Nurses' experiences of person‐centred care planning using video‐conferencing

Abstract Aim The aim was to illuminate how nurses experience person‐centred care planning using video conferencing upon hospital discharge of frail older persons. Design Care planning via video conferencing requires collaboration, communication and information transfer between involved parties, both with regard to preparing and conducting meetings. Participation of involved parties is required to achieve a collaborative effort, but the responsibilities and roles of the involved professions are unclear, despite the existence of regulations. Method A qualitative content analysis was conducted based on 11 individual semi‐structured interviews with nurses from hospitals, municipalities and primary care in Sweden. Results This study provides valuable insights into challenges associated with care planning via video conferencing. The meeting format, that is video conferencing, is perceived as a barrier that makes the interaction challenging. Shortcomings in video technology make a person‐centred approach difficult. The person‐centred approach is also difficult for nurses to maintain when the older person or relatives are not involved in the planning.

and unite coordinated efforts at home in order for the frail older person to leave the hospital in a safe manner. Thus, a coordinated care-planning meeting, initiated by the nurses at the primary healthcare centre, takes place prior to discharge.
Coordinated care planning can provide opportunities to capture the frail older person's need for care, and support coordinated care planning efforts. The care-planning meeting involves the patient, relatives and professionals from different healthcare providers, and aims to plan and transfer information regarding care. However, the nurses are the main professional group in the care-planning meeting. The care planning should be done in such a way that communication is efficient and safe (Chichirez & Purcărea, 2018), and the older person receives care of high quality, continuity and security (Svensson et al., 2016). However, there appears to be a lack of trust between the different parties involved (Larsen et al., 2017;Larsson et al., 2019), similar to what has been observed in person-centred care (Forsman & Svensson, 2019), since deficits in collaboration and communication are common (Nordmark et al., 2016). Thus, coordination between hospitals, primary care and municipal care is an important issue in the healthcare of frail older persons with complex care needs (Kneck et al., 2019).
As an approach to conduct care-planning meetings, video conferencing is now used increasingly often. A growing number of functions in the healthcare system are being performed digitally (Westerlund & Marklund, 2020) as video technology is employed in telemedicine technology (Baker & Stanley, 2018;Ignatowicz et al., 2019), teleconsultations (Diedrich & Dockweiler, 2021) and virtual care delivery (Li et al., 2021) such as pain management programs (Walumbe et al., 2021). Video technology can improve the efficiency of care and increase the access to specialist expertise (Nilsson et al., 2010).
The Covid-19 pandemic has demonstrated the possibilities and importance of video technology in healthcare. Almost all types of meetings can now be conducted using video conferencing, partly as a result of visitor limitations during the pandemic. The scope of this study is limited to care-planning meetings using video conferencing in which multiple healthcare professionals meet the patient and his/her family together. While the use of video conferencing in care-planning meetings has not been investigated to a great extent, research shows that healthcare professionals are generally positive to using the technology in this context (Newbould et al., 2017;Shubber et al., 2018). Pols (2012) argues that technology can offer adequate alternatives to personal communication since physical contact should not be necessary in meetings, instead, the health and healthcare context should be in focus. Hence, video conferencing creates new opportunities, but also new aspects to consider, since there are challenges in digitalization of healthcare (Allwood, 2017).
In order to avoid dehumanization in an increasingly digitized care setting, it is important to promote relationships and consider the older persons' autonomy and dignity (Jacobs et al., 2017). A personcentred approach is not always easy to maintain, as healthcare meetings via video conferencing seem to imply some sort of barrier between people (Hedqvist & Svensson, 2019). Understanding of how technology and video conferencing can support and improve healthcare for older people is lacking (Beirao et al., 2016;Ignatowicz et al., 2019). Moreover, extant literature recounts an extensive need for increased involvement of patients in the dialogue about health conditions, and calls for preparation for the care after discharge (Forsman & Svensson, 2019;Lindblom et al., 2020). Furthermore, aspects related to the nurses' experiences and the person-centred care presented to patients, need to be considered. It is also important to understand the potential benefits, limitations and professional implications that affect the adoption and use of video conferencing (Penny et al., 2018). Therefore, further studies are required to understand nurses' experiences of how older persons' care needs can be coordinated by using video conferencing, while at the same time maintaining a person-centred approach at a physical distance.
The aim of this paper is to illuminate how nurses experience personcentred care planning using video conferencing upon hospital discharge of frail older persons.

