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Video consultation is increasingly used in different health care settings to reach patients. However, little is known about telehealth in psychological counselling for vulnerable patients with somatic and chronic conditions such as rheumatoid arthritis and diabetes.
This study aimed to develop and pilot test a telepsychology module for inclusion in the app My Hospital (Mit Sygehus) to provide remote psychological counselling to vulnerable adults with either rheumatic diseases or diabetes.
With inspiration from participatory design, the content of the telepsychology module was developed through user involvement and evaluated by individual interviews with patients and psychologists as well as questionnaires.
We developed a module with our patient partners that targeted patients with rheumatic diseases and diabetes in relation to the psychological challenges of living with chronic diseases. The module included information, tools, exercises, and videoconferencing. In total, 16 patients and 3 psychologists participated in the pilot test. Psychological counselling was described by 4 themes: “The good relation despite physical distance,” “The comfort of being at home,” “The pros of saving time on transport and energy,” and “A therapeutic alliance at a distance.”
Psychological counselling in relation to somatic care can be provided by videoconferencing supported by web-based or mobile delivery of tailored information, tools, and exercises without compromising on the quality of care. To ensure a good alliance between the patient and psychologist, a first face-to-face meeting is important. The home location provided patients with a safe environment and increased accessibility and reduced travel time to the hospital.
Telehealth in rheumatic and diabetes care is increasingly used to reach patients in rural areas as well as to maximize patient care in terms of reduced travel time to hospital sites and the convenience of consulting with clinicians from the patients’ own homes [
It is well known that patients with rheumatic diseases, such as rheumatoid arthritis, face challenges because of symptoms including joint or muscle pain and fatigue [
Hence, the purpose of this study was to develop and pilot test a telepsychology module for inclusion in My Hospital to provide remote psychological counselling to vulnerable adult patients with either rheumatic diseases or diabetes.
This study was inspired by participatory design where the idea is to engage users to innovate and develop technologies in collaboration with developers [
This study was inspired from hermeneutics, where the perspective has been to understand the participants’ lived experiences in relation to living with rheumatologic diseases and diabetes to develop a service that meets the patients’ needs [
The participants were treated, followed, and recruited at the Department of Rheumatology and Steno Diabetes Center Odense, Odense University Hospital, Denmark. Patients were referred by nurses or doctors at the outpatient clinic to the department’s psychologists because of psychological challenges arising from living with chronic rheumatic disease or diabetes. The sampling was purposive and patients aged ≥18 years with rheumatic diseases or diabetes were considered eligible; however, the psychologists assessed the burden of disease. Thus, patients excluded were those who did not have any device at home (computer or tablet) and those who were assessed by the psychologist to be too sick for inclusion in the study, such as patients with very severe psychological problems. Furthermore, 3 psychologists participated in the study. The psychologists were master-level counsellors: 1 was newly qualified, 1 had a few years of experience, and 1 had more than 5 years of clinical experience.
Data collection was divided into 2 processes (
Data collection.
First, a mock-up of the module including information and tools was developed based on clinical and specialist knowledge from the psychologist (unblended when published). The mock-up was discussed and re-designed in collaboration with a patient diagnosed with rheumatoid arthritis and a professional communicator specialized in patient involvement. The information and tools in the module were adjusted in an iterative process until they were accepted by all. Data were collected through track-change, notes, and meetings. Based on the feedback and changes, a prototype of the module was developed and included in My Hospital. The module included information on aspects such as everyday life with chronic disease, concerns, and acceptance, a worksheet with the cognitive behavioral model [
My Hospital.
Three psychologists from the departments were involved in the service, and 16 patients were invited to participate in the real-life test, in which usual counselling (individual planned sessions including 2-8 sessions) was converted into videoconferencing supported by the module in My Hospital and included information, tools, and exercises and homework between sessions. However, the first session was performed face-to-face at the hospital to ensure good relation as an important starting point for counselling. Furthermore, the psychologist was able to assess whether videoconferencing would be relevant and safe considering the severity of psychological problems.
