Broadband nursing: A multi‐method evaluation of a one‐way video‐conferencing health information and advice service: “InVision”

Aims and objectives

This paper provides an evaluation of what is, perhaps, the most innovative service being offered as part of the series of DiTV pilots (see Gunter et al., 2001 for a résumé of these). The study examines how and why members of the general public used a one‐way video‐conferencing information service through their televisions, and explores issues pertaining to this kind of healthcare delivery. In particular we wished to discover:

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  how many people used the service;

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  the circumstances surrounding, and reasons for, its use;

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  the information needed, in terms of its type (i.e. instructions, diagnosis, information to supplement that from other sources etc) depth and range;

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  the degree to which these needs were met;

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  the perceived authority and trustworthiness of the information obtained;

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  the advantage the system gave staff over the traditional telephone service;

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  the issues relating to the novel nature of the facility, such as the importance of seeing a nurse;

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  the use of images, and the perceived appropriateness, usefulness of them;

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  ease or difficulty of use, from both the users’ and the nurse/call handlers’ perspectives;

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  problems encountered by staff and users with the service as currently designed and operated;

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  the impact of the service on other health services.

Methods used

A multi‐method approach was adopted. This combined transaction logs of use with survey and interview findings. The log data provided a record of user behaviour, including the extent to which users “walked through” the InVision log‐in pages (often before declining to make a connection), session lengths and images shown. Survey and in‐depth interviews examined motivations, reasons and outcomes. The data gathering methods were employed, as described in Table I.

It can be seen that low numbers of respondents participated in the evaluation. This was because the total number of users was low (163), nurses often forgot to ask callers if they would be willing to be contacted (as they were taken up with making best use of a novel and experimental system) and other users were hard to find from a previous Living Health survey. Nevertheless, the authors believe that the triangulation of a number of datasets, and the pilot nature of the service and its evaluation, allow for these limitations. Certainly, a coherent and informative picture emerged from the information available for analysis.

Interview transcripts were “framework” analysed (Richie and Spencer, 1994). This approach involves a systematic process of filtering and sorting material into themes, and has been used often in health/medical research (i.e. Buckland and Gorin, 2001; Leydon et al., 2000). Two researchers independently coded and sorted the data. The call scripts were examined by a medical professor, who classified the queries into types, and indicated where he felt images would have been appropriate. A detailed explanation of how log data are analysed can be found in a number of articles published by the authors (Nicholas et al., 2001a, b).

Findings

Use and users. Over the period of study, from 30 July 2001 to the end of November 2001, there were 1,380 requests for the InVision service. In all, however, as can be seen from Table II, just 163 InVision sessions were completed.

Low use of the service can be ascribed to a number of possible factors:

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  Small potential user population.The service is available to 38,000 subscribing households, in the Birmingham area. Clearly, only a small percentage of these service users would actually need a nurse consultation at any one time, let alone be inspired to consult such a new system to do so.

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  Discouragement of casual users. Using NHS Direct InVision is not the same as reading health news stories on Living Health. The Direct Marketing portrays the service in a serious light. This was due to Living Health's (and NHS Direct's) desire to manage demand for the service. Indeed, in the terms and conditions section on the Living Health screen it states: “NHS Direct InVision is a confidential service intended to provide callers with medical advice or information and to help direct them to other NHS services they may need. It should be used for its intended purpose only”.

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  Lack of publicity. The service did not received any marketing support of any kind from September 2001 when a Direct Mail shot was made to Flextech subscribers in the Birmingham area.

Circumstances of use. Questionnaire returns showed that 68 per cent of respondents (questionnaire and interview respondents combined – the base number for all percentages given in this paper) contacted the service for someone else. A toal of 62 per cent of men, however, compared with only 31 per cent females, telephoned regarding a query related to themselves. Most female callers (56 per cent) contacted the InVision service for a query relating to a child.

