2.1 Aim and objective

This study aims to explore outpatient clinic nurses’ experiences with video consultations and to identify the organisational prerequisites they consider important for successful implementation of video consultations in outpatient clinics.

3.1 Design and theoretical framework

Given the study’s objectives to shed light on outpatient clinic nurses’ experiences and perceptions, a qualitative exploratory research method was used [13]. The study adopts a hermeneutic approach to enable an interpretive understanding of outpatient clinic nurses’ lived experiences. Hermeneutics is appropriate because the aim is to interpret how meaning is constructed within these experiences [13]. The hermeneutic approach recognises that understanding is always situated and influenced by the researchers’ pre-existing knowledge and understanding, which is made explicit and reflected upon throughout the analytical process. Interpretation of the findings is developed through continuous movement between parts of the data and the whole, allowing meaning to evolve during analysis [13]. The reliability of this study was ensured through descriptions using Lincoln and Guba’s criteria for trustworthiness during the analysis process [14]. To ensure transparency and completeness in reporting, the study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. The checklist guided the study throughout its development, execution, and reporting phases [15].

3.2 Data collection

3.2.1 Sampling and recruitment.

The study was carried out in a university hospital located in the capital region of Denmark, specifically within a cardiology outpatient clinic spread across two sites in Copenhagen. Two focus group interviews were conducted, one in each location familiar to the participants to create a comfortable contextually relevant setting and to avoid transport time for the participants. Different locations also allowed the study to capture potential variations in local practices and perspectives across the outpatient clinic sites. The focus group interviews were conducted to gather information from the different participants’ point of view [16]. Further, to understand and explain the meanings, beliefs, and cultures that influence the participants feelings, attitudes, and behaviours [16]. The groups were designed to include five to eight participants: small enough to allow each individual to participate fully and be heard, yet large enough to allow for varying opinions and perspectives [16].

The interview dates were chosen by the first and last author, and all nurses from the outpatient clinic working on the selected dates were invited to participate in the focus group interviews. In total 17 clinical nurses. The nurse managers ensured that information about the interviews was communicated, and that time was allocated within the outpatient nursing programs.

All outpatient clinic nurses were invited to participate in the focus groups. None were excluded. The participants were all female nurses working in cardiological clinical practice and knew each other from their daily work. Although the invited outpatient clinic nurses were relatively homogeneous, variations in participants’ digital experiences as well as attitudes and preferences were assumed variated. Exploring these differences was considered important to support a relevant subsequent implementation. Four invited nurses cancelled due to having scheduled time off, and one due to being too busy on the interview day (Table 1). All participants were knowledgeable about video consultations, having been introduced to the technology and trained on its use through a partner training session during the implementation process in 2021. This training included a brief technical introduction, instructions on scheduling video consultations, and operational guidance. A flowchart was created to help clinicians determine the suitability of video consultations. Although video consultations were prioritised for implementation at the time of the interviews, their use was optional in both outpatient clinics, and in-depth experience was not required.

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Table 1. Participant characteristics.

https://doi.org/10.1371/journal.pone.0339752.t001

All outpatient clinic nurses were equipped with headphones and a video camera connected to their computers in the consultation rooms. For video consultations, nurses connected with patients via an e-health platform, which required a link accessible through a smartphone, tablet, or computer. Other than connecting via a video link on the health platform, video consultations necessitated the same preparatory work as physical consultations. While video consultations were accessible to all participants, they had not been implemented to the same extent as physical or telephone consultations.

3.2.2 Data sources/collection.

The first author was a registered nurse with a Master of Science in clinical nursing and the last author was a registered nurse with a Ph.D. First and last author who were responsible for conducting the interviews, participated in a pre-understanding interview [17] conducted by the third author. This preunderstanding interview aimed to reveal the author’s preunderstanding of the topic, thereby promoting explicitness and transparency during the data collection and processing stages [17]. Both authors possess an in-depth experience as clinical registered nurses in the cardiological field. The first author had no clinical experience with outpatient clinic treatment or virtual consultations. The last author has long-standing experience with outpatient clinic treatment and virtual consultations. The first author moderated both interviews and thus had the responsibility to facilitate discussions and exchange of ideas between the participants [16]. The last author ensured that all themes were covered through the questions from the interview guide (Table 2) and that all participants could express their views [18]. Physical interviews took place in undisturbed meeting rooms located within the participants’ clinical settings to ensure privacy and minimise interruptions. The interviews were conducted in the afternoon, at a time when most participants had no scheduled patient consultations. Conducting the interviews physically enabled attention to body language and interaction patterns while supporting open discussions and nuanced exchanges within the relatively homogeneous group. The interviews were conducted in the participants’ native language (Danish).