The patient was given written instructions on how to access the app or web platform My Hospital and how to use My Hospital for videoconferencing as well as relevant contact information (phone numbers for the psychologists and IT support). The patient was verbally informed about the option of videoconferencing as an alternative to same-room counselling, necessary equipment (tablet or computer with a microphone and a camera, a well-functioning internet connection), a plan B in case of technical issues or dissatisfaction with the videoconferencing format (telephone counselling or same-room counselling), and the option of trying out videoconferencing with IT support before the first videoconference with the psychologist.
Results from the first phase showed that necessary equipment included a computer or a tablet with a camera, a microphone, and a strong internet connection. Smartphones were not recommended because of the small screen size and because they are hand-held devices. The study was based on “bring your own device” to minimize cost. Patients were automatically notified 15 minutes before a preplanned videoconference through a notification from My Hospital. This allowed the patient to “sign in” to the video platform so that the psychologist could start the videoconference. Data from the testing phase were collected through individual, semi-structured interviews with patients, and psychologists. MJR and JDM carried out the interviews. All interviews with patients were conducted by telephone or in the same room. The interviews varied between 30 and 60 minutes. All interviews were audio recorded. In addition, a short questionnaire was automatically sent to the patient by My Hospital after each videoconference. Furthermore, statistics from My Hospital showing the “click-rate” on different topics and indicating the topics that the patients read the most were collected. Finally, psychologists were asked to fill in log books on experiences with videoconference.
The data from the development phase were used to adjust and re-design the tool as well as to create preliminary guidelines for the service using a PDSA (Plan-Do-Study-Act) cycle approach [
According to Danish law, qualitative studies do not require approval from scientific ethics committees. However, this study was approved by the Danish Data Protection Agency (18/51158). The participants received both oral and written information before signing informed consent in compliance with the Helsinki Declaration. Data were stored and secure in a logged SharePoint, Region of Southern Denmark.
Results from the real-life pilot test are presented below. In total, 16 people agreed to participate in this study. Characteristics of the participants are shown in
Characteristics of participants (n=16).
Characteristic | Value |
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Men | 3 | ||
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Women | 13 | ||
Age (years), range | 25-59 |
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Rheumatologic diseases | 13 |
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Diabetes | 3 |
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Mean | 4.3 |
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Range | 2-10 |
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In-person session | 1-3 |
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Video session | 1-6 |
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Telephone session | 0-3 |
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Mean | 53 | ||
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Range | 4-130 |
A total of 45 videoconferences were conducted. All counselling sessions were of a shorter duration, varying from 1 to 10 consultations (including face-to-face and telephone consultations). Of the 16 patients, 6 (38%) agreed to participate in an individual interview. The remaining 10/16 (62%) patients were not able to participate because of their psychological state. Furthermore, individual interviews were conducted by 2 psychologists, and questionnaires were answered by patients after each videoconference.
The thematic analysis revealed the following 3 themes: “The good relation despite physical distance,” “The comfort of being at home,” and “The pros of saving time on transport and energy.”
In general, all participants had a good relationship with the psychologist despite the use of videoconferencing instead of same-room counselling. The foundation was established in a first same-room meeting, which all the participants described as very important to establish a trusting and safe environment. One woman said, “Initially, you do not know who you are going to meet, so it is nice to meet face-to-face” (Patient #4). However, one participant stressed that even though the relation was different from that in a same-room meeting, it was still good enough to ensure valuable counselling.
It’s different (video conferencing)...although I would like to give in…it’s just not the same as when we sit in the same room.
On the other hand, some (3/6) of the other participants stated that videoconferencing was as good as same-room meetings. Thus, the majority (4/6) of participants did not see videoconferencing as a barrier for the topics and issues to be discussed. One major reason for that was the professional skills of the psychologist in ensuring high-quality counselling through videoconferencing.
