Barriers to the implementation of virtual care programmes for patients with chronic wounds: Qualitative empirical research

Abstract

Aim

To assess the barriers to the implementation of virtual care for patients with chronic wounds from wound therapists' perspective.

Design

A qualitative study.

Methods

The study was conducted in two consecutive phases: (1) literature review, (2) descriptive qualitative study. In the first phase, texts published in English until 2023 were identified using international databases. The entire text of the selected studies was evaluated independently by two reviewers. Data analysis was carried out using textual content analysis. In the second phase of the study, twelve participants from Iranian wound care clinics participated. Data were collected through focus group discussion and analysed using conventional content analysis. Integration of both phases was conducted in the data analysis stage.

Results

The most important barriers in providing virtual care to patients with chronic wounds were identified into five categories including lack of policymaking in virtual care, ethical challenges in virtual information and communication technology, social, economic and cultural issues, IT users' insufficient knowledge and limitation of virtual care scope of practice.

Conclusion

The findings of the present study identified different barriers in the implementation of virtual care for patients with chronic wounds. In order to successfully develop a virtual care programme, it is necessary to adopt suitable policies regarding information and communication technology, provide the necessary legal frameworks, assign an adequate budget and consider the ethical, cultural, social and social issues.

Implications for the Profession and/or Patient Care

Identifying barriers to developing a virtual care programme will help manage patients with chronic wounds at home.

Impact

This study accurately identifies barriers to providing virtual care for patients with chronic wounds and helps plan to address these barriers and facilitate the development of a virtual care programme for these patients at home.

Reporting Method

This research has adhered to the SRQR reporting guideline.

No Patient or Public Contribution

The involvement of patients or the public in the design, or conduct, or reporting, or dissemination plans of this research was not suitable.

1. INTRODUCTION

A chronic wound can be defined as one that has failed in terms of the time and sequence of wound healing phases to establish anatomical and functional integrity and may last from 4 weeks to more than 3 months (Järbrink et al., 2016). Chronic wounds create a vast number of problems for patients (Eriksson et al., 2022). They impose a heavy burden on patients' physiological condition, social functioning and psychological health. Moreover, chronic wounds increase patients' financial burden due to the costs of long‐term management of wounds (Huang et al., 2021). Also, the prevalence of chronic wounds increases with age and other concomitant diseases (Dimunova et al., 2020). In Iran, it is estimated that the incidence and prevalence of chronic wounds will increase in the future decades in line with the predicted increase in the prevalence of chronic diseases and their risk factors, progress in health care, prolonged survival and changes in population age structure (Akhkand et al., 2020). Therefore, patients, families and societies are asking for changes in chronic wound care that would address its physiological, psychological, social and financial aspects (Kardiyudiani & Lorica, 2021).

2. BACKGROUND

Healthcare provision models have developed in recent years. The focus is mainly on preventive medicine, primary health care and providing in‐home service to patients (Probst et al., 2014). Therefore, wound care must be simplified to the extent that patients and families can provide it at home (Eriksson et al., 2022). The COVID‐19 outbreak in early 2020 imposed negative impacts on the methods, duration and quality of wound care services, and these services were suspended temporarily or permanently. However, there were some positive results, and doctors and nurses gave positive feedback regarding remote health care (Karadag & Sengul, 2021). In fact, COVID‐19 obligated healthcare providers to employ technology in order to support patients' needs, such as wound care. As a result, regular face‐to‐face wound care visits changed into remote visits. This increase in and acceptance of telehealthcare paved the way for innovations in wound care provision (Kostovich et al., 2022).

