. Data generated from these discussions may then inform strategies for collecting additional descriptive practice data, that is focus group/

| Researcher characteristics and reflexivity
HA's professional background is as a GPN and advanced nurse practitioner in general practice. While shared professional identity may aid rapport, it might also be anticipated that participants may make assumptions about the researcher's views of general practice, which may influence decisions around sharing information. Consequently, the potential impact on participants will be considered (Hammersley & Atkinson, 2007). HA's underlying views of nursing and its position in healthcare may be informed by socialization in nursing, general practice culture and the wider healthcare context. It is therefore important to reflexively and critically challenge views throughout the study and the context in which data are generated and analysed will be considered. This will be achieved by exploring alternative explanations and seeking disconfirming cases. Regular research team meetings will be held with PG and JA. PG is a registered nurse with a secondary care background who works in nurse education and JA is a health services researcher who does not have a clinical background.
Both have significant experience of health research and neither will be directly involved in data collection or analysis. Consequently, it is anticipated that research team meeting discussions will facilitate reflection and questioning of analytical ideas.

| Data analysis
Data from focus groups/interviews, observations and documents will be analysed thematically based on the framework approach described by Pope et al. (2000). This consists of: familiarization with the data; developing a thematic framework; indexing (coding) the data; charting; mapping and interpretation. This approach is grounded in the raw data and is both informed by study aims and objectives and a priori conceptualisations. Data from different elements of the study (focus group/interview transcripts, observational fieldnotes and documents) will initially be analysed separately and then integrated in each case. They will then be compared and contrasted across case sites. Coding will be underpinned according to a priori concepts of an adapted NASSS framework (Greenhalgh et al., 2017). Data will be analysed using a constant comparative approach, with data collected and analysed concurrently. This enables developing themes and potential relationships to be tested. Interpretation of data may be influenced by the personal and professional attributes/experiences of the researcher. Consequently, a reflexive approach will be taken and a diary will be used to support reflexivity, to document analytical processes and to create an audit trail of the decisions taken and the processes of analysis.

| Ethical considerations
The study received a favourable review from the University of York's  (2018) and university policies. Copies of consent forms and information leaflets will be given to each participant.
As a workforce study of GPNs in general practices, the study is not considered to be ethically contentious. However, qualitative studies focus on a small number of participants, as well as in-depth contextual detail. This may, therefore, impact on protecting participants' identities. Because of this, information will be presented at a level which limits potential for identification of participants and sites.
There is a potential for inconvenience for participants and/ or practices given the nature of the study. This will be minimized through careful communication and negotiation with the individuals and organizations involved. As the study is taking place in participants' workplaces (or remotely), it is not anticipated that any expenses will be accrued, and no reimbursement will be necessary. No incentives will be offered to either practices or participants.
There is a potential for the study to reveal issues about working practices and behaviours and this is made clear in the study information. Although the study is considered unlikely to reveal information requiring disclosure, because it is related to working practices, there is a potential for inappropriate or concerning behaviour to be revealed. In this event, the individual will be informed that a concern will be raised and it will be reported through the general practice's procedures for raising and escalating concerns.

| Validity and reliability/Rigour
Quality in qualitative studies can be established through consistency between findings and broader knowledge, recognisability and relevance of findings to others, including those in similar settings, and through reflexivity (Hammersley, 1998

| DISCUSS ION
The nature of this study necessitates that it is conducted during an ongoing pandemic at a time when general practice is under severe pressure. As a consequence, the study has been planned to: • Minimize disruption to general practices and participants by using routinely collected practice data and offering flexibility in terms of remote data collection and information provision.
• Offer flexibility to participants re whether focus groups or individual interviews are preferred and offering to attend meetings remotely if preferred by sites.
• Depth of data collection will be balanced with pressures on participating practices and participants. It is expected data collection will take place over 6 months.
• The safety of the researcher also needs to be considered and the study design allows flexibility in terms of the need for the researcher to attend in-person or remotely.

| Limitations
We recognize patient experience is important and funding does not allow direct evaluation of this in the current study. However, as the GPN workforce is central to primary healthcare delivery, potential issues faced by GPNs in the pandemic era have the potential to impact patient care. Consequently, this study will identify aspects of workforce practices brought about by the pandemic to inform and enhance future practice, GPN education and to inform patient care. Identifying factors which may support the GPN workforce has the potential to positively influence patient care.
Qualitative studies are based on information-rich data,  (Holloway, 2008). While experiences of individuals and general practices involved in this study may not be directly applicable to other workforces, findings may resonate with similar institutions and workforces. Furthermore, using the NASSS framework (Greenhalgh et al., 2017), may allow organizations to recognize key factors which they may choose to use to provide support for their GPN workforce.

| CON CLUS ION
It is anticipated this study will identify and explore aspects of patient care and workforce practices brought about by the pandemic to inform and enhance future practice, GPN education and to inform patient care. It is also intended to highlight potential difficulties and negative aspects of implementation. Key factors for success in implementing and supporting different ways of working for GPNs will be identified and working practices and systems which develop and streamline care delivery, improve patient care and support the wellbeing of the primary care workforce will be highlighted.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the authors.