Remote nursing consultations: how to get them right
Video consultations are here to stay. Here’s how to prepare for this ‘new normal’ in patient care
- Advice from the RCN and NHS England suggests the need for virtual consultations will continue for some time
- How to ensure patients understand the process and get as much out of video and phone consultations as face-to-face appointments
- The steps to take to set up appointments, support vulnerable patients and undertake difficult conversations remotely
The COVID-19 pandemic has seen an increase in remote consultations, with healthcare professionals keen to protect patients and themselves from the virus.
Guidance from NHS England and the National Institute for Health and Care Excellence states clearly that face-to-face contact should be minimised in all settings during the pandemic.
The pandemic has meant an increased need for video consultations
For many nurses this has meant using video or phone consultations for the first time, or in a much more significant way.
But how should a nurse go about this, how can it be done safely, and what can enable healthcare professionals and patients to get the most out of the experience?
How to get the most out of remote consultations
New guidance issued by the RCN says that the need for remote consultations is likely to continue for some time. This means it is worth all healthcare staff getting to grips with this method of communication, as it looks likely to be a key means of contact with patients for the foreseeable future.
Step one: triage
An initial triage will decide whether a remote consultation is appropriate.
The RCN says a remote consultation could be appropriate for a straightforward follow-up or an assessment when the patient's medical records are accessible and the nurse has the information to be able to treat, prescribe medication or arrange follow-up for a prescription if necessary.
It is important that the patient has the capacity to understand the process.
A face-to-face consultation may be necessary if the patient has complex needs, there is no access to their records, they lack capacity, they need to be physically examine or receive treatment such as an injection, or there is a need to assess the home environment.
Before the consultation
Administrators should call to arrange the appointment timeslot and check this is suitable for the patient. Older or vulnerable patients may need assistance with the consultation.
NHS England suggests that services consider using a pre-call questionnaire for patients to self-score their health.
Sarah Cubbin, lead nurse for common cancers at Clatterbridge Cancer Centre NHS Foundation Trust, has used remote consultations for a few years.
She says dealing with the technology can be the most frustrating element for nurses.
NHS England and NHS Improvement have procured a 12-month licence for the platform Attend Anywhere, which her service intends to use and she says looks straightforward.
She normally uses remote consultations for a particular group of patients with mutation-driven lung cancer who have long-term four-weekly follow-ups.
‘Feedback we get from patients is that they feel quite comfortable about remote consultations’
Sarah Cubbin, lead nurse for common cancers, Clatterbridge Cancer Centre NHS Foundation Trust
‘This particular group includes a wide range of ages,’ she says. ‘We had some misconceptions about who this would appeal to, but a lot of older people we approached were more keen to try it than younger people.
‘For a lot of people getting to a hospital can take a lot of time, they may need a relative to come with them and they may both have to take time off work. Most patients go through a tunnel with a toll to get here, so it costs money and time and can be quite stressful.
‘Feedback that we get from patients is that they feel quite comfortable about remote consultations.’
Establish IT support
She says that decent IT support is essential for successful remote consultations.
Her key advice for a successful consultation?
‘Be patient, do as much of the paperwork as you can before the clinic and don’t start out with a huge clinic,’ she says.
‘You need to feel confident with the technology and be sure that the patients have all the information they need about accessing the appointment beforehand. If someone is struggling with the technology it can help if there is someone with them who can help sort it out.’
The benefits of remote consultations
Remote consultations can help during the COVID-19 pandemic by:
- Preventing the transmission of the disease by reducing the need for patients to travel to hospital or other healthcare settings
- Allowing clinicians to speak to patients who are unable to travel to hospital, such as those in at-risk groups, or who are self-isolating or have travel difficulties
- Allowing clinicians to carry out clinical work from home so that staff in at-risk groups, or who are self-isolating or have travel difficulties, can continue to work. This helps healthcare providers to meet increased demand in certain areas
Source: NHS England
Setting up the consultation
Clinicians working from home should choose a neutral setting and background so that the patient is not distracted by glimpses of their domestic set up, says Roger Neighbour, a retired GP and former president of the Royal College of General Practitioners (RCGP).
Writing for the RCGP website, he suggests dressing professionally, ensuring that the consultation won’t be interrupted and avoiding sitting against a source of bright light.
He also gives advice about framing: ‘Landscape feels more natural and gives a feeling of a comfortable separation between you and the patient; portrait view can feel too “in your face”. Adjust your position so that your head is central in the patient’s view.'
He adds that the patient should be able to see your facial expression without straining and preferably also your hands, as hand gestures are an important part of communication.
Introductions and consent for a virtual consultation
At the start of the consultation, the nurse should establish they are speaking to their patient and introduce themselves and anyone else in the room – even if they are not on camera.
The RCN suggests that as an extra security check, patients should be asked to give their phone number or address.
