Abstract
Aim
To describe staff experiences with the use of videoconferences with forensic psychiatric outpatients during the COVID-19 pandemic.
Method
Semi-structured interviews with staff at forensic community services in the Region of Southern Denmark.
Results
Nine semi-structured staff interviews were conducted. Two main themes were identified through thematic analysis: Challenges due to technical uncertainty and the Use of videoconferences as support in clinical assessment and treatment. The second main theme also included a number of subthemes: Lack of opportunity for observation of a patient’s overall situation; Compromise of nurses’ professionalism; Limitation of disturbing stimuli means more focus on the conversation; Telephone contact vs. video contact—pros and cons; Expectations reflect attitudes; and Will professionalism be changed based on organizational and political perspectives?
Conclusion
Staff opinions on use of videoconferences in psychiatric patients differed. The nurses in particular were concerned about whether professionalism could be maintained. Others experienced patients focusing more on the conversation when it took place via video because there were fewer disturbing elements. In general, expectations seem to influence attitudes toward using videoconferences.
Background
Telemedicine solutions are increasingly being used in the treatment of psychiatric disorders, and videoconferences (VCs) in psychiatry are one of the most common forms of telemedicine [Citation1]. VCs allow for easily accessible contact and increased access to care, and VCs may be an alternative to face-to-face (FTF) conversations, also in forensic psychiatry [Citation1–6]. VCs can result in the same clinical outcome as FTF interviews [Citation2,Citation3,Citation7–11], and their use is cost-effective [Citation11]. There are many advantages associated with the use of VCs, but there are also a number of disadvantages. For example, VCs are not suitable for all patients, lack of personal contact can affect the relationship between patient and staff, and technical challenges and lack of standards can be a challenge [Citation5]. The majority of patients in forensic psychiatry are diagnosed with schizophrenia spectrum disorders [Citation12,Citation13], and VCs seem feasible in these patients as well as in patients with bipolar disorder [Citation11,Citation14]. Treatment motivation and completion are low in forensic psychiatric patients [Citation5]. However, patients diagnosed with schizoaffective disorder have a better attendance rate, fewer appointments are cancelled by patients, and follow-up visits using VC are less time-consuming than in-person visits [Citation11]. The better attendance rates indicate that patients are motivated to use VCs [Citation5]. One concern regarding the use of VCs in patients with schizophrenia spectrum disorder is that the hallmark symptoms of the psychotic disorder may present challenges [Citation11,Citation15]; however, the distance afforded by VCs can be a positive factor in these patients. Psychiatric patients experience a higher degree of comfort during VCs because the distance afforded by the interaction is less anxiety-provoking and reduces the overstimulation seen in some in-person interactions [Citation6,Citation15]. VCs for crisis intervention have also led to a decrease in hospitalizations [Citation15]. In addition, patients experience a number of benefits, such as improved convenience, less stigma, more privacy, care in secure settings, and reduced transportation [Citation4,Citation5,Citation16–18]. Both patients and staff are generally satisfied with the use of telepsychiatry [Citation2,Citation16], and results indicate that satisfaction increases with the number of VCs held [Citation19,Citation20].
Staff satisfaction is one of the most important factors in the successful implementation of VCs [Citation6]. However, a lack of evidence regarding the benefits of VCs and relational and technical challenges can reduce satisfaction and the experience of advantages, especially among the staff [Citation2,Citation5,Citation16,Citation19,Citation21,Citation22]. Research also indicates that some staff experience difficulty reading body language, difficulty negotiating distraction and engagement, difficulty negotiating technology for care, and increased fatigue and administration. However, some also experience an increased intimacy with patients because they gain a glimpse into a patient’s home life [Citation23]. In the Region of Southern Denmark, all psychiatric patients should be offered digital contact if professionally relevant [Citation24]. The purpose of using telepsychiatry is to offer flexibility, create greater coherence, and reduce transport time, absences, and cancellations [Citation25]. Despite clinical evidence and a number of benefits, VCs have not been implemented to a similar extent in daily practice [Citation2,Citation4]. To achieve a nuanced understanding of the use of VCs, more research and qualitative studies are needed on the benefits and efficacy of VCs, and more focus needs to be placed on clinical variables such as compliance and evidence-targeted specific diagnoses [Citation1,Citation4,Citation16,Citation17,Citation20,Citation26–29].
Eighty percent of forensic psychiatric patients are treated as outpatients in Denmark [Citation30]. However, the use of VCs in forensic psychiatry is limited. Physical contact was difficult during the COVID-19 pandemic, and the number of virtual contacts (both video and telephone contacts) in forensic psychiatry in the region of Southern Denmark increased from 290 in 2019 to 2060 in 2020. Of these, 260 (2.5%) were VCs; the rest were telephone consultations. The aim of this study was to describe staff experiences with VCs during the COVID-19 pandemic and provide future perspectives on the use of VCs in forensic psychiatric outpatients.
