Clinician experiences of a hybrid virtual medical service supporting rural and remote hospitals: a qualitative study

At no time has it been more important to consider the impact that delivering health care has on providers than in the post‐coronavirus disease 2019 (COVID‐19) period, when an already stretched workforce has been further depleted, resulting in serious workforce shortages across health professions. This has been particularly challenging in rural and remote areas, where it is harder to attract skilled and experienced clinicians.1,2 The historically inequitable access to health care and poorer health outcomes for people in rural areas3 are exacerbated by the workforce crisis.

The Virtual Rural Generalist Service (VRGS), launched in February 2020, was developed in response to chronic medical workforce shortages in rural western New South Wales.4,5 The VRGS is a hybrid virtual medical model that supports small rural hospitals when a local doctor is not available or requires relief. Most VRGS care is delivered via video consultation, facilitated by local nursing staff. Each VRGS doctor is also required to work 25% of their shifts in‐person within sites in the district.

Evidence regarding the clinician experience of virtual health care is mixed. Virtual models servicing rural areas can upskill local clinicians, increase confidence in the safety and quality of care provided, and provide high job satisfaction.6,7 Conversely, there is evidence that rural clinicians are less receptive to telemedicine than their urban counterparts,8,9 and virtual care can be seen by rural health care providers as a threat to their professional autonomy and livelihood.10 Virtual consultations require clinicians to develop new skills and can affect the interpersonal dynamics between doctor, patient and nurse.11 Local staff play a critical role in the uptake and implementation of virtual medical care,7 especially nurses;11,12 however, virtual care can create extra workload for these staff, necessitating role re‐evaluation and re‐definition.13

As part of a comprehensive evaluation of the VRGS, which included the experiences of patients and carers,14 health outcomes15 and an economic analysis,16 we sought to understand the experiences of clinicians involved in this novel virtual hybrid model of care: the doctors delivering the service, the on‐site nurses facilitating the service, and local general practitioners who work in the rural hospitals supported by the VRGS.

Methods

We used a qualitative approach to explore clinicians’ experiences of the VRGS. We report this study in accordance with the Standards for Reporting Qualitative Research.17

Study setting

Our study was conducted within the Western NSW Local Health District — a large rural health district with 38 inpatient facilities, 31 of which are small hospitals that are medically supported by the VRGS when required.

Participants

Three staff cohorts were invited to participate in an interview or focus group:

• doctors who provide medical care via the VRGS;
• nursing staff at facilities serviced by the VRGS (“site staff”), including health service managers and nurse managers who are registered nurses and often fill clinical shifts in these small sites; and
• general practitioner visiting medical officers (GP VMOs) (ie, general practitioners who work both in the local community and at the hospital).

Data collection

All staff members in each cohort were sent an email invitation to participate by a researcher not employed by the health service. Participation was voluntary. In the case of site staff, the invitation was issued via health service managers, who were asked to support staff to participate during work time. Other cohort members were emailed directly. Site staff and GP VMOs had the option of participating by phone or online. VRGS doctors had the additional option of being interviewed in person during a training workshop.

Semi‐structured interviews and focus groups of up to five participants were conducted between 7 April 2022 and 16 March 2023 by two independent researchers from the University of Sydney experienced in qualitative evaluation (one of us [AT] and a consultant) using semi‐structured interview guides (Supporting Information). Focus groups were limited to staff members in the same type of role (eg, health service manager) to minimise any coercive effects. Individual interviews were offered in addition to focus groups for expediency given the challenge of aligning availability of busy nurses in small rural sites during a period of workforce shortages. Written and/or verbal consent was obtained from each participant. Recruitment for each cohort ceased once data saturation was achieved (VRGS doctor and site staff cohorts) or the target number of participants was reached (GP VMO cohort). Saturation was deemed to have been reached when no additional insights or issues were being raised during interviews.

Individual interviews and focus groups were digitally audio‐recorded, transcribed and de‐identified before analysis. All data were stored securely in non‐identifiable form.

Data analysis

Transcripts for each cohort were coded manually by one of us (AT) and analysed using a content analysis approach informed by the Consolidated Framework for Implementation Research.18 We used researcher triangulation to corroborate the analysis by having experienced qualitative researchers (two of us [ES and TS]) check two randomly selected transcripts from each cohort.

Ethics approval

The study received ethics approval from the Greater Western Human Research Ethics Committee (project number 2021/ETH01355).