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Table 2. Interview guide.

https://doi.org/10.1371/journal.pone.0339752.t002

The interview guide was created based on a systematic literature review, clinical experiences, and qualifications of the first and last authors. Although the interview guide was not formally pilot tested, it was thoroughly discussed and refined among the first and last author prior the interview. The interview guide served as an inspiration to unpack the participants’ experiences and perceptions. It was created to uncover what was deemed valuable in patient-provider relationships, explore different perspectives and requirements of physical consultations, identify perceived limitations, and reflect upon the potential of video consultations. It was emphasised that reaching a consensus was not the goal; rather, the aim was to encourage the participants to share their experiences, perspectives, and curiosities with one another [18]. All themes and related questions were thoroughly discussed. While the questions did not always follow the interview guide’s chronological order, the guide was instrumental in ensuring that all themes were illuminated to sufficient depth and nuance. To support a safe and confidential discussion environment, the interviews were initiated with a short informal chat followed by

a clear and transparent framing of the study aim before diving into the topic. The intended use of the data and the procedures related to anonymity and confidentiality were clarified. Verbal and nonverbal facilitation techniques were used throughout the interviews to acknowledge and accommodate difficult or conflicting emotions and viewpoints. The moderators applied affirmative communication and active listening strategies and deliberately avoided interrupting participants. Further progressively focusing the participants’ attention on the topics of most significant interest [18]. The facilitator of the interviews tried to take advantage of the group homogeneity in terms of educational background and current context in facilitating open communication, exchange of ideas, and a sense of safety in expressing conflicts of concerns [16].

Each session lasted approximately 90 minutes and was audio-recorded. The interviews were transcribed verbatim by the first author. The names of the participants were anonymised and replaced with numbers for analysis and reporting. For dissemination purposes, the transcribed data used to support the result were translated by the first author. Translation accuracy was verified by the first and last author. Data collection was considered sufficient and data saturation achieved, when the interviews provided rich and nuanced insight relevant to the research aim and to the context of video consultation implementation.

3.3 Ethical considerations

Participation in the study was voluntary and took place during working hours. Both written and oral information about the study was provided to the participants, and written informed consent was obtained from all participants before starting the interviews. The study did not require approval from Danish research ethics committees (Journal No. F-23075094), since the study does not involve experiments on live-born human individuals, human gametes, experiments with drugs, testing of medical devices or similar procedures.

3.4 Analysis

The transcribed interviews were analysed using thematic analysis, for systematically identifying, organising, and gaining insights into patterns of meaning or themes across the interview data [19]. The thematic analysis acknowledges the active role of the researcher in identifying patterns/themes, deciding on their relevance, and reporting them to the reader [19]. The process begins as researchers identify potential patterns of meaning and issues of interest that can occur during data collection. The analysis involves constantly moving back and forth between the entire dataset, the coded extracts of data being analysed, and the ongoing analysis of the data being produced [19]. The hermeneutic approach was used to facilitate a deeper understanding of the interview text by alternating between parts of the data and the dataset as a whole, interpreting the findings by continually questioning their meaning [13]. The analysis followed the six phases of thematic analysis recommended by Braun and Clarke (2006), as we wanted to work systematically with data while interpreting it in terms of meaning, context and understanding. Braun og Clarke offer a systematic structure for analysing qualitative data:

1. Phase 1: Familiarising oneself with the data implied transcribing the data as an interpretative act, reading and re-reading the data, and searching for meanings and patterns.
2. Phase 2: Generating initial codes entailed a systematic examination of the entire dataset, paying full and equal attention to each item and identifying aspects that might form the basis of repeated patterns. The coded data were organised into meaningful groups relative to the study’s aim.
3. Phase 3: Searching for themes involved sorting the initial codes into potential themes, with all relevant coded data extracts collated within these identified themes. A mind map was used to create an overview and understand the connections between themes, using separate pieces of paper with the name of each code and brief descriptions to experiment and organise themes. Codes that did not seem to belong anywhere were collected in a ‘miscellaneous group’.