Improvement of the healthcare system requires the use of innovative healthcare models in the world (Canadian Nurses Association, 2019). There are some digital infrastructures and technologies that can provide remote and immediate health care for many health conditions to almost everyone, at any time, regardless of their location (Steinhubl et al., 2018). Due to the use of visual assessment, video and telephone‐based counselling and text‐based information (Kim et al., 2022), virtual care of chronic wounds has the capacity to improve patient care, provide timely access to wound care, facilitate communication with wound specialists and empower patients to manage their wounds (Barakat‐Johnson, Kita, et al., 2022). Considering the chronic nature of these patients' wounds that require regular management, virtual care can increase the efficiency of the healthcare system and be effective in managing these patients (Asham et al., 2020). In addition to facilitating wound assessment and accelerating the treatment, this healthcare method can decrease the challenges resulting from patients and families' lost time and the costs of in‐person visits (Kostovich et al., 2022). It seems that remote wound care measures through the provision of patient‐centred care can provide shared decision‐making between the patient and healthcare personnel and develop a strong relationship with patients and their families, educate patients and encourage them to report negative aspects of treatment (Gethin et al., 2020; Lindsay et al., 2017). In the provision of virtual care, the use of a live video conferencing platform allows healthcare professionals to collect required information from patients, ask specific questions, provide advice, or observe wound self‐monitoring at home (Ohannessian, 2015). According to reports, remote wound care has the potential to provide the same outcome as routine in‐person wound care and can become the gold standard and be combined with in‐person care if complex wound care is needed (Lindsay et al., 2017). Nonetheless, there are barriers to providing virtual care to patients with chronic wounds. These barriers include conflicts in cost‐effectiveness, service cost reimbursement, care standardization, integration into the current routine care (Shelton & Reimer, 2018), low image quality, low internet speed, lack of space in patients' houses for photography equipment and their concerns about misuse of wound pictures (Kim et al., 2022).

Therefore, before implementing remote wound care, information and communication technology management needs to be improved so that it can be used for virtual meetings (Gagnon et al., 2014). Considering the challenges facing the health system as new technologies are being rapidly developed as solutions (Moore et al., 2015), studies suggest that there is little evidence on the use of virtual care for patients with chronic wounds, and this kind of care has a limited role in chronic wound management (Barakat‐Johnson, Kita, et al., 2022; Bondini et al., 2020; Kostovich et al., 2022; Moore et al., 2015). As the barriers to the use of virtual care for patients with chronic wounds have not been studied yet (Barakat‐Johnson, Kita, et al., 2022; Gagnon et al., 2014; Kuhnke et al., 2019), different studies have stressed the significance of virtual care in meeting the future needs of wound care as a field needing more assessment (Barakat‐Johnson, Kita, et al., 2022; Bondini et al., 2020; Kostovich et al., 2022; Moore et al., 2015). Accordingly, it is necessary to analyse wound therapists' understanding of the barriers to providing virtual care to patients with chronic wounds so that we can increase the effectiveness of the wound care system and services and improve decision‐making by the health system policymakers and managers.

3. THE STUDY

3.1. Aim

To assess the barriers to the implementation of virtual care for patients with chronic wounds from wound therapists' perspective.

4. METHODS

4.1. Design

This study was a part of a complete action research related to a Ph.D. dissertation in nursing education. The present study was carried out in two consecutive phases: (1) literature review, (2) descriptive qualitative study. As an emerging field of study, in the first phase, we conducted a scoping review to provide an overview of the state of the literature regarding barriers to providing virtual care to patients with chronic wounds and to identify and analyse knowledge gaps. The primary purpose of descriptive qualitative study is to describe a phenomenon, investigate a problem, or an issue. This approach can encompass a wide range of questions related to people's experiences, knowledge, attitudes, feelings, perceptions and views (Smith et al., 2014). In the second phase, the descriptive qualitative research design was chosen to elucidate the perceptions and experiences of wound therapists regarding barriers to providing virtual care to patients with chronic wounds, with the aim of providing policy recommendations in this regard. Integration of both phases was conducted in the data analysis stage.

