Experience with videoconferencing between a neonatal unit and the families' home from the perspective of certified paediatric nurses

Abstract

Parents of preterm-born infants need support after returning to their homes with their baby. We studied the experience of certified paediatric nurses (CPNs) with the use of videoconferencing between the neonatal intensive care unit and the families' home. Families were given a home videoconferencing unit, which allowed them to contact staff at the neonatal unit, day and night. Over a period of 12 months, ten families used the videoconferencing equipment. Families made a median of 4 telemedicine calls each (range 2–30). Narrative interviews were performed with 10 CPNs after the study ended. Qualitative thematic content analysis was applied to the interview data and one theme was identified: smoothing the transition of infants from the neonatal unit to the families' home. The CPNs found that videoconferencing helped them to assess the overall situation at home and facilitated the relationship between parents and the infant. The CPNs felt that they were able to provide security to the family. The use of videoconferencing was considered as a generally positive experience and as a tool to improve nursing care at home.

Introduction

There is an increased awareness among health professionals regarding the pressure that the parents of preterm-born infants are exposed to. Being discharged from the neonatal unit is challenging for the parents of preterm-born infants,^1–3 who experience excitement and happiness, as well as anxiety and insecurity.^4–8 After homecoming with their preterm-born infant, parents generally want to have someone whom they can contact with their questions and problems about raising the infant.⁹ Such support includes providing explanations and keeping the lines of communication open.¹⁰ In the USA, a programme called Baby CareLink provides videoconferences between the neonatal intensive care unit (NICU) and the family at home, which allows parents to see their infant and receive teaching and support from the staff.¹¹ However, it is important to clarify the form of support that the families need. Further research is also needed about how families can best be supported after returning home with their preterm-born infant.¹²

The northern part of Sweden has a large land area and sparse population. This creates certain limitations, making it impossible to obtain neonatal home nursing care. Consequently, the question arises whether videoconferencing could be used for supporting parents of preterm-born infants after homecoming. We have therefore studied the use of videoconferencing to support parents of preterm-born infants at home. The aim of the study was to describe the experience of certified paediatric nurses (CPNs) with the use of videoconferencing between the NICU and the families' home.

Videoconferencing

As part of a larger study, videoconferencing was carried out between the NICU and family homes. The study lasted from September 2006 to September 2007. The videoconferencing systems (VSX 3000, Polycom) were all-in-one units, including camera, display, stereo speakers and microphones (see Figure 1). The families were required to have a high-quality broadband connection, allowing 512 kbit/s transmission in both directions. At the hospital the data network run by the County Council was used, although with the necessary security clearance. The same type of videoconference equipment was used at the NICU and in the families' home (Figure 2).

Figure 1

The all-in-one videoconferencing system used in the study. Reprinted with permission from Polycom Inc.

Figure 2

Videoconferencing between the family in their home and staff at the NICU. The same type of videoconference equipment was used at the NICU and in the families' home. (Photo credit: Birgitta Lindberg, reprinted with permission)

Before an infant is finally discharged from hospital, most parents go home with their infant on leave. The length of that leave varies from a few days to several weeks, and depends on the baby's medical condition and the parents' confidence about being at home with the infant. During the families' initial stay at home, common practice is for parents to have contact with the CPNs by telephone. In the present study, they were given the option of using the videoconference system to contact the staff at the NICU. The intention was to offer support to the parents, as a supplement to usual care, and not for other purposes such as earlier discharge of the infant or to reduce costs.

All the CPNs were given detailed information repeatedly, and were shown the videoconference equipment and trained how to use it. Two CPNs from the NICU were involved throughout the planning and implementation, and took an active part in informing and supporting their colleagues at the NICU. They also acted as a linkage between the researcher and the staff at the unit. It was desirable to include the nurses in the early stages of the project, so that they could advocate their specific needs.¹³ Over a period of 12 months, ten families used the videoconferencing equipment (see Table 1).

