Staff experiences of delivering COVID-19 remote home monitoring services

Overview

This chapter draws on a manuscript by Sidhu et al.150 published in Journal of Health Services Research and Policy (2023): https://doi.org/10.1177/13558196231172586. This is an open access article under the term of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits use, distribution and reproduction in any medium, provided the original work is properly cited (see https://creativecommons.org/licenses/by/4.0/).

What was already known

• Remote home monitoring may have some benefits for patients, health-care systems and staff (e.g. flexibility/independence/fast access to clinicians).
• Some challenges and concerns with remote home monitoring have been highlighted (e.g. lack of supportive infrastructure within NHS organisations to facilitate successful implementation and delivery, staff training, treating patients living with a range of long-term conditions which may include physical and/or cognitive impairment).
• However, there is a paucity of evidence on staff experiences and the factors influencing delivery of COVID-19 remote home monitoring services.

What this chapter adds

• Delivery of remote home monitoring services for COVID-19 involved delivery of either technology-enabled and analogue services, or analogue-only services. Staff were involved in a range of tasks including monitoring, escalation, and service evaluation.
• Staff generally reported positive experiences of delivering the service, felt that it was easy to deliver and valued support, but staff would have benefited from further training.
• Factors influencing delivery of remote home monitoring services for COVID-19 included: support for delivering the service, NHS resources and capacity on staff workload, multidisciplinary team dynamics, and patient (dis)engagement.

Introduction

The impact of remote home monitoring services on NHS staff or staff experiences is not yet known.36,151–154 Delivering remote home monitoring services may affect job satisfaction for staff155,156 – that is, if staff are reluctant to deliver remote services full-time, due to valuing face-to-face interactions with patients11,156,157 and concerns over ‘call-centre medicine’.157 Previous research has indicated that many staff acknowledge benefits of remote home monitoring, including flexibility and independence for staff, fast access to clinicians for patients living with chronic (e.g. respiratory and heart failure) and acute (e.g. COVID-19) conditions,158,159 and improved continuity of care and communication of risks between staff and patients.160 Despite these putative benefits, clinicians have expressed concerns that some patient characteristics, including physical and cognitive impairments, may present challenges for remote home monitoring services.160 Additionally, staff report concerns about lack of training and the exclusion of some service user groups if alternatives to remote care are not provided.161,162

Despite previous research on remote home monitoring models for other conditions, there is a paucity of evidence on staff experiences of delivering care as part of remote home monitoring services. A range of individual, organisational and environmental factors have been previously proposed to influence health-care professional behaviours,163 but the factors (barriers and facilitators) influencing delivery of COVID-19 remote home monitoring services are not yet known.

This study explored staff experience of delivering COVID-19 remote home monitoring services. The study reported in this chapter aimed to answer the following questions:

1. What was the nature of ‘work’ that staff undertook to care for patients with COVID-19?
2. How were staff supported to deliver remote home monitoring services?
3. What factors (barriers and facilitators) influenced delivery of COVID-19 remote monitoring services?

Methods

A summary of the methods is provided below; further details can be found in Chapter 2 and Report Supplementary Material 1.

Design

This chapter draws on data from workstream 3 (staff survey data) and workstream 4 (staff interviews). Data collection for this study took place between February and June 2021.

Sample

Staff who led and/or delivered COVID-19 remote home monitoring services (see Chapter 2 and Chapter 4 for site and staff sample details).

Measures

We iteratively developed the survey and semistructured topic guides specifically for this study (see Chapter 2, Project website documentation – Study instruments).

Procedure

We conducted a survey with staff from 28 sites, and interviews with staff from 17 sites (see Chapter 2 for details).

Analysis

Inductive thematic analysis was used to analyse interview data inputted into RAP sheets.70 Additionally, a subset of transcripts (n = 17) were independently thematically coded to validate interpretations from the analysis of RAP sheets.

Survey data were analysed on a complete case basis (excluding participants with missing data) using descriptive statistics (using SPSS, version 25). Open text responses were coded using inductive thematic analysis.

