How,when and why is emotional support delivered using videoconferencing by adult palliative care services successful? A realist synthesis

Step 1: Clarify scope

To identify potential explanations for successful palliative care emotional support by videoconferencing (hereafter referred to as ‘the programme’) a familiarisation search of relevant literature was undertaken, including searching with Publish or Perish software (https://harzing.com/resources/publish-or-perish). Papers from a scoping review that detailed digitally enabled psychosocial interventions with videoconferencing in palliative care ²² provided initial thoughts about the reasons, resources and contexts that trigger emotional support outcomes. This helped identify ideas to formulate a rough/initial programme theory about the reasons for emotional support delivered in real-time at distance by videoconferencing (hereafter referred to as ‘video-enabled’ or ‘video call’).

Step 2: Search

Literature about emotional support interventions by video call in palliative care spans several knowledge domains so the following databases were searched: AMED, Medline, PsycINFO, SCOPUS, TRIP and Overton.io database. Websites were also searched for patient or carer accounts. Searching took place on 16th January 2023. There were no date restrictions. There were three search term concepts: videoconferencing; adult palliative care services and remote delivery of emotional, psychological, psychotherapy support interventions. Precise terms were adjusted as appropriate for each database. See Table 1 for eligibility criteria. Full search terms are presented in Supplemental Table A. Searching continued in an iterative manner as ideas became clearer during the review process; this is in keeping with the realist approach. Figure 1 shows the four foci that developed as searching proceeded. Citations were selected if they addressed or added different perspectives on outcomes, contexts, stakeholders and resources.

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Table 1.

Eligibility criteria.

Criteria	Include	Exclude
Types of papers	Empirical research any study design and non-empirical work (e.g. professions’ guidance documents, web pages, opinion pieces)	/
Language	English	Not English
Period	No date restrictions	/
Population	Adult (18+ years) patients with advanced life-shortening conditions; OR informal caregivers of adults receiving palliative care services; informal caregivers of adult patients with advanced life-shortening conditions; OR bereaved informal caregivers of adults receiving palliative care services	Patients and/or their informal caregivers with no diagnosed life-shortening conditions or terminal illnesses; children with palliative care needs
Intervention	Emotional support interventions delivered to adults using videoconference technology. These include (but are not limited to) interventions undertaken by healthcare practitioners and those trained in arts therapies, coaching, chaplaincy, counselling, psychology, psychotherapy, and mindfulness and delivered by any real-time video platform	Audio-only emotional support interventions such as telephone counselling, self-directed web interventions, mp3 files, apps for self-management
Context	Palliative care in community settings (own home, residential care or prison) or in-patients of specialist palliative care units	Remote monitoring or video consultations solely focused on physical symptoms or physical or medical regimens

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Figure 1.

Iterative decision-making process for selecting sources.

Step 3: Selection, appraisal and data extraction

Retrieved citations were imported to reference management software EndNote (https://endnote.com) and duplicates removed. Reference lists of systematic literature reviews found during the searching phase were scanned for further relevant papers. To facilitate teamwork all citations were imported to Rayyan (Systematic review software https://www.rayyan.ai/). Titles and abstracts were read by M.W., eliminating ineligible papers. A proportion of retrieved citations were double checked by three additional independent reviewers (C.W., A.N., N.S.), ensuring papers demonstrated sufficient information to address the review question. Thirty-two eligible papers were read in full; one was further excluded for the reason of double counting. ¹⁹ Disagreements were resolved through discussion.

Retrieved sources were read to determine fitness for purpose noting their ‘relevance’ (does the paper contain data relevant to the topic or theories identified in step 1?); ‘rigour’ (is the source credible? Does it support the conclusions drawn from it?); ‘richness’ (how might this contribute to theory building or testing?)^28,29 and their usefulness in contributing to the purpose of the synthesis. Supplemental Table B shows how this was operationalised for the retained sources. Papers deemed not relevant (n = 8) and maybe relevant (n = 9) were set aside. The remaining 15 citations for 13 papers were retained for appraisal.