The psychologist is really good and she does well on video. She is present and the relationship is almost as good as when we meet face-to-face (in the same-room).
The participants felt that the psychologist not only had professional skills but also had special skills in relation to the use of technology and videoconferencing, that is, making eye contact, using appropriate tone of voice, pausing, and using tools.
Although the experience of videoconferencing use was positive, technical problems were described as an important barrier. The majority (5/6) of participants experienced different types of technical problems, all of which affected the session. However, the participants managed to continue the session by video, and they highlighted the importance of a “plan B” if there were problems such as knowing how to reconnect to video or switch to a telephone call.
In general, the participants had a very positive experience of the “home” sessions, as their home provides a safe environment. As 1 participant said, “I could cry...I had a secure environment, it's my home after all” (Patient #4). However, the participants stressed that there are certain challenges when therapy is provided at home. Sessions at home were new to everyone in the household and this required special attention. The participants had to find a suitable room for the conversation, and some (2/6) of the participants experienced lack of respect from family members. One participant said, “they just opened the door and came in…my husband…Oh, I just wanted to pick something up” (Patient #2). Lack of privacy was described by some (2/6) of the participants as something they had to talk about with their family members. On the other hand, one of the participants had her husband join the session. In general, the possible barriers at home were minor compared to the benefits of staying at home to “avoid transport and fatigue” (Patient #5).
All participants described the benefit of not having to go to the hospital for counselling. Even for patients who live near the hospital, it could be stressful and take a lot of energy not only because of driving but also because finding a parking space can sometimes be impossible. Patients with rheumatic diseases (6/6), in particular, found it beneficial to stay at home, as their conditions were often associated with severe fatigue. As 1 patient said, “... when you do not have any energy left it doesn’t matter if you have to drive 1 or 50 kilometers” (Patient #4). The energy saved by staying at home was valued as important, and it enabled patients to participate in sessions and not cancel even on “bad days,” as the energy saved could be spent on counselling instead. One participant said, “So even though it had been a day with pain and lack of energy, I didn’t have to take the car, I just had to open my computer” (Patient #4). All participants described the benefit of saving time on transportation as saving energy, which enabled them to “use your energy on the right things” (Patient #6).
The interviews with psychologists revealed another meaningful theme: “A therapeutic alliance at a distance.
In general, the psychologists were a little skeptical about the use of videoconferencing, and they questioned whether it was good enough and whether the therapeutic alliance could be built and maintained. They were worried about technical failure, as it would affect the alliance and leave patients on their own. On the other hand, the psychologists described how patients might benefit from the service, as many patients deselect same-room counselling because they already have too many appointments at the hospital and lack the personal resources to participate.
But there is also a unique opportunity to reach out to those who do not have the personal resources as it is takes too much energy and might have anxiety as well.
Thus, the benefits of videoconferencing compensated for the risk of technical problems. With time, the psychologists experienced that the therapeutic alliance was the same as that in same-room counselling. However, to ensure a good patient-psychologist alliance, both psychologists stated that the first session should always be face-to-face in the same room. Furthermore, they described how videoconferencing actually provided extra information, as the psychologist met the patient in their home and got a view of the patient’s daily life.
…it also affects the alliance as I can see a part of their life that I do not otherwise have access to, namely their home.
The benefits for patients were evident for the psychologist, as the home provided a safe environment for the patient. One of the psychologists said, “... I actually do not think there is a big difference (in the contact and alliance same-room versus video conferencing)…” [Psychologist #2].
However, it took courage to try videoconferencing because psychologists have to move away from the well-known consultation room to video. They described a feeling of losing control because of the unknown. In this new “room,” technology played a significant role because the risk of failure and technical breakdowns led to concerns among the psychologists, as it could prevent delivery of good, high-quality service. Especially in complex cases, the psychologist needed a sense of safety and in these cases, they were more concerned about the technology and distance to the patient.
...if I picked up something like a trauma, I was very aware of getting the patient to a same-room counselling next time.