Type of advice sought and offered. With the small interviewee sample, low number of calls taken by each individual staff member and small number of nurse scripts available, it is difficult to generalise about either the callers or the information required. The nurse's call scripts break down enquiries into the categories shown in Table III.

Of great interest in this context is the percentage of queries judged to be principally about seeking reassurance. No fewer than 36 per cent of calls were considered to be for this reason, even if ostensibly asking for factual information. For these callers, using a service in which the communication afforded is richer than text or voice only channels is advantageous in that the more “human” element of information imparting required to convey reassurance is enhanced with the visual element. The promotional material for the service anticipated this: “if you or your family are unwell, you can rely on face‐to‐face advice and reassurance 24 hours a day, seven days a week”.

The nurses gave several examples of callers who were more concerned with being reassured or with simply communicating with a nurse than with bald medical or treatment facts. One woman, for example, was distressed about her husband's drinking and violence. In this case the nurse decided that the facility of the system to show images or video clips was of no import to the caller, who simply needed reassurance that help was available. In this case, details of relevant support groups were offered. Another caller enquired ostensibly about (influenza) symptoms, although it soon became clear that he merely wanted to engage in conversation. A “small minority” of calls were reportedly terminated by staff, as being inappropriate.

The interviewees indicated that they only wanted instructions or basic information, but all agreed that seeing the nurse on the screen was reassuring. Interestingly, despite very positive evaluations of the information received, only 19 per cent of questionnaire and interviewee respondents received more than they would have via a traditional telephone service (telephone callers receive the same information, as it is generated from the CAS system in each case, but do not have the image‐enriched or more personalised communication experience offered by InVision). Statistics generated from the system corroborate this by showing that only 20 per cent of all calls were handled using images. Although this might seem surprising at first, of the 64 call scripts analysed only two were considered to warrant images. The lack of use of this facility may be more indicative of callers using the service more to be able to see the nurse whilst conversing, than of them seeking visually presented information. This tends to support previous research literature indicating the richer nature of visual communication (Daft and Lengel, 1984, 1986).

Users were asked what kind of advice the nurse gave them (Figure 2).

People plainly took the advice offered, with 70 per cent of respondents saying they followed all the advice given, and 22 per cent indicating they followed some of it. These findings are comparable to research undertaken on the NHS telephone helpline (O'Cathain et al., 2000), where 85 per cent followed all the advice given.

Satisfaction. Over 90 per cent of the telephone respondents said the service had been very or quite useful. Figure 3 gives an indication of why users found the service helpful. Half the respondents felt reassured by the information given, an outcome that dominated open telephone questions and interview findings.

Statistical analysis showed that only one relationship could be tied to the characteristics of InVision viewers and that was if the user found health books an important source of health information (Figure 4). Nearly half of those users saying that health books were an important source of health information had used the InVision service compared to about a quarter of other users. This may indicate that there may be a group of users who prefer a “visual” element to their information, or that those callers are more independent minded and prefer to research a health topic than go straight to their doctor.

Authority and trustworthiness of the information. The authority and trustworthiness of the information was more of an issue with regard to the main Living Health service, as it may not have been so apparent that the NHS were involved in information provision (the InVision service was described as part of NHS Direct, and this was more obviously the case with a nurse being part of the service).

The vast majority (87 per cent) of questionnaire respondents said that the nurse “knew what she was talking about all of the time” (including all four interviewees). Interviewees were aware from the on‐screen information that both the nurses and the information were provided by NHS Direct. Three of the four had used the NHS Direct telephone help‐line, and did not consider the possibility that any organisation other than the NHS was providing the service. This contrasts with results from others interviewed about their use of the on screen information pages that comprise Living Health, and with results from the general Living Health questionnaire mentioned earlier. Regarding the latter, a number of questions sought respondents’ views about the NHS. Over three‐quarters (77 per cent) felt the NHS was a symbol of trust generally, and an even higher proportion (83 per cent) agreed that they trusted the information because the NHS was involved.