Sources were scrutinised for the author’s explicit or implicit theory about why interventions work/succeed (or do not) and these data were extracted and assembled in a matrix (Supplemental Table B).

Step 4: Analysis and synthesis

The four constructs of NPT ²⁵ are summarised in Figure 2.

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Figure 2.

Four constructs of NPT.

These provided the review’s initial explanatory theory for how successful emotional support could be achieved by videoconferencing as set out in the following initial programme theory:

New video-enabled ways to deliver emotional support would be successful (monitoring) if staff and geographically isolated service users were committed to working together remotely (sense-making) because they valued seeing each other in real-time (participation), and they had the material resources and organisational support (action) to do this.

To test this, each included source was appraised using the NPT coding manual. ³⁰ The manual’s 12 questions aided data extraction, helping to target information about contexts, mechanisms, and outcomes of interventions. Ideas were generated for how each source addressed the review question. Synthesis developed through identifying the endogenous processes of relational work described between healthcare professionals and their patients, and exogenous processes that refer to the operational and institutional systems shaping how people act, both of which encompass NPT’s four constructs. ²⁵ Retroductive thinking aided by the heuristic ‘if-then-because’ helped identify potential motivators for the uptake of the programme by stakeholders. Synthesis was sense checked by a fourth independent reviewer (D.D.).

Step 5: Main findings

This realist synthesis tested NPT’s assumptions about the relational work done by those delivering and receiving video-enabled emotional support in palliative care as set out in the initial programme theory. It generated hypothetical causal relationships between such interventions’ contexts, mechanism and successful outcomes. The findings are reported here in narrative form to illustrate these potential causative links and to highlight connections with NPT’s four constructs. Ten context-mechanism-outcome configurations (CMCOs) were developed from which five rival and sibling explanations were postulated to explain how, when and why video-enabled emotional support maybe successfully implemented. These five explanations address the efforts made by people (individually and collectively) to adopt a new intervention. They represent hypotheses to test NPT’s framing of the programme theory set out at the start and were refined further through consideration of how the COVID-19 pandemic changed access to services and funding. These are set out below, include the NPT descriptions and linked to relevant CMOCS, along with illustrative quotes.

‘Shifting balance of power and agency’ (CMOCs 1–3)

Taking up video-enabled emotional support interventions in contexts of service innovation or circumstances of a global pandemic inevitably shifts how people interact with each other. Whether patients and carers receiving emotional support video calls at home^32,39,41 or in the in-patient unit, ³³ more effort is required by staff to ensure the programme works and to collaborate with the recipients of their care. ³⁵ This is potentially an increased burden on staff, triggering reluctance to adopt this way of working. The relational activities in planning and resourcing videoconferencing, along with carrying out the intervention necessitates all stakeholders to agree on its value. For patients and carers, the benefits are the conservation of financial and physical resources usually expended on going to healthcare meetings in the hospice or hospital site. Staying home also means patients feel less dependent on others to transport them to appointments. Instead, the healthcare professional becomes a guest in the patient’s home, and the patient, being more relaxed, feels empowered to engage actively in the video call. People to advocate/support the patient can also be added virtually to the meeting. The efforts made to implement the programme shifts the power dynamic in favour of the patient or carer:

I think sometimes when you go face-to-face, especially with some of the big consultants, it’s kind of a bit daunting or a bit off putting or they’re kind of a bit, like, okay I’ve got so much time there’s a whole waiting room of people out there. Whereas if you’re on telehealth maybe it would give you a bit more confidence to say, oh wait a minute I need to just ask you this or hang on I need to ask you this. And just give you that bit more confidence because you’re not actually there with them. . . you’re in their space aren’t you, whereas at home you’re on your own grounds, so you’re kind of more confident anyway. ‘Patricia, Time point 2, 202’ P4 Keenan et al. ⁴¹

