Understanding how virtual care has shifted primary care interactions and patient experience: A qualitative analysis

INTRODUCTION

The widespread and rapid implementation of virtual care has introduced evolutionary changes in the context, process, and way primary care is delivered. The objectives of this study were to: (1) understand whether and how virtual care has shifted the therapeutic relationship; (2) describe the core components of compassionate care from the patient perspective and (3) identify how and in what circumstances compassionate care might be amplified.

METHODS

Participants living in Ontario, Canada were eligible if they had interacted with their primary care clinician following the rapid implementation of virtual care in March 2020, irrespective of virtual care use. One-on-one semi-structured interviews were conducted with all participants and data were analyzed using inductive thematic analysis.

RESULTS

Four themes emerged across 36 interviews: (1) Virtual care shifts communication patterns but the impact on the therapeutic relationship is unclear; (2) Rapid implementation of virtual care limited perceived quality and access among those who did not have the option to utilize it; (3) Patients perceive five key elements as central to compassion in a virtual context; and (4) Leveraging technology to fill gaps within and beyond the visit is a step towards improving experiences for all.

DISCUSSION

Virtual care has transformed the ways in which patient-clinician communication operates in primary care. Patients with access to virtual care described largely positive experiences, while those whose interactions were limited to phone visits experienced decreased quality and access to care. Attention must shift to identifying effective strategies to support the health workforce in building virtual compassion competencies.

Effectiveness of Life Goal Framing to Motivate Medical Students During Online Learning: A Randomized Controlled Trial

Introduction

Educators need design strategies to support medical students' motivation in online environments. Prompting students to frame a learning activity as preparing them to attain their life goals (e.g., helping others) via their clinical practice, a strategy called 'life goal framing', may enhance their autonomous motivation, learning strategy use, and knowledge retention. However, for students with low perceived competence for learning (PCL), life goal framing may have an adverse effect. A randomized controlled trial was conducted to test the effectiveness of life goal framing and the moderating effect of students' PCL.

Methods

First- and second-year medical students across four Canadian universities (n = 128) were randomized to receive a version of an online module with an embedded prompt for life goal framing, or one without. Students' motivation, learning strategy use, and knowledge retention were assessed. Differences between conditions on each outcome were estimated using Bayesian regression.

Results

Students' PCL was a moderator for autonomous motivation but no other outcomes. The prompt did not have a statistically significant effect on any outcome, even for learners with high PCL, except for a small effect on link-clicking behaviour.

Discussion

The results of this study suggest that learners' autonomous motivation is influenced by how they make meaning of instruction in terms of their future life goals and their present confidence. We cannot recommend life goal framing as an effective design strategy at this point, but we point to future work to increase the benefit of life goal framing for learners with high confidence.

The impact of Stress Management and Resilience Training (SMART) on academic physicians during the implementation of a new Health Information System: An exploratory randomized controlled trial

OBJECTIVE

The Stress Management and Resilience Training (SMART) program is an evidence-based intervention designed to build resilience in physicians in clinical practice. The objective of the current study was to assess the impact of the SMART program on academic physicians' levels of resilience, subjective happiness, stress, and anxiety, and specifically during the implementation of a new hospital-wide Health Information System (HIS).

METHODS

A total of 40 physicians in a tertiary care academic hospital were randomized (allocation ratio 1:1) to either the SMART intervention or the control condition. The SMART intervention consisted of one mandatory two-hour in-person workshop and an optional 24-week online program, designed to support the materials delivered in the workshop. Outcome measures were assessed using validated scales administered online at baseline and at 3-months and 6-months follow-up.

RESULTS

After adjusting for baseline levels of each outcome, no statistically significant intervention effect was observed for resilience, subjective happiness, stress or anxiety at 3-months or 6-months follow-up. However, physicians in the intervention group demonstrated improvements in resilience, stress and anxiety at follow-up that were within the range of clinically relevant differences.

CONCLUSIONS

The findings of this exploratory study provide modest support that the SMART intervention may be beneficial for proactively addressing physician wellness during the implementation of a new HIS and that larger randomized trials are warranted.

TRIAL REGISTRATION

NCT04384861.

History's Toolbox in Health Professions Education: One Skill-Based Session on Social Determinants of Health

Aimed at clinical educators, this article reports on the use of a single skill-based session that introduces learners in Health Professions Education (HPE) to basic techniques from the discipline of history. The premise of the teaching method is a correspondence between medicine's social determinants of health (SDH) and categories of analysis commonly used by historians. At the center are eight categories, or "tools": social, cultural, intellectual, technological, political, economic, racial/ethnic, and gendered. Like the direct and specific implications of many diagnostic signs, each of these adjectives indicate to historians specific types of factors, or determinants. The intervention employs the demonstration-performance teaching method (explanation, demonstration, supervised practice, and evaluation). After the session, learners are able to: use "history's toolbox" as a systematic method for evaluating socio-cultural phenomena inherent in SDH; differentiate eight types of determinants in a historical case study that represents socio-cultural complexity; recognize how categorization simultaneously enhances some determinants while obscuring others, and how the use of constructed social categories in medicine can function to help and harm patients and populations. The intervention described is rooted in scholarship and theoretical questions belonging to the discipline of history, but these are not discussed. Neither the historical content nor the teaching method described here is appropriate for research or teaching in the discipline of history.

