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• To read the findings of a study that explored patients’ and professionals’ experiences of virtual clinics during COVID-19
• To recognise the need to assess individual patients when considering the use of virtual clinics
• To acknowledge the need for appropriate training and equipment for staff to enhance their experience of virtual clinics
Background The coronavirus disease 2019 (COVID-19) pandemic resulted in the rapid implementation of virtual clinics to conduct consultations via telephone or video to minimise contact between staff and patients.
Aim To investigate the experiences of patients with cancer and healthcare professionals of virtual clinics during COVID-19 and to explore ways to improve their experiences.
Method A qualitative study involving semi-structured interviews with 36 patients and ten healthcare professionals at a London NHS trust. Data were analysed using thematic analysis.
Findings Five themes emerged from analysis – acceptance, benefits, communication, technology and choice. Most participants were accepting of virtual clinics and supported their continuing use. The average satisfaction rating for virtual clinics was higher among patients than among healthcare professionals; many healthcare professionals suggested that support in setting up video-based virtual clinics might improve their satisfaction.
Conclusion Patients’ individual needs should be considered when deciding whether to use virtual or face-to-face clinics, while staff require appropriate training and adequate equipment to enhance their experience of virtual clinics.
Cancer Nursing Practice. doi: 10.7748/cnp.2023.e1854Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated software
Poovamnilkunnathil A, Nabhani-Gebara S, Dalby M (2023) Exploring patients’ and healthcare professionals’ experiences of virtual clinics during COVID-19. Cancer Nursing Practice. doi: 10.7748/cnp.2023.e1854
Published online: 11 December 2023
The World Health Organization (2020) declared the coronavirus disease 2019 (COVID-19) outbreak a pandemic on 11 March 2020. As a result of the pandemic, many areas delivering non-COVID-19 healthcare – including cancer services – had to stop or reduce their services significantly to prioritise the care of patients with COVID-19 and prevent transmission of the virus (British Medical Association (BMA) 2020). Timely cancer detection, diagnosis and treatment are vital to improve the likelihood of favourable outcomes (Neal et al 2015, BMA 2020). As patients with cancer are often immunosuppressed, they are already susceptible to infection and are at risk of developing severe complications if exposed to the coronavirus, which could result in the need for invasive ventilation or even death (Neal et al 2015, BMA 2020).
In the UK, many hospitals rapidly implemented virtual clinics to minimise contact between staff and patients where possible. A virtual clinic, which can be conducted using telephone or video, is a scheduled appointment between a patient and a healthcare professional for the purpose of a clinical consultation, advice or treatment planning (Greenhalgh et al 2016). Virtual clinics are encompassed within telehealth, also referred to as telemedicine, where medical information is exchanged from one site to another through electronic communication to improve a patient’s health (Tuckson et al 2017). Teleoncology is a term that describes the use of virtual clinics in oncology (Debnath 2004, Tashkandi et al 2020, Dalby et al 2021).
Evidence suggests that virtual clinics have been effective in reducing waiting times, travel time and travel costs and increasing efficiency in the use of healthcare resources (Sirintrapun and Lopez 2018, Al-Shamsi et al 2020a, Gilbert et al 2020, Pham et al 2020, Smrke et al 2020, Tashkandi et al 2020). However, there are also challenges associated with their use, such as problems using technology, issues related to patient confidentiality and lack of accessibility for some patients, for example those with impaired hearing or where there are language barriers (Odeh et al 2014, Sabesan et al 2014, Jones et al 2018, Wallis et al 2020).
The study presented in this article builds on a previous study by Dalby et al (2021), conducted at the same London trust, which evaluated a telephone-based virtual clinic for patients (n=55) with cancer. The findings indicated that although participants had a good understanding of the need for virtual clinics, they would have liked to have had the option to choose between virtual or face-to-face clinics. Overall, participants had a good experience of virtual clinics but found them challenging to use when they had issues involving side effects and pain management or when they felt they needed a physical assessment (Dalby et al 2021).
To investigate the experiences of patients with cancer and healthcare professionals with virtual clinics during COVID-19 and to explore ways to improve their experiences.
The study was undertaken at a large teaching trust in north-east London with four main hospital sites and involved patients and healthcare professionals. A literature review was first undertaken to develop an understanding of patients’ and healthcare professionals’ experiences of virtual clinics, particularly in cancer care.