For healthcare professionals the change in working practice also conserves time travelling to see patients at home, especially those in rural locations:

Many clinicians note telemedicine visits are shorter and more focused than in-person visits. While this can increase efficiency, creating space for patients and families to share their thoughts and feelings is arguably even more important than it was before the COVID-19 pandemic. e13 Calton et al. ³⁴

When circumstances provide staff with new opportunities to innovate services that connect with new patient groups, shifts in ways of working can benefit all stakeholders. For instance, Ozier et al. found that a structured 10-weekly counselling intervention by video call worked well for people with challenging symptoms of cognitive impairment due to a brain tumour. ³⁹ However, shifts in usual professional-patient relationships can leave staff feeling less than satisfied with their work, especially where non-verbal interpersonal exchanges usually core to their roles are removed by using videoconferencing:

The lack of human touch was identified as a barrier for professionals as they feared that patients would consider the care provided using telehealth to be impersonal. p7 Keenan et al. ⁴¹

Context-mechanism-outcome configurations:

‘All in this together’ (CMOCs 4–5)

In the context of a crisis that prohibits usual in-person care, creating networks of participation around a new practice, and finding ways for everyone to work together are the social mechanisms proposed by NPT for successful implementation. In such situations patients and professionals are motivated by a desire to receive or deliver a service:

Throughout the lockdown we felt supported. Anne, from the social work team called regularly, sometimes just to see how I was, and the spiritual care team have been wonderful. Laurence from the team arranged video meets with Sunil which he really appreciated and he calls me too. Hospice UK ³⁷

Staff work together to make the transition from in-person to online therapeutic encounters accessible for service users. They build into the virtual environment the same kinds of values (or social affordances) that are qualities of the in-person setting.^34,35,41 This may require delivering materials resources, technical support, online communication etiquette and staff training to everyone involved:

The PCT nurse coordinator (A.F.) arranged for the tablet to be brought to the patient’s room, scheduled times for each call, and obtained contact information for family members. The coordinator prepared the family regarding the patient’s condition and what they might see in the ICU room. The chaplain, ICU nurse practitioner, and bedside nurse donned PPE and established a video link with each family member using the tablet. The chaplain sang hymns, read his favorite Bible verses, and prayed with them. P995 Ritchey et al. ³³

This has been a difficult time for both the bereaved and staff. The bereaved have a reduced, non face to face service. The staff feel powerless and are restricted from doing the job they are passionate about. That said a great deal of learning has been going on and staff have been imaginative in finding new approaches. ‘(#418 palliative care specialist nurse)’ p7 Pearce et al. ³⁶

Context-mechanism-outcome configurations:

‘Fear of missing out’ (CMOCs 6–7)

Another explanation for outcomes in circumstances where ‘care as usual’ is no longer possible – such as during COVID-19 restrictions – is people’s fear of missing out or of being excluded, which could result if they do not transition to video call interventions. For the professional this may be a fear of not being able to do their job, resonating with ‘shifting balance of power and agency’, or anxiety that ceasing to work as usual diminishes their professional identity and worth. For example, when new bereavement services developed during COVID-19, others were suspended, and staff were furloughed. Such situations mobilise stakeholders to see the benefits of taking up new practices, in NPT terms this is ‘sense-making’ (see Figure 2)

The pandemic was a powerful motivator for systemic change that propelled us to find new ways to provide caring and connectedness for patients at the EOL and their families. Our experience shows that although technology does not replace face-to-face encounters, it can offer meaningful connection. P996 Ritchey et al. ³³

The social isolation required during the pandemic compounded patient and family stressors and diminished the patient’s access to clinicians and to his usual support network and coping strategies. p203 Mackey et al. ⁴²

I feel it’s the isolation that is causing the greatest emotional and mental anguish. p7 Pearce et al. ³⁶

For the patient, accepting the programme may be motivated by a fear of isolation, or concerns about missing out on important relationships or receiving services.