Results

In total, 46 staff members participated and 37 transcripts were produced (Box 1). All staff who volunteered to participate were interviewed (individually or within a group), with four exceptions: one GP VMO who was unavailable in the timeframe required for the study, one GP VMO who did not know what the VRGS was, and two nursing staff who did not respond despite multiple contact attempts to arrange an interview. The collapsed codes common across all clinician cohorts are shown in Box 2.

VRGS doctors

All the VRGS doctors who were interviewed were positive about the service, but identified some operational changes which could improve it. They considered the VRGS innovative and were proud of it.

It's an exciting thing to be part of. A lot of it's quite historical, so this feels very new and exciting and modern, and a real change to medical thinking and a paradigm for looking after rural health. (VC03, VRGS doctor)

VRGS doctors expressed high job satisfaction. The role provides them with professional fulfillment and compatibility with their personal circumstances.

It's a great way to be able to deliver rural and regional medicine, practise the type of medicine you want to practise, but also in a way that is compatible with my family. (VC03, VRGS doctor)

If I had to choose between face to face or this, this is more my long term … because I feel it's providing enough challenge for me, on a personal kind of professional level … you're still seeing [emergency department] patients, but then at the same time it's convenient and the people are just amazing. So I mean it's ticking everything. (VC05, VRGS doctor)

Many of the VRGS doctors were living and/or working as clinicians in rural western NSW or had done so previously. They valued being able to support their rural medical colleagues and help provide a sustainable medical service to rural communities. They viewed the in‐person requirement of their contracts as important, but most said that they had been unable to fulfill this requirement during the COVID‐19 pandemic period due to travel restrictions.

The VRGS doctors unanimously expressed high regard for the VRGS service leaders. Doctors felt like valued partners in the development of the novel service and were highly invested in the service.

[VRGS leaders] are accessible and they listen and they take on board our concerns, and it's a work in progress, but you never feel like they're just shutting us down, or we're just someone they've employed. We are actually working together as a team to try to work out what is the best model. What can we improve? (VC05, VRGS doctor)

Site staff

Site staff were also overwhelmingly positive about the VRGS. Nurses working at isolated sites were grateful for the clinical support.

Even just them casting their eyes over through the camera and then just knowing what you're doing is the right thing to do … is beneficial for the [nursing] staff who feel quite isolated, especially at night. (MA11, health service manager)

Health service managers noted that the VRGS model fits at some sites better than at others. VRGS “works beautifully” (MA05, health service manager) when it is used regularly in a scheduled way so that staff “know who to call when” (MA05, health service manager), and where there is a good working relationship between the local GP VMO and VRGS doctors. It was noted that VRGS works less well for sites that have primarily residential aged care patients as the electronic medical record software is unsuited to long term management, and end‐of‐life care is not seen as the particular interest or expertise of VRGS doctors.

The virtual component of the VRGS model relies on the presence and skill of nursing staff. Nurses want more training for this responsibility and require better resourcing given the increased workload it entails.

The skill match and the skill upgrade for nurses has not kept pace with the VRGS and the virtual care world. (MA02, health service manager)

One of the big issues for us has been around the time [virtual care] takes at this end, which isn't factored into the process in any capacity. It is far more time consuming [for nurses] than having an actual doctor here. (MA08, health service manager)

Some health service managers suggested that introducing a new non‐clinical virtual support role could relieve nurses of some of the administrative and technical tasks involved in facilitating virtual care.

Site staff were unhappy when VRGS doctors demonstrated a poor understanding of the limitations of their small rural site, and those at rural sites felt that this lack of understanding communicates a lack of care.

Sometimes some [VRGS] doctors on the other end just do not get how isolated we are, how limited our resourcing is, what we can actually do here. (MA11, health service manager)

It actually puts a negative impact into the workforce … they're happy to provide a service to us, but they care so little about us that they don't even bother to find out what we can and cannot do. (MA02, health service manager)

Site staff saw the in‐person component of the VRGS model as highly valuable for expanding VRGS doctors’ understanding of the local context, as well as building rapport and providing in‐person education for nursing staff. Staff at sites where VRGS doctors had worked in‐person shifts said that this had been “really amazing” (MA09, health service manager) and wanted more in‐person VRGS shifts.

GP VMOs

The GP VMO cohort was the most heterogenous cohort; their views about the VRGS ranged from highly positive to highly negative.

The majority of GP VMOs interviewed said that the VRGS provides good quality of care most of the time and is necessary to provide medical coverage in the region. Many GP VMOs expressed gratitude for the overnight cover offered by the VRGS and said that this makes working in rural areas more attractive, and several of them said that their positions would be unsustainable without this support.