Views on the video‐conference facility. There was an overwhelming appreciation of the fact you could see the nurse. Responses to the open question in the telephone survey: “When connected to nurse was it helpful to see her?;” almost exclusively mentioned the personal nature of the communication and the reassurance it gives: “you feel reassured by her body language”, “easy when you can see her face – a lot more personal”, “more human”. One interviewee observed that being able to see the call‐handler made it easy to judge the engagement and interest being shown by the nurse: “when you talk blindly on the phone you have no idea whether they are just going through the motions”. All interviewees said that they were very confident the nurse was well informed, but tended to relate this to his/her presence on screen (“It was obvious the nurse knew [the information being imparted, because] she was so confident”; “Oh yes, she had a good grasp of the situation. You could see that just by looking at her”). The non‐verbal aspect of the service appears to be as important as the information offered, and users comments support Walther's (1996) finding that video‐conferencing can be as communication‐rich as face‐to‐face encounters.

Further research is needed to investigate and measure the benefits of the enhanced communication afforded by visual information. The literature is far from clear on this. Thompson and Ogden (1995) found that the ability to see the respondent in a telephone conversation gave only a small improvement to understanding, and Whittacker (1995) feels that the cost does not warrant use, in terms of the minimal increase in benefit. Studies in an educational, rather than a medical, setting, however, show more positive results. In his review of multi‐media research, for example, Mayer (1997) concludes that animated images do enhance learning, particularly when accompanied by verbal explanation.

In short, it seems as if the visibility of the nurse, regardless of any additional functionality of the system, is a valuable asset, adding considerably to the authority of the information imparted. Interestingly, psychological studies (e.g. Sellen, 1995) looking at video‐conferencing purely in terms of communicating or conversing, indicate that tele‐conferencing and audio‐only telephone conversations do not differ markedly in terms of conversational behaviour (degree of formality, turn‐taking). Nevertheless, the promotion of reassurance or trust has been shown to be enhanced by a video communications channel (de Greef and Ijsselsteijn, 2001).

Ease of use. Usability proved to be almost a non‐issue. Comments were that it was “dead easy”, “simple” and that there were “no problems at all”. The only real problem was that the system “timed out” if calls were not answered by call centre staff after ten minutes. When this happened, the InVision reference number was deleted. Callers had to then go back through the system to generate a new one, a process that some users described as difficult. Logs show that others gave up at this point.

The service in the context of wider health information seeking. The extent to which the service was used in tandem with other sources of information was plainly of interest as we are currently researching a number of different digital platforms – Internet, touch‐screen kiosk and other DiTV applications. The telephone questionnaire asked whether users had also used the NHS Direct telephone service. Of the respondents, 61 per cent had previously used NHS Direct. The researchers’ previous questionnaire survey of Living Health channel users generally (Nicholas et al., 2002b) found that respondents who had phoned NHS Direct in the last 12 months were more than twice as likely to use the Living Health service as were users who had not telephoned – 65 per cent of those people who had phoned NHS Direct in the last 12 months had also used Living Health – this was only true of 37 per cent of people who had not used the NHS Direct telephone line.

Face‐to‐face interviewees were probed further on the other sources they used, and the interplay between them, and their dealings with the medical professionals. Three of the interviewees had used the information pages of Living Health, and two had used the NHS Direct telephone service. As to the interplay between sources, the Living Health channel was thought by interviewee Internet users to be better than the Web, as the source was “more reliable”. Despite an apparently rich array of sources being employed, only one InVision caller described trying to find the required information from elsewhere before making the call. Interestingly interviewees were keen to describe how they used the service as a substitute for going to the doctor, but appeared to have no misgivings about using alternative information sources in order to avoid the InVision call which also, of course, tied up health professionals’ time.

