Background
During the COVID-19 pandemic when public health restrictions limited in-person care across health sectors, primary care providers – to varying extents – used virtual care to deliver healthcare. Virtual care has been defined as remote patient-provider interactions that use any form of information and communication technology (e.g., phone, video) to facilitate and/or optimize patient care [1]. In 2022, family physicians were responsible for 59.5% of virtual visits across Canada [2]. Primary care is the first point of contact patients have with the healthcare system, where their needs are addressed through the provision and coordination of care over time and includes longitudinal relationships across the lifespan [3, 4]. In primary care, team-based care – care that involves the strategic distribution of work among members of a team aimed at sharing responsibilities to improve patient care – is becoming more common and often involves nurses as key participants [5]. In nursing, primary care fits within a community health sphere that also includes public health and home health [6]. Primary care nurses, including Nurse Practitioners (NPs), Registered Nurses (RNs), and Licensed Practical Nurses (LPNs) (Registered Practical Nurses [RPNs] in Ontario) are involved in virtual care delivery alongside family physicians and other providers in primary care teams. There were twice as many nurses involved in virtual care in 2020 compared to 2017 [7].
In Canada, nurses across all designations practice within primary care settings, including NPs, RNs, and LPNs/RPNs [8]. NP legislated scope of practice (i.e., scope of practice informed by provincial/territorial legislation, and professional regulation/standards) [9] includes diagnosing illnesses/diseases, prescribing medications, ordering diagnostic laboratory tests, making referrals to specialists, and performing advanced procedures. RNs’ legislated scope of practice may require orders from family physicians or NPs to carry out certain tasks, however, their contributions remain comprehensive [10, 11], especially in rural settings where they may practice autonomously under an expanded scope of practice [12, 13]. LPNs/RPNs have a legislated scope of practice that allows them to care for patients with predictable outcomes; their roles often require collaboration with NPs, RNs, or other primary providers [9, 14]. Notably, nurses’ legislated scope of practice may differ from their actual scope of practice which may be expanded or limited based on nurses’ professional knowledge/skills, their practice environment, and their patients’ needs (e.g., the actual scope of practice of nurses in rural environments may be expanded compared to those in urban settings) [9].
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The growing presence of virtual care provision within primary care has important implications for the enactment of nursing care and the training of nurses. A Canadian survey reported that nurses in primary or community care settings are more likely to deliver care virtually than nurses in other settings, such as acute care [7, 15]. Previous studies highlight the implications of virtual care from family physician perspectives [16‐19]. To promote high quality care that is accessible and equitable, there is a critical need to also understand nurses’ experiences with virtual care during the COVID-19 pandemic (e.g., how nurses plan and provide care, assess and monitor patients, and collaborate with other healthcare providers) and potential skills and resources that nurses need to facilitate the efficient and effective use of this modality.
Purpose and study aims
In this study we explored the experiences of primary care nurses in the delivery of virtual care during the COVID-19 pandemic and the barriers and facilitators they encountered that influenced their contributions to virtual care delivery. More specifically, we aimed to: (a) outline the roles that nurses carried out in their delivery of virtual primary care services; and (b) describe what helped or hindered nurses’ transition to and use of virtual care in primary care during the COVID-19 pandemic. Primary care nurses’ roles refer to the specific tasks and/or responsibilities that primary care nurses were asked or required to do during the stages of the COVID-19 pandemic (with potential to vary across designations) [20].
Methods
Study design
This study is part of a larger qualitative case study [20] examining four regions in Canada: the Interior, Island, and Vancouver Coastal health regions of British Columbia (BC); the Ontario Health West region in Ontario (ON); the province of Nova Scotia (NS); and the province of Newfoundland and Labrador (NL). The larger project aligned with Yin’s case study methodology [21] and aimed to delineate the actual and proposed roles of nurses in primary care during the COVID-19 pandemic, including the challenges and supports they encountered. We followed the same protocol used for a related study that focused on family physicians [20]. For the current paper, we focused on data related to virtual care delivery.