Semi-structured interviews were used as the data collection method. Interview schedules were developed for both participant groups based on themes derived from the literature review and themes linked to the National Cancer Patient Experience Survey (Hasson et al 2020). The schedule comprised 11 open-ended questions and one closed-ended question, which asked participants to rate their overall experience of virtual clinics on a scale of 1 (low) to 5 (high). Questions were relevant to each participant group, but both groups were asked if they would support the use of virtual clinics in the future and why. The interview schedules were emailed to patient volunteers at the trust, both those with cancer and those without cancer, for feedback before being finalised.
All interviews were conducted by telephone by the first author (AP, a pre-registration pharmacist at the time of the study), who received interview training from the third author (MD). Data collection took place between 1 February and 30 April 2021.
For patient participants a mixed sampling approach was adopted, involving consecutive sampling in tandem with systematic sampling to reduce sampling bias. A report was taken from the trust’s electronic patient record (EPR) system to identify patients who met the inclusion criteria, which were:
• Oncology or haematology outpatients at the trust, receiving biological/targeted therapy, chemotherapy and/or radiotherapy, post- and pre-surgical or under surveillance.
• In receipt of cancer care between 1 September 2020 and 15 January 2021.
• Had attended at least one telephone or video virtual clinic since June 2020 and had previously had face-to-face consultations.
A total of 227 patients were identified, of whom 191 declined to participate, leaving 36 patients across the four main hospital sites who completed semi-structured interviews. The sample size of patient participants was determined by data saturation, where data collection stopped when repeated themes arose from the participant groups.
For healthcare professional participants, purposive sampling was adopted involving an email invitation to take part in an interview sent by the trust’s patient experience and engagement lead for cancer (at the time of the study this was the third author, MD). The inclusion criteria for healthcare professionals was all healthcare professionals involved in the multidisciplinary cancer team who had undertaken at least one virtual clinic. A total of 34 healthcare professionals from all tumour groups were approached, ten of whom agreed to participate in the study.
• A triage system to assess patients according to need and degree of urgency could help identify those who require a face-to-face rather than a virtual clinic consultation
• Providing healthcare staff with training on using virtual clinics could address issues such as lack of confidence in communicating with patients in this way
• Provision of an equipment checklist for patients and healthcare professionals might help to ensure they are prepared to take part in a virtual clinic
• Providing patients with the choice of a virtual or face-to-face consultation will support shared decision-making
The qualitative data obtained from the interviews were analysed by the first author (AP) using Braun and Clarke’s (2006) six stage framework. The analysis generated five themes – acceptance, benefits, communication, technology and choice.
Ethical approval was obtained from the delegated ethics committee at Kingston University London. Consolidated criteria for reporting qualitative research guidelines were used (Tong et al 2007). Data were anonymised by providing individual IDs to participant names and were stored on a password-protected computer.
Participant information sheets were read over the telephone before the start of each interview before gaining the participant’s informed verbal consent to continue. With participants’ permission, the interviews were audio-recorded and later transcribed verbatim. NVivo 12 was used to store the transcripts and support the thematic coding process.
|Asian British - Indian
|Asian British - Bangladeshi
|Asian British – Pakistani
|Asian or any other Asian background
|Black British – Caribbean
|Black British – African
|Black or any other black background
|Any other white background
|Type of virtual clinic
|Head and neck
|Tumour group (profession)
|Skin (cancer nurse specialist)
|Upper gastrointestinal (oncologist)
|Type of virtual clinic
|Mixed use of both
Findings relevant to each theme are discussed below and are illustrated by participant quotes.
In response to the question asking if they would support the use of virtual clinics in the future, 81% (n=29) of participants stated that they would. Furthermore, most (n=22, 61%) rated their experience of virtual clinics as 5 (out of 5) (Figure 1). Despite this apparent acceptance of virtual clinics, several participants commented that they should be used cautiously on a case-by-case basis:
‘It’s a good idea and a bad idea. [Face-to-face is a] bad idea because of COVID which we all understand, but at the same time certain situations need a hands-on [approach] for you to move it on.’ (Patient 2)
‘I would support it, of course not in all situations. But in some situations, I would support it… It saves time and if the situation just requires talking, more talking than any direct thing to show, it would be good.’ (Patient 3)
Examples given by participants for when a virtual clinic may be appropriate included where a hands-on approach was not needed, for follow-up consultations and for sharing test results.
