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Telehealth videoconferencing has largely been embraced by health care providers and patients during the COVID-19 pandemic; however, little is known about specific techniques for building rapport and provider-patient relationships in this care environment. Although research suggests that videoconferencing is feasible and can be effective for some types of care, concerns about the impact of technology on provider-patient relationships exist across health disciplines. Suggestions for adapting some in-person rapport techniques, such as the use of small talk, eye contact, and body language to facilitate trust, personal connection, and communication during videoconferencing encounters, have been discussed in the popular press and clinical commentaries. Notably, evidence regarding the effects of these strategies on rapport and clinical care outcomes is lacking. Understanding how to establish rapport in videoconferencing visits is especially important in oncology nursing, where rapport with patients enables nurses to become a source of emotional support, helping patients adapt and navigate the cancer journey.
This study aims to investigate the nature of nurse-patient rapport in ambulatory cancer care videoconferencing visits. The objectives include exploring how patients with cancer and nurses describe experiences of rapport and strategies for cultivating rapport in videoconferencing visits and similarities and differences identified by patients with cancer and nurses between experiences of rapport in videoconferencing and in-person visits.
Semistructured narrative interviews of patients with cancer and nurses will be conducted to understand the experience of rapport building in videoconferencing visits. Nurses and patients will be interviewed separately to facilitate an understanding of the perspectives of both types of participants. Interviews will be conducted on a secure videoconferencing platform. This qualitative descriptive study will describe participant experiences in a manner that, although not without interpretation, is as close to the data as possible. The research team will meet regularly to discuss, define, and document codes, categories, and themes, and the team will maintain a detailed audit trail of analytical decisions. In addition, member checking will enhance the rigor of the study. Nurse and patient interviews will be analyzed separately using identical procedures and may be explored side by side in the final analysis to provide a comparative analysis. Data management and analysis will be performed using NVivo 12.
Data collection will begin during summer 2021, with results from the data analysis anticipated by winter 2021. A research team trained in qualitative methodology will use conventional content analysis to analyze the data using first- and second-level codes derived directly from the transcribed text data.
This study aims to determine what behaviors, communication techniques, and relational practices need to be adapted in videoconferencing telehealth visits, setting the foundation for future development of interventions and evidence-based practice guidelines for relationship building during videoconferencing telehealth visits.
PRR1-10.2196/27940
When the replacement of ambulatory in-person visits with videoconferencing suddenly became essential for persons with cancer because of the COVID-19 pandemic, providers had little experience or existing research to support this change in practice [
Review studies of videoconferencing in telehealth, although often focused on feasibility and acceptability for patients who are geographically underserved, show that this computer-mediated modality has utility and even comparable outcomes with in-person care for patients with a variety of chronic diseases and mental health challenges [
Although research suggests that videoconferencing is feasible and can be effective for some types of care, concerns about the impact of technology on provider-patient relationships exist across health disciplines. Nurses, physicians, and mental health providers have expressed concern that the two-dimensional interactions in video conferencing coupled with the loss of physical proximity, presence, and touch depersonalizes care and inhibits the providers’ ability to best understand the patient and demonstrate care [
Rapport has been defined as a connection established with another person based on respect, acceptance, empathy, and a mutual commitment to engagement [
Studies suggest that relationship development and communication in videoconferencing encounters, although similar to in-person interactions, present unique challenges that can affect rapport, diagnostic accuracy, and treatment compliance when not addressed [
The purpose of this qualitative descriptive study is to explore the nature of nurse-patient rapport in ambulatory cancer care videoconferencing visits. The use of videoconferencing in telehealth nursing is relatively new, especially in oncology ambulatory care. With little existing research to build on, prioritizing studies that provide a foundation for future inquiries is essential. This gap requires a descriptive, exploratory study to increase our understanding of nurse-patient rapport in such a context. Knowledge gaps include an understanding of the attributes of videoconferencing experiences for nurses and patients, along with antecedents, facilitators, barriers, and outcomes. The proposed study will address (1) how patients with cancer and nurses describe experiences of rapport and strategies for cultivating rapport in videoconferencing visits and (2) similarities and differences identified by patients with cancer and nurses between experiences of rapport in videoconferencing and in-person visits.
