Video-confidence: a qualitative exploration of videoconferencing for psychiatric emergencies

De-institutionalisation, in the form of providing patient services through outpatient clinics and day treatment rather than hospital stays, is a strong and growing trend in healthcare services. In psychiatric hospitals, this process began in the 1960s and benefitted most psychiatric patients, although many were left without proper care [1]. The process of de-institutionalisation occurs today partly for economic reasons and partly because new treatment options are making it increasingly feasible. In addition, maintaining life in patients’ own communities is also believed to help them better manage their disease and their lives [1].

The Ministry of Health and Care Services in Norway aims to improve collaboration between the different levels of healthcare services, as well as to reduce unnecessary and compulsory admissions in acute psychiatric wards, by re-organising and de-institutionalising healthcare services [2]. However, such changes may be particularly challenging in rural areas, especially for psychiatric emergencies, where the availability of specialists is limited.

Tele-psychiatry, via real-time videoconferences (VC), is increasingly being used to provide advanced consultative services in areas that lack local access to psychiatrists [3]. The use of VC can improve this access by connecting psychiatrists to health personnel and patients from a great distance, and a broad range of mental health issues has been successfully handled using this technique. Studies have found that tele-psychiatric services used in non-urgent situations have increased patients’ access to therapy, increased patients’ satisfaction, saved time and reduced patients’ need for travel [3]-[10]. Young patients have stated that the use of VC communication in therapy alleviated their previous anxieties about consulting a psychiatrist [5]. In addition, via regular access to specialists through VC, health personnel experienced increased knowledge and improved confidence in assisting patients locally [3].

Both in psychiatric and somatic medicine, medical emergencies are characterised by complexity, uncertainty, lack of information, distances between patients and health personnel and decisions that may be retrospectively judged by others as suboptimal. The use of VC in these situations may therefore be thought of as challenging and as causing an unwanted shift of focus away from the patient and towards technology. At the same time, there is a need to develop new methods for providing proper emergency care for mentally ill patients in rural areas. The use of VC in psychiatric emergencies has been found to be safe, effective and satisfactory for both the patients and emergency health staff [11],[12]. There is, however, limited research on the use of VC for psychiatric emergency consultations [11],[12], and there is a need for increased knowledge of emergency tele-psychiatry in operation.

The aim of this article is to explore the experiences of patients, psychiatrists and nurses regarding the use of VC for consultations in psychiatric emergencies and how the technology influences their confidence. The article is based on a qualitative study of the implementation of the first Norwegian tele-psychiatric emergency service, which was established in 2011 by the University Hospital of North Norway [13].

The regional psychiatric centres were found to largely operate autonomously. On-call psychiatrists were regularly contacted via telephone by the nurses, although not on a daily basis. Because the use of the telephone was a well-established practice between the regional centres and the psychiatrists, the VC system was mostly seen as a supplement to the existing telephone communication. VC was used in the more challenging situations, in which the nurses or psychiatrists were uncertain about the patient’s assessment and/or further treatment. In most cases, telephone calls were used as dyadic communication; e.g., between one nurse at a regional psychiatric centre and the on-call psychiatrist. When using VC, however, the patient and often a second nurse were also included in the communication.

In the analysis of the participants’ experience with applying VC, various accounts relating to confidence emerged and were grouped into a core empirical theme. We found that having access to the VC system increased the experience of confidence in challenging psychiatric emergencies in four different ways: (1) by strengthening patient involvement during psychiatric specialist assessments, (2) by reducing uncertainty, (3) by sharing responsibility for decisions and (4) by functioning as a safety net even when VC was not used. We explore these accounts in more detail in the following subsections.

In this discussion, we reflect on our findings in a larger context, both theoretically and in relation to practical implications. It is important to note that the use of VC analysed in this paper is within the context of medical emergencies. In both psychiatric and somatic medicine, decisions need to be made within a short timeframe, during which confidence in actors, their handling of tasks and their decision-making is of great importance to effectively address any acute situation. It has been demonstrated that communication technologies that are well-integrated into team collaboration increase quality by applying knowledge and experience across personnel and locations [17]. In previous trials of VC within the context of simulated cardiac arrest, visual contact through VC improved the confidence of both the rescuers and the nurses [18],[19]. In addition, hospital teams worked together more efficiently and with greater confidence when VC was used as a collaboration tool for complex medical emergencies and traumas [20],[21]. Our study has shown that VC may increase certainty, improve the sharing of information and contribute positively to teamwork in challenging psychiatric situations. The presence of VC as a treatment tool therefore supports preparedness for medical emergencies.

At a more conceptual level, we have identified two main mechanisms for generating stronger confidence within the provision of emergency psychiatric care: (1) using VC for collaborative problem-solving across locations and professional levels that involve patients and (2) maintaining VC as a feasible resource for challenging situations. Both the psychiatrists and the nurses emphasised how the use of VC for collaborative problem-solving across locations and professional levels increased their confidence. By solving a problem through a team process, their uncertainty about the right assessment was reduced, and they shared the responsibility for decisions made in challenging situations.