Benefits reported by participants mostly related to cost savings, with regard to parking and travel, saving time, keeping safe during COVID-19, efficiency, increased convenience and increased productivity:
‘You save all that travel time and that waiting time. I think you can just get on with the rest of your life ‘cause it does take a massive chunk of your day… in terms of efficiency and saving everybody’s time you know… just not being in a space where it’s not safe for everyone this worked out quite well.’ (Patient 15)
‘If I had gone into the hospital, they would have told me exactly the same thing as what they told me over the phone so therefore I don’t mind, if the blood results weren’t good, they wouldn’t be good for me… if there was nothing wrong, I wouldn’t want to come in… saves me having the Monday morning off and work late and all that – for me it really helped me out.’ (Patient 28)
‘I would [support use of virtual clinics in the future] because it takes a burden off the NHS staff. Especially COVID, less contact with people. Yeah, it’s got its pluses for the future.’ (Patient 6)
Participants’ comments regarding communication during telephone-based virtual clinics were organised into three subthemes: patient-healthcare professional relationship; language barriers; and non-verbal cues. For example, participants commented that having an existing relationship with the healthcare professional made it easier to communicate with them during the virtual clinic. Some said family members assisted them with communication when there were language barriers. However, one participant mentioned that even during face-to-face consultations, the healthcare professional mostly communicated with her son, and that she felt she was not able to contribute to the discussion. Other participants felt that non-verbal cues were lost during a telephone-based virtual clinic, as the healthcare professional’s facial expressions had enabled them to better understand the situation being discussed.
Some participants discussed ease of communication in relation to managing issues such as side effects or pain:
‘It was fine actually because I did have a few questions about like pain management and stuff and yeah it was absolutely fine.’ (Patient 5)
However, for others explaining their symptoms during a telephone-based virtual clinic could be challenging:
‘At times… especially with respect to [referring to the particular body parts]… because you can’t see it physically I can’t actually pinpoint what I’m referring to.’ (Patient 31)
Most participants (94%, n=34) had experienced telephone clinics (Table 1) and were mainly comfortable with using this type of technology. Several of these participants expressed an interest in video virtual clinics and said they would have liked to have tried this method of consultation, although some had some concerns:
‘No connection problems. But I don’t think I’d like a video call from any doctor not even my own, because I don’t understand how to set it all up and I only have my phone and that’s it.’ (Patient 34)
The two participants who had experienced video virtual clinics expressed great acceptance of the technology and although they acknowledged that using an unfamiliar system was slightly challenging, they found that it was manageable and would therefore continue to use it when offered:
‘It wasn’t that easy downloading it, but I got there in the end. I had a few attempts, but I got there in the end.’ (Patient 29)
Participants emphasised the importance of choice in terms of future use of virtual clinics. Although many patients trusted healthcare professionals’ judgement on whether they required a face-to-face consultation, they suggested they would not want this option to be removed completely. Participants preferred the idea of an integrated approach where they were given the option to go into the hospital when they felt it was necessary:
‘Now that my treatment has stopped at some point it would be good to have a physical exam just because it’s not just me examining myself. For peace of mind. You know maybe within like three months [of] finishing treatment, it would be good to go in [for] a physical exam or something like that, but I don’t think it would need to be that regular.’ (Patient 5)
‘It’s different for every single patient. For me, it’s okay at the moment ‘cause as I said I don’t have any issue, so over the phone is much easier instead of me travelling, going there. And as now, what we have is better if we stay at home. But some people, they want face-to-face, so…’ (Patient 8)
In general, participants also wanted to be given a choice between attending video or telephone virtual clinics, with many saying they had become more familiar with the use of video software due to the COVID-19 restrictions.
Findings relevant to each theme are discussed below and are illustrated by participant quotes.
In response to the question on whether they would support the use of virtual clinics in the future, 90% (n=9) of participants said they would. However, only one participant rated their satisfaction with the virtual clinics as 5 (out of 5) (Figure 1). Most healthcare professionals attributed this to not having experience of video virtual clinics.