Nurses and patients will be interviewed separately to ensure that both can speak freely about their experiences and to facilitate understanding of the perspectives of both types of participants. Semistructured interviews will be conducted on Zoom (Zoom Video Communications), a secure videoconferencing platform. Narrative interviewing guidelines will be used, providing participants with the opportunity to describe their experiences before the researcher asks any probing questions. This approach aligns with our qualitative descriptive methodology by focusing on how participants describe their experience of rapport using everyday language to provide insight on videoconferencing [
The study recruitment, consent process, and data collection will be conducted remotely because of COVID-19 restrictions. Stratified purposive sampling will be used to recruit participants from an academic ambulatory oncology center in the northeastern United States. Providers at this center have had recent experiences with videoconferencing visits to provide rich data about these encounters. Stratification will include the number of telehealth videoconferencing visits that patients and nurses have experienced. The literature suggests that the level of experience influences ease of use and perceptions of telehealth videoconferencing visits [
The inclusion criteria for patients are (1) adults (aged ≥18 years), (2) able to read and converse in English, (3) receiving care and undergoing active treatment at the identified oncology ambulatory care center, (4) have participated in at least one videoconferencing visit with a nurse from the identified oncology ambulatory care center within 3 months before the interview, and (5) enrollment in the oncology ambulatory care center’s secure web-based platform with the necessary technology to conduct the videoconferencing interview. Patients with a medical diagnosis related to cognitive impairment (eg, Alzheimer disease or related dementias) will be excluded. The inclusion criteria for nurses are (1) licensed registered or advanced practice nurses employed at the oncology ambulatory care center for at least a year after orientation and (2) participation in videoconferencing visits with patients at the identified oncology ambulatory care center.
The institutional review board (IRB) application for this study is currently under review. The Center for Research in Nursing and Patient Care Services within the cancer center supports the facilitation of this study. The applicant’s university IRB will also review the proposal after it has been approved by the cancer center. Approval from both participating IRBs will be received before beginning the study. Written informed consent will be obtained from all participants before data collection.
The research methods, including qualitative interviews and asking for demographic information, involve minimal risk to participants. A study information sheet, which includes the study purpose and activities as well as the primary researcher’s contact information, will be provided electronically to participants. This will allow participants to contact the research team directly. This information will also be shared verbally during the consent process and included in the informed consent form. Participants will be informed that their participation is voluntary and can be stopped or rescheduled at any time. Participants will also be informed that they can withdraw from the study at any time without any impact on their care or employment. The researchers will maintain open and honest communication throughout the process and create an environment of trust and safety by answering all questions and allowing participants as much time as necessary. Patients will be allowed to include their informal caregivers in this process because the literature suggests that such inclusion may reduce the burden of the recruitment process for patients with cancer [
Care will be taken to contextualize any data that could potentially threaten the confidentiality and privacy of participants. For example, exemplar quotations will simply refer to participants by number or pseudonym when presenting the results. Data collected from participants will be deidentified and used only for research purposes and associated dissemination. Participants will be assigned unique identification numbers that will be used on all data collection forms and data files (ie, interviews, transcripts, and demographic questionnaires). Electronic files, including the key for the unique identification numbers and corresponding participant names, will be stored on the researchers’ computers on a secure password-protected hard drive or server with firewall protection and multifactor authentication. Any hard copies of transcripts or field notes will be stored in a double-locked location. Only members of the research team will have access to the electronic and printed files. Interviews will be conducted on Zoom, the institution-approved secure videoconferencing platform with approved data management and security features that allow secure recording and storage without recourse to third-party software. Zoom security measures include user-specific authentication, real-time encryption, and the ability to back up recordings to the aforementioned secure password-protected server.
Participation in this study offers no direct benefits to the nurses or patients who participate. However, participants may find it beneficial to discuss and reflect on their encounters and the nurse-patient relationship. They may also feel a sense of satisfaction from contributing to the advancement of knowledge and future practice implications attributed to the study. Nurses and patients will be invited to attend the presentation of the study results. Evidence demonstrates that both patients with cancer [
Conducting interviews on the institution-approved platform will allow recruitment and data collection to proceed even as social distancing is maintained during the ongoing pandemic. Recruitment of participants will be carried out at the oncology clinics at the ambulatory care center where nursing videoconferencing is currently part of the care process. Nurses and patients will be recruited through a combination of efforts, including announcements at nursing staff meetings, postings on a web-based study recruitment message board, and the distribution of study brochures. Nurses will be recruited into the study first, and they will be invited to share the study information sheet with eligible patients. Interest in, and support for the study has been obtained from the cancer center’s nursing leadership, who will foster opportunities for the research study to be presented to nursing staff. Nurses will self-identify and be asked to share the study brochures with patients who may be potential participants in the study. Information about the study in web-based research bulletins will also allow patients to self-identify. Participants interested in participating in the study will be screened and provided information on the study and informed consent by the researchers through telephone or email. A time for the interview will also be agreed upon. The written consent and demographic data collection will be carried out through Research Electronic Data Capture at the time of the interview. All patient and nurse interviews will be conducted on the institution-approved videoconferencing platform to ensure a secure encounter. Patients will be allowed to include their informal caregivers in this process because the literature suggests that this reduces the burden of the recruitment process for patients with cancer [
Individual nurses and patients will be interviewed separately. Interviews will be conducted on Zoom, the institution-approved platform, which is used by the ambulatory care center. Using the institution-approved platform will ensure that the participants are familiar with the technology and will also prompt memories of their experiences of rapport in videoconferencing encounters. Videoconferencing has been shown to be a feasible and acceptable vehicle for collecting qualitative data, with both researchers and participants reporting high levels of satisfaction [
Interview guides for nurse and patient participants are under development by the research team to direct the semistructured interviews. Seminal research by Radwin [
Follow-up probing questions
How would you describe rapport?