Mr. H enjoyed his virtual visits with the palliative care team, reporting that it gave him comfort to see team members’ faces, even if not in person. p204 Mackey et al. ⁴²

Context-mechanism-outcome configurations:

‘Follow the leader/money’ (CMOCs 8–9)

Change is made possible when institutional level practices organise new ways in which people work to implement the programme. NPT describes these as ‘implementation contexts’. These make up an organisation’s resources, providing structure and procedures for the settings in which the new intervention can be operationalised. This includes social relations where those with high status, power, or control of finances unlock these resources, in NPT terms this is ‘action’. Staff are thereby incentivised and motivated to adopt new practices:

. . .the University of California, San Francisco (UCSF) has mandated telemedicine be used to care for palliative care and nonpalliative care patients in ambulatory settings, whenever possible. Similarly, many hospice agencies are currently offering most, if not all, social work and chaplaincy support by telemedicine. [. . .]. To support these changes, many telemedicine regulatory measures are being relaxed. e12 Calton et al. ³⁴

In times of systemic disruption, innovation is required to overcome barriers and identify new strategies for a business to persevere (e.g. maintain healthcare service delivery). [. . .]

The prerequisites to innovation include not only knowledge, expertise and experience, but also courage, creativity and fearless leadership. p993 Ritchey et al. ³³

Where political mandates determine organisational funding, leadership of the knowledge specialist can be an advantage.

The Gold Line offers, in the minds of our participants, the opportunity to elude the structural barriers to accessing responsive care by enabling faster responses by GPs, District nurses and accident and emergency departments because a ‘specialist’ service has enabled it. p5 Middleton-Green et al. ³²

Context-mechanism-outcome configuration:

‘Comply or die’ (CMOC 10)

Pressure exerted within organisations to change working practices may be triggered by financial and job losses. People worried about employment security may feel pressured to take up new ways of video-enabled working, which reduces rather than maintains usual in-person emotional support. This illustrates NPT’s sense-making construct. This explanation contrasts with the positive views described above; the implementation of the programme constrains services:

Bereavement care fell to a wide range of staff members, including some with limited experience of or training in supporting bereaved people who had to rapidly develop the required communication skills. p3 Pearce et al. ³⁶

In 2020, COVID-19 restrictions and donor confidence prompted a funding crisis in the hospice sector, resulting in a 40% drop in hospice fundraising in 2020–2021. Government stepped in with emergency funding to purchase capacity from the sector, without which many hospices would have struggled to survive. However, this most welcome emergency funding has now ended and, without a sustainable funding model, hospices struggle to raise enough money to provide services that are vital to the mental health and wellbeing of their patients. p2 Hospice UK ³⁸

Context-mechanism-outcome configuration:

Refining programme theory

These five explanations address ways people may work individually and collectively to adopt a new intervention. These can occur across the healthcare ecosystem and are not mutually exclusive. In fact, a cascading influence is suggested that show how generative mechanisms move from organisational leader to health professional to service user, as Pawson states ‘The actual intervention takes shape according to the power of the respective parties’ p3 (24).

The findings suggest that implementing the programme changes power dynamics between patients and practitioners activating several causal chains of behaviour, that are responsive to financial and interpersonal contexts.

A significant trigger for change was the COVID-19 pandemic. Prior to this, sources report that uses of videoconferencing for palliative care delivery was slow despite staff readiness and patient acceptability.^31,33

As the pandemic unfolded, there was a general embrace of rapid initiation and utilization of telehealth by the PCT [palliative care team], patients, and the entire healthcare system. p994 Ritchey et al. ³³