Table 1

Characteristics of the families (n = 10) and the use of the videoconference equipment

	Median	Range
Fathers' age, years	37.5	29–44
Mothers' age, years	33.5	28–39
Infants' gestational age at birth, weeks	31.5	24–33
Infants' gestational age at arrival home, weeks	36	34–39
Videoconference equipment installed in the families' home, days	14	6–22
Number of telemedicine calls	4	2–30

Methods

A qualitative method was chosen in order to describe the experiences of CPNs of the use of videoconferencing between the NICU and the families' home.

Participants and procedure

A total of 10 CPNs, all women, participated in the study. The criteria for participation were: being a registered nurse with specialist training in paediatric nursing, experience of working in the NICU, and experience in the use of videoconferencing between the NICU and families' homes. The participants were aged 32-58 years (median = 49), and they had been working as a CPN in neonatology for 1–33 years (median = 7.5).

The study was approved by the appropriate ethics committee. The CPNs were assured that their participation was voluntary and that they could withdraw at any time, without declaring the reason. They were also guaranteed confidentiality and anonymity in the presentation of the results.

Data collection

Personal interviews using a narrative approach^14,15 were conducted with the CPNs within a month after the videoconferencing stopped. All the interviews were conducted by the same person. The interviews were guided by questions to cover the CPNs' experience with the use of videoconferencing. The interview started with the leading question: ‘Please tell me about your experiences with the use of videoconferencing.’ When needed, follow-up or clarifying questions were asked.¹⁶ Interviews were conducted at the CPNs' workplace at a time convenient for them. The recorded interviews lasted for 30–40 min, and were transcribed verbatim and cross-checked for accuracy.

Data analysis

A qualitative thematic content analysis^17,18 was used to describe the manifest and latent content of the text. All the interview texts were included in the analysis. To obtain a sense of the content, the interviews were read several times. Guided by the aim of the study, the meaning units were identified, and then condensed and grouped into categories in several steps, by subsuming similar content into broader categories. After determining the final categories, the meaning units were re-read and compared with the categories. The categories were then related to each other and subsumed into a theme, i.e. threads of meaning that appeared in several categories.¹⁸ The authors checked and reached agreement on the theme and categories.

Results

The theme that emerged was smoothing the transition of infants from the neonatal unit to the families' home. Within this theme, the four categories were:

Enabling meetings with the whole family;

Facilitating assessment of the overall situation at home;

Providing security to the family;

Difficulties with continued use and development.

Enabling meetings with the whole family

The CPNs felt that the use of videoconferencing made it possible for them to face the family and it was almost like meeting them in the same room. They experienced videoconferencing like a conventional meeting with the families at the unit. However, the rapport felt in those meetings was not experienced when using the telephone. Nevertheless, the CPNs emphasized that at times, they experienced some distance when using videoconferencing, thus highlighting that human contact could not be totally replaced. The CPNs described the joy that the parents showed on seeing them, which was experienced as shared happiness. Another opportunity with videoconferencing was that the sibling was a natural part of the meeting and it was also important to pay attention to the infant. Furthermore, as both the staff and parents could hear the same communication, the risk of mistakes related to communication was reduced. The CPNs stated that the meeting with the families would be adversely affected if they did not know the family members. However, there was usually someone on duty who had met the family before.

The use of videoconferencing could be demanding. The CPNs felt their presence more during the meeting, as it was not possible for them to hide, like when using the telephone. They described occasional feelings of being observed by the parents. Other opinions were the dislike of being visible in a picture, although for some, this did not matter at all. Some CPNs expressed their difficulty in being natural, and felt that their manner, in a way, was affected. On the other hand, they also felt that they would get used to videoconferencing in due course.

Facilitating assessment of the overall situation at home

By using videoconferencing, the CPNs were able to observe the family, and thereby assess the situation at home and the relationship between the parents and infant. When compared with using the telephone, both seeing and hearing provided another dimension, as the body language could be observed. The CPNs expressed thoughts about not previously being fully aware of the importance of non-verbal communication. A relaxed atmosphere at home, observed through videoconferencing, indicated that the parents could manage looking after the baby. On the other hand, it was also possible to notice, for example, if the parents were worried or if the infant seemed to be unwell. Giving instructions and information to parents was eased by seeing, and it was possible to obtain confirmation about whether they understood or not. The use of videoconferencing was also found to enable discussion on each other's decisions, as there was often more than one member during the videoconferencing, similar to the NICU environment. On the other hand, some CPNs felt that it was not always necessary to use videoconferencing, and that sometimes assessments could be made by just talking with the parents by telephone. The CPNs emphasized that contact with the families generally was based on personal conversation; nevertheless, small talk seemed to be of significance for the parents. However, the problems that parents raised were the common difficulties, such as feeding problems, which in most cases, could be solved themselves.

