Integration of quantitative and qualitative results
Efficacy
In this study, we examined, by integrating quantitative and qualitative data, whether a distance interview method is inferior to a direct face-to-face method in terms of facilitating behavioral changes and disease management in patients with diabetic nephropathy. Quantitative analysis showed that all indicators improved in both groups, with dietary stage, medication, HbA1c, diastolic BP, BMI, self-efficacy score, and QOL score showing comparable changes, respectively, in the two groups. However, although both groups showed improved behavior changes regarding self-monitoring, a greater improvement was found for the CG. Self-monitoring, which involves setting goals for oneself and performing daily evaluations, is a primary method of implementing behavior change and achieving continuity. Our findings show that both interview methods are effective for encouraging the adoption of self-management; further, in terms of taking medication and improving the main clinical indicators, we found that the distance method is not inferior to the direct face-to-face method. However, when considering long-term effects, based on the respective degrees of improvement in behavioral change, the direct method seems to be more effective.
These findings were supported by qualitative data. Many participants in the distance method group reported that they found the self-monitoring technique difficult to understand without hands-on demonstration. Additionally, we analyzed the characteristics of the participants who did not show any behavioral change; all had low adherence to self-management, except for drug therapy, and were obese. Obesity causes abnormal glucose tolerance, abnormal lipid levels, and hypertension, and also increases the risk of cardiovascular disease and death [30]. The nurses felt that high-risk patients with diabetes and obesity had trouble understanding the associated risk factors (such as edema and high blood pressure), and the nurses consequently had difficulty motivating the participants to perform self-monitoring. This was because the nurses could only perform physical assessment through observations and interviews via the tablet. Encouraging patients to learn proper self-monitoring methods early in the intervention leads to an understanding of physical risks, a sense of crisis, and increased motivation. Therefore, we believe that at least one face-to-face interview, in which detailed health status is assessed and motivation is provided, may be necessary for such patients.
Feasibility
The completion rate for both groups was approximately 80% and, for the remaining 20%, the reasons for withdrawal were not related to convenience. This indicates that once participants are successfully engaged, they are likely to complete the program. This indicates that the feasibility of the approach was of an acceptable level.
Although the IG provided a high overall evaluation, more participants and nurses from the CG reported feeling confidence in the method, satisfaction with the physical condition assessment, and overall satisfaction, all of which were consistent with the interview data. In the IG, the nurses needed to learn additional skills to compensate for the lack of direct observation and ability to perform physical examinations. A means of helping nurses obtain such skills would be performing step-by-step demonstrations using tablets.
Development of trust relationships, engagement, and motivation to effect behavioral changes: Participants in the IG felt confidence in their nurses. However, some participants in this group reported that they were unable to discern the nurses’ facial expressions on the tablet’s small screen, and that voice transmission was occasionally interrupted. With respect to the motivation for behavioral change induced by the nurses, both groups showed behavioral changes and improved self-management indicators. Self-monitoring, however, improved to a greater degree in the CG than in the IG. In addition, the participants in the CG reported being better able to understand the self-monitoring methods when compared to those in the IG. We installed on the telenursing tablet a video that explained self-monitoring, but the participants seldom watched it, and the nurses were unable to fully confirm the participants’ understanding or implementation of self-monitoring.
Obtaining accurate information needed for health assessments: As mentioned above, the nurses felt that it was difficult to motivate patients based on detailed physical risk assessment. For patients with diabetes, improving self-monitoring ability and the motivation to perform self-monitoring and to adhere to treatment are essential components for the adoption of self-management behaviors that improve the health condition and QOL [31,32,33]. In order to achieve this goal through the medium of telenursing, improvement in telecommunication is necessary, as this would allow nurses to assess patients’ physical conditions, and would also allow the patients to gain an understanding of their physical status and the effects of self-management [34].
Operability of the device for distance interviews: A small number of participants reported that they could not satisfactorily send/receive sound and/or images, even when they tested the telecommunication connection quality in advance. Some participants had reduced visual acuity associated with aging or diabetic retinopathy, but none had visual-field loss or severe visual disturbance. In an effort to address difficulties regarding using the device, we post-mailed to the participants, before the interviews had commenced, a manual that provided instructions regarding how the tablet should be operated. Most participants followed the instructions in the manual and did not experience any related issues when participating in the interviews. However, one participant had difficulty operating the tablet, and the nurse provided instructions regarding its operation via telephone. Based on these findings, we believe that patients with visual impairment should have face-to-face interviews instead of distance interviews, because such patients cannot see clearly images or the nurse when using the tablet device. Moreover, patients who are not accustomed to telecommunications devices, such as older patients, may also need special consideration [35, 36]; such patients should receive face-to-face interviews if they have difficulty operating the tablet, or family members could be trained in its operation so that they can provide assistance (i.e., the family may participate in the interview or operate the tablet on behalf of the patient) [37]. In the present study, the tablets were only used for the transmission of images and voice. The quality of the telecommunication devices used in telenursing has an impact on the safety and effectiveness of the health care provided [38]. The development of new devices that facilitate communication with and the education and empowerment of patients would be desirable; in particular, functions for visualizing data for self-management or monitoring would be a valuable addition [39,40,41].
The above findings suggest that, for patients who do not have specific characteristics that make remote interventions difficult, distance interviews may be a feasible substitute for face-to-face interviews.
Limitations
This study featured a small sample size and, to address this, we applied a triangulation approach; however, interpretation of the results remained limited. Therefore, along with strengthening the motivation of target populations to participate in such research, future large-scale trials in this area should seek to obtain further evidence of the effects of the distance interview method. Additionally, in this study almost 80% of the employees who met the inclusion criteria refused to participate. While this indicates a need to develop a distance-education tool that is convenient for such individuals, it also implies that, in order to achieve effective recruitment. For example, it seems necessary that the nurses explain to the participants their risk of aggravating the disease and conducts motivation interviews.
Implications for practice
In developed countries such as Japan, health systems are now focusing on chronic illnesses such as lifestyle-related diseases and cancer. Disease-management programs, especially those for preventing people with diabetic nephropathy requiring dialysis, are a high priority. This distance-education method, which involves the use of ICT devices, facilitates the provision of health care to people all over the world, regardless of location and time constraints.