First author completed phase 1–3.

1. Phase 4: Reviewing themes required refining the themes through critical reviewing. First, we considered whether the codes formed a coherent pattern and adequately captured the perspectives within the coded data. Second, reading alternating sections of the text generated new understandings of the individual sections and the text as a whole. The refinement process continued until no substantial new insights were added.
2. Phase 5: Defining and naming themes involved identifying the ‘essence’ of each theme and determining what aspect of the data each theme captured.

Researcher triangulation was conducted by the first and last author to validate the analysis in phase 4–5. Coded data were used as a basis for reflective discussions between the first and last author about content and meaning, and consensus was reached through these discussions to achieve a nuanced understanding of the data. The themes were not understood as emerging directly from the data but were actively generated through the researchers’ interpretative engagement with patterns of shared meaning across the coded dataset.

1. Phase 6: Producing the report entailed reporting the reasons for theoretical, methodological, and analytical choices, describing the coding and analysis processes in sufficient detail to capture the essence of the points without unnecessary complexity, and providing a thorough description of the context to ensure transferability. Quotations from the interview text were used to illustrate the analytical process, supporting the transparency and trustworthiness of the findings and the authors’ interpretations of the data (Table S3 in the appendix in S1 File). In this phase, the entire research team completed peer debriefing and researcher triangulation to validate the interpretation.

4.1 Video consultations must be offered at the right time

A common view was an overall concern about the increasing use of technological solutions in outpatient clinic treatment and care activities, which illustrates an underlying tension between technological expansion and professional discretion in clinical decision-making. In general, the participants saw both possibilities and limitations in the different types of consultations: physical, telephone, and video. When choosing among these types, both patients’ and nurses’ preferences were considered important factors. One participant noted:

‘I think that those patients I speak with over the telephone are the same patients I would offer a video consultation’. (Participant 12)

The participants acknowledged the nurses’ role in initiating the use of technology and how the different consultation types are presented to patients. Positioning nurses as gatekeepers highlights their agency in mediating technological implementation. All agreed that video consultations should be carried out if patients demand or prefer them:

‘Whether it is the choice between attendance [physical consultation] or video consultation, I think they should be allowed to choose (…) I think it would be a shame if they were forced to do video just because we believe it is smart’. (P9)

The participants expressed that the first meeting with a patient should preferably be a physical consultation because it establishes the relationship. This reflects an implicit hierarchy of consultation forms, where physical presence is constructed as foundational for relationship-building. They acknowledged that subsequent nursing consultations could be conducted effectively via video, offering value to some patients. The participants also noted that video consultations could be an efficient means of collecting additional information about the patient’s daily life, thus serving as a good alternative to telephone consultations by supporting their memory of the patient:

‘I see their faces on the screen, and I don’t always remember what they look like if I speak with them on the phone. (…) You can get some information about their daily lives in a way. (…) Yesterday, one was smoking while we were having the consultation; she only took one drag of the cigarette, but at least it was enough for me to remember asking her to consider stopping smoking’. (2)

The participants highlighted that the choice of consultation type (physical, telephone, or video) should be tailored to the specific needs of each patient:

‘I had an old lady who couldn’t get out of her bed. Her daughter then helped her join a video consultation, and then I spoke with both. It would be troublesome for her to get to the hospital for a physical consultation, but on the other hand, she is dependent on her daughter to help her. She could never manage it by herself’. (P2)

However, others emphasised that the use of video consultations could initiate a stronger cross-sectoral collaboration by including home care nurses and general practitioners in these consultations to collectively support vulnerable patients. Video consultations could also be used to involve relatives who might not attend physical consultations. There was a consensus that involving the primary care sector and relatives could be highly beneficial for patients but would require further development and integration into care and treatment workflows to monitor specific care and treatment tasks and system access. The findings indicate that increased use of video consultations depends on aligning technological options with nurses’ clinical judgement, patient preferences, and organisational structures that support flexible and coordinated care delivery.

4.2 Nursing care must remain as a relational practice

The participants expressed ambivalence regarding the justification for video consultations compared to physical consultations, framing them primarily through an efficiency-driven logic rather than clinical or relational rationale:

‘It’s an efficiency improvement system [the video consultation], that’s how I see it. It’s because we must achieve several things in the shortest possible time. We do this because we can (…) it’s not necessarily a good thing’. (P1)

The quote illustrates how video consultations were received as embedded in a broader organisational rationality of optimisation and time-efficiency, which was not necessarily aligned with nurses’ professional judgement of what constituted “good care”. The perceived nurse shortage across the healthcare system influenced the nurses’ perceptions and perspectives on implementing video consultations. Nurses are aware that resources must be distributed and utilised wisely, and they were concerned that patients should benefit from all the time allocated. The participants felt that the political agenda and arguments supporting telemedicine, and the benefits of video consultations had not been clearly communicated by the department or hospital management, leading to reduced motivation to adopt video consultations. Furthermore, the participants agreed that video consultations do not save time but rather degrade the quality of nursing care by challenging traditional patient interactions. The participants feared that video consultations would diminish their job satisfaction by reducing the relational dimensions of their clinical work:

‘If the management said all consultations must be virtual, then I know I would find it boring’. (P8)

As the quote illustrates, the participants not only fear reduced variation in work tasks, but also how video consultations were associated with a potential loss of professional meaning derived from direct patient interaction and relational engagement. Nonetheless, they were aware of the necessity of keeping pace with technological advancements in society to meet patients’ evolving demands and expectations. The participants also expressed the need to acquire new knowledge and skills to adapt effectively.

The participants were strongly committed to providing nursing care that ensures and maintains patient empowerment, safety, and security. More specifically, all participants felt a great responsibility to support and encourage their patients to manage their heart disease effectively. One participant expressed:

‘We must educate the patients to react to symptoms, take care of themselves, and prevent (…) the aggravation of heart failure. We must guide them in weight loss, diet, physical activities, and lifestyle risk factors, explaining the importance of taking the prescribed medicine’. (P4)

The nurse’s professional identity seems deeply grounded in embodied, relational and ethically orientated care. A common view was that the desired achievements in nursing consultations required physical contact to establish a meaningful relationship with the patients. This indicates that resistance to using video consultations is not merely practical but rooted in normative understandings of what constitutes ‘good nursing’. From the participants’ perspective, a meaningful relationship required ‘good chemistry’, empathy, and intuition:

‘The patients’ understanding does not only require explanation, but it also demands that you really get under their skin, and then we try to ensure the patients’ feeling of safety. (…) We enlighten their hearts (…) we really have to listen to the patients and embrace them’. (P5)

A participant described feeling that video consultations diminished the value of her education and clinical experience by undercutting her professional competencies:

‘I feel it’s a devaluation of my education and my life experience as a nurse (…) intuition and empathy’. (Participant 1)

This indicates that relational care may be constructed as embodied and intuitive, which may be difficult to translate into digital formats.

The participants felt a strong sense of responsibility towards their patients and thus had to advocate for the most suitable consultation type. The findings indicate that ambivalence towards video consultations reflects a tension between efficiency-driven organisational logics and nurses’ relational and embodied understanding of “good care”, and highlights nurse-identified organisational prerequisites for increased use, aligning digital solutions with professional identity clear communication and organisational support.

4.3 Missing initiatives for enabling nurses to use video consultations

The participants emphasised that management had an important role in directing how nurses and other healthcare professionals should prioritise video consultations. This underscores that implementation is not only an individual responsibility but organisationally embedded. Some participants were concerned that video consultations would only increase the nurses’ workload with additional tasks, such as teaching patients to use the technology, dealing with technical issues, and meeting a demand for greater availability and flexibility. When patients needed earlier appointments than scheduled, participants found it more straightforward to offer a telephone consultation rather than a video consultation because it felt easier to integrate into an already busy schedule as they were perceived as more adaptable to ad hoc clinical demands:

‘I had a patient in a video consultation yesterday whom I wanted to see again soon. However, I had no appointments available for either physical or video consultations. Instead, I had to offer a telephone consultation, where I could call her during the day without a specific time’. (P2)

The organisation of the outpatient clinics and scheduling of patients sometimes acted as barriers to video consultations because only telephone consultations could be flexibly added as an extra option. This points to a misalignment between technological possibilities and infrastructural realities. The participants stated that management wished for video consultations to be offered equally alongside physical and telephone consultations in the outpatient clinic. Furthermore, management needed to prioritise time for education and the development of digital competencies to ensure high-quality video consultations. However, this managerial ambition was experienced in tension with limited clinical time and competing demands, indicating a gap between policy expectations and the situated realities of implementation:

‘It is difficult to make changes when there isn’t time for it. (…) What is it, really? What should I do when I have a video [consultation]? It’s very rare that we have enough time, and then you don’t take ownership of it because it [the implementation process] feels a little sloppy, and then you become sloppy, too’. (Participant 12)

At the beginning of the video consultation implementation process, the participants received partner training to become familiar with the technology. However, they mentioned that it was too brief:

‘It [the implementation of video consultations] worked very well, but it should have lasted a little longer. To implement something takes not only a day. It takes months to maintain changes. (P12)

After the partner training, the participants felt they lacked support in addressing questions and challenges related to video consultations. This lack of sustained scaffolding meant that responsibility for implementation was largely transferred to individual nurses, which in turn shaped the motivation and ownership in practice. They argued that adequate resources must be allocated to training staff to maintain motivation, given that outpatient clinic nurses’ time was scarce and utilised to the maximum, which indicates that motivation is structurally conditioned rather than individually driven.:

‘There was a long period last summer where it didn’t work at all (…) maybe it’s different now, but then I stopped planning video consultations because I ended up calling on the telephone anyway. (…) If you have to discover yourself, that it doesn’t work [the video link] when you are sitting with the patient, then the motivation disappears’. (P11)

The participants explained that they often used telephone consultations when video links did not work, leading many to prefer telephone consultations. It was a commonly held belief that video consultations require different communicative competencies to maintain good relationships with patients compared to telephone or physical consultations. The participants explained how video consultations demand alternative approaches to understanding patients’ perspectives and symptoms when not all senses can be engaged in the overall assessment of the patient. Additionally, facilitating video consultations requires different approaches compared to physical consultations:

‘... it’s a bit of an art to give time and breaks when you communicate through a video consultation in contrast to how we normally communicate in the physical consultation’. (P2)

Beyond the need for education on conducting video consultations for nurses, the participants also highlighted the necessity of educating patients on how to use video consultations effectively. In current practice, patients’ technical support needs fall on the nurses, with time allocated for this support detracting from the consultation time, thus necessitating a prioritisation of technical support over health-related discussions. This illustrates how telemedicine implementation redistributes not only tasks, but also the boundaries of clinical responsibility in practice. Looking ahead, the participants anticipated that telemedicine would face far fewer challenges and barriers. However, this expectation of “automatic” adoption coexisted with continued uncertainty regarding technological reliability and clinical readiness:

‘I think it will change automatically. Seniors, including myself, have a little fear of it [video consultations] because we didn’t grow up with it. (…) I’m afraid that the technology won’t work’. (P7)

Despite anticipating that the demand from future patients may lead to the natural adoption of video consultations, the participants agreed on the importance of being proactive in preparing themselves for these future demands. The findings suggest that increased use of video consultations depends, from the nurses’ perspectives, on aligning managerial expectations with clinical realities particularly by addressing time constraints, limited implementation support, and the fit between digital workflows and everyday nursing practise.

5.1 Strength and limitations of the work

5.2 Recommendations for further research

The findings of this study indicate unmet needs and suggest areas that may lead to better implementation of video consultations in outpatient clinic settings. Based on this knowledge, recommendations for guidelines can be proposed. To ensure successful and sustainable implementation, management must foster a motivated workforce capable of developing innovative solutions to emerging challenges. Management must ensure that staff members possess the knowledge, skills, and attitudes to support the integration of video consultations on par with telephone and physical consultations. Thorough and systematic training of nurses is necessary, along with a sustained focus on identifying and addressing the opportunities and challenges presented by the technology in relation to patient care. Future research should focus on practice-oriented approaches to implementation. Comparative studies examining differences in patient outcomes, communication quality, and workflow efficiency between video, telephone, and physical consultations would provide valuable insights into the most appropriate use of each consultation format. In addition, interventional studies evaluating the effect of structured nurse training programs, implementation strategies, or technological support initiatives could help identify effective methods for strengthening staff competencies and confidence in video consultations. Multi-center studies across outpatient clinics and healthcare settings are also recommended to explore organisational differences.