Providing security to the family

The CPNs found that access to staff through videoconferencing made some parents willing to take the step to go home, sometimes at an earlier stage, and still be confident. However, it was not always easy for the parents to go home despite offering them this access. The CPNs stressed that parents need to feel ready and prepared to take the infant home, and should not be forced to go home. Some CPNs were not convinced that it was feasible to let the family go home earlier than usual, owing to the availability of videoconferencing. However, towards the end of their period at the NICU, parents usually manage to take care of their infant and only need someone who can supervise them, which CPNs emphasized was possible through videoconferencing. The CPNs reflected that the parents could be given confidence by making them aware of the fact that they could have video contact with the staff at the NICU. The CPNs thought that it was important for the families to have access to the staff at all hours, which they said was perceived by parents as a feeling of safety. The CPNs also said that the use of videoconferencing gave a sense of security to the family after returning home with the infant.

The CPNs felt that the distance between the unit and the families' home was reduced, as by using videoconferencing they could make virtual visits to the family. Nevertheless, after coming home, parents were able to take control over their own situation as it was the parents who initiated the use of videoconferencing. However, CPNs expressed that the focus of using videoconferencing was the individual families' needs and wishes. Staff had to adjust to the families and decide on the time to communicate based on the parents' schedule. Sometimes, when the CPNs were busy, they had to give parents a time for a new appointment, but if it seemed to be an emergency they had to prioritize it. The CPNs described that when staying at the NICU, the parents sometimes had to wait, but when they went back home, the condition was reversed — the family could plan and did not have to adapt to the staff and current practice. The CPNs also stressed that families with the experience of using videoconferencing welcomed its use and hence considered it more advantageous to offer this opportunity to other families. They also stated that parents discussed their positive experiences of using videoconferencing, which made other parents interested in having this facility after homecoming. Videoconferencing did not ease the work of a nurse, but made it easier to provide support to the family. Some CPNs stated that the use of videoconferencing should be continued as they felt that it was supportive for the parents.

Difficulties with continued use and development

The use of videoconferencing was considered as a generally positive experience and as a tool to improve nursing care at home. The CPNs underlined that it was exciting to be a part of the project. However, some of them also felt that they had less experience in using videoconferencing. The CPNs expressed their willingness to widen the use and reflected on multiple uses, for example, for children needing extra care, children with heart disease, children with cramp or just needing extra control. The CPNs were convinced that the use of videoconferencing should be a part of continuing care, because parents are used to information and communication technology and anticipate that its use would be a new standard within neonatal care. However, their positive experiences on the use and user friendliness were seen as preconditions for further use. The videoconference system was very easy to use and was mostly well-functioning. Conversely, occasional technical problems made the use difficult, for example, when the picture was rather dark or even worse when there was a problem with the connection. The CPNs felt that when the technology failed to work, the parents might get frightened to use videoconferencing. Nevertheless, before they had used the equipment, some CPNs expressed fear, although this was not a problem after they had used it and knew that they could handle it. Another drawback was the bag in which the equipment was transported, which was too big and clumsy.

A common opinion was that videoconferencing was not utilized to its full potential, which would require the CPNs to change their way of working. To provide the opportunity for the family to go home earlier, the technology would need to be introduced earlier. Some CPNs said that it was at a very late stage, not long before the family was about to go on leave, that they were told about the opportunity to have access to the staff at the NICU by using videoconferencing. Although all families may not be interested in having this access, at least they must be informed about the possibility. For optimum use of videoconferencing, cooperation among different professional groups and planning for families who return home are important, and individual discussions about when it is likely for the family to go home are significant. However, the CPNs stressed that professional changes need some time to become a natural part of work.