| THEORE TI C AL BACKG ROUND
Hospital discharge, that is, the transition of frail older persons from hospital to their homes, requires coordination of care planning between different healthcare providers. Care planning using video conferencing is increasing, while care planning during in-person meetings is decreasing. At the same time, video conferencing implies challenges for person-centred care.

| Coordination of care planning
To provide good healthcare to frail older persons with multiple illnesses, interprofessional collaboration is necessary (Ekdahl et al., 2010;Ivanoff et al., 2018). This implies an active and ongoing partnership between people from distinct professional cultures, as well as from different healthcare providers. Collaboration requires that professionals, and nurses in particular, work together to solve problems and provide common healthcare efforts (Donnelly et al., 2021;Pullon et al., 2016). Coordination between different healthcare providers such as hospitals, primary care and municipal care, is thus an important prerequisite for providing functioning healthcare to frail older persons with complex care needs. Timely information sharing among healthcare providers is a necessary part of the coordination process. However, the healthcare that older persons receive from multiple providers is often unorganized and confusing (Elliott et al., 2018). The coordination can be adversely affected by lack of trust between different healthcare providers (Larsson et al., 2019). Interaction and interpersonal relationships emerge as central aspects in well-functioning coordination and care-planning meetings that focus on older persons' healthcare and discharge from hospital (Larsson et al., 2017;Petersen et al., 2019).
Thus, high demands are placed on nurses in the collaboration and coordination processes, as well as in care-planning meetings, to promote shared decision-making regarding the older persons' care among the healthcare professionals as well as the patient and relatives (Hansson et al., 2018). Thus, patient engagement processes are also important in order to enhance appropriate coordination for the best interests of the older person.
Personnel from relevant healthcare professions, with skills needed for meeting the older persons' need for healthcare and social care efforts after discharge, participate in the care-planning meetings. Today, video conferencing is a widely used alternative to in-person meetings for care planning, partly due to the Covid-19 pandemic (Liu et al., 2021). Video conferencing is the technology that is considered most similar to in-person meetings (Park et al., 2014).

| Care planning via video conferencing
Video conferencing makes it possible for professionals, such as primary healthcare nurses, municipal nurses, municipal assistance officer, rehabilitation professionals from the primary healthcare centre and from the municipality, and others, to attend a meeting at the same time together with the patient (Larsson et al., 2019). This is considered positive for the frail older person as it provides an opportunity for people with different professions to meet, and it enables personalized care planning before discharge from the hospital (Hofflander, 2015). Video conferencing also enables relatives to participate in the care planning even if they live far away or cannot go to the hospital. Studies show that video-conference meetings generally take less time than in-person meetings and tend to be more well-structured. In addition to the meetings being shorter and more efficient, travel times also decrease dramatically (Nordmark et al., 2016;Vollenbroek-Hutten et al., 2017). A study on nurses' attitudes towards care planning via video conferencing shows that their overall attitude towards using this technology for meetings is positive, especially as it increases efficiency (Shubber et al., 2018). There are, however, some concerns in the literature among nurses that frail older persons may be overridden in video-conference meetings. One of the most difficult aspects of having a video-conference meeting is to make sure that all participants are aware of, and involved in, what is happening (Marlow et al., 2016). Nurses should include the older person and relatives in the video-conference meeting (Graves & Doucet, 2016). However, older persons and relatives often feel excluded in the meetings (Hedqvist et al., 2020). Human contact, touch and non-verbal behaviour are presented as very important parts of the care, parts which are jeopardized by the use of video conferencing (Miller, 2010).
Video conferencing enables meetings to take place without the requirement of being physically present in the same room (Ignatowicz et al., 2019). The performance of the video-conference system, which is based on Internet connectivity, image and sound quality, strongly influences the meeting experience, as limited image quality as well as small screen images hinder communication (Allen et al., 2008). Delays in sound transmission adversely affect the conversation and communication as it becomes difficult to maintain a natural flow and take turns in the conversation. Studies show that it can be more difficult to establish and maintain trust in each other in a video-conference meeting, compared to face-to-face. Thus, there are several challenges associated with video-conference meetings, and video conferencing does not always live up to its expectations.
In fact, the implementation and use of video conferencing in care planning have proven to be more complex and time consuming than initially anticipated (Shubber et al., 2018). In video-conference meetings, challenges can increase further with the number of participants. Communication through video conferencing is perceived to be more difficult than it would be face-to-face, and impairs the ability to build trust with the patient (Graves et al., 2018). Factors that determine the quality of a video-conference meeting are related to the possibilities of establishing human interaction, where eye contact is an important aspect.

