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.
VC communication between the regional centres and the on-call psychiatrist involved the patient directly, as opposed to the established use of telephones, and strengthened patient involvement. Although some of the patients said they had been sceptical about communicating through VC in advance, they experienced stronger confidence and a feeling of being taken more seriously afterwards the VC consultation. The patients emphasised that the direct contact with the psychiatrist made them calmer and ensured that the right assessment and decisions were being made.
VC gave me the possibility to speak directly with the psychiatrist while the nurse was sitting next to me. I could actively take part in the assessment. (Patient 5)
I may have become annoyed, or maybe offended, if the communication about my mental health had been based on the view of the nurse. It was nice to be able to present my own story [directly to the psychiatrist]. (Patient 3)
This statement by Patient 3 emphasises the need or wish for expert assessment from a specialist and not `based on the view of the nurse’. For patients in this situation, experiencing that extra efforts are being made to ensure the highest quality of care is very meaningful. Patient 3 also said, `VC was helpful and calming. I understood that they took me seriously when they had to use VC’. From this patient’s perspective, the use of VC meant that all available resources were being used to provide the best help possible.
The nurses and psychiatrists also found that VC enabled stronger patient involvement.
A telephone call is quicker. In spite of that, I am more satisfied with my work after VC because the patient has received a better service. (Nurse 4)
Through VC I can see and talk directly with the patient, and then I get a better overview of the situation when I feel it is necessary. A VC consultation provides more than a telephone call. (Psychiatrist 5)
When the psychiatrist meets the patient [..] more people have observed and evaluated [the patient], we all know each other’s thoughts, and of course this improves the confidence both for the patient and for us. (Nurse 5)
The patients got more involved in the communication between the nurse and the psychiatrist when VC was used, and this changed the social dynamics of the consultation. When the voice of the patient was no longer mediated through the nurse, the nurse was relieved of a mediator’s responsibility, as pointed out above. The patient felt that he or she was taken more seriously by being allowed to take part in direct dialogue with the highest level of formal expertise.
In challenging psychiatric emergencies, the nurses at the regional psychiatric centres were sometimes uncertain about how to respond; they would then ask the on-call psychiatrist to see the patient. In these situations, they would also want to discuss the patient’s situation and have access to help to collaboratively decide on the best treatment options. In these situations, using VC reduced uncertainty and ambivalence. One of the nurses said that using VC provided an opportunity `to assess the patient together with someone who also can see the patient, who can see the same things as I, or maybe something I haven’t seen, which makes the assessment sufficient’ (Nurse 10). When the psychiatrist had seen the patient, the nurse also gained professional support for his or her preliminary assessment, which improved their confidence in their own skills:
What I consider most important is that the psychiatrist can watch the patient and assess the patient based on what he sees. This is a support for me, if I have observed the same things. (Nurse 9)
In challenging situations or when in doubt, the psychiatrists also wanted to see and talk with the patient in order to make well-considered decisions. When VC was not used, a telephone call was made by the nurse to the psychiatrist to present their view and interpretations and to discuss next steps. However, aspects of the patient’s condition that were difficult to convey verbally and that potentially would require direct observation were potentially lost or overlooked when the psychiatrists only received information through the nurse. Therefore, the quality of assessment and decision-making was strengthened through the VC contact between psychiatrist and patient. The psychiatrists said that having the patient visible on the screen in front of them was important.