4.2. Setting and participants

This study was conducted in wound care clinics of East Azerbaijan Province, Iran between March and August, 2022. There are six wound care clinics in this province, which are privately managed. These clinics provide services to patients with chronic wounds in a single shift on some days of the week. In each wound care clinic, two or three wound therapists, all of whom are nurses, work part‐time. All of these centres were selected for sampling in this study. To select the participants, purposive sampling was used with maximum variation in terms of work experiences, age, educational level and organizational position. The researcher, with the help of wound clinic managers, selected wound therapists who met the inclusion criteria. Inclusion criteria included wound therapists with at least one‐year experience of working in wound care clinics, providing healthcare or managerial services to patients with chronic wounds for 2 years, having bachelor's degree or higher and informed consent to participate in this study. Also, in order to obtain more information, managers of wound care clinics and medical informatics specialists were invited to participate in the study. Exclusion criteria included unwillingness to participate in the study and resignation from one's role or duties as a wound therapist.

4.3. Data collection

Data collection was done in two phases. In the first phase, in order to understand the barriers introduced in the literature, a comprehensive search was done in Iran's databases including SID, MagIran and IranDoc and foreign databases including Scopus, Web of Science, PubMed, Ovid, Science Direct and CINAHL using relevant keywords. Grey literature was also searched through Google Scholar, ProQuest Dissertations and Theses and government and professional associations' websites. For example, the search strategy used for PubMed, which was based on keywords and their combinations using Boolean operators (AND, OR and NOT), is presented in Table 1. This strategy was also used for other databases. Studies published in English until 2023 about providing virtual care or related topics whose full texts were accessible were included in the study. As the methodology for this phase, the methodological framework proposed by Arksey and O'Malley was used (Arksey & O'malley, 2005).

TABLE 1.

Search strategy used in PubMed database.

Database	Keywords for database search
PubMed	Search terms “Virtual Care”, “Virtual Visit”, “Virtual Consultation”, “Virtual Monitoring”, “Virtual Follow‐up”, “Online Care”, “Telecare”, “Virtual Clinics”, “Telehealth”, “Telemedicine”, “Digital Health”, “e‐health”, “m‐health”, “Video Conference”, “Technology”
	Keywords combination “Virtual*” OR “Virtual Care” AND “Telemedicine” OR “Telehealth” OR “Digital Health” “Technology” OR “Video Conference” AND “Challenges” OR “Barriers” OR “Obstacles” AND “chronic wound” OR “Wound care”

In the second phase, to understand the context and barriers from the perspective of participants, the desired data were collected using focus group discussions during four 2‐h virtual sessions and two 2‐h in‐person sessions according to a predetermined schedule through a semi‐structured interview guide along with audio recording and field notes. The first author was the moderator at the focus groups and another researcher conducted field notes. Focus groups facilitate the communication between the participants (Pope & Mays, 2020). This method was chosen due to obtaining appropriate information as a result of the interaction of the participants, and they gave more depth and accuracy to the collected data by supplementing each other's statements. After obtaining the participants' consent and before holding the sessions, necessary explanations regarding the objectives and method of the study and about how and when the sessions would be held were given to them. Moreover, they were reminded that participation is voluntary, the information would remain confidential, and they could withdraw at any time without facing any consequences. Due to the busy schedule of wound therapists during the day, it was not possible to hold in‐person group discussions with all of them at the same time. First, the meetings were held virtually and through the social network (WhatsApp) during 42‐h sessions. In this way, according to the schedule, before the meeting, a question was given to the participants on WhatsApp. The participants sent their answers in the WhatsApp group as voice messages, text, word documents and pictures of a handwritten answers on paper within 48 h after receiving the question. The information that may have been ambiguous or not expressed in the received answers was clarified and revealed with the researcher by asking additional questions virtually. During the two‐hour meeting, all the answers received were discussed by the focus group and the final conclusion was made.

The opinions and answers of each session were separately analysed by the research team. Finally, to achieve more in‐depth information, possible questions and the final decision were discussed in the presence of eight of the same participants, plus one wound clinic manager and one medical informatics specialist in two 2‐h in‐person sessions.

The interviews began with a general question; for instance, they were asked to state their experiences of working in wound care clinics and providing in‐home services to patients with chronic care. Afterward, to obtain more in‐depth information, the main questions were asked:

• What is your view of providing online and virtual healthcare services?

