Throughout the accounts of various facilitators regarding the use of telemedicine in the care of patients with diabetic foot ulcers, it was observed that health care professionals were highly enthusiastic about the idea itself. Nevertheless, they encountered challenges in the process of the telemedicine intervention, at least in the initial phase that was followed for this study. Exploring these challenges in-depth, it was possible to identify four key conditions perceived by the health care professionals involved to be crucial to a successful telemedicine care delivery experience; user-friendly technology and training, a telemedicine champion, committed and responsible leaders and effective communication channels at the organizational level.
User-friendly technology and training
The health care professionals in this study emphasized the importance of having a user-friendly technology upon which to rely when using telemedicine. After the initial phase, in which they noted some minor difficulties with the mobile phone, passwords and the web ulcer record, the technology seemed to function very well. Many of the health care professionals experienced the technology as easy to learn and use, and this facilitated the intervention for that group. As one explained it, “The technology must be easy to use, and it is. If it takes a lot of time and attention it would make us more reluctant to use it.” Opinions similar to this were common across the focus groups with both primary health care and specialist health care professionals. They frequently emphasized the need for technology that actually helped them in their work without being too time consuming: “One must remember that using this technology is one of many tasks during our day.” There was also agreement on recognition that the telemedicine technology was improving all the time. Participants across all of the focus groups highlighted the importance of being asked and listened to when adjustments were made with the technology.
To learn to use the technology, the health care professionals in the intervention arm in primary health care were invited to participate in an early meeting with the patient when wound care was being performed in the hospital outpatient clinics; however, in some cases, this aspect of the intended plan seemed to slip away as time went by. This led to some differences in how they experienced the training in using the technology and what that training consisted of. In contrast to the health care professionals in specialist health care, those working in home based care services seemed to have more varied experiences in the training for using the technology. Over time, some experienced having to manage the training of their new colleagues in using the technology, and help them perform the wound care expected as part of the intervention. The following example illustrates the frustration they experienced when this occurred:
One of my colleagues received training in using the technology from me. She chose not to use the computer when reporting to the outpatient clinic. She used the smart phone because she had problems with the password on the computer I think. She had many problems in the beginning,…She told me later that she was frustrated and wanted to quit.
Some of the health care professionals in the home based services also experienced the training to be unsystematic. They found this challenging, because they felt they were given more responsibility than expected. In such situations, they expressed the desire for access to more training as needed over time because, when they were not using telemedicine, they forgot how to use it. However, even with gaps in systematic training, the health care professionals generally remained enthusiastic, because they clearly saw the potential benefit for the patients.
A telemedicine champion
Although the health care professionals generally described the use of the new technology in a positive manner, they also emphasized the importance of having someone close to them who could facilitate the telemedicine intervention. The health care professionals in the outpatient clinics felt that some colleagues in the intervention were their “leading lights or champions” when using this new technology. They referred to these facilitators as essential to this intervention, and crucial for the telemedicine intervention’s success. Such individuals were described as facilitating the intervention by being professionally updated, engaged in the intervention and performing the practical tasks like maintenance and adjustments in the technology; they seemed highly committed to and enthusiastic about using telemedicine.
The importance of having a colleague who could champion this intervention was described as a prominent success condition among those who experienced it as well as those who did not. The following example illustrates the role played by such a facilitator in their midst:
Well, we have some among us who facilitate it all. They have encouraged us, and when some of us think this is too much work, they have been there with their enthusiasm. This enthusiasm has been valuable to us.
In contrast, it was found that the health care professionals in primary health care in particular were unlikely to have a champion at hand to serve in this facilitator role. Instead, they experienced having to be their own champion in motivating and performing the intervention. This made them more vulnerable to exhaustion in relation to the telemedicine intervention, especially when they were the only one over time or during specific periods in their particular district to be using it.
Committed and responsible leaders
From the perspective of the health care professionals, it was apparent that a related condition of success beyond colleague facilitators was having organizational leadership within their care systems that was aware of and supportive of the telemedicine intervention. Focus group participants highlighted the need for a committed and a responsible organizational leader to support the conditions under which success was made possible. Their accounts made it apparent that the locations and contexts of their work – such as whether they worked in specialist health care or in primary health care – influenced the likelihood of having a leader appropriately positioned in a role with the ability to support the use of telemedicine in their daily care.
The specialist health care work setting made it possible for the leaders to play a more active role when applying the telemedicine intervention in diabetes foot care. Because they were visible in the outpatient clinics, the leaders actively contributed in different ways. They were conscious of being available when needed for the health care professionals taking part in the intervention. The health care professionals experienced their leaders as supportive and helpful in organizing their everyday tasks in the outpatient clinic so they could perform the intervention as planned. One nurse leader in an outpatient clinic described her experience in this manner: “I help in organizing on a daily basis so everything works out fine. I try to be there if they need me. They are skillful, and it is nice to be a part of this.”
In contrast to the leaders in specialist health care, the leaders in primary health care were unable to provide the same level of direct support, mainly because they did not work alongside the nurses in home based care in the same manner. As home based care nurses work in the homes of their patients across a wide geographical area, they have to work independently and make many decisions on the spot without direct access and support from their leader. Therefore, the leaders in home based care services operated from the sidelines rather than in the more visible role of leaders in the outpatient clinics. The differing organizational structures between these two kinds of settings shaped the distinct roles of leaders and thus their approach towards supporting the intervention.