I feel more confident when I in fact have seen the patient face to face. (Psychiatrist 2)
I am more certain with a decision I might not make otherwise without having seen the patient. [Seeing the patient through VC] is something different than receiving a story told by others. (Psychiatrist 1)
At times, when I don’t know the nurse or the patient, and if it is a serious situation, I may feel uncertain. If the story told by the nurse is not in lined with the story from the referring general practitioner, my gut feeling tells me something is not right. Then I may have a need to enter the situation myself. (Psychiatrist 5)
I think we have to see the patients. If we cannot meet them face-to-face, we should see them on VC. This service would have been less certain without it, and we might need to take chances. I believe the risk would have been greater if we didn’t meet the patients ourselves with VC (Psychiatrist 3)
The use of VC was therefore regarded as a method to ensure high-quality decision making, which increased the confidence for all involved that the best decision was being made for each patient. This included the opportunity of receiving a second opinion from a psychiatrist or having immediate access to the experience and competence of a psychiatrist in a challenging situation. Also, during VC sessions, several participants are able to present their views, thereby increasing both the understanding as a group comprised of the clinicians and the patient and the collective confidence in — and commitment to — the decisions being made.
The use of VC increased the confidence of both the nurses and psychiatrists because more than one person was able to observe and communicate with the patient. VC made it easier to share the responsibility for patient treatment, which was especially important in challenging situations, such as for suicidal patients. For the nurses at the regional centres, sharing the responsibility for decision-making with a psychiatrist was of great support.
My assessments are supported in situations in which I would otherwise feel alone. (Nurse 2)
Assessment of suicidal patients [..] is a responsibility I do not want to have. (Nurse 8)
For me, this is all about shared responsibility. [..] VC gives me the opportunity to discuss my concerns, the patient may participate in the discussion, and then decisions can be made. (Nurse 8)
The psychiatrists emphasised that the nurses at the regional centres in general had made safe and sound patient assessments before contacting the psychiatrists. In some cases, however, the nurses needed a psychiatrist’s confirmation of their assessment. One of the nurses said, `It is also important to receive confirmations that you have done and said the right things’. (Nurse 10)
Although the use of VC was usually initiated by the nurses at the regional centres, some of the psychiatrists reported that they asked for VC when, during a telephone call, they heard that the nurse felt insecure. As Psychiatrist 2 said, `I suggest VC when the regional staffs are uncertain and I am unable to form a picture of the patient and the problem’. The combination of not being able to see the patient with their own eyes and feeling that the nurse was uncertain about, for instance, the seriousness of a situation, was a motivation for initiating VC. This led to the professional support from the on-call psychiatrists being more specific and sensitive to each patient’s case. The psychiatrists’ direct view of the patients provided a stronger experience of a shared responsibility. They became involved as an observer together with the nurse and were not just an external advisor.
A safety net
Finally, the nurses and the psychiatrists emphasised the availability of VC as a safety net. Although they did not actually use VC very often, the on-call system implied that the psychiatrists could be accessed by the regional centres through VC 24 hours a day. With a specialist only a VC connection away, the healthcare providers felt less uncertain in seriously and challenging psychiatric emergency situations.
I feel much more confident. [..] I come to work with a much greater degree of calmness than before. (Nurse 10)
There is always someone there. [..] I am never alone. (Nurse 8)
VC as a safety net was reported as being particularly important during the evenings, nights and weekends, when there were fewer health personnel at the centres.
I often work night shifts, and I know there is always a psychiatrist on call to help me in the event of an emergency. [..] Yes, I do feel it has eased my work. (Nurse 7)
I feel more confident when I know we have the VC opportunity. The staffs know it, and the patients know it to some degree. I believe it has a positive contagious effect on us all. (Psychiatrist 5)
The improved confidence among the nurses may have actually led to more seriously ill patients being admitted to the regional centres rather than sending them to the acute hospital ward in Tromsø. Based on VC as a 24-hour safety net, the nurses knew that they could consult a psychiatrist for further assessment at any time. If the patient’s condition changed, the patient could be reassessed, and decisions could be quickly revised if required.
The availability of VC is almost as important as the actual [use of] VC. It gives us all a degree of confidence. We can just use it if we need it. (Psychiatrist 5)
The safety net argument is of major importance in emergency care, as this work is characterised by having to immediately solve problems using any tools at hand. The opportunity of expanding the telephone communication between the psychiatrists and the regional centres by VC has value as an option itself.