• What changes need to be made in virtual in‐home care for patients with chronic wounds?

• What possible barriers are there to providing virtual care?

• What are the requirements of virtual care implementation in wound care clinics?

To enrich the collected data, probing questions such as why, how, who, etc. were asked during the focus group discussions. In this study, data saturation was reached when no new or conflicting information was obtained from the focus group interviews.

4.4. Data analysis

The two data sets were first analysed separately. The text content analysis approach was used to analyse the data resulting from the review of the texts. For this purpose, the entire text of the selected studies was evaluated independently by two reviewers. After careful study and extracting the required information, the extracted results were first summarized in the data extraction table and then analysed manually and the codes were extracted. In the qualitative part, to analyse the data extracted from group discussions, conventional content analysis introduced by Hsieh & Shannon was used (Hsieh & Shannon, 2005). To analyse the data extracted from group discussions, each audio, visual and handwritten piece of data was assessed and transcribed separately after each focus group discussion. The data recorded in in‐person sessions were transcribed accurately and word for word after being listened to several times. Afterward, all the interviews were transcribed, and the field notes were analysed several times. When the texts were read several times, the words, sentences, or paragraphs were considered meaning units. Based on the meanings, they reached the level of abstraction and conceptualization and were given specific codes. To merge and categorize the codes resulting from the literature review and interviews, the codes were put in a table against each other. In fact, the codes were compared in terms of their similarities and differences and were categorized as more abstract categories using labels. After frequent and constant comparison of the categories by the research team and in‐depth reflection on them, the contents of the data were selected as the main categories. The coding and categorization of the data into categories and sub‐categories were constantly discussed by the research team until they reached a consensus about them.

4.5. Data trustworthiness

In this study, to check the integrity and consistency of the data, Guba and Lincoln's criteria were used (Speziale et al., 2011). Their criteria include credibility, dependability, confirmability and transferability. Data credibility was achieved through constant involvement with the research topic, participants and data. The texts of the interviews, extracted codes and sub‐categories were shared with the participants, and their feedback was taken into consideration. Moreover, the results of the interview analysis were discussed by the research team in several sessions. The members of the research group had different specialties, which contributed to the data credibility. The dependability of the data was ensured by precise documentation and recording of all aspects of the research process, which enabled us to prepare a report on it. To improve the confirmability, the process was reviewed by two observers and checked by two experts in qualitative research. Finally, purposive sampling with maximum background variation was used to improve transferability of data.

4.6. Ethical considerations

This study was approved by the Ethics Committee at Research Vice‐chancellor of Tabriz University of Medical Sciences (IR.TBZMED.REC.1400.771). The informed consent forms were obtained from all participants. The work was conducted following the Declaration of Helsinki. We confirm that all methods were performed in accordance with the relevant guidelines and regulations.

5. FINDINGS

In the initial search, 2326 studies (2307 from the database search and 19 from grey literature) were identified. After screening the titles and abstracts, 93 full texts were reviewed, of which 14 studies met the inclusion criteria (Figure 1).

FIGURE 1.

Flowchart of the study selection process.

Twelve informants participated in this qualitative study (Table 2).

TABLE 2.

Demographic characteristics of participants.

n = 12	Number
Gender
Male	9
Female	3
Age/year
20–29	3
30–39	6
40–49	2
50–59	1
Marital status
Single	1
Married	11
Level of education
Bachelor of Science	7
Master of Science	2
Ph.D.	2
Physician	1
The position of participants
Wound Therapist	10
Manager	1
Medical informatics specialist	1
Work experience in domain of wound/year
1–5	4
6–10	3
11–15	3
16–20	1

The results indicated that the most important barriers in providing virtual care to patients with chronic wounds can be classified into five categories including lack of policymaking in virtual care, ethical challenges in virtual information and communication technology, social, economic and cultural issues, IT users' insufficient knowledge and limitation of virtual care scope of practice, with 17 sub‐categories as discussed below (Table 3).