With increased self-confidence mobilised by engaging in videoconferencing it seems that patients and caregivers may value taking more ownership of their healthcare consultations. Where health professionals feel motivated to collaborate with patients through video-enabled interventions both may gain an increased sense of competency and self-worth. Consequently, if the uptake of the programme occurs in a relational context that alleviates fear and isolation positive therapeutic alliances can be established and a successful outcome achieved. ³⁷ This point is reinforced by Sarmento et al. whose research highlights the importance of reducing fear to engender feelings of security in palliative patients being cared for at home. ⁴⁴

While positive outcomes may result from actions by well-resourced stakeholders responding to circumstances where life as usual is disrupted, this may not always be the case. In fact, getting access to palliative care is difficult for those in financial hardship, which itself is a cause of social isolation. ⁴⁵ Videoconferencing may be regarded as a good way to address social isolation, but only having options of emotional support by videoconferencing may reinforce feelings of exclusion and isolation from palliative care services. ³⁸ Services cannot rely on videoconferencing as a quick fix for social exclusion. The interwoven factors of deprivation faced by those with palliative care needs (including limited material resources, technical knowledge and skills), must be addressed first. The collective efforts to address educational and material limitations outlined in the included papers (and hypothesised in the synthesis) suggest ways mitigation can be made to prevent exclusion.

Financial resources, staff digital literacy and enthusiasm for adopting a new way of working influence the long-term sustainability of video-enabled emotional support once COVID-19 is controlled. The normalisation of the new intervention was picked up during data analysis by question 12 of the NPT framework ‘How have interventions and their components become incorporated in practice?’ Reported interventions offer templates for safe management of patient care during COVD-19 or potential future service developments rather than foundations that are being built on. Pearce and others warn that reduced income for palliative care – delivered mainly by charities – will negatively impact the provision of care.^36,38 In the context of financial scarcity an organisation’s viability may be threatened, leading to choices to redeploy staff into new roles. If these staff feel neither trained or committed to this, feelings of being deskilled and demotivated can result. ⁴⁶

The initial programme theory was refined through the synthesis process as:

Successful emotional support delivered by videoconferencing in palliative care is feasible when it addresses feelings of isolation and maintains patient/carer engagement with services. It depends on stakeholders being motivated and resourced to adapt and innovate interventions appropriate for those least familiar with technology. To do this staff need leadership and organisational cultures that enhance their professional self-worth and technical competencies, that foster inter-agency collaborations and mitigate digital exclusion of service users.

This refined programme theory supports NPT’s four core constructs (sense-making, participation, action and reflexive monitoring) by recognising how networks of relationships between patients, professionals and organisational managers can facilitate changes in practice across the healthcare ecosystem. It suggests that collaborative relationships are most likely to be activated in circumstances characterised by social isolation or where people feel in danger of alienation from what is important to them. As a social action theory focused on collective efforts to implement and sustain new interventions NPT does not account for feelings implied by people’s responses to the opportunity of video-enabled emotional support interventions. Further theories were sought.

NPT and alternative theory development from CMOCs

As outlined already NPT and realist synthesis were used to answer the review question. While NPT is increasingly aligning with a realist approach, it is conceptually different to it. ⁵⁸ NPT puts its focus on actions taken through relational work which are shaped by organisational structures. Realism uses abductive and retroductive reasoning to consider hidden motivators and contextual determinants driving these actions. ²³ In realist terms, feelings are understood to activate behaviours in response to contextual conditions, and this synthesis highlighted how feelings of isolation in situations of living with terminal illness, or during COVID-19 pandemic restrictions or disrupted employment conditions may mobilise people to engage with videoconferencing if given the opportunity. NPT explained ‘how’ success is mobilised through the collective and individual actions of people working together. However, while NPT does describe ‘mechanisms’ in its own terms ³⁰ it was clear in the synthesis process that NPT could not fully account for people’s motivation and feelings (the why), or their responses to available resources (what) which could lead them to behave as they did. ⁵⁸ Three alternative theories were considered to see if they better addressed this.