Participants and recruitment
From each study region, we invited NPs, RNs, and LPNs/RPNs who were eligible to practice and employed in a primary care setting during any period of the COVID-19 pandemic (i.e., from March 2020 to January 2023 – the end of the study period). Nursing students and nurses in solely academic, research, or administrative roles were excluded. We employed a maximum variation sampling approach [22] to recruit participants across a diverse range of characteristics, including regulatory designation, gender, primary care setting (e.g., community health centre, physician-led clinic), community size, and practice models (e.g., team-based care) known to impact nursing roles in primary care [23].
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We employed multiple recruitment strategies tailored to suit provincial contexts and research ethics board approvals. Recruitment invitations were disseminated through newsletters, emails, and social media channels of relevant organizations. Research assistants sent study invitations via email to individuals identified from practice lists and search platforms of regulatory bodies (e.g., NS College of Nursing) and professional associations (e.g., Nurses and Nurse Practitioners of BC). Primary care clinics that had nursing staff were identified through online searches and study information and requests to participate were sent via email. Lastly, where permitted by regional ethics boards (i.e., BC, NS, NL), we used snowball sampling in which participants were asked to recommend eligible colleagues who may be interested.
Data collection
We conducted semi-structured interviews with nurses between May 2022 and January 2023 until data saturation was reached (i.e., no new themes emerged) [22, 24]. The regional Principal Investigators (MM, LH, JL, EGM) created an interview guide, which we pre-tested across the broader study team that included nurses. We made slight modifications to the questions to accommodate provincial or regional variations in nursing responsibilities, health system contexts, and pandemic epidemiology and responses. Research assistants from each region who had experience and expertise in qualitative interviewing (CV, LM, SS) conducted interviews by telephone or Zoom (Zoom Video Communications), depending on participant preference. Each interview was recorded, transcribed verbatim, de-identified, and verified for accuracy. Research ethics boards across all four regions approved this study. Prior to initiating the interviews, we obtained informed consent from all participants. We password protected and securely stored audio recordings. We used unique codes to identify participants to help conceal their identity in this study.
Data analysis
We used an applied thematic analysis approach, which was exploratory (or inductive) and driven by the content/data provided by participants [25]. We developed a robust coding template through a collaborative approach. Team members from each region independently coded selected transcripts from each of the four regions. Following this, we met to compare and refine codes and definitions. We reconciled disagreements through discussion until consensus was reached. Through an iterative process, the research team developed a harmonized coding framework that was then used by all researchers to code transcripts in their respective study regions. We used NVIVO 12 software (QSR International) to code interviews and explore thematic patterns and relationships within the data. For the current paper, we performed a sub-analysis of codes related to virtual care.
Study rigour
We employed several strategies to ensure methodological rigor [22, 24, 26], including the use of experienced interviewers, meticulous documentation of all procedures, verification of participant responses during interviews, and the provision of detailed descriptions and illustrative quotes when presenting results. Our interdisciplinary study team included RNs, family physicians, and individuals with public health and health systems expertise, allowing us to draw on expert knowledge throughout different stages of the study and enrich the interpretation of findings.