Design and method
The study was designed as a qualitative study based on a pragmatic approach and consisted of semi-structured interviews with staff. An interview guide was developed in alignment with the aim of this study.
Context and participants
The study was carried out at forensic community services in the Region of Southern Denmark. Staff (nurses, psychiatrists, and psychologists) using VCs in daily practice in these services were asked to participate in the study.
Analysis
The interviews were audio-recorded and subsequently analyzed using a general inductive approach and the thematic analysis outlined by Braun and Clarke to identify, analyze, and report themes within the data [Citation31]. The thematic analysis was undertaken by the first author and discussed and interpreted with the co-authors through the following phases: (Citation1) The recordings were transcribed verbatim and then read and reread; (Citation2) Semantic units of meaning related to the study aim were identified; (Citation3) Coding and collating of data relevant to each code were undertaken manually; (Citation4) Collating codes into potential themes was performed; (Citation5) Themes were reviewed and refined; (6) Definitions and names were generated for each theme.
Ethics
Each participant’s anonymity was guaranteed, and the strictest confidentiality was maintained by the researchers. During the reporting of the interviews, quotes were extracted anonymously, thus rendering it impossible to identify individual participants. On inclusion, participants received thorough information about the purpose of the study and how the results would be used. Oral and written consent were obtained from each participant. The Regional Scientific Ethics Committee for Southern Denmark considered that formal approval was not required (Project-ID: S-20210133).
Results
Nine semi-structured interviews with staff were conducted. Staff included one psychiatrist, one psychologist, and seven nurses. Interviews were carried out either by telephone or at forensic community services. The interviews lasted 30–48 min. Two main themes were identified: (Citation1) Challenges due to technical uncertainty; (Citation2) Use of VCs as support in clinical assessment and treatment. The second main theme also included a number of subthemes: Lack of opportunity for observation of the patient’s overall situation; Compromise of nurses’ professionalism; Limitation of disturbing stimuli means more focus on the conversation; Telephone contact vs. video contact—pros and cons; Expectations reflect attitudes; Will professionalism be changed based on organizational and political perspectives?
Challenges due to technical uncertainty
Technical challenges such as interruptions, being unable to see each other, and audio delays arose during some conversations. Experiences and focus on technical challenges varied among staff. However, technical challenges seem to play an important role, especially for nurses. The staff mentioned that an essential prerequisite for good contact and communication was that patients mastered the technique. They often experienced that the patients could not figure out how to use the technique and that many patients made no effort to familiarize themselves with the technique.
And then, you as a therapist, don’t know what to do. You can’t just fix it for them. It’s simply too complicated.
VCs were usually conducted via the app MitSygehus, which is implemented in all departments of psychiatry in the Region of Southern Denmark and requires access with a personal code. The conversations take place via smartphones, tablets, or computers in an encrypted system, but during the COVID-19 pandemic, the use of Facetime was allowed for a short period. Here, technical challenges were fewer because the technique was simpler, and the system used was better known than MitSygehus. Some patients even asked that all the VCs be carried out via Facetime. However, not all patients have iPhones, which is a prerequisite for using Facetime.
Also, many of our patients change their phone numbers, which causes problems.
To make the use of VCs easier for the staff, the technique should be simple, easily accessible, and carefully explained.
There could be an opportunity for greater flexibility in emergency situations if you were better acquainted with the technique.
Use of VCs as support in clinical assessment and treatment
Overall, staff agreed that VCs had to be combined with FTF contact and that an existing therapeutic relationship was a prerequisite for using VCs as clinical support. The nurses, especially, often mentioned that VCs are best suited for clarification of a concrete problem or during the last part of a course of treatment. The contact between patient and therapist is not the same during VCs as it is when they meet FTF, and therefore, VCs are best suited for a more formal conversation because the conversation becomes more concrete with less room for small talk. However, VCs can be used as a supplement in some patients and to support the treatment when the patient is working or moving. In addition, VCs may allow for flexibility in emergency situations. Whether the use of VCs is suitable for a patient depends more on an individual assessment and the patient’s clinical condition than on the patient’s diagnosis:
It hasn’t so much to do with the diagnosis. It has more to do with how badly they are affected and how well they otherwise function.
It’s always the same topics we talk about. The subject matter is the same, but the quality isn’t.
The following sub-themes elaborate on the staff’s experiences and considerations regarding the use of VCs as support in clinical assessment and treatment.