A qualitative study on the Virtual Emergency Department care experiences of equity-deserving populations

Patients from equity-deserving populations, such as those who are from racialized communities, the 2SLGBTQI+ community, who are refugees or immigrants, and/or who have a disability, may experience a unique set of challenges accessing virtual models of care. The objective of this qualitative study was to describe the experiences of patients from equity-deserving communities and their family members who received care from a Virtual Emergency Department (ED) in Toronto, Canada. Forty-three participants (36 patients and 7 family caregivers) with different and intersecting identities who used the Virtual ED participated in the study. Semi-structured interviews were conducted to explore reasons for accessing the Virtual ED, barriers to access, and how the Virtual ED met their care needs and expectations, including ways their experience could have been improved. Thematic analysis was used to identify themes from the data. Patients from equity-deserving populations described negative past experiences with ED in-person care, which included recounts of discrimination or culturally insensitive care while waiting to see the ED physician or nurse. Conversely, participants found the Virtual ED to be a socially and culturally safe space since they could now by-pass the waiting room experience. However, virtual care could not replace in-person care for certain issues (e.g., physical exam), and there was a need for greater promotion of the service to specific communities that might benefit from having access to the Virtual ED. Targeted outreach to help raise awareness of the service to equity-deserving communities is an important future direction.

Peer support provider and recipients' perspectives on compassion in virtual peer support stroke programs: "You can't really be supportive without compassion"

BACKGROUND

Peer support programs demonstrate numerous benefits, including emotional, instrumental, informational, and affirmational social support. Since the COVID-19 pandemic, many peer support stroke programs in Canada have been delivered virtually. Compassion must be consistently applied to build meaningful interactions, but the shift to virtual services may have changed the quality of interaction and compassion in virtual services. While compassion is recommended in health and social services to improve outcomes, satisfaction, and service quality, compassion in virtual peer support stroke programs remains understudied. We aimed to describe compassionate support in virtual peer support stroke programs from peer support providers' and recipients' perspectives.

METHODS

This qualitative descriptive study was guided by Sinclair & colleagues' model of compassion. Peer support recipients or peer support providers participated in interviews transcribed and analyzed using a hybrid thematic analysis.

RESULTS

Sixteen were peer support recipients, six were peer support providers, and two were both peer support providers and recipients. Participants agreed that compassion was essential in these programs. Participants perceived compassion to be a result of the virtues of compassionate facilitators (i.e., genuineness, passion, and empathy), relational space, and communication within the virtual peer support stroke program (e.g., sense of awareness or intuition of compassion, aspects of engaged peer support provision), virtuous response (e.g., knowing the person and actions that made the peer support recipient feel like a priority). Compassion was facilitated by listening and understanding peer support recipients' needs as they relate to stroke (i.e., seeking to understand peer support recipients and their needs), attending to peer support recipients' needs (e.g., timely actions to address their needs), and achieving compassion-related program outcomes (e.g., alleviating challenges and enhancing wellbeing). The absence of these components (e.g., lacking genuineness, passion and empathy) was a barrier to compassion in virtual peer support stroke programs.

CONCLUSIONS

Study findings describe facilitators and barriers to perceived compassion in virtual peer support stroke programs and provide practical recommendations that can be adapted into programs to improve program quality.

A Digital Self-Administered Check-Up Assessment and Evaluation of Risk Communication in Older People

BACKGROUND

Digital health tools can significantly contribute to the continuum of care and support for persons with their self-management role. Despite the increasing adoption of digital health tools, little is known about the uptake and comfort of use among older persons.

METHODS

A mixed methods design was used to assess the feasibility and utility of the check-up (CU), a self-administered digital health assessment for older persons. For the older person, qualitative interviews and de-identified CU assessment data were collected. A focus group was held to gain the health provider perspective.

RESULTS

A total of 32 online CU assessments were completed, and 17 individuals participated in interviews. Three main themes were identified: digital literacy and accessibility, communication of risk and role within the circle of care.

CONCLUSION

Self-administered digital assessments are feasible for older adults. Strategies for adoption should focus on accessibility and collaboration with health professionals to maximise utility and understanding of assessment results.

Use of an electronic wellness instrument in the integrated health and social care of older adults: a group concept mapping study

BACKGROUND

Health system fragmentation directly contributes to poor health and social outcomes for older adults with multiple chronic conditions and their care partners. Older adults often require support from primary care, multiple specialists, home care, community support services, and other health-care sectors and communication between these providers is unstructured and not standardized. Integrated and interprofessional team-based models of care are a recommended strategy to improve health service delivery to older adults with complex needs. Standardized assessment instruments deployed on digital platforms are considered a necessary component of integrated care. The aim of this study was to develop strategies to leverage an electronic wellness instrument, interRAI Check Up Self Report, to support integrated health and social care for older adults and their care partners in a community in Southern Ontario, Canada.

METHODS

Group concept mapping, a participatory mixed-methods approach, was conducted. Participants included older adults, care partners, and representatives from: home care, community support services, specialized geriatric services, primary care, and health informatics. In a series of virtual meetings, participants generated ideas to implement the interRAI Check Up and rated the relative importance of these ideas. Hierarchical cluster analysis was used to map the ideas into clusters of similar statements. Participants reviewed the map to co-create an action plan.

RESULTS

Forty-one participants contributed to a cluster map of ten action areas (e.g., engagement of older adults and care partners, instrument's ease of use, accessibility of the assessment process, person-centred process, training and education for providers, provider coordination, health information integration, health system decision support and quality improvement, and privacy and confidentiality). The health system decision support cluster was rated as the lowest relative importance and the health information integration was cluster rated as the highest relative importance.

CONCLUSIONS

Many person-, provider-, and system-level factors need to be considered when implementing and using an electronic wellness instrument across health- and social-care providers. These factors are highly relevant to the integration of other standardized instruments into interprofessional team care to ensure a compassionate care approach as technology is introduced.