Table 1
Demographic characteristics of participants across four study provinces, organized by gender, nurse type, community size, and years in practice
Demographic Characteristics | Ontario N = 27 | Nova Scotia N = 20 | British Columbia N = 13 | Newfoundland and Labrador N = 16 | Total N = 76 |
|---|---|---|---|---|---|
Gender*, n (%) | |||||
Men or non-binary | 1 (3.7) | 1 (5.0) | 2 (15.4) | 0 (0) | 4 (5.3) |
Women | 26 (96.3) | 19 (95.0) | 11 (84.6) | 16 (100) | 72 (94.7) |
Nurse Type, n (%) | |||||
RPN/LPN | 9 (33.3) | 1 (5.0) | 0 (0) | 5 (31.3) | 15 (19.7) |
RN | 9 (33.3) | 11 (55.0) | 11 (84.6) | 6 (37.5) | 37 (48.7) |
NP | 9 (33.3) | 8 (40.0) | 2 (15.4) | 5 (31.3) | 24 (31.6) |
Community Size**, n (%) | |||||
Rural | 10 (37.0) | 11 (55.0) | 1 (7.7) | 6 (37.5) | 28 (36.8) |
Small Urban | 5 (18.5) | 6 (30.0) | 3 (23.1) | 0 (0) | 14 (18.4) |
Urban | 12 (44.4) | 3 (15.0) | 9 (69.2) | 9 (56.3) | 33 (43.4) |
Mixed | 0 (0) | 0 (0) | 0 (0) | 1 (6.3) | 1 (1.3) |
Years in Practice, mean (SD) | 13.6 (10.1) | 15.6 (11.3) | 17.7 (11.2) | 14.0 (9.8) | 14.9 (10.3) |
Results
We conducted interviews with 76 nurses in total; the length of interviews ranged from 24 to 125 min (mean = 58 min). Nurses of each regulatory designation were interviewed (n = 24 NPs, n = 37 RNs, n = 15 LPNs/RPNs). Most nurses identified as women (n = 72, 94.7%) and worked in an urban primary care setting (n = 33, 43.4%) (Table 1). Three key themes and various sub-themes were identified (Table 2), including (1) variable adoption of virtual care among nurses, (2) facilitators and barriers to virtual nursing practice, and (3) impacts of virtual delivery on care provision by nurses.
Table 2
Descriptions of themes and sub-themes
Theme | Sub-theme | Description |
|---|---|---|
Variable adoption of virtual care among nurses | Nurses’ roles in virtual care varied by designation, geography, and team composition | |
Facilitators and barriers to virtual nursing practice | Previous virtual care experience | Familiarity with virtual approaches supported nurses’ transition to virtual care delivery |
Guidance documents | Nurses had limited practice guidance to support virtual assessments; however, new consent documents supported privacy concerns in virtual care | |
Funding models | The lack of an appropriate fee code to bill for virtual visits meant nurses in fee-for-service practices were less involved in virtual care compared to salaried nurses (who did not need to rely on such codes) | |
Availability of and access to equipment and resources | Nurses were provided equipment or used their own personal resources; patients had poor digital literacy and/or did not have the resources needed for them to receive care virtually | |
Impacts of virtual delivery on care provision by nurses | Workflow | The integration of virtual care had variable impacts on effectiveness and efficiency in nursing care delivery |
Elements of patient-centered care | Patient preferences were prioritized; patients were assessed more holistically; and nurse-patient relationships were impacted when using virtual care | |
Bridging the gap using virtual care | Nurses used virtual care to check in with patients and ensure care was maintained (e.g., through education and promoting self-care) when in-person visits were limited |
Variable adoption of virtual care among nurses
Despite the sense that “… it all turned to … virtual care, like overnight” [BC5, RN], the use of virtual care and nurses’ roles in providing virtual care varied between practices. One NP in a rural clinic transitioned entirely to virtual care in the early days of the pandemic: “In the initial lockdown … we basically transitioned straight over to virtual care … I didn’t see anybody in person for about a month” [NS1, NP] while another participant did not have any experience with virtual care: “…throughout the entire pandemic I … stayed in-person with my patients, I have never done virtual” [NS2, RN]. An NP in an urban setting noted that both virtual and in-person visits were offered: “…we certainly offer virtual options, but by and large, we have been physically in-clinic the entire time” [NL2, NP].
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Nurses performed many different functions to support the delivery of virtual care. For example, LPNs/RPNs helped coordinate virtual care appointments for other providers where they were “responsible for setting up phone calls” [NS1, LPN]. In ON, an RPN described using virtual care to relay test results to patients at the behest of physicians in the clinic:
I was somewhat involved with virtual care, mainly that doctors would send me messages regarding blood tests or any other laboratory workup or imaging … it would be my responsibility to call the patient and inform them of the message that the doctor wanted to relay … I would kind of be the middleman between the patient and the physician. [ON14, RPN]
An RN noted that physicians were sometimes the ones who took on the majority of virtual care responsibilities, while nurses were still heavily involved with in-person visits:
[Physicians] had certain days that they would be in the office, like maybe one or two days a week … but they were doing a lot of virtual visits. I was in the office five days a week, seeing patients in-office … some of my work was over the phone. [BC4, RN]
Facilitators and barriers to virtual nursing practice
Participants identified four factors that enabled or impeded their delivery of virtual care: previous virtual care experience, guidance documents, funding models, and availability of and access to equipment and resources.