| Person-centred care via video conferencing
Over the past two decades, person-centred care has gained more attention, especially in relation to research and policies linked to high-quality health care (Mead & Bower, 2000). Currently, there is no uniform definition of the concept of person-centred care, but a recurring theme concerns the ethical issue of treating patients as persons (Epstein & Street, 2011). A prerequisite for performing person-centred care is the healthcare provider's ability to communicate and interact with the patient in a person-centred manner.
In providing health care, professionals are required to be open and responsive to each patient, perceive the patient as an expert, with regard to his/her own health, and treat the patient as a partner and an equal person.
Previous literature has found that person-centred care has a positive impact on healthcare outcomes (Olsson et al., 2013).
Person-centred care, which involves shared decision-making, aided decision-making and meaningful encounters, gives frail older persons the possibility to confirm and retain a position in the context, and increases their well-being and independence (Forsman & Svensson, 2019). Video conferencing specifically challenges personcentred care, as the professionals encounter a work phenomenon that entwines task execution and relationship building within a vir- Some people can also feel uncomfortable with the lack of physical contact. Moreover, older persons with dementia or hearing disabilities may lose some of the communication and participation in careplanning meetings via video conferencing (Graves et al., 2018). Such disabilities are quite common in frail older persons with complex needs for care, which have to be coordinated and planned after hospital discharge.

| ME THOD
The study used an inductive qualitative descriptive method (Graneheim & Lundman, 2004). The data collection was conducted through individual interviews with nurses with experience of con-

| Participants
A strategic selection of experienced nurses from hospitals, the municipalities and primary care were invited to participate in the interviews. Including nurses from different organizations made it possible to get a variety of responses and study the phenomenon from several perspectives. Eleven nurses (10 female and one male) accepted the invitation to participate. Their professional experience varied between 5 and 23 years, and all participants had experience in care planning via video conferencing. The participants of the study are described in Table 1.

| Collection of data
The data were collected between April 2019 and March 2020. The study thus started before the Covid-19 pandemic. During the end of the data collection period, the Covid-19 virus emerged. Therefore, the use of video conferencing increased during this study, in the beginning of the pandemic.

The data collection method was semi-structured individual in-
terviews with open-ended questions. An interview guide was used as support so that the same questions were asked at each interview (Kvale, 1996). Follow-up questions were used to confirm, reflect on and get a deeper understanding of the participants' stories (Polit & Beck, 2016). Each interview lasted between 40 and 90 min; they were conducted at places chosen by the participants, and were recorded and transcribed verbatim.