Interview and survey findings were triangulated to compare consistency of findings relating to research questions.71,72

Results

Participant characteristics

Surveys were received from 292 NHS staff (70 clinical leads/service managers, 222 delivery staff) and 58 interviews were conducted with staff (23 clinical leads, 28 delivery staff, 7 data staff. See Chapter 4 and Report Supplementary Material 2 for demographic characteristics.

Findings

The nature of ‘work’ that staff undertook to care for patients with COVID-19 remotely

Staff were involved in remote monitoring services delivered in one of two ways: technology-enabled with analogue services (21/28 sites), and analogue-only services (7/28 sites) (see Chapter 4 for further details).

Daily, staff would assess the nature of referrals made to the service, monitor data uploaded by patients regarding oxygen saturation, temperature, or breathlessness (as a minimum), and if necessary, determine whether data warranted escalation in patient care (phone call to the patient, sending paramedics to the patient, directing patients to seek emergency acute secondary care).

Staff survey responders reported a range of work-related tasks they had been involved with when delivering their respective services (see Table 13). The more frequently cited tasks included monitoring activities (80%) and escalation processes (70%).

The majority of clinical leads and delivery staff felt services they provided had a positive or very positive impact (47%, n = 127/266) or neutral impact (32%, n = 85/266) on their workload. However, delivery staff and service leads also reported that services increased their workload (21%, n = 54/266).

Support and training provided to staff to deliver remote home monitoring services

Service leads reported being supported in many ways by NHSEI and other organisations; for example, obtaining pulse oximeters (54%) and receiving guidance for implementation (43%). Delivery staff (88%) reported that they were adequately supported in their role (see Table 14).

In terms of training, 68% (n = 200/292) of staff survey respondents (managers/leads and delivery staff) reported having received training or training resources as part of their role. However, the amount and nature of training received was difficult to determine. Delivery staff lacked knowledge of and familiarity with the NHS CO@h competency framework (which sets guidelines for staff training to deliver both services and undertake patient assessment); only 9.5% (n = 21/220) reported having completed the framework and 35.5% (n = 78/220) were unsure. See Report Supplementary Material 7 for a training and support summary.

Forty-one per cent (n = 28/69) of clinical leads/service managers and 12% (n = 26/222) of delivery staff reported that they had further training or support needs (beyond that already received) (Table 15).

Interview findings highlighted that clinical delivery staff, particularly nurses, raised concerns that training led by senior clinicians largely took the form of shadowing and/or receiving brief overviews on each part of the service. As a result, initially many nurses felt a lack of confidence, especially when communicating risks associated with COVID-19, and remained dependent on senior clinicians. This dependency subsided as their experience grew. During this period, nurses welcomed those senior clinicians who were readily accessible:

[. . .] you don’t need to know everything. You’re not a doctor. You just need to get all the information and you can always get a doctor to give them a call. [ . . . ]. So, don’t panic. Just, yes, reassure them and if you’re unsure, just get a doctor to give them a call.

Factors influencing delivery of COVID-19 remote home monitoring services

Staff knowledge and confidence

Delivery staff reported feeling confident or very confident in their ability to carry out their responsibilities (92%, n = 204/222) and were clear about the requirements of their role (91%, n = 202/221). Delivery staff reported few difficulties completing tasks as part of delivering services and most staff reported these tasks to be easy or very easy (range between 54% and 73% across tasks). The most challenging tasks seemed to be using IT systems and working with other COVID-related services – with lower numbers of staff reporting these tasks as easy (see Table 14).