The lack of the opportunity to observe the patient’s overall situation compromised the nurses’ professionalism
Both staff and patients experienced that they lost something. Because VCs were shorter than FTF conversations, patients might have felt cheated in relation to the quality of treatment. The staff expressed doubt whether what they saw on the video was representative of how the patients felt, partly because non-verbal communication, such as body language and nervousness, was less obvious. The nurses often expressed that they lacked an impression of the patient’s overall situation, for instance, regarding personal hygiene, if they did not visit the homes. They experienced gaining more knowledge about the patient and more observations during home visits than during VCs:
I cannot see what the patient’s apartment looks like, and I cannot observe the patient’s hygiene. I also find it really difficult to assess mood and psychotic symptoms. I don’t see any advantages of using VCs except in situations where patients are too far away for a visit…
Based on the staff’s current experiences but also on notions and attitudes about the future use of VCs, there may be a number of situations where VCs can be considered as a supplement during the course of treatment.
Limitation of disturbing stimuli means more focus on the conversation
Staff experienced that some patients stayed more focused on the conversation when it was carried out via a VC, especially if they needed a low-impulse environment. An interesting experience came about in connection with COVID-19 restrictions when VCs were used in a residential facility, and staff lent their iPads to patients:
The thing is that some of the patients are often disturbed by all kinds of external stimuli when we sit and talk FTF. However, with VCs, there was more contact, or there was much more focus on the conversation. They thought it was fun and exciting. These patients were probably people who sat for hours in front of their computers. Maybe they were a bit nerdy and used to online gaming. It was interesting to me because I thought it was actually easier for me to talk to Peter today because he’s used to looking at a small screen. Many of the patients are somewhat nerdy; it’s their only life, and for once, I was where he was.
It’s part of the nature of the disease that you can’t start off right away - there was someone recently who said that it is a complete waste of time to sit and ask if the weather is nice. We can both see that it is. They go straight to the core of the problem. The experience has been that it works for far more people than we thought. We actually also thought that the patients would become paranoid about who was listening and what was being recorded. It’s either the patients don’t become paranoid, or it’s because we haven’t spoken with patients who have those thoughts.
Telephone contact vs. video contact—pros and cons
Staff did not agree on whether the use of VCs was better than telephone contact. Some staff felt that an advantage of VCs compared to telephone conversations was that it was easier to spot medication side effects. Others mentioned that VCs could be an opportunity for more contact with patients than that provided by a telephone call:
I think contact is better in one way or another when there is a picture to look at. So, it’s like it’s a little more earnest, a little more… serious…
Expectations reflect attitudes
There were large differences in how often the staff had used VCs. The results indicate that the different perceptions regarding the use of VCs were based on assumptions and attitudes and not on actual experiences:
To be honest, I've offered it to very few people because I don’t think it’s right. I think it is disrespectful to a psychiatric patient to even think of doing this.
Some staff had read that some patients felt more relaxed during a VC. Others imagined that the patients’ paranoid ideas got worse, while others imagined the opposite. One staff member indicated that it could be used in 20–30% of her caseload.
The staff’s own expectations regarding the conversations when VCs were used seemed to play a significant role, especially if one expects that using VCs should be the same as sitting in the same room.
Ninety percent of the content of my conversation with a patient is being present (FTF), and you just can’t be that on video. It’s also very much about myself. I find it difficult to sit before a screen and be perceived from a screen because I don’t think that VCs enable me to do the same as I can when I meet FTF, and VCs are subject to hundreds of misinterpretations when we converse in that way. There are large margins of error, especially in this category of patients.
Will professionalism be changed based on organizational and political perspectives?
Even though a large part of the staff did not like to use VCs, some saw a number of organizational advantages. Using VCs means saving resources, including saved travel expenses for the patients, and it is easier to have a conversation within the planned time when VCs are used. The shortage of doctors is a major problem in psychiatry, and some of the staff saw potential in using VCs because they enable better use of staff time. However, a concern regarding political interference was also expressed.
Of course, the downside can be if there is some kind of political interference, because this might result in our not seeing the patients in person, and that’s what we should do…
The nurses, in particular, expressed concern that management and politicians might like the idea, but “they can’t demand that we use it because it will never work”.
Use of VCs can, for example, be used in residential settings, but only if you have to think about costs. But in general, you don’t save money by weakening the therapeutic process, and use of VCs can increase costs in the long run.
Discussion
The aim of this study was to describe staff experiences of using VCs during the COVID-19 pandemic in addition to telephone consultations and FTF consultations, and to illuminate perspectives regarding the inclusion of VCs in the treatment of forensic psychiatric outpatients. Two main themes were identified, Challenges due to technical uncertainty and Use of VCs as support in clinical assessment and treatment. A number of subthemes were identified in connection with the second main theme.