| Data analysis
The interviews were analysed using an inductive method for content analysis, elucidating both manifest and latent content (Graneheim & Lundman, 2004). The inductive analysis involved a back-and-forth process between the text and the authors' experiences, and between parts of the text and the whole, which eventually created a new understanding (Elo & Kyngäs, 2008;Hsieh & Shannon, 2005).
Manifest content refers to what is directly expressed in the text, and latent content refers to the interpreted meaning of the text.
The analysis began with the text being repeatedly read through naïve reading to get a sense of the whole, based on the purpose of the study. Subsequently, the text was divided into meaning units that were condensed and coded. Codes with similar content were grouped into nine sub-categories that formed three categories, with respect to manifest content. Finally, the overall theme emerged, highlighting the latent content and the underlying meaning of the text (Graneheim et al., 2017;Graneheim & Lundman, 2004). An example of the analysis process is described in Table 2.

| RE SULTS
An overall theme, three categories and nine sub-categories illuminate how nurses experience person-centred care planning using video conferencing upon hospital discharge of frail older persons, as presented in Table 3.

| Preparations
The informants described the importance of careful preparation of different forms of work in connection with care planning via video, based on a shared responsibility among caregivers to assess the patient's status and the efforts provided to improve the situation.

| Different forms of work
The informants pointed out that there was no common conceptual apparatus, which meant that several different terms were used to describe the care-planning meeting; pre-meeting, reconciliation meeting, planning meeting, care-planning meeting and meeting about CIP.

| Assess status and efforts
The informants described the importance of being able to follow the status of the patient during the hospital stay in order to correctly assess and plan the interventions. It was also considered important that information about what efforts had been provided to the patient before the hospitalization was documented in the common IT system.

Another important aspect in assessing status and efforts was that
participating parties knew what their own and other organizations could offer to the patient and relatives in terms of care. One of the most difficult parts of assessing status and efforts, as highlighted by the informants, was assessing whether and when a CIP would be im-

| Conduct the meeting
The informants emphasized the importance of creating a structure, agreeing on decisions and documenting, to effectively conduct video-conference care-planning meetings.

| Create structure
The informants pointed out the importance of having a chairman for the meeting, who allows everyone to speak. The chairman was also expected to be the rapporteur.

| Agree on decisions
The informants emphasized the importance of agreeing on decisions about which efforts would be relevant to apply after discharge. The informants pointed out the ongoing discussion among care providers about the need for rehab and home care for patients. The informants also highlighted other problems in connection with discharge, such as disagreement with the doctors' decisions, whether the patient was really ready to be discharged or when the discharge was to be planned.
How can you think the patient is ready for discharge … can't participate in the care planning even once because they are so bad… but you can't keep on arguing with a patient with home care and rehab (11).

| Document jointly
The informants expressed disappointment that the patients' documentations were not regularly updated by all care providers.
Lack of time and knowledge about what to document and where, were considered to be the reasons. To remedy the problem, they urged each other to document relevant information in the common IT system. It emerged that those who did not attend a meeting could communicate their assessments and efforts in the IT system either before or after the meeting.
You have to be in the system all the time as well… so it takes quite a lot of time (3).

| Person centring
The informants said that care planning via video presupposes that care-providing parties listen to the person and adapt the situation to meet in a person-centred manner through a monitor.

| Listen to the story
Listening to the patient's story is one of the important, basic principles of person-centred care, the informants said. It was important to be able to balance between allowing the patient to speak about his/her life and deciding when the story became too long. During the meeting, it was important to respectfully direct the conversation towards the planning, and at the same time maintain the interaction with the patient.
When you can, direct the conversation to this planning that has to be done, but the interaction with the patient is the most important (5).

| Adapt to the situation
The informants pointed out that video conferencing as a meeting format has become a first choice over physical meetings in care planning, without giving the patient much choice. They considered that since the care-planning meeting put the patient and relatives in a vulnerable situation, it was important to provide information, show the patient respect and make the patient truly involved in the decision-making. They said that when there was an established relationship with the patient, it was easier to adapt the situation and make the patient more involved in the video conference.
It was also easier to know how the patient worked and what she or he wanted help with. The informants described that the patients would be so happy to recognize someone on the other side of the screen that it seemed as if they forgot that they were not sitting in the same room.
It is a vulnerable position as a patient to sit there… oh, then they appreciate that they recognize me… hey, [xxx] now I recognize you (10).