Some participants also suggested that the return to a face-to-face clinic would not be progressive:
‘I worry about… going back to face to face – if there isn’t a strategic plan of how we’re going to do this. It would seem to me a great opportunity for me… if we all did this there would be much improvement in terms of patient experience and expectations… it would be met more reliably. My concern is that we will all drift back into what we did and we wouldn’t have learnt any lessons – that we can look after people really well using virtual consultations.’ (Healthcare professional 6)
Some participants who used telephone virtual clinics suggested it was challenging to develop a rapport with a patient without being able to see them. Others commented on the practical challenges:
‘We don’t mind the odd follow-up over the phone, but we are very against doing skin cancer follow-ups over the phone. Something that looks normal to the naked eye, when you look at it through the dermatoscope you can see that it’s a melanoma. And you cannot do that over a video.’ (Healthcare professional 1)
Some participants identified that the time taken during virtual clinics was equal to or slightly longer than face-to-face consultations:
‘There’s a preconception that phones [virtual clinics] are really quick, but for me they’re not. They take just as long as they do with a face-to-face because I ask them the same questions. I do pause and give them an opportunity to raise things. Sometimes I even feel like phone takes longer…’ (Healthcare professional 9)
For some participants, the length of time taken to undertake virtual clinics was due to administration issues and a lack of organisation in their specific teams or clinics.
One participant noted that patient waiting times were significantly reduced, which meant patients were more accepting if there were any ad hoc delays:
‘There’s an enormous benefit because… they’re not hanging around for hours, so they haven’t been up since 7am waiting for transport to arrive 2 hours later for their appointment that’s 5 minutes. So, they can be sitting in their house in their pyjamas with a cup of coffee and if I’m running late then it doesn’t matter.’ (Healthcare professional 6)
Some participants suggested that video virtual clinics enabled them to observe the patient’s social setting, which helped them to better understand the person and accommodate any additional needs.
Participants shared various challenges related to communication, for example the removal of ‘human interaction’ when using Language Line (a telephone interpreting service provided by the trust) with patients whose first language was not English. Additionally, lack of organisation could result in communication issues:
‘With phone clinics, people end up getting phoned kind of at any time because we have two consultants and two registrars sort of sharing patient lists and we’re having to learn how to make that work… we’re all in separate rooms, we don’t really know who’s phoned who.’ (Healthcare professional 2)
The loss of verbal and non-verbal cues was also raised as an issue. For example, some participants described how a patient’s family member might relay information to the person in a different tone to how the healthcare professional had intended, which could affect how the information was understood. One participant commented:
‘Phones are a little bit more difficult [compared with video] because again it’s the loss of the cues. Whereas you can be saying very little but there’s a comfortable silence. Silences are not comfortable over the phone. There is a bit more of a pressure to fill it or to… say “thank you!” and put the phone down.’ (Healthcare professional 6)
Participants expressed challenges in accessing and lack of training in information technology (IT), which negatively affected their acceptance of virtual clinics. In general, participants said they experienced problems with the IT systems related to EPR systems, teleconferencing and note taking, which increased their workload and often delayed their appointment with the next patient. One commented:
‘Information technology at [the hospital] is a problem. It doesn’t work properly. It is working but there is often a lot of problems with network, therefore video as a way of relaying your image to a patient might not always work as well as it might do. Certainly, our teleconferencing systems are dire at times, this week I had to report them again and we’re having to report them most weeks.’ (Healthcare professional 4)
Some participants identified the need for equipment to be able to fully benefit from video clinics. Most participants said they were limited to using telephone virtual clinics due to lack of equipment or had to bring in their own equipment from home:
‘We don’t have the opportunity to do video consultations… having known that the main focus was to switch to remote consultations we still don’t have the equipment… Cameras – we have been asking for webcams from the beginning to have video consultations and for all the remote meetings so that’s really frustrating.’ (Healthcare professional 5)
Many participants suggested that not all consultations would be suitable for virtual clinics and that they would therefore choose the most appropriate method for specific patients. For example, two participants commented that it was challenging to use a virtual clinic when a patient required a physical assessment. One said:
‘As physios we’re very hands-on… using a lot of tactile feedback to help gauge an assessment… not being able to have that tactile feedback and visually see things as easily, it’s definitely impacted on patients’ treatment I would say.’ (Healthcare professional 8)
In contrast, other participants, whose role did not involve physical assessments, found that there were fewer distractions for them and the patient by using telephone virtual clinics:
‘Seeing a person can be distracting for me and the patient. The fact that you are monitoring constantly without thinking, the facial expressions, the nodding, you know. That’s taking your attention away from how you feel…’ (Healthcare professional 10)
Most participants said they wanted to experience video virtual clinics to gauge their suitability for their specific discipline and offer this choice to patients.