Although the survey data indicated that staff felt satisfied with the support and training received as well as confident delivering the service, not all felt this way. Staff reported that the need to develop new knowledge, skills and confidence about engaging with online monitoring platforms and undertaking clinical assessments via telephone, early on in the implementation of these services was a barrier to delivery, as training was not always embedded in a timely way during service implementation. A significant minority of nursing staff felt unsupported and distressed at having to work on a remote home monitoring service. At one site, staff initially ‘hated [the service] with a passion’ with some staff finding the accountability of assessing patient risk remotely and then determining appropriate treatment too stressful and threatened to leave their roles unless changes were made to their training (e.g. increasing the number of hours of training, who was providing training, and greater shadowing when staff first deliver the service). Nursing staff, at times felt ‘at risk’ of potentially making mistakes in relation to monitoring and decisions about potential escalation in the rapid scale-up of services. Often staff were relying on their previous experiences of working with SOPs (in GP and secondary care) and were unfamiliar with newly established practices when delivering care remotely and hence transitioning to a new remote workplace culture with risk assessment, interpretation, and potential escalation of patient care at its centre was difficult. However, there were a number of exceptions:

Working in A and E I can see some really acutely unwell patients and we use kind of an A to E approach where it’s kind of a system that we look at looking at airway, breathing, circulation, etc. And then, say, when I’m speaking to a person on the phone, what we are concerned about is the breathing and things, so you’re kind of able to transfer that knowledge.

Influences on staff workload

Members of staff felt their workload was increased more than initially expected (Table 15) as they were often dealing with wider determinants of ill health that were having a substantial impact on patients’ well-being. For example, given the nature of COVID-19, staff were supporting some patients who had lost employment, were taking care of others diagnosed with COVID-19, or who also had mental health problems.

While the majority of clinical leads/service managers felt there were enough staff and sufficient capacity to deliver services as intended, delivery staff reported having to balance their role within these services with other roles (Table 16). Redeployment of staff facilitated capacity to deliver services and scale-up when needed, as these staff were often working solely on remote home monitoring services.

Both clinical leads and delivery staff expressed concern that redeployed staff members would not be available during future surges in patient cases.

We delivered on existing staffing. So it was mainly done via bank. We did have bank admin and bank drivers for deliveries and collections. [. . .] But it was done on existing staffing. So the staff that we already had stepped up, took on extra shifts, it was all done on bank and goodwill.

Staff reported having discussions within their team regarding which technology-enabled platforms should be used (N = 4) and could be easily integrated with existing patient record systems. For example, staff welcomed apps and/or online platforms that could be integrated with existing familiar primary care patient record systems. Technology which could not be integrated meant greater time taken by staff to upload patient data on to multiple databases, which was resource intensive, cumbersome, and increased the risk for potential mistakes. In other sites (N = 3), staff did not feel included in decisions on which apps and/or online platforms would be deployed for remote monitoring. The use of these platforms felt imposed and limited early engagement with the technology:

And my honest personal view was at the time I felt like we had a clever little app that we were trying to fit a service for, that was my personal view. And so, I took a little bit of convincing . . .

Multidisciplinary team dynamics

Where sites adopted a multidisciplinary team model of working, there were at times tensions between professional groups, especially where there was historically a lack of co-working between the groups. This remained problematic until services were more established and roles became more distinguished (e.g. GPs understanding that remote home monitoring services were not replacing their duty to continue doing home visits during the pandemic).

A key facilitator was determining the correct mix of staff that needed to be involved in the delivery of the service. Of the staff survey respondents, 71% (n = 206/292) reported their role within services to be clinical, 29% (n = 86/292) non-clinical, and 2% (n = 5/292) were students/volunteers. In a small number of sites, only clinical staff were involved in monitoring patients, whereas most sites involved a mix of both clinical and administrative staff. Volunteers were also used at two sites to support the administrative duties associated with setting up services.

Implementation was facilitated by good communication between members of the clinical team. Service leads tried to identify staff with the necessary communication skills to undertake remote monitoring consultations via telephone, such as active listening, and picking up cues regarding a patient’s current condition without physical examination. Delivery team members, in turn, wanted to make service managers aware that they needed flexibility regarding how each call was made as staff wanted to be able to provide patients with emotional support as well, which, at times meant longer phone calls.