| Meet through the screen
According to the informants, it was more difficult to meet the patient as a person via the screen, and they experienced a form of distance when the proximity was lost in the video meeting. Some aspects were absent, such as eye contact, head movements, gaze, handshake and how the person's physical appearance. Vision, hearing and cognitive impairments made the video meeting more difficult, but the informants believed that the same difficulties could also exist in physical meetings. They considered that the screen did not directly affect the outcome of the meeting.
Don't feel that what is lost compared to a physical meeting have any effect on the result (1).

| DISCUSS ION
Healthcare planning via video conferencing is experienced differently by nurses from different healthcare organizations. Healthcare planning via video conferencing is also different from in-person meetings, from a person-centred care perspective. We have identified nurses' experiences of healthcare transition from hospital to the person's home, coordination and collaboration among healthcare professionals, as well as a person-centred work practice in healthcare planning.
The study shows that video conferencing as a meeting format has become a first choice over physical meetings when planning care for frail older persons who need coordinated care interventions at home after discharge from hospital, even before the Covid-19 pandemic. When a frail older person leaves the hospital, it is important to assess care needs, and plan and coordinate care interventions together with care providers, the older person and relatives. Wellfunctioning information transfer in an online journal is a necessary tool based on current legislation. But for this to work, coordination of care providers' professional resources and interprofessional collaboration is required (Larsson et al., 2019;Pullon et al., 2016). The results show that there is a lack of requirements from the management regarding the nurses' competence and education.
Nurses currently do not need any form of formal education at the advanced level to work with care planning via video conferencing.
Knowledge of assessment and collaboration to achieve coordinated care was also requested. Research shows that nursing staff trained at the advanced level excel in comparison with undergraduates, thanks to their deeper knowledge about independently assessing and planning care measures to avoid "unnecessary" hospitalizations (Glassman, 2016;Jobe, 2020).
In this study, it emerged that when care planning is carried out via video conferencing, a barrier is created that requires the nurses to strengthen the older person by creating an interaction that is maintained throughout the meeting (Graves et al., 2018). It also emerged that the nurses sometimes lack ability to listen to the older persons' Hedqvist and Svensson (2019) point out that lack of information about the structure and content of the video conference makes it difficult for older persons and relatives to prepare for the meeting. They experience insecurity and feel neglected in a situation unknown to them. Our study also shows that older persons have limited opportunities to really influence care design: the scope for action is too small and they experience that they are not given any choices during the video conference itself. Facchinetti et al. (2021) believe that this is because the care staff need to inform, involve and prepare the older persons for the discharge, so that they can handle their condition at home without feeling abandoned. Sinclair et al. (2020) found that functioning coordinated planning of care interventions before discharge has become more important in connection with the outbreak of the Covid-19 pandemic in 2020. The pandemic has thus accelerated the development of the digitalization of collaborative working methods such as coordinated planning of care interventions via video conferencing. Silsand et al. (2021) show that the use of video conferencing offers opportunities to use healthcare professionals' time more efficiently, reduces travel times and improves the exchange of information across healthcare providers' professional boundaries.

| CON CLUS IONS
In summary, this study concludes that it is complex to create a sustainable way of working for nurses with regard to planning and coordinating care interventions. It is difficult to maintain person-centred care unless the older person or relatives are involved in the care and in the care planning throughout the entire process. Although a cornerstone of person-centred care is meeting face-to-face, video conferencing can be seen as a complement in care for coordination and follow-up of care and treatment. More research is needed to study different methods using digital tools for improved coordination of care for frail older persons with complex care needs.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data available on request due to privacy/ethical restrictions.

E TH I C A L S TATEM ENT
The study has been approved by the Swedish Ethical Review Authority [Approval number: 932-18].