In our study, to determine if the psychiatrist needed to be contacted, the nurses always performed an initial assessment for each patient. Often the psychiatrists confirmed these assessments; hence, collaborative problem-solving improved the nurses’ confidence in their own skills and competence. This finding is in line with previous studies comparing the effectiveness of VC to telephone calls, which found that the VC groups had increased confidence among participants and improved their ability to collaborate as teams [18]-[22]. Including the patient in the VC-mediated team process allowed him or her to take an active part in their assessment and felt included in the decision-making process. Patient involvement meant that the patient’s voice could be heard without first being filtered through the nurse.

The second main mechanism that we identified was maintaining VC as a safety net for challenging situations. This safety argument is of major interest because it challenges the idea of frequent use as a success criterion for technological innovations. Having the opportunity to use VC in a difficult situation is a source of confidence even when it is not used. Accordingly, it has been demonstrated that having a specialist’s e-mail address is important for chronically ill patients even if no e-mails are ever sent [23]. For the nurses at the regional psychiatric centres, just knowing that they could access the on-call psychiatrist through telephone or VC whenever they need it made them calmer and feel less alone. This opportunity is also an important aspect of confidence for the psychiatrist; i.e., knowing he can see and talk with the patient directly if he consider that it is necessary. VC as a safety net improved confidence among the nurses. Having the VC system set-up and being trained in how to use it strengthened the regional centres’ ability to handle and admit challenging and more seriously ill patients. A very important finding is that this effect was not dependent on the actual use (or frequency of use) of the VC system; rather, it was only related to having the VC equipment installed and being confident in using it. In addition, all parties knew that the nurses could contact the psychiatrist again later for reassessment if the patient’s situation worsened.

The introduction of VC is a minor technological innovation, as VC technology has been well-established for many years. However, our study confirms that in psychiatric emergencies, including VC into a network between regional psychiatric centres and specialists at a central hospital may trigger significant organisational development. The nurses experienced the support of specialists, both as confirmation of their own assessment and as a safety net for dealing with challenging situations. At the same time, the patients experienced that the VC connection represented a major effort being made for their sake: It was a reassurance of the health personnel taking the needs and worries of patients seriously. Our analysis supports the sociological notion of a paternalistic public health service [24], in which patients trust doctors’ advice more than other health personnel’s assessment. Also, to some degree, this explains the effect of direct contact with the psychiatrist: Being taken seriously is related to the progress of the actual consultation, as well as to the formal position of the clinician who manages the consultation.

The VC installation afforded another level of regional collaboration for handling psychiatric emergencies. By applying an affordance perspective[25],[26], we emphasise how various actors perceive the application of VC differently and how these different perceptions contribute to organisational changes within the delivery of emergency psychiatric services over time. By having direct access to the psychiatrist, the patients felt that they were taken more seriously. The nurses experienced VC as providing shared responsibility and as a safety net, and the psychiatrists were able to provide better assessments as the patients were visible and given a more active role. While these experiences reflect affordances of VC in psychiatric emergencies, the four themes in our analysis are related to various aspects of confidence that are not related to purely technical qualities. Rather, the potential use of VC provides a greater transparency between the central and local healthcare providers, as well as between these providers and the patients. This may represent a `good circle’ of developing greater trust between actors in the provision of emergency psychiatric care.

Our analysis also supports a more reserved belief in the collaboration/education argument for implementing tele-medical applications: Stronger professional confidence among local healthcare staff may in the long run give them a more independent position in relation to centrally placed specialists. However, due to the inclusion of patients’ voices in our analysis, we have identified that patients in very vulnerable situations have a need for direct access to the highest level of formal expertise. Although well-founded assessments were made by the nurses in this study, patients submit to a taken-for-granted warranty in a doctor’s clinical gaze. While health service provision is becoming more interdisciplinary, specialised health advice today comes from many more sources than just medical doctors. However, physicians’ knowledge and practice hold a strong position in the general population [24], and this needs to be taken into consideration when handling particularly vulnerable mentally ill patients.

This study has demonstrated that an emergency psychiatric service delivered by VC may improve the confidence of psychiatrists, nurses and patients in challenging psychiatric emergencies. Even if VC is not used often, it serves as a safety net for challenging situations, which increases the confidence of both nurses and psychiatrists. This illustrates that frequent use is not necessarily a success criterion for the application of technological innovations to emergency care.

When VC is used as an alternative to telephone calls, a group of people can see and hear each other at the same time. This means that all participants-patients, nurses and psychiatrists-can take an active role in the assessment and decisions-making process through face-to-face communication. VC is a richer mean of communication through which participants, especially patients, experience increased trust in each other and improved confidence in the decisions that are made. We therefore conclude that VC can be an important tool for building confidence in psychiatric emergencies and that patients, nurses and psychiatrists experienced that VC enables the provision of high-quality services for patients who need emergency psychiatric care that is located close to their homes.

MT, SRB, GØS and AT planned and designed the study. MT conducted the interviews. MT and AT coded and analysed the interview data. MT and SRB drafted the manuscript. GØS and AT revised the document for important intellectual content. All authors have read and approved the final manuscript.