How do you experience rapport with your nurse in a videoconferencing visit? For example, what does it look like and how does it feel? How does it feel and look when you do not have rapport with your nurse?
How do you go about developing rapport with your nurse in a videoconferencing visit?
How does the experience of rapport with your nurse in a videoconference visit compare with a traditional in-person encounter? What are the differences in your visits when videoconferencing is used? Is it easier to establish rapport in-person?
How does having a videoconference visit affect your ability to communicate with your nurse?
What factors do you think may be influencing or have an impact on your ability to build rapport with your nurse in videoconferencing visits?
Would you want to continue videoconferencing visits once the COVID-19 pandemic is controlled? Why or why not?
Is having rapport important to you and if so, why or why not?
Is there anything else you would like to share with me?
Conventional content analysis will be used to analyze the qualitative data collected in this study. This approach is useful in exploring areas where little is known and robust descriptive data are needed to better understand the research questions [
With each interview representing the unit of analysis for this study, data preparation will include reading through each entire transcript while listening to the entire interview and noting important topics in the margin. The data preparation phase allows for immersion in the text data and for the researchers to become familiar with each case as a whole [
The goal of the organizational phase is to label and condense the data into meaningful units, allowing patterns and relationships within the units to emerge. Initially, research team members will go line by line through the transcript, applying meaningful codes [
Second-level coding will explore relationships and patterns in the data, resulting in categories and themes [
Code names, definitions of codes, and exemplar quotes will be constructed in a codebook using the data analysis management tool NVivo 12.0 (QSR International Pty Ltd). During the initial weeks of the analysis, the authors will individually code the same cases and meet as a team to compare and define codes. Once all research team members agree on the coding of 20% of the transcripts, a codebook will be created to guide coding of the remaining transcripts. The team will continue to meet to discuss new codes and revise the codebook as needed. As the codebook evolves and agreement between team members becomes consistent, team members will code different cases. Bimonthly scheduled coding meetings will be used to discuss and clarify the coding of uncertain data segments. Suggested codebook revisions will always be discussed until an agreement is reached. Changes will be documented in analytical memos to ensure documentation of the process and clear, consistent data coding. Any revisions in codes will require revisiting the previous coding to ensure the integrity of the analysis.
The final phase of the analysis process is reporting. Exemplar quotes from the participants will be used as evidence of the findings [
The study’s rigor, also described as trustworthiness in qualitative research [
Risks for bias in general include the effects of the researcher on the participants; the effects of the participants on the researcher; and the researcher’s own perspectives, experiences, assumptions, values, and beliefs. More specific risks for bias include the influence of COVID-19 as the context that increased the use of videoconferencing, level of experience of the participants with videoconferencing, and the use of nurses to help with recruitment. In qualitative research, the researcher is the instrument [
IRB approval will be obtained before beginning data collection. Data collection will begin during summer 2021, with analysis expected to be completed by winter 2021.
Few studies have focused exclusively on rapport building in videoconferencing [
Unique barriers to rapport in videoconferencing visits have also been reported as secondary findings, and they include uncertainty around patient privacy [
By focusing our exploration exclusively on patient-nurse rapport in oncology ambulatory videoconferencing visits, this study seeks to fully describe this experience from both nurse and patient perspectives. The study will also seek to understand the unique challenges, facilitators, and barriers to developing and experiencing rapport in these computer-mediated encounters. This investigation may validate some of the incidental findings from other studies or uncover new considerations.
A strong and supportive nurse-patient relationship is especially important for persons with cancer. Looking at how the movement toward videoconferencing visits during the COVID-19 pandemic affects the nurse-patient relationship and the capacity to maintain high quality, supportive cancer care is essential, given the likelihood that telehealth videoconferencing visits will become an enduring component of cancer care. Although caring within the videoconferencing technological environment may require adapting our practices, it must not detract from the essential nature of nursing. One view of caring in a technological medium is described by Locsin and Purnell [
The pandemic makes this exploration of rapport in telehealth videoconferencing with nurses and patients timely. The rapid and successful use of videoconferencing visits, coupled with potential benefits to patients, providers, and health care systems, suggests that patient care using this technology will likely continue to be a significant component of oncology ambulatory care even after the pandemic has subsided [
institutional review board
PDK and JCDG designed the study protocol. PDK drafted the initial manuscript, and JCDG contributed to critical reviews and revisions of the manuscript. All authors approved the final manuscript and agreed to its publication.
None declared.