Nurses

Views on the video‐conference facility. The capacity to show images on screen was considered by the nurses to be particularly advantageous, despite their low use. This was said to overcome many problems callers had in describing a condition or understanding instructions, problems apparently endemic in the normal telephone‐only service. One nurse, for example, described how many people were unable to follow instructions for undertaking the meningitis “glass test”. Typical problems included using an opaque receptacle, or putting the glass on the skin top down so that only the rim makes contact with the skin. When the InVision video is shown, the caller is not only more likely to understand the activity, but also “is never likely to forget” and may possibly demonstrate the procedure to friends with children.

In addition to image and video clip availability, nurses also described using gestures as a major benefit of the system. This proved extremely useful, for example, with a caller complaining of a sore throat. By placing her own hands at various points around her throat and neck, the nurse was able to establish that the caller might have been suffering from problems with her epiglottis. One nurse also explained that if there were no suitable images for the condition, hardcopy material can be shown, by holding the relevant page at the camera. This practice is aided by the facility to zoom the camera in and out.

Ease of use. Nurses were apprehensive at first about doing so many activities at once: appearing on TV screens, being worried about making sufficient eye contact with the camera, concentrating on following the CAS, and managing the images. However, it seems to have taken a very short time to master these different requirements – one staff member even described the system as being “so user friendly even Noddy [a character from children's literature] could manage”. There were, nevertheless, some difficulties. The first centred on the unique code call handlers are required to enter on their telephones when taking InVision calls. For other NHS Direct calls, each nurse or call handler has his or her own number. If the individual's number, rather than the InVision one, is entered, they inadvertently receive ordinary telephone enquiries, creating much confusion to caller and nurse alike.

Second, unfamiliarity with the system meant some nurses could not exploit the InVision facilities to the full, with staff occasionally forgetting to show the images or videos available. There was even the case where the caller complained of a rash, the perfect subject for image use, and the nurse who handled the call commented: “I remembered I could have shown pictures of what she might have had, the moment the call was finished”.

Professional issues:

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  Concerns about images shown. There were some about photographs of cardiac vascular pulmonary resuscitation (CPR). One nurse felt that no CPR images should be shown, as the nurses were not qualified to describe the process over the telephone (unlike ambulance staff) and that the photos were not a sufficient guide. Anyone needing such treatment would be automatically routed to an operator whom the centre staff would instruct to call an ambulance. However, it was decided eventually that, for completeness, the images of some CPR techniques should be included on the system and that the professional judgement of the staff would prevail. The sensibilities of patients were also a concern with regard to the choice of images. Here again, some images were rejected. An extreme example is that of a child with cyanosis (a bluish discoloration of skin and mucous membranes due to excessive concentration of reduced haemoglobin in the blood). One symptom of the condition is blue lips. In the photograph initially to be used the infant “looked dead”. This depiction of such an extreme form of the condition was considered “totally inappropriate”. It is worth mentioning here that callers do have the option of asking the nurse to remove any image they find disturbing.

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  Privacy and security concerns. Staff safety and privacy is an issue with the service. As the nurses are visible on screen, they may be recognised by the caller. This was a concern at first, particularly between two members of the staff who had personal reasons for not being seen. Neither nurse has handled InVision calls. However, the risk is considered generally to be lower than for those working “on the wards” or in A&E, who are seen by hundreds of people a week. In fact, in one sense, the InVision service is also “safer” than the voice‐only service. This is because calls from mobile devices cannot be traced. InVision callers, on the other hand, can be identified through their set top box code number. Apart from security fears, one staff member expressed discomfort at being seen on screen because she had a “negative body image”. Thus, she felt her own rapport with patients was inferior to that she enjoyed undertaking the telephone‐only service.

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  Priority over other services:Another issue was that of the priority given to InVision over other NHS Direct callers. While the initiative was in its initial three months pilot stage, such callers were placed at the top of the waiting queue and therefore provided with the service immediately when other callers might have to wait two or three hours for the NHS Direct staff to call them back. According to the staff member charged with NHS end of the project development, nurses were not happy about giving this priority. The ethos of the NHS is, of course, to provide treatment according to clinical needs. This arrangement clearly violated that principle, and it is, therefore, no surprise that there was some disquiet over it.