Establish the reason why this is a remote consultation instead of face to face, saying something such as: ‘Unfortunately during the COVID-19 crisis we can’t visit people at home or get them to come into the surgery for their review, so I have contacted you by phone/video call today.’
NHS England says some patients may need reassurance that they are receiving the same level of care as in a face-to-face appointment.
Take and record verbal consent for a virtual consultation. Nurses should also check that the patient is able to understand them.
Following the principles of mental capacity legislation, nurses should check that patients can hear, understand them and are able to talk freely.
If the nurse has reason to suspect that the patient is having any difficulty with understanding or communication, ask if there is someone there who could join the conversation and help them.
Establish and document the name of the friend or relative and their relationship to the person.
Meeting the patient’s needs
The main part of the consultation will depend on the patient's needs. RCN guidance sets out a number of case studies, including a mental health appointment and a discussion about childhood vaccination.
Nurses who have been using remote consultations say that for some patients they are more suitable than a face-to-face appointment.
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Rita Sudra, diabetes specialist nurse for young adults at Barts Health NHS Trust in London, works for a service that has offered remote consultation to patients for several years.
She runs a nurse-led clinic for young adults aged 16 to 24 and the majority choose to have video consultations.
‘When we carried out research, we found that patients felt we were more focused on them than at our traditional clinic,’ she says. ‘In an appointment, they can feel we are looking away at a screen all the time, but during a remote consultation they feel they have more eye contact.
‘I can also check their data from their blood glucose monitor at the same time on the same screen, without looking away. On the whole, it is really good.’
How video consultations differ from phone consultations
Phone consultations have the benefit of being a familiar and available piece of technology, but they do lose the visual element of communication.
Queen’s Nurse Allison O’Kelly, clinical lead for east Cornwall memory service at Cornwall Partnership NHS Foundation Trust, has been carrying out follow-up phone calls with patients who have received a dementia diagnosis since the pandemic started. Previously these appointments would always have been in person.
‘It feels like we have gone beyond diagnosis and prognosis to something more holistic. It is different, but a good different’
Allison O’Kelly, clinical lead for east Cornwall memory service, Cornwall Partnership NHS Foundation Trust
‘We set it up like an appointment, with a set time, so they are ready and have someone with them if they want,’ she says.
‘It is the same as calling them into the clinic. It is vital that people have the chance to have these conversations as there are often questions they were too upset to think about at the time and we can also let them know about support services that are available.
‘While it has been a big change, I would say 90% of people have been really appreciative of the phone call.’
Challenges can arise when people are upset, she says. ‘We all have it drummed into us that only 7% of communication is verbal,’ she says. ‘I can’t see what they look like or what they are doing. It is harder to comfort someone who is upset or distressed when you are on the phone.’
But the phone calls aren’t just a poor substitute for a normal appointment, Ms O’Kelly says.
‘A lot of the people are self-isolating, so in a call we always include a welfare check to see if they are getting their shopping and other support they need. It feels like we have gone beyond diagnosis and prognosis to something more holistic. It is different, but a good different.’
Ending the consultation
The healthcare professional should summarise agreed actions from the appointment, ensuring the patient understands these and any timescale before ending the appointment.
Nurses should remember to give patients a chance to ask any final questions, says NHS England.
Check the patient has sufficient medication and check their preference for future contact. Ask whether they would be happy to have another virtual appointment.
To end, the nurse should tell the patient they are going to close the call and say goodbye, before actually closing the connection.
After the consultation: next steps
Ensure the patient’s records are updated and any referrals, follow-up appointments or prescriptions are arranged or initiated before moving on to the next patient call.
Record details of the conversation clearly, either immediately or as soon as possible, making a note of the time and date of the call. Nurses should document clearly that this was a remote consultation during the COVID-19 pandemic.
If appropriate, send a prompt follow-up letter or email to the patient to summarise the call and the plan, says NHS England.
Difficult conversations: planning for future care
Healthcare professionals are increasingly having to have difficult and sensitive conversations with patients remotely due to COVID-19.
These conversations should include realistic planning for future care, says RCN guidance.
After explaining that they wish to discuss something important with a patient about their health, the RCN says that nurses should ask the patient what care or treatment they want if their health suddenly deteriorates.
Nurses can explain that the patient may not be well enough to make decisions about their treatment in those circumstances, so making a plan in advance can help to ensure that their wishes are respected.
Talk about the patient’s priorities in life
Patients should be asked about the things that matter most to them in life and what their priorities would be if they became critically ill.
Discuss and agree recommendations for realistic emergency care and treatment that might be considered for them, and any treatments they would not want. The conversation should include their feelings about cardiopulmonary resuscitation.
Repeat any decisions made and ask the patient if they are correct. Document any agreed priorities, goals of care and treatment recommendations.
Finally, offer patients a record of the conversation by email or post.
Source: RCN courageous conversations
Erin Dean is a freelance health journalist