Discussion

The present study described the experience of CPNs with the use of videoconferencing between the NICU and family homes. The study had certain limitations, such as the relatively small sample size and the fact that participation was based on those who were interested. However, the results showed that videoconferencing had facilitated the transition of preterm infants from the neonatal unit to the families' homes. It was considered to be a tool for CPNs to improve nursing care for the family after returning home with their infant. Furthermore, the CPNs were able to meet the whole family and thereby have a cordial relationship. Advances in technology now allow nurses to provide nursing care to patients in alternate care sites and remote geographical areas.¹⁹ A study in children with subacute health-care needs showed that video played an important role during the early stages at home, enabling parents to become confident in caring for their child, and helping them to establish a strong rapport with the health-care providers.²⁰ Although videoconferencing can give the feeling of meeting the family, it cannot totally replace face-to-face visits.²¹ It is important to bear in mind that if telemedicine was used as a replacement for standard care, instead of being used just as an adjunct, then the positive results might not be replicated.²² On the other hand, as shown in a study of virtual homecare visits,²³ nurses felt that most visits would not have been significantly better if performed in person.

The present study showed that the CPNs felt that video and sound helped them to assess the overall situation at home — they could observe the family and study the parents' body language. Thus, videoconferencing allowed remote assessment while supporting parents at home.²⁰ Communication can be described by nurses as a source of both weakness and strength in helping to support parents. However, non-verbal cues were described as important.²⁴ The importance of facilitating effective communication through active listening and the skilled use of non-verbal communication is clear, and should not be underrated.²⁵

The present study showed that the CPNs felt that they could provide security to the family by offering parents access to videoconferencing day and night. Parents need consistent encouragement, ongoing reassurance and positive feedback regarding their competency to cope with the situation.²⁶ It is also important to recognise that access to staff by videoconference may not be perceived as supportive for all parents, so its use must be adjusted according to the individual families' needs. On the other hand, the study demonstrated that after coming home, parents were able to take control of their own situation and thereby the use of videoconferencing. In a study concerning care of children with complex health-care needs, professionals felt that parents were able to exercise a greater degree of power in their home than the hospital environment.²⁷ Casey speculated that the balance of power shifts when the relative is on home territory and the nurse is the stranger.²⁸ Furthermore, instead of viewing themselves as experts, nurses must alter their perception of the relationship and regard parents as the ultimate experts in their own child's well-being; however, nurses are still valuable in the partnership. The role of nurses does not change in telehealth, only the way in which it is delivered and the locations differ.¹⁹

The experience reported in the present study was generally positive and the CPNs reflected on continuing and even developing the use of videoconferencing. Professionals who are conducting telehealth interventions may need further experience in using the technology to feel comfortable with the approach,²⁹ which accords with our findings. Even those participants who are unfamiliar with the technology are able to use it with little training and glean benefits.³⁰ Nevertheless, our results showed that user friendliness was of great significance.

The CPNs in the present study stated that videoconferencing was not utilized to its full potential. However, this would require the CPNs to change their way of organizing their work. If people continue to work in the same way even after introducing new technology, then they may not realise the potential improvements in process and outcome.³¹ A central problem in telemedicine is the organizational problem of knowing how best to take advantage of the technology.³² However, it is notable that telemedicine initiates changes in health-care service delivery to the home that are difficult to anticipate and manage.³³

Despite the perceived benefits, the question of whether the nurses would accept new technologies still needs to be addressed. Acceptance and use of information technology greatly depends on personal technical skills, workplace culture and the perceived benefits of the new system.¹³ The results of our study showed that nurses saw the use of technology as a natural part of health care in the future. As highlighted by Simpson, nurses provide care and compassion that cannot be matched even by the most advanced technology.³⁴ Although technology can help nurses to care better, this does not eliminate the need for nurse professionals.

The results of the present study have implications for staff working with families in the context of neonatal care. After the project was completed, videoconferencing became permanently incorporated into a new standard of neonatal care in the county of Norrbotten.

Footnotes

Acknowledgements

We are grateful to the CPNs who participated in this study and to all the staff at the NICU. We thank the Department of Health Sciences and the Centre for Distance-Spanning Healthcare (CDH), Luleå University of Technology, Sweden, and the Norrbotten County Council, Sweden.

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