Despite the concerns about the technology, the psychologists found that the videoconferences combined with the information and tools in the app were a good alternative to face-to-face sessions even though the technology might break down. Becoming familiar with the service was described as important, and the psychologists described how they had to develop new communications skills for videoconferencing to facilitate a good therapeutic alliance, for example, a plan B if the video failed.
...the patients also adapt fairly quickly (red. to video conferencing) when it has small delay in the sound or picture… you might interrupt each other…but it was okay as it did not impact on the conversation or the therapeutic alliance.
A brief questionnaire was released in My Hospital after each videoconference with the purpose of obtaining the patient’s immediate assessment of the counselling. A total of 16 patients completed the questionnaire. Data showed that the most common reason for choosing a virtual session again was “saving time on transport” followed by “Physical challenges e.g. parking, stairs.” The questionnaire also evaluated the information, accessibility, and quality of the virtual session. The results are shown in
Evaluation of the service (n=16).
Overall, videoconferencing was associated with a high degree of satisfaction with respect to information about the videoconferencing, the overall experience, the use of My Hospital, and the quality of sound and picture. However, data showed that there is room for improvement, as 6/16 (38%) participants rated sound quality as average or poor and 3/16 (19%) participants rated the quality of the picture as average.
The telepsychology module including information and tools in the form of text, videos, audio files, pictures, exercises, and videoconferencing was included in My Hospital. Once patients had been assigned to a treatment pathway in My Hospital, they could see an overview of topics related to the psychosocial challenges that can arise from living with a chronic disease. Data from My Hospital showed that topics such as “fatigue,” “pain,” “when illness strikes,” and “when illness is invisible” had the most views.
This study aimed at developing and pilot testing a telepsychology module for inclusion in My Hospital to provide remote psychological counselling to vulnerable adult patients with either rheumatic diseases or diabetes and psychological problems. The findings revealed that telepsychology and psychological counselling in relation to somatic care can be provided by videoconferencing and supported by tailored information, tools, and exercises.
To meet the needs of patients, we co-created a module in My Hospital together with a patient, a psychologist, a staff member specialized in patient communication, and IT experts to ensure inclusion of relevant knowledge from all participants [
A limitation of this study is that it was a small-scale study. However, the aim of this study, like other small-scale qualitative studies, was to provide in-depth exploration of the phenomenon under investigation. Therefore, the intention of this study was to develop and investigate the potential of telepsychology, including web-based tools and videoconferencing, for psychological counselling of patients with either rheumatic diseases or diabetes. It has to be taken into account that only 16 patients participated in the test, and that only 6 (38%) of these accepted participation in an individual interview. However, it is important to acknowledge that this study included vulnerable patients with severe psychological challenges, so the low degree of participation in interviews was somewhat expected.
That said, we have provided rich descriptions of both the development of the module (eg, information, worksheets, exercises) and potential of videoconferencing. The analysis was conducted in collaboration with co-researchers to increase reliability. To warrant validity, quotes from the interviews were used to link to the participants’ original statements. Hopefully, this will allow the readers to judge whether the findings of this study are transferable to their own contexts.
Telepsychology and psychological counselling in relation to somatic care can be provided by videoconferencing and supported by web-based or mobile-delivered tailored information and tools. However, to ensure a good patient-psychologist alliance, the first session should always be in the same room. With a well-established alliance, the patients’ homes provided a safe environment and enabled them to conserve their energy that could be used on the right things, which is of great importance especially to patients with rheumatic diseases and severe fatigue. In patients with diabetes, the benefits were accessibility and reduced travel time to the hospital.
information technology
Plan-Do-Study-Act
We wish to thank all the participants involved in the study and especially the patient representatives who contributed to the manuscript. We also wish to acknowledge Lea Bohn, Centre for Medical Technology (CIMT), Odense University Hospital, for assistance in reviewing the manuscript. This study was supported by the Odense University Hospital Innovation fund.
None declared.