TABLE 3.

Results.

Categories	Sub‐categories
Lack of policymaking in virtual care	Insufficient preparation of information and communication technology infrastructures
	The lack of a definite legal framework for virtual care services
	Insufficient budget for providing technology and communication equipment
	Inaccessibility of specialized technology
	Problems in accessing the internet
Ethical challenges in virtual information and communication technology	Threats to the security of personal information
	The possibility of invasion of privacy
Social, economic and cultural issues	Cultural resistance
	The possibility of unequal distribution of healthcare services in society
	Patients' financial problems
IT users' insufficient knowledge	Low levels of education and electronic health literacy
	The lack of skills needed to use technology
	Unwillingness to use technology
Limitation of virtual care scope of practice	The difficulty of physical examination and accurate evaluation of patients and their wounds
	The impracticality of providing some specialized wound care services
	Families' inability and inefficiency in participating in virtual care process

5.1. Lack of policymaking in virtual care

The lack of policymaking in virtual care was identified as the main barrier for the successful implementation of the virtual care programme for patients with chronic wounds. In this regard, the participants in the group discussions said that the required infrastructure for virtual care implementation for patients with chronic wounds has not been provided. This category consisted of five sub‐categories: insufficient preparation of information and communication technology infrastructures, the lack of a definite legal framework for virtual care services, insufficient budget for providing technology and communication equipment, inaccessibility of specialized technology and problems in accessing the internet.

5.1.1. Insufficient preparation of information and communication technology infrastructures

In Iran, the virtual provision of healthcare services is not included in the policies, and the development of information and communication technology infrastructures has not been considered. Currently, there is no national framework for providing virtual care to patients with chronic wounds. The participants explained that insufficient information and communication technology infrastructures have caused many problems regarding the acceptance of virtual care, especially during the COVID‐19 pandemic. They mentioned the poor performance of the IT department of the Ministry of Health in relation with virtual care:

There must be a data monitoring base (a separate department consisting of different specialists, such as medical, nursing, psychology, pharmacology, medical engineering, medical industrial design, and medical law specialists) for identifying the needs and challenges, monitoring the outputs of virtual care, planning, and implementing virtual care. Also, the elite and those with a modern view of technology must be allowed to be in charge of the IT department of the Ministry of Health. (Wound therapist)

5.1.2. The lack of a specific legal framework for virtual care services

The lack of a specific legal and monitoring framework related to providing virtual care to patients with chronic wounds was one of the important issues that were also discussed by the participants. They reported that there are limitations in terms of legal permits for providing virtual care, and the laws of providing virtual care are not defined:

Before implementing virtual care, we must specify the laws related to virtual care. If we talk about the care that can be provided virtually, we need to determine the laws related to it. If there are any faults, who should be accountable, and where can clients complain to? (Wound therapist)

5.1.3. Insufficient budget for providing technology and communication equipment

In line with the evidence in the literature, the participants stated that an insufficient budget for providing technology and communication equipment is a potential barrier to the successful implementation of virtual care. According to them, changes in policymaking in order to allocate a budget to purchase the resources required for virtual care provision include the costs of developing virtual care platforms, equipment costs, the salary of therapists and specialists in this field, IT support and educating the users:

Financial problems are among the challenges affecting all social groups and can intensify the other barriers to virtual care implementation. Also, some patients have financial problems and cannot afford to buy the electronic equipment. (Wound therapist)

5.1.4. Inaccessibility of specialized technology

The inaccessibility of specialized technology for providing virtual care to patients with chronic wounds was one of the issues mentioned by the participants. The participants highlighted the lack of access to the secure and reliable online and offline software platforms that wound therapists need and stated:

We need a high‐performance platform, such as a cloud space, a website, or reliable software through which we can provide virtual care. Moreover, this platform must be able to provide online and offline information to wound therapists and patients. (Medical informatics specialist)

5.1.5. Problems in accessing the internet

The participants unanimously agreed that access to high‐speed and inexpensive internet for providing virtual care to patients with chronic wounds is limited in Iran. Furthermore, the lack of access to the internet is a problem in some places such as rural areas. Moreover, sending or playing videos or pictures with high resolution is not possible due to the low internet speed.