The findings show that virtual clinics were accepted well by patients and healthcare professionals and that most participants in both groups would support the continued use of this consultation method. However, healthcare professionals were less satisfied with virtual clinics than patients.
For some participants virtual clinics lacked the ‘personal touch’, but having an existing relationship with the healthcare professional appeared to make it easier for some patients to communicate with them in a virtual clinic. This could suggest that virtual clinics are unsuitable for new patients who have not yet developed a relationship with their healthcare professional. Hasson et al (2020) found that the relationship between the healthcare professional and patient had a significant effect on patients’ experience and acceptance of using telephone follow-up consultations for a portion of their cancer care or treatment.
Language barriers made virtual clinics challenging for some patient participants in the present study. Participants in both groups discussed the difficulty in accessing the trust’s translation services and how sometimes family members had to be asked to interpret. Language barriers can reduce healthcare professional and patient satisfaction and the quality of patient care and safety (Al Shamsi et al 2020b).
The present study identified a number of benefits of virtual clinics for patients and healthcare professionals, for example travel-related cost savings and increased efficiency and productivity. This is consistent with the literature, which emphasises the time saving aspect of virtual clinics as a significant benefit (Greenhalgh et al 2016, Gilbert et al 2020, Smrke et al 2020, Tashkandi et al 2020, Dalby et al 2021). Snoswell et al (2020) found that the time saved by using virtual clinics offered patients and healthcare professionals an opportunity for greater productivity. However, some healthcare professionals in the present study commented that virtual clinics took up a similar amount of time to face-to-face consultations.
Participants in both groups commented that virtual clinics are not suitable for all situations, for example where patients require a physical examination. Rutherford et al (2020), who explored the potential benefits and drawbacks of virtual clinics in general surgery, reported that although patients believed that medical staff could provide care without being able to undertake a physical examination at every appointment, they also believed that a physical examination was an important part of a consultation. Healthcare professionals in Vas et al’s (2022) review of the feasibility and effectiveness of virtual clinics compared with face-to-face consultations commented that certain disciplines, such as rheumatology and gynaecology, required hands-on clinical examination.
Conversely, some healthcare professionals in the present study, such as psychologists, found that using telephone virtual clinics enhanced their consultations, by being able to focus on what the patient was saying or feeling with no distractions. Additionally, participants in both groups felt able to discuss issues such as side effects or pain management in a virtual clinic. However, this contrasts with Dalby et al (2021) who reported that patients found it difficult to explain treatment side effects and post-surgery symptoms in a telephone consultation. This could be due to the type and severity of the issue.
The findings show that both sets of participants would have liked to have tried a video virtual clinic but were not given that choice or were unable to access that option. For example, healthcare professionals did not have access to reliable equipment and had to use their personal equipment, such as laptops, webcams and headsets for consultations. This is supported by Vas et al (2022), who found that one of the most commonly reported issues in delivering virtual clinics related to limited technological resources and that many healthcare professionals used their own equipment, such as mobile phones.
Dalby et al (2021) found that some patients liked the idea of alternating face-to-face consultations with telephone consultations. In the present study, although most patient participants said they would support the use of virtual clinics in the future, their main concern was the complete removal of face-to-face consultations. Patients wanted to have the option of seeing their healthcare professional when they thought it was necessary. This was supported by the healthcare professional participants.
One limitation is the small number of patients and healthcare professionals who participated in a video virtual clinic. This could indicate that video virtual clinics have not been successfully implemented at the trust. The findings cannot be said to reflect the experience of others who have participated in a video virtual clinic.
Patients who declined to participate in the study largely belonged to ethnic groups where language barriers were an issue or where their family member/carer was not able to assist them in the interview.
Selection bias was possible in the healthcare professional data, as purposive sampling was used and specific healthcare professionals were approached to save time.
The findings from this study suggest that the use of a virtual clinic in cancer care is acceptable for patients and healthcare professionals and that both groups would support their use in future. However, healthcare professionals were less satisfied with virtual clinics than patients, in part due to lack of training and lack of access to the associated equipment. Benefits of virtual clinics include time and cost savings and increased efficiency. However, language barriers and inadequate technology can negatively affect the experiences of patients and healthcare professionals.
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