Previous virtual care experience
The transition to virtual care was smoother for nurses with previous experience in virtual care delivery, as noted by one RN who had experience in remote nursing where they relied on telephone-based care for certain activities, such as triage:
…we talk to people about the [vitamin] B12, we talk to a lot of people about cholesterol already over the phone. So, I was used to it and actually… I used to outpost nurse and … triage a lot of people … overnight when I was on call… So, I’ve had a lot of experience with that. [NS7, RN]
Another nurse in NL recalled being unfamiliar with virtual care which made for a challenging transition when virtual approaches were adopted: “[delivering care virtually] was such a learning curve, we felt like we were … just trying to get used to what virtual meant” [NL3, NP].
Guidance documents
Participants noted that, as virtual modalities were newly integrated into nursing practice and rapidly adopted during the pandemic, there was little guidance on best practices: “[we] weren’t really given guidance or anything” [NL1, RN]. Nurses reflected on the need to adapt their patient assessments as they could not perform hands-on care, and at times, could not see their patients (i.e., telephone-based care). Nurses also had to learn which conditions could be adequately addressed by virtual care, noting some assessments that were better suited for in-person visits. For example, an NP noted that musculoskeletal conditions were “an easy thing to diagnose with a physical assessment” [NS3, NP], but not by virtual care. Similarly, another NP reflected upon assessing a patient’s knee:
… [you were] really having to focus a lot more on your history taking or, if you were lucky enough to have your patient on video, being able to at least see some things on video … [virtual care] changed the way we practice and the way we gather information from our patients. [ON7, NP]
An RN recalled that many behavioural cues were difficult to detect on a virtual visit compared to an in-person visit: “… just from somebody walking in and smiling at me, I can tell a lot of things” [BC5, RN].
Nurses also recognized the need for new processes to aid in the delivery of virtual care. An NP practicing in an urban centre recalled developing practice guidelines for specific patient populations to inform the execution of virtual visits:
… myself and a few other NPs worked to develop … clinical practice guidelines for adults and pediatrics and … we didn’t have very much to go on, so we kind of used the limited resources that we had to come up with clinical pathways or guidelines to help us assist patients virtually and determine the best course of care for these patients. [NL14, NP]
Nurses also noted challenges with privacy during virtual care visits and the importance of obtaining informed consent. One NP recalled how telephone-based virtual care was her primary approach because of uncertainties surrounding how to protect privacy of patient information (e.g., data security) in video-based virtual platforms: “We did mostly phone … we did have access to like a virtual platform … but there was a lot of concerns about personal health information and rules … there was still … a lot of unknowns about privacy” [NS3, NP]. Another NP discussed a newly integrated consent process which was required for each visit:
…it came out about having to inform patients that this is a virtual visit and what that entails and getting their consent … for video … so we had to read that to our patients every time we call them so they [could] consent. [NL3, NP]
Funding models
Primary care funding models also had an impact on nurses’ engagement in virtual care delivery, especially in NS. In clinics funded by alternate payments plans (e.g., blended capitation) nurses were salaried (i.e., fixed compensation); they often practiced within a team where their roles were more comprehensive, and they delivered care virtually. One salaried NP who commonly performed virtual care and had familiarity with this modality described how her transition to virtual care was simpler than the transition experienced by her physician colleagues who were limited by the absence of virtual care billing codes in the early stages of the pandemic:
I always did some phone calls. I’m paid by the hour … I’m not like, the physicians [who] are fee-for-service, they have to bill appropriately … they can only bill for things that were in-person. So, there was no virtual option for them to bill. [NS1, NP]
Furthermore, this NP felt that her compensation model was favorable to addressing routine patient concerns and was an approach she used prior to the pandemic as well:
… for like really quick things … for example like, somebody’s thyroid medicine needs to be adjusted. You don’t need to physically assess them because they’ve been on the medicine for a long time … I always would have done that on the phone anyway. [NS1, NP]
Similarly, an RN described that the telephone-based care she delivered was straightforward and did not rely on service billing because she was a salaried employee: “… I’m paid through NS Health Authority and I’m paid a salary, so I don’t really get into like, billing as far as visits go” [NS3, RN].