The participants stated:

The lack of access to the internet is an issue in some places, and both therapists and patients may face this problem, because some towns and villages do not have high‐speed internet, and even we do not have access to the internet sometimes. (Wound therapist)

5.2. Ethical challenges in virtual information and communication technology

Considering the ethical concerns in virtual care before its implementation was a serious challenge. Therefore, the significance of this issue was highlighted in each of the sub‐categories.

5.2.1. Threats to the security of personal information

The adoption of virtual software platforms includes the digital collection of information and the use of sensitive medical information among patients and clinicians, which can lead to security risks for the collection, use and disclosure of sensitive personal data. Regarding this issue, some of the participants also believed that preserving the security of personal information is a vital factor for the success of virtual care because therapists have many concerns about information confidentiality, cyber security and loss of clinical information on virtual care platforms:

The main barrier is the lack of a comprehensive data protection base that can protect patients' data, preserve its confidentiality, and provide information to clients at all times. In fact, clients should monitor the measures taken for him and approve them. (Wound therapist)

5.2.2. The possibility of invasion of privacy

According to the findings of the literature review, patients' lack of trust in the privacy of the technology used in virtual care provision and their concerns about the lack of a private space for having proper and uninterrupted communication in virtual visits and when receiving virtual care were discussed by the participants in the focus group discussion sessions. Something interesting that they mentioned was the possibility of non‐specialists providing wound care and virtual profiteers taking advantage of patients:

One point to consider about virtual care is the issue of non‐specialists, especially in wound care. A wound specialist must have a certificate. There are lots of non‐specialists introducing themselves as wound specialists and providing some in‐home services that even specialists do not dare provide. (Wound therapist)

Another point in this regard is the problem of virtual profiteers. Just as providing in‐person services has been affected by non‐specialists, they will be able to do the same in virtual care more easily, and people's interests can be threatened much more easily. (Wound therapist)

The participants suggested that the regulations and policies of each platform used for virtual care provision must be determined, and the required laws and protective measures must be devised for it.

5.3. Social, economic and cultural issues

The participants highlighted some concerns about social, economic and cultural issues in providing virtual care. They said that virtual care has the potential to unfairly exclude some patients from virtual care provision. Some of them were also mentioned in the texts. The following issues were described as challenges in this regard.

5.3.1. The possibility of unequal distribution of healthcare services in society

There are potential barriers, such as the impracticality of providing virtual care in all areas, the problem of providing sterile materials and equipment for depressing wounds and not having capable people in the family to help the patient and provide care when guided remotely by a wound therapist. These required conditions are not equally available to everyone in society. Also, the problem of establishing medical communication with some groups such as those with visual impairment or hearing loss or those lacking the skills to use technology, especially the elders, increase the inequalities of health in society:

Using new technologies is difficult for the previous generation, who comprise most of our chronic wound patients. I have seen that the elderly were more dissatisfied during the COVID‐19 pandemic when making appointments was moving toward virtual methods. These people could not adapt to the new circumstances. (Wound therapist)

5.3.2. Patients' financial problems

Most of the participants stressed the fact that patients with chronic wounds cannot afford to buy equipment, such as smartphones, tablets, etc. They also stated that most patients have problems paying the costs of virtual care since wound care services are not covered by insurance:

The lack of access to electronic equipment such as mobile phones and tablets is a challenge affecting all social groups, and financial problems can exacerbate this issue. (Wound therapist)

The data indicated that electronic equipment and online facilities are not available to everyone and most people do not have easy and inexpensive access to communication facilities.