I come back here to these remote sites primarily because of VRGS … I'm happy to work long hours because I know I'm generally not going to be disturbed [overnight] for lots of things that you are in other places. (SS02, GP VMO)

VRGS, for me, was a game‐changer. Seriously, if I had to keep doing it 24 hours a day, either I would've had a heart attack, or I would've had a mental burnout and I would've just quit. (SS09, GP VMO)

The minority of GP VMOs who expressed dissatisfaction were unhappy with virtual medical services in general, not only the VRGS. They cited diminishment of local doctors’ autonomy, diminishment of service quality due to lower clinical competence and higher workload, and investment in virtual services “eroding the norm of having a doctor on the ground” (SS07, GP VMO).

Discussion

In our study, the majority of clinicians saw the VRGS as a successful innovation that increases access to medical care in rural areas, supports the local health workforce, and provides good quality care for patients, particularly in emergency departments. The model relies on the availability and skill of local nurses to facilitate virtual consultations and requires increased investment in training and resourcing for the nursing workforce. The in‐person component of the model was highly valued for familiarisation with the local context, team building, and the training provided to nursing staff by VRGS doctors when they are on site.

Our results indicate that, from a local clinician perspective, the VRGS model of care can improve support for local staff and potentially improve quality of patient care. Although the quantitative impacts of the VRGS on staff retention and attraction have not yet been explored, our findings suggest that the VRGS addresses some of the concerns known to affect attraction and retention of staff,19 such as lack of support and after‐hours relief.

Health care providers’ knowledge of local context is particularly important in rural sites with unique historical and demographic characteristics spread across a wide geographical area. As noted by health service managers, each site is different. Local nuances, such as the diagnostic resources available and the distance to the nearest procedural health facility, affect treatment and discharge planning.7 As well as the in‐person component of the VRGS model, the intentional recruitment of doctors familiar with the challenges of rural medicine, and training specific to building local knowledge, has helped increase the acceptability of the VRGS model to site staff. The results of our study are of interest as there is broad acceptance of a genuinely hybrid employment model in the VRGS supporting and maintaining the delivery of face‐to‐face care by local and visiting medical officers.

The results of our study confirm previous findings that the viability and effectiveness of virtual care relies on in‐person staff.7,11,12 The quality of assessment provided by the VRGS relies on hands‐on clinical examination conducted by a local nurse. In a rural context where there is wide variability of skill and experience — with many inexperienced and overseas‐trained nurses, high staff turnover, and reliance on agency staff to fill workforce gaps — standardising and maintaining nursing assessment skill levels is a constant challenge requiring ongoing investment. Concurrent with the implementation of the VRGS, the local health district established a specialist team (the Rural Generalist Nurse Education Team [RG NET]) that delivers tailored clinical examination and assessment modules for rural nurses;5 however, our results suggest that nursing staff feel that more training and support is required.

It is important to patients and carers that a nurse is present during the virtual consultation.14 However, this is challenging for nurses, who consistently report that the virtual modality adds to their workload — for example, needing to access and operate technology and address technical difficulties when required. This increase in workload is multiplied by the recent profusion of virtual services now being offered to rural sites, such as virtual pharmacy and allied health. Such a significant culture shift requires re‐evaluation of workforce configuration, with the potential need to create new non‐clinical roles to facilitate the administrative and technical elements of virtual care.13

Our results suggest that service developments could improve the clinician experience of the VRGS model. These include:

• ensuring consistent fulfillment of the in‐person component of the VRGS model of care (adherence has improved since the period of this study);
• implementing additional training for nursing staff to increase and standardise workforce skill levels, particularly in clinical assessment; and
• relieving workload pressure for nursing staff by considering the impact of virtual care on clinical staff time and creating a non‐clinical “virtual support” role at each site to support multiple virtual services.

Our study had some limitations. Firstly, the clinicians who participated in our study may have been biased owing to the self‐selection method. Secondly, recruitment of site nursing staff was mediated by health service managers and could have been influenced by them, intentionally or unintentionally. Thirdly, some GP VMOs had difficulty isolating their views about the VRGS from those about other clinical services; for example, some conflated their feedback about the VRGS and vCare (a 24/7 emergency specialist service within the local health district). Finally, we did not sample the views of medical specialists who interact with the VRGS.

In conclusion, rural clinicians see the VRGS as a successful innovation which increases access to medical care in rural areas, supports the local health workforce, and provides good quality care for patients. The model offers a translatable solution to rural workforce challenges by filling medical workforce gaps and making rural clinical positions more attractive and sustainable. The in‐person component of the model is central to its acceptability and effectiveness.