In contrast, other nurses were restricted and could not deliver care virtually when practicing in a fee-for-service practice (because physicians could not bill for the virtual services nurses provided), causing their practices to remain in-person throughout the pandemic:
… as a private family practice nurse, I cannot do virtual care … we reached out seeing if we could get funding for me to do virtual and there was not an opportunity. So, we kind of sat down and decided … how are we going to see patients to ensure patient care was continued and I was not going to do virtual, so throughout the entire pandemic I have stayed in-person with my patients, I have never done virtual. [NS2, RN]
Availability of and access to equipment and resources
Nurses needed equipment to deliver virtual care. For some participants, these resources were provided to them by their employer: “Everything was given to us; everything was paid for. Even our cell phone that we used or our home phone, we got all of that paid for” [ON16, RN]. One NP described her quick access to platforms to conduct video-based visits: “… within a week I was able to do Zoom visits with patients, which was fantastic” [NS6, NP]. Other nurses had to use their own equipment to deliver virtual care: “I use my own computer … the Health Authority didn’t give us a computer. We used our own phones” [NL14, NP]. Moreover, equipment did not always function smoothly causing interruptions to the delivery of care: “I would be in the middle of an … appointment and the whole system would crash” [ON25, RN]. Some nurses in the study found that the equipment available to them did not support video-based virtual appointments: “… the platform was there, but you don’t have the headpiece. And the computers that we use don’t have speakers and the equipment is old …” [BC13, NP].
Patients’ comfort and skills with using technology, as well as access to equipment, were identified as barriers to providing virtual care. For example, for certain aging populations, virtual care “…worked well because their son or daughter was the one doing it, not because they were able to”; nurses were “…relying … on [patients’] family supports …” [NL1, RN] to help patients navigate the technology. In addition, nurses recognized that not all patients had the necessary equipment to navigate video-based virtual visits: “some [patients] still have flip phones, some don’t even have cell phones” [NS4, NP] and “a lot of them don’t have access to a [smartphone] or a computer so that made Zoom a little bit more challenging” [BC10, RN]. Other patients had equipment that was not suitable for virtual care: “… technologically … I wasn’t sure that they were even hearing us properly… the phone or the tablet they were using, the camera quality was so low that it was useless …” [NL1, RN]. One NP recalled a patients’ struggle with poor internet availability in a rural community:
I had one patient say to me, ‘well, I’m actually at the end of my driveway because it’s the only place I can … get Zoom on my cell phone’ … the infrastructure for internet rurally was quite poor in 2020. [NS6, NP]
Impacts of virtual delivery on care provision by nurses
Nurses in this study noted that virtual care changed the way they approached their practice. Virtual care impacted nurses’ workflow, their ability to incorporate elements of patient-centred care in their practice, and their ability to bridge the care gap when in-person care was affected.
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Workflow
Many nurses reported that virtual care improved the efficiency and effectiveness of their practice. One NP described how in-person visits were perceivably longer than they needed to be, and that telephone-based virtual visits were shorter and allowed her to see more patients in a day: “… it’s improved our workflow as well, right? … [patients] seem to linger longer in the office than they do on the phone … I think it sped up our processes and allowed us to see more patients …” [ON7, NP]. Another NP expressed similar feelings about the efficiency of a virtual visit:
… phone calls are a lot quicker. People aren’t having to come walk down the hall – “Oh, I’ve got to go to the bathroom first” … because they get nervous … or they have to take off their coats and sit in the chair. And I also find they get more to the crux of the matter because they’ve got other stuff to be doing … whereas sometimes when … they get in here … it’s a social visit and that’s great for them … but it doesn’t help medical-wise … [NS5, NP]
Another nurse, however, suggested that virtual care created a need for additional time to complete indirect patient care, including paperwork and reviewing laboratory reports:
… I got to know patients more because they talk a lot and they start talking about their families … but because I spent that chunk of time all day on the phone, I felt in the evenings I had to spend catch-up time with doing prescriptions or going through bloodwork… [NL3, NP]
For this NP, the change in workflow delayed care delivery and essentially increased her workload. Virtual care also impacted the way nurses collaborated with other healthcare providers:
… when you say, ‘come and look at this’ and … you sit down and three of you – the physician, myself and the client – would sit there and have a full-blown conversation, [patient concerns] would be kind of tweaked out a little quicker. Like everything took twice as long … when you were collaborating [using virtual care]. [NS7, RN]
This RN felt that the collaborative nature of in-person practice was lost in virtual care because it was difficult to have multiple providers on the same virtual visit, and the ability to quickly bring together and consult with colleagues was lost when providers were not co-located.