5.3.3. Cultural resistance

The participants believed that concerns about religious and cultural issues can lead to the unacceptability of virtual care in patients and families. Moreover, facing a cultural barrier when including virtual care as part of routine care can lead to virtual care not being accepted as a new approach. In this regard, it was stated in group discussions:

Any new change faces disagreements in society at first. In our opinion, to include virtual care in routine care, we face a cultural barrier because people still prefer that a specialist visit their patient at home and provide the necessary instructions. (Wound therapist)

5.4. IT users' insufficient knowledge

One of the important barriers to providing virtual care to patients with chronic wounds is their insufficient knowledge and skills. The participants stated that patients do not have the knowledge and skills to use the technology used in care provision. This category consisted of three sub‐categories, namely low levels of education and electronic health literacy, the lack of skills needed to use technology and unwillingness to use technology.

5.4.1. Low levels of education and electronic health literacy

According to the participants, the low level of education in patients with chronic wounds due to old age has made it difficult for them to use new technologies. Moreover, they believed that digital health literacy is low in patients with chronic wounds, and they do not have sufficient knowledge of the internet, electronic equipment and software platforms:

In our country, Iran, the elderly are not usually well‐educated, and the use of devices such as mobile phones or other technologies is almost impossible in areas where Farsi is not the main language. (Wound therapist)

5.4.2. The lack of skills needed to use technology

The inability and lack of skills needed to use new technology due to old age was mentioned as a statistically significant factor in implementing virtual care. In this regard, the participants also believed that the elders do not have the basic skills needed to properly use smart technologies and depend on others for using them:

Some patients do not have enough skills to properly use communication tools and software. Some of them cannot even send a picture of their wound on social networks such as WhatsApp or Telegram. (Wound therapist)

5.4.3. Unwillingness to use technology

Some patients' and families' lack of interest and patients, wound therapists', and managers' lack of preparation to provide virtual care were among the other challenges mentioned in this study. In this regard, some wound therapists stated:

Patients and medical teams might become bewildered when encountering a new method of care, and patients may feel desperate and alone and show no interest in this method. (Wound therapist)

5.5. Limitation of virtual care scope of practice

Limitation of virtual care scope of practice is another important challenge that can occur when providing care to patients via telephone or video conferencing platforms. From the participants' viewpoint, the obscurity and limitation of virtual care scope of practice for patients with chronic wounds were statistically significant variables in the implementation of virtual care and providing suitable services. The following points were described as the challenges in this regard.

5.5.1. The difficulty of physical examination and accurate evaluation of patients and their wounds

The participants declared their concerns about wound therapists' inability to perform a physical examination, environmental assessment and accurate analysis of details, which are normally done during in‐person visits. They said that wound palpation, analysis of new or old signs, and evaluation of the smell of the wound drainage are not possible in virtual care:

Patients must be examined, wound features must be thoroughly observed, and the wound must be seen up close. That is because some signs such as the smell, color, and concentration of drainage and the type of wound are of great importance in decision‐making. (Manager)

In the literature:

To safely assess patients in the provision of wound care through online consultation, clinicians must consider whether remote assessment is likely to yield sufficient information to allow for clinical judgment or whether more extensive assessment and investigation is required. (Milne, 2021)

As most of the videos/pictures sent are not enough for an accurate assessment of the wound, and there is a need for patients' ability to state their symptoms, they suggested that an instrument be designed for a complete virtual assessment of wounds.

5.5.2. The impracticality of providing some specialized wound care services

The participants stated that providing some healthcare services virtually to patients with chronic wounds is not possible. They reported that treating third‐degree wounds, wound culture and wound debridement is not possible in virtual care. That is because patients and families are not capable of doing such things at home and the patient must be treated in person in the clinic:

Performing invasive procedures such as debridement is beyond families' capability. They cannot assess and identify circulation and may not even be able to dress a common wound because they do not have the spirit to face wounds and bleeding. (Wound therapist)

5.5.3. Families' inability and inefficiency in participating in virtual care process

Although the participation of relatives and the patient's family virtually in the matter of treatment and care in video consultations by healthcare professionals can improve the decision‐making about treatment and care, but the degree of involving these people in patient visits is not clear in virtual care. In this regard, some