You spend a lot of your time actually reassuring patients that they’re doing all right. They’re frightened. They’re very frightened. And they always know somebody that’s been in hospital and has had a really bad experience.

Staff experiences of patent engagement or disengagement

All staff felt that delivery of remote home monitoring services was facilitated by patients engaging with services and having confidence as well as sufficient digital literacy to send their measurements and readings. Survey staff reported high levels of patient engagement with their service (96%, n = 209/219). Delivery staff generally reported that service users experienced few difficulties in using the oximeter to take readings (91% well/very well: n = 193/212) and providing readings over the phone (91% well/very well: n = 186/205). However, providing readings via an app was reported to have more difficulties (78% well/very well: n = 134/172). Staff felt that those patients who were living with a long-term respiratory condition (e.g. COPD) were more comfortable dealing with episodes of breathlessness and therefore were less in need of the advice and exercises provided by nurses for managing COVID symptoms.

Staff also identified specific groups which they felt required more support and found it more difficult to engage (e.g. those who were older, had health difficulties or lacked sufficient digital literacy), and other groups who were more likely to disengage with services (e.g. younger patients, those who had returned to work following self-isolation, or those with few acute symptoms associated with COVID-19). Often, asking next of kin or family members to provide readings helped to maintain engagement which also facilitated effective delivery of the service. In addition, delivery staff felt that some patients preferred to provide oximetry readings with the support of a member of the remote home monitoring team over the telephone. There were a number of barriers to delivering remote home monitoring services relating to patient engagement (e.g. having to chase patients who did not submit readings, patients not answering the phone, delays in provision of oximeters or other equipment and patients receiving too little written or oral information).

Discussion

Key findings

Staff were involved in flexibly delivering a range of technology-enabled and analogue remote monitoring models for COVID-19. Staff generally reported positive experiences of delivering the service, felt that it was easy to deliver and valued support. A range of training and support opportunities were provided but staff would have benefited from further training especially when undertaking clinical assessments remotely, determining how best to escalate care of patients whose condition may be deteriorating from COVID-19, and how best to provide follow-up care. Findings also indicated different factors which influenced delivery of remote home monitoring models, including appropriate support and training, staff knowledge and confidence, capacity and workload, multidisciplinary team dynamics, and patient engagement or disengagement.

How findings relate to previous research

Given the rapid transition to using remote home monitoring models and technology to support people living with COVID-19 and long-term health conditions, our findings extend literature on the training needs and experiences of staff asked to use such methods within a wider context of workforce challenges across primary and secondary care.154 Staff were generally comfortable pivoting away from their usual front-line services during the pandemic; however, the impact on how staff managed this transition varied with some feeling an additional burden while others welcomed greater responsibility and the opportunity to support the NHS’s response to the pandemic. For some delivery staff, remote home monitoring brought new challenges especially when completing consultations over the telephone compared to face-to-face. In some cases, such a change led staff to reconsider their professional role, beliefs, as well as capabilities when treating patients. Similar learning has been found in previous reviews, citing nursing staff in particular as being concerned about the impact of digitally enhanced modes of working on the staff-patient relationship.164 However, patient experience findings indicated that the staff-patient relationship was not jeopardised by remote monitoring (see Chapter 9 or Walton et al.165). Staff experiences on the modality of COVID-19 remote home monitoring and impact of staff are explored elsewhere (see Chapter 11).

Staff received a range of training and support to deliver remote monitoring models as described in our evaluation. Unfamiliarity with nationally designed competency frameworks and a desire for bespoke training to reflect local organisational working meant that some staff may have been better equipped to work more independently than others. Front-line delivery staff, in particular, were asked to rapidly transition from usual methods of providing face-to-face treatment to remote ways of working with limited available evidence of the effectiveness, benefits/challenges and staff experiences of remote home monitoring services.153 Given the speed at which remote home monitoring services were implemented, this left a significant gap between staff skills, competency and confidence.