Lastly, virtual care changed patients’ expectations for accessing care, thereby increasing nurses’ workload. One NP noted that when patient-provider messaging was available, patients believed that nurses were readily available to respond to questions:
… it kind of created the expectation that I could be accessible immediately to people … and then whereas I would normally see 12 people a day in-person, all of a sudden, I’m getting 15 messages on top of [who] I’m scheduled to call. So, just establishing what the protocol is for [contacting nurses to ask questions virtually] and communicating that effectively … so that [patients] understand the process. [NS3, NP]
Nurses had to address this issue and ensure patients understood nurse-patient communication processes to maintain a manageable workload.
Elements of patient-centred care
The availability of virtual care promoted patient-centred care by allowing patients to receive care according to their personal preferences. In particular, virtual care was an attractive option for patients who lived in rural areas and/or who had to travel far for in-person care: “… if [patients] weren’t close to the hospital, like if they lived in another community and they just wanted to do it over the phone, then [we] gave them that option…” [NL16, LPN]. Nurses were also sensitive to patients who avoided in-person visits to minimize COVID-19 transmission risk:
…we also have some patients who would rather … stay at home as much as possible, whether that’s someone who’s immunocompromised or … someone in the elderly population who may not want to put themselves at unnecessary risk … for a respiratory illness such as COVID. [NL20, RN]
Alternatively, when patients wanted an in-person clinic visit (instead of a virtual visit), nurses reassured patients that it was possible: “I have had some people that did want to come in. We don’t refuse that. I never do…” [NS5, NP]. One RN noted that in-person care was the preferred option for some patients because it allowed them to stay connected and reduced their perceived feeling of social isolation:
… some of our clients who are very lonely, and our clinic and our providers are their only way to connect with people, and they’re already isolated, and [virtual care] was isolating them even more, I think [a medical visit] was an opportunity for them … to stay connected and to come in in-person was, was one way to do that. [BC10, RN]
Overall, when it came to virtual care, patient preferences were fluid which further emphasized the need to prioritize and respect the views of patients. For example, some patients – who initially experienced challenges with virtual visits – began to favor this modality: “…some of my seniors now prefer … phone calls, because we’ve all gotten so good at figuring things out over a phone” [BC7, RN].
In addition to patient preference being placed at the forefront of care, some nurses felt that video visits allowed them to assess patients’ home environments and consider the whole patient in their care plan, including their physical and emotional needs. One RN recalled that “… we have seen … some people’s places and we have discovered that they may be hoarders, or that they’re not taking their medication …” [ON25, RN]. Assessing the whole patient also meant including the patients’ family in their virtual appointments and plan of care. One NP described family involvement when a patient experienced hearing difficulties during their virtual visit: “… in some cases, there may be a family member or support person who would communicate … on behalf of the person, right? If they had any difficulty understanding” [NL4, NP].