Technical challenges were highlighted as a prominent theme. However, experiences varied among staff, but there seemed to be agreement that the use of simple and well-known techniques such as Facetime, rather than the hospitals’ MitSygehus system, decreased the technical challenges for both staff and patients. As in other studies, technical challenges were common [Citation5,Citation18,Citation20,Citation32]. Staff who have experienced technically successful VCs are more likely to use video again [Citation20]. This is supported by the results in the present study and indicates that easily accessible and simple systems can be a prerequisite for routine use of VCs.
There appear to be differences in opinion regarding professional views of the use of VCs, as shown in the results of other studies [Citation5,Citation6]. Experiences in this study were closely linked to expectations and attitudes. Staff did not agree on whether VCs were suitable for patients with schizophrenia. Some staff expected that the patient’s symptoms would worsen, while others perceived the patients to be more relaxed during VCs. Staff expectations seemed to play a significant role in terms of experiences and attitudes toward the use of VCs. Existing research shows that staff are generally more skeptical than patients [Citation2,Citation21,Citation33,Citation34]. However, VCs can be feasible for patients with schizophrenia spectrum disorder or bipolar disorder [Citation11]. Patients experienced a higher degree of comfort because the distance provided by VCs is less anxiety-provoking and reduces the overstimulation seen in some in-person interactions [Citation15]. In keeping with these findings, staff with positive expectations experienced that patients were more focused on the conversation and that there was better contact because they were not distracted by external stimuli. One of the reasons for concern among nurses in this study was that they were often worried about compromising their professionalism because they felt unable to experience the patients’ overall situation and had difficulty reading non-verbal communication when VCs were used.
In the Region of Southern Denmark, the use of VCs in the care of psychiatric patients has been possible for a number of years. However, only a small proportion of patient contacts, even during the COVID-19 pandemic, took place as VCs. One explanation could be that only a few staff members had used VCs prior to the COVID-19 pandemic [Citation6]. Several of the staff could see a number of organizational advantages, but others had a number of concerns. Nurses mentioned concerns about their professionalism as well as concerns about organizational changes and political interference. For example, several were worried that the use of VCs could become a requirement, meaning that they would no longer see the patient’s FTF, which the nurses expected would impair treatment. A large number of the staff felt that it was not necessary to use VCs, and therefore, their use was perceived as less acceptable, corresponding to a deterministic view of using technology [Citation35,Citation36]. Here, the technology is perceived as setting the framework and governing how health professionals must carry out their jobs. [Citation36] This perception is often associated with a risk factor in relation to the interpersonal relationship. In contrast, an instrumental approach to using technology in the health sector presents a perception that technology has the potential to be a useful tool for making processes more efficient and simpler [Citation36]. One staff member estimated that 20–30% of her caseload could benefit from the use of VCs. This feedback was based on both positive experiences and positive expectations. In an instrumental approach to the use of technology, it is assumed that you can foresee the practical effects of the technology and that staff will experience a number of benefits [Citation36]. The instrumental view often collides with everyday practice, as it is only possible to identify effects and challenges when the use of technology is implemented on a large scale. In a Danish context, there is very little experience and few research results on the use of VCs in psychiatry. Therefore, it can be difficult to predetermine the effect. However, based on the results from international studies, it cannot be ruled out that increased use may change the perception of technology because opportunities and limitations will become more apparent.
Limitations
The study was characterized by several strengths and limitations. A strength was that it provided knowledge about staff experiences in forensic psychiatry that have not previously been investigated in a Danish context. It would strengthen the study if it had been possible to include patient interviews. However, only three patients were interviewed, and therefore, it was not possible to include this aspect in the study. The staff recruited the patients, but no systematic overview was available regarding how many patients they had asked and what the reasons were for non-participation. It would have strengthened the study if more doctors and psychologists had been interviewed.
Perspectives and Future Research
This study, like other studies in forensic psychiatry, is characterized by both positive and negative opinions from staff on the use of VCs [Citation5]. In general, there is a lack of evidence on the use of VCs, and it is important to ensure that the use of technology has added value for the patient and treatment [Citation5]. Existing research indicates that VCs must be adapted to a greater extent to the needs and preferences of both patients and staff [Citation5]. One way to do this could be to adapt their use to the individual user and to develop best practices to promote well-being and prevent fatigue and burnout by mental health staff [Citation5,Citation23]. There is a need for more studies focusing on the clinical effect, possibilities, and limitations before future perspectives can be identified and a more user-centered design can be developed [Citation5,Citation23]. However, the results suggest that simpler techniques can increase the use of VCs.
Acknowledgments
The authors would like to acknowledge Jascha Fonden (Grant 2021-0039) for funding the study and Edwin Stanton Spencer for the English language review.
Disclosure statement of conflicting interest
The authors declare that there is no conflict of interest.
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