The nature and quality of training delivered to front-line delivery staff was dependent on those providing senior clinical insight. Consequently, some delivery staff experienced substantial levels of uncertainty about using their own clinical judgement to independently assess and communicate risk. This was, to some extent, later addressed by the development of SOPs and other working materials. This uncertainty may have impacted on the ability of delivery staff to communicate risks effectively with patients, especially those living with multimorbidities as well as COVID-19 which may have led to patients to revaluate self-management practices. Remote home monitoring may not always remove the need for in-person examinations.166

Our findings demonstrated workload differences for those balancing their workload with other commitments versus those who were redeployed. This supports findings from the first wave of the pandemic, in which staff were able to focus on delivery of remote home monitoring services due to cancellation of elective care/other activities, and the redeployment of staff.36 Delivery staff, particularly nurses, remained committed to taking a patient-centred approach to providing care that took account of the emotional and physical impact of COVID-19 on patients. As with previous research,152 our findings highlighted that staff were often not directly involved or lacked a level of autonomy with respect to wider organisational change, despite wanting to share views on how models should be implemented locally.

Given the range of skills required to deliver remote home monitoring models, a multidisciplinary approach is needed for COVID-19 and chronic disease management in general.167 Previous research from the United States showed that team-based care (physicians, nurses, administrative staff) led to more effective implementation of COVID-19 remote home monitoring services and higher patient satisfaction than single practitioner-led models.129 Similar findings were found in another study with chronic heart failure patients, who expressed a greater desire to speak with a range of health professionals when being digitally monitored using a range of technology enabled devices.168

Strengths and limitations

One strength is that we used mixed methods to study staff experiences of COVID-19 remote home monitoring services, and our study included a large sample of participants working across a range of job roles in primary and secondary care. However, variation between case study sites (see Chapter 4) made it difficult to synthesise findings, which may limit transferability of findings.

Our findings may not be representative of all staff views and experiences. For example, the response rate for our staff survey was 39%. Therefore, it is possible that staff who were less engaged with services may have been less likely to complete the survey.

Implications for policy and practice

Current levels of training may not be adequate to support both clinical leads and delivery staff to undertake a wide range of ‘work’ when managing patients with COVID-19. Staff need the opportunity to be better informed for delivering the service; e-resources should be available to staff, that can be accessed as and when required, and staff should receive bespoke training relevant to their service and organisation. Service leads should consider whether they need to introduce formal sign-off mechanisms to ensure staff have been trained adequately and to a required standard. Staff largely felt confident in their ability to deliver remote home monitoring services but found apps and online platforms difficult to navigate as part of monitoring. It would be valuable, where possible, to involve staff when deciding which apps and/or online platforms to adopt during service development and implementation. Notably, delivery staff lacked confidence when communicating the risks associated with COVID-19 to patients. As a result, organisations implementing remote home monitoring services should promote multidisciplinary approaches where delivery staff have ready access to clinical oversight, especially when a patient has deteriorated to a stage where escalation is required.

Primary and secondary care organisations need to consider staff capacity for delivering home monitoring services, given redeployed staff will no longer be available as routine health-care services recommence.

For staff to take a patient-centred approach, staff should be given flexibility within services to discuss wider contextual issues that can contribute to ill health and to provide emotional support to patients experiencing anxiety and other difficulties.

Future research

Further research is needed to explore the following topics: staff experiences of delivering care for COVID-19 and other health conditions using remote monitoring models, the competency and skill set required to deliver remote monitoring services, how training should be designed, and how best to embed training during the set-up and implementation of services across primary and secondary care sectors.

Conclusions

Remote monitoring models can play a crucial role in managing a large number of patients for a range of health conditions; however, the success of delivery is dependent on the right workplace infrastructure for delivering these models of care. While staff in our study show high levels of acceptability for managing patients using remote models, issues remain around confidence when making clinically informed decisions and a dependency on clinical oversight. Delivery of remote home monitoring services is also influenced by patient engagement or disengagement with these services.