Table 3 Results from content analysis in the context of mechanisms and components of Normalization Process Theory

A.1 Differentiation

B.1 Initiation

C.1 Interactional Workability

D.1 Systematization

Health care in CF apart from VC

• According to nursing staff, the health care of patients is sufficient compared to health care outside of CF

• Reduced access to health care for inmates during the night and on weekends

• Nursing staff in CF work autonomously. This involves decision-making processes without physician’s support. Taking responsibility for first-line medical decisions is part of nursing staff’s professional identity

• Medical staff has to be present during VC to prevent damage to VC equipment

• No additional time was allocated for VC

• Additional workload caused by implementing VC: VC has to be conducted in addition to regular workload

• Timely documentation of VC by telemedicine physicians was necessary

• Lower amount of sick days (patients), since VC provided the possibility to schedule a consultation immediately instead of having to wait for regular consultation hours of physicians in CF

• Duplication of work: Patients had to consult the physician in the CF in addition to VC

• VC were suitable for times when no physician is present in the CF

• VC were not suitable for emergencies

• VC were suitable for night shifts or as background services

• VC should be implemented at an appropriate time (avoiding vacation season, staff shortage, renovation in CF)

• Nursing staff had a positive impression of telemedicine physicians and describe them as open-minded and communicative

• Collaborating with telemedicine physicians was easier if telemedicine physicians spoke in a calm, neutral and professional way during VC

• It negatively impacted their cooperation when telemedicine physicians questioned the medical treatments administered by physicians in CF

• The possibility to use interpreters during VC was seen was an advantage

• Image and sound artifacts had an impact on the quality of VC

VC compared to regular health care

• Staff situation and resources are limited in CF and provide little room for VC

• VC are more time-intensive in terms of preparation and documentation of the consultations, VC are less time efficient

• Many processes in CF are paper based and thus require physical presence of a physician (for signatures etc). Signatures cannot be provided during VC yet

A.2 Individual specification

B.2 Legitimation

C.2 Relational integration

D.2 Individual appraisal

• On an individual level, members of the nursing staff were curious of the new health care service/VC

• Nursing staff was sceptical towards the new technology/VC

• Telemedicine physicians had different experiences in working in CF, ranging from many years of experience to no experience at all

• Computer skills were beneficial for the acceptance of the new health care service

• Telemedicine physicians should be trained in medical treatment of patients with addictive diseases

• Most nursing staff were already experienced in consultations via telephone

• Medical staff had a strong positioning as self-sufficient problem managers. To a large extent, they made first-line medical decisions on their own

• Nursing staff perceived the implementation process as a top-down-process

• Flexibility/adaptability required from telemedicine physicians

• Building mutual trust is essential for a successful long-term cooperation between nursing staff and telemedicine physicians

• Establishing a trustful cooperation between nursing staff and telemedicine physicians takes time

• Nursing staff motivated patients to participate in VC

• Establishing a trustful relationship between telemedicine physicians and patients takes time

• Instructions provided by colleagues (nursing staff) were not sufficient as initial training

• Enough time and a quiet environment was essential to practice and learn how to conduct VC

• VC can become a routine practice if practiced regularly (learning by doing)

• Discrepancies in terms of technical knowledge of nursing staff and members of the technical support hotline of the telemedicine provider

• Telemedicine physicians were satisfied with the remuneration for VC

A.3 Communal specification

B.3 Enrolment

C.3 Contextual integration

D.3 Communal appraisal

• VC should be implemented at an appropriate time (avoiding vacation season, staff shortage, renovation in CF)

• VC was considered meaningful in non-critical situations, e.g. sick leave or substitution, when enough time was available

• VC were described as an alternative when physicians were absent (e.g sick leave of physicians, on weekends or during night time)

• VC without a patient was considered useful by nursing staff

• Data protection and medical ethics had to be guaranteed during VC

• Recurring time delays (due to technical or organizational issues) during VC negatively impacted the implementation process

• The weekday, time of day and available nursing staff (for VC) need to be planned and agreed upon in advance

• To ensure continuity, telemedicine physicians need to be appointed to specific CF

• Physicians in CF cannot be replaced by VC

• VC should be implemented at an appropriate time

• VC were suitable for evaluating the inability to work and for issuing sick leaves

• VC were suitable for admission examinations only to a limited extent

• It was not possible to treat the same number of patients in the same amount of time using VC compared to regular consultation hours

• To ensure sufficient training, initial training courses should be offered for new colleagues (nursing staff) at the beginning of their employment

• Insufficient internet connection and frequent interruptions of image and sound obstructed VC

A.4 Internalization

B.4 Activation

C.4 Skillset workability

D.4 Reconfiguration

• Nursing staff acknowledged that VC can provide additional support for their own medical decisions when needed

• VC were perceived as unnecessary if telemedicine physicians had to refer patients to existing health care services in CF

• VC can prevent transfers of inmates to nearby hospital or physician outside of CF

• Nursing staff feel supported in their decision-making by VC

• Technical equipment had to be installed.

• A suitable room for VC had to be found

• Instruction and training of nursing staff was needed

• Training should to be provided by specialists of the VC company

• When equipment was missing it was quickly provided by the telemedicine provider

• In case any technical problems occurred, they were quickly solved by the telemedicine provider

• The quality of the internet connection had an impact on the quality of VC

• Weekly VC hours need to be planned in advance: patients need to be selected for VC while considering the medical specialty of the available telemedicine physician

• To facilitate the conversation between telemedicine physicians and patients, nursing staff acted as medical “interpreters” during/after VC

• A clear and neutral wording facilitated the communication with the patients

• Communicating with patients and nursing staff was the most important tool during VC, since telemedicine physicians were not able to physically examine the patients themselves

• VC should be used in a needs-oriented and flexible way

• The possibility for patients to talk to telemedicine physicians without nursing staff in certain cases (e.g. psychiatric cases) should be provided

• Additional medical specialties for VC: Dermatology, urology, rheumatology, ear nose throat specialists

• Organize VC in collaboration with other federal states, e.g. using a shared database of telemedicine physicians (if the pilot project is implemented in other federal states)

• Image and sound quality should be improved

New tasks/responsibilities of nursing staff:

• In addition to their regular tasks, nursing staff took over physicians’ tasks during VC (e.g.auscultation, palpation)

• Nursing staff acted as intermediaries, mediators and facilitators between telemedicine physicians and patients during VC

• Nursing staff passed on information to telemedicine physicians during VC: medical history of the patients, specific information about the CF (e.g.available medication, possible medical procedures)

• Organizing, preparing and following-up VC

Extension of VC/additional equipment:

• Digital, electronic stethoscope and otoscope

• High-resolution camera, dermatoscope

• Offer the possibility to upload documents into the software in order for telemedicine physicians to access them directly (physician’s letter, diagnostic findings, medical imaging)

• Interpreter (already exists)

• Camera for specially secured detention areas in CF, body camera for nursing staff

• Provide telemedicine physicians with access to electronic files of the CF (interface)

• Offer training with new equipment