Despite this difference, many health care professionals in home based care services participating in the telemedicine intervention experienced their leaders to be a positive factor in the use of telemedicine, even though they did not engage in it directly. Some of them characterized them as “leaders on the sideline.” As one explained: “In my municipality it is not organized at all. There is no guarantee that I will be sent to a patient involved in the intervention. I have to tell my leader to send me there.” Another member of that focus group quickly responded: “It is the same where I work, I have to remind my leader to send me to the right patient.” Clearly this was not the case in every municipality, as some experienced their leaders as mindful of which nurse to send when patients were involved in the intervention: “In our place the leader makes sure that the health care professionals involved in the intervention visit patients involved in the intervention.”
Even where health care professionals had to organize and manage the telemedicine use on their own, they could still feel some support from leaders when they experienced their attitudes toward telemedicine to be positive. However, when unexpected events occurred, with either equipment or patients in the intervention, their experience was that they had to manage it by themselves. Therefore, taking ownership of the telemedicine intervention seemed to be of utmost importance for the health care professionals in the primary health care context. Overall, we also found that the home based care nurses needed to be more highly qualified and autonomous than those in specialist services. In some focus groups in the primary care context, we encountered reports such as this: “I do not think they (the leaders) know what we are doing when we are using telemedicine.” Another study participant explained: “There is an interest for this intervention by the leaders, but they are not so interested in knowing more about the intervention. My leader is pleased with the fact that I am handling it all.”
Among the health care professionals in home based care services, some concerns were expressed about the vulnerability of the intervention with respect to overall leadership. In particular, where there were limited numbers of health care professionals involved in the intervention, it could seem that no one was assuming full responsibility. Some of these health care professionals expressed the view that their leaders did not know what they were dealing with on a daily basis when using telemedicine, and they had to organize their working day as best as they could. When there were no leaders fully engaged in the intervention, it seemed most vulnerable. This was especially the case when those involved were unable to participate in the intervention, such as when care staff were sick, on maternity leave or holiday, or there was a change in the job situation. As one explained: “It has been a challenge when I have been on a holiday. No one is responsible then. No one follows up these patients in particular.” Another similarly commented: “I wish we were two health care professionals involved in the intervention because my experience is that when I am away no one follows up messages from the outpatient clinic.” The effect of such situations was that the intervention was not carried out as intended, and pictures were not taken and reported as planned. Because performing wound care and documentation within the intervention was more time consuming than usual care, some of the health care professionals had to argue for spending more time with patients. They interpreted this not as a lack of enthusiasm from their leaders, but rather as a lack of involvement in the intervention because they trusted the health care professionals to perform the intervention as planned.
It was noted that some participants in a focus group interview with the leaders in home based care services described a similar limited degree of involvement in the intervention to that which the health care professionals in that setting had experienced. For example, some were very uncertain about what the elements the intervention actually consisted of, and did not know what kind of training the health care professionals had in relation to the intervention. They strongly felt that they had delegated responsibility for performing the intervention to the selected health care professionals in the municipality, and seemed satisfied with the situation. A comment by one leader illustrates: “Some nurses were given this responsibility. They have taken this responsibility, and have control. I am here on the sideline, but I find it exciting.” Another agreed: “It is the same in our municipality. Those nurses involved in the intervention have total control, and they inform me when needed. I just follow them from the sideline.” In this manner, the leaders relied on the competence of the health care professionals and made them responsible for carrying out the intervention. While they did not feel that they had facilitated anything for the health care professionals, they stated that they were very positive with respect to the intervention. For these leaders, the intervention was not perceived as time-consuming at all. They reflected primarily on the positive aspects of care that this intervention contributed to, such as more competence in wound care within all health care professionals in primary health care.
Effective communication channels at the organizational level
The final condition for success observed in this study had to do with effective lines of communication within health care organizations. In primary health care there are leaders at several levels. The leaders in primary health care felt that they missed information about the intervention, and had some concerns that information from “higher up” in the system did not reach them at all. Furthermore, they did not know who to talk to in order to get such information. A typical remark in the focus group by the leaders was: “I do not receive much information. I do not know if there is any key person to ask either. If there are any meetings for some key persons, they do not pass on information to us.” In addition, opinions like this were expressed: “If leaders higher up in our system know something they should inform us. We do not know if this project is still running.” Several felt that this intervention should have been more strategically driven by leaders above them who were prepared to keep them better informed. Lack of information impeded the ability of the leaders to follow up on the implementation of the telemedicine intervention and fully support their staff in the implementation process.
Effective communication was also influenced by the fact that, in each municipality, there were only one or two selected health care professionals in home based care services involved in the intervention. From the perspective of the specialist health care professionals involved in the intervention, this facilitated communication in that they found it easier to have to cooperate with only a few individuals in primary health care. As one explained: “We do not want more people to be involved. It is much easier to communicate with a few.” In contrast, those involved in the intervention in the primary health care experienced this to be a problem because of the vulnerability in there being too few involved when some of them could not participate for various reasons. Then communication sometimes broke down or was delayed, which might threaten the continuity of the foot ulcer follow up care.
To summarize, identifying these four distinct but intersecting key conditions for success provides additional layers of knowledge about the complex processes involved in introducing telemedicine in diabetes foot care.