Finally, nurse-patient relationships foster collaborative decision-making (between the nurse and patient) – a foundational element in patient-centered care. Nurses noted that their ability to develop trusting nurse-patient relationships was perceivably lost when using virtual care:
I felt like, at times, we were getting more done and seeing more people … over the phone. But we were missing that connection that happens with face-to-face and probably missing out on … that nonverbal stuff, right? … The volume of people that we could see in a day … was much greater than what we could do in-person … but … it didn’t feel a lot of the time as meaningful as that face-to-face. [NS11, RN]
Bridging the gap using virtual care
Virtual care allowed nurses to respond to patient needs in ways that would have been difficult to do when in-person care was limited during the pandemic. One RN recalled checking in on patients to make sure their needs were met and to identify any outstanding concerns: “I was working from home, doing a lot of phone calls to patients to check in on them and make sure that they had access to healthy food, had someone to check on them…” [ON13, RN]. Similarly, another NP assessed whether patients with chronic diseases had prescription refills and other medical needs met:
I ran clinical lists of … my diabetics and my asthmatics [who] might need refills on stuff just to keep them okay until I could see them in the office. I spent a fair amount of time … calling people and checking in on them if I didn’t have scheduled appointments. [NS1, NP]
Virtual care also provided opportunities to connect with and care for patients when an in-person visit was not possible. For example, when caring for a patient with chronic wound care needs, an RN recalled: “… when we delayed an appointment, we didn’t say, ‘…we can’t do your dressing this week because of COVID’.… You can’t leave a dressing on for seven extra days. So, we would do a lot of verbal teaching over the phone” [NL1, RN]. Nurses educated patients through virtual visits and guided them to provide at-home care when health care providers were inaccessible.
Discussion
Using qualitative interviews, we drew upon the experiences of NPs, RNs, and LPNs/RPNs in their provision of virtual care during the COVID-19 pandemic to describe the implications of virtual care on nursing practice in primary care. Virtual delivery (through telephone and/or video) impacted nursing care processes in both positive and negative ways. Virtual care necessitated changes in the way nurses planned patient visits, assessed patients, compiled medical histories, and collaborated with other healthcare providers.
First, nurses’ level of autonomy and actual involvement in virtual care varies. NPs in this study were notably more involved in virtual care delivery than RNs and LPNs/RPNs. Some RNs and LPNs/RPNs acknowledged that they were not involved in virtual care delivery at all during the pandemic; rather, their roles were limited to in-person care. Similar findings were noted by Anderson et al. [27] whereby NPs were more likely to deliver virtual consultations and RNs continued to deliver a large portion of their care in-person during the COVID-19 pandemic. Alternatively, another study in Quebec, Canada [28] noted that RNs/LPNs (referred to as clinical nurses) were more involved in telephone consultations pre- and post-pandemic compared to NPs, and all nurses remained equally involved during the pandemic. This variation in nurses’ roles in virtual care delivery across primary care settings outlines that roles are not solely reliant on the nurses’ level of training, but rather on patient needs, organizational structures, and legislation [9].
Our findings align with previous studies calling for policy and practice guidelines for the use of virtual care by nurses [27‐29]; however, to help guide practice, studies have identified clinical scenarios for which virtual care is appropriate (across disciplines). A framework presented by Segal et al. [30] focused on clinical situations (e.g., assessment, concerns requiring specimen collection) and contextual factors (e.g., extended travel time, patient preference) that favored either in-person or virtual primary care, many of which were noted by nurses in this study. The appropriateness of virtual care (versus in-person care) has been a focus of discussion and there are resources available to inform providers when virtual care should be used or avoided. For example, the Faculty of Medicine at the University of British Columbia in Canada has provided a practice guide for RNs in primary care to inform what activities can be done virtually, should be modified for virtual care, or require an in-person visit [31]. Guidance documents informed by resources like these have the potential to educate nurses on virtual nursing practice as they engage in this new modality.