Belongingness raises awareness of the value of social connectedness for wellbeing ⁶³ and as a mitigation for loneliness. Expanding NPT’s explanation for the relationships generated in this synthesis by adding in other theories (‘layering theories’) ⁶⁴ is an outcome of this synthesis. This may explain the different levels in the programme theory, where implementing the emotional support intervention (itself a complex system) may benefit some stakeholders while disadvantaging others. The value of belongingness for a palliative care population is an important outcome of this review and supports Bradley’s research on hospice day service. ⁶⁵

Strengths, limitations and future research

A strength of this realist synthesis is its focus on emotional support interventions and the factors that combine to make these possible using videoconferencing in palliative care. Understanding why, when and how to deliver such interventions successfully could be valuable to providers and service users wanting to use technology to extend the reach of in-person services. This review recognises that emotional support is integral to the care of those living with non-curative illnesses and deserves increased investigation. ⁶⁶ Understanding the different cultural contexts for emotional support interventions was beyond the scope of this review, however NPT’s emphasis on building trust through collective efforts is of relevance.

This review had several limitations. Only using English language publications narrowed the pool of sources, excluding other healthcare systems and cultures where emotional support interventions and usages of videoconferencing may be different from sources included here. Two recent systematic reviews highlight different structural inequities of digital health policies across the socio-demographic spectrum. For people living in low- and middle-income countries technological and social infrastructure problems are significant barriers to the reliable implementation of digital health interventions. ⁶⁷ In upper-middle income and high-income group countries like those of our included sources people least likely to access health services by videoconferencing were aged over 65 years, had lower household incomes and lower educational attainment and English was not their first language. ⁴⁷ The depth of data within the included studies meant it was not possible to conduct a comparative analysis across different healthcare systems, although we do acknowledge that culture and context will have a major effect on implementation. We have noted this in areas where it seemed particularly important. Efforts to build trust and a sense of belonging central to the programme theory developed in this synthesis align well with the cultural safety that Moecke et al. argue is critical for culturally-informed telehealth services for indigenous groups in United States, New Zealand, Canada and Australia. ⁶⁸

Another constraint noted in searching the literature is the under-reporting of psychological practitioners’ contributions to the multi-professional care of patients and families. To overcome this ‘emotional support’, initially defined using UK NICE guidance^43,69 as embracing interventions by psychological specialists at levels 3–4, was widened to include interventions by health and social care professionals at levels 1–2. While a systematic approach was taken to this review it is possible that synthesis of other sources not included here may provide different explanations.

This review considered literature arising from two distinct historical times (before and during COVID-19), where the pandemic shifted videoconferencing from novel interventions (context) to essential activities (mechanisms). Videoconferencing normalised during COVID-19 has become mainstream and is increasingly used to mitigate the pandemic’s unfolding effects on the mental wellbeing of the general population. Whether palliative care providers continue to adapt their services to include videoconferencing will depend on how they have been impacted by factors described in this review. ⁷⁰ Sustainability of telehealth interventions as an integrated part of palliative care will depend on different factors, including concerns that if videoconferencing replaces in-person sessions the quality of interventions will suffer. ³⁶ This realist synthesis highlights how intrapersonal, interpersonal and structural features are variously activated by the contexts in which palliative care is delivered.

Recommendations

One recommendation from this review is for better training of practitioners to confidently deliver online interventions, and to assess and meet service users’ psychological needs. This is consistent with Levoy et al.’s rapid review of palliative care delivery changes during the pandemic which found the increased demand for psychological and spiritual support was not adequately met by existing services. ⁷¹ Likewise, a recent survey of hospice care professionals felt they lacked sufficient knowledge and skills to address psychological issues. ⁷² Finally, consistent documentation of where in the patient and service care pathway emotional or psychological support is identified and delivered would improve clarity and could improve overall care. ⁷³ Further research on specific system-level factors and stakeholder roles (e.g. healthcare professionals, caregivers, patients, and policymakers) that facilitate or hinder implementation of videoconferencing for emotional support would be a valuable next step.