Similar to other studies, we identified a number of facilitators and barriers to the sustained use of virtual care modalities in primary care. Providers who have training and/or experience in virtual care are better able to adapt to virtual care delivery [17], though considering how broad virtual care is, it remains unclear whether their comfort is only with the modality and role they experienced (e.g., telephone, video, assessment, education) or with virtual care generally, across all modalities/roles. Also, nurses in this study recognized that their compensation within different funding models impacted their potential to engage with virtual care delivery, which is a concept that has been previously presented in both Canadian and international literature. A study carried out in NL, Canada [32] noted that funding models had an impact on RN integration in primary care where fee-for-service models were more restrictive to nurse optimization (i.e., exercising an actual scope of practice that is narrower); conversely, models funded by alternate payment plans promoted a team-based approach to care, often allowing RNs to practice to their full legislated scope. Despite NPs’ legislated scope as primary providers, funding models that require direct billing (i.e., fee-for-service) also limit their roles in primary care settings across Canadian provinces and territories as many still cannot bill independently for the services they deliver; therefore, NPs are required to bill patients privately or practice under the supervision of a physician or team [33, 34]. In Australia, James et al. [35] conducted a study in primary care within a COVID-19 context where they noted that nurses’ roles in primary care were suboptimal because physicians could not bill for services delivered by nurses, so physicians opted to carry out virtual visits themselves to financially benefit from the care being delivered.
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Furthermore, our findings highlight the potential of virtual care to influence elements of patient-centred care, by providing greater choice to patients in how they access care, gaining more avenues to gather information about the patient as a whole and developing nurse-patient relationships. Incorporating patient characteristics and preferences aligns with nursing values and ethical responsibilities as nurses are often seasoned in their application of patient-centered care [36, 37]. A study from the United Kingdom during the COVID-19 pandemic noted that the presence of support systems (e.g., family members during virtual at-home visits) had a positive impact on patient experience with virtual care delivered by nurses [38]. Our study also highlighted ways in which virtual care bridged the care gap when in-person visits were limited, particularly in the context of a longitudinal nurse-patient relationship. Previous studies have noted the importance of maintaining patient relationships and an overall patient-centred approach to care to sustain the delivery of high-quality care [16, 27, 39, 40].
Despite the perceived benefits, nurses sometimes felt that virtual care reduced efficiency and increased workload in their practice; a finding which has been previously reported in a review evaluating the impact of technology on nurse workload in rural settings [41]. Also, nurses experienced the impact of inadequate virtual care infrastructure (e.g., equipment) which likewise impacted virtual care implementation (especially during the COVID-19 pandemic) for nurses in a study involving patients with chronic wounds [42].
Limitations
Nurse perceptions in this study are limited to four jurisdictions across Canada; therefore, this study is not transferable to all primary care nurse experiences with virtual care during the COVID-19 pandemic considering the differences in pandemic responses and epidemiology that existed across jurisdictions. Also, while the interview guide was comprehensive and informed by a chronology of COVID-19 pandemic response stages, nurses were not directly questioned on virtual care experiences. Rather, these ideas organically emerged with probes used to foster further reflection.
Conclusions
As nurses become increasingly integrated in primary care settings, and as virtual care becomes a standard model of delivery, virtual nursing practice requires focus. Nurses require exposure to virtual care delivery to develop a necessary skillset, supported by the development of guidelines and standards specific to virtual primary care. Future research should focus on exploring the variability that exists across nurse designations in virtual care to identify professional and regulatory needs in virtual nursing practice; and explicitly analyzing funding models that can be leveraged to support virtual nursing practice in primary care. Overall, study findings highlight nurses’ involvement in virtual care delivery across primary care teams in Canada, and the ways in which future pandemic plans should acknowledge how virtual care has impacted the work of nurses in primary care.
Acknowledgements
Thank you to the NPs, RNs, and LPNs/RPNs who took the time out of their busy work schedules to participate in our study. Your insights are valuable to our learnings and the overall impact of our research. Also, thank you to all members of our research team and knowledge users involved on this project.
Declarations
Ethics approval and consent to participate
We obtained ethics approval from each of the regional research ethics boards: Simon Fraser University and the University of British Columbia (File: H20-02998); Western University Research Ethics Board (File: 120519); the Nova Scotia Health Authority Research Ethics Board (File: 1027959); and the Health Research Ethics Board of Newfoundland and Labrador (File: 20222815). Prior to initiating any interviews, we shared an information and consent form with all participants which outlined the voluntary nature of their involvement in the study, the risks and benefits associated with their involvement, and the confidentiality of information collected. As per approval from the above ethics review boards, we obtained verbal informed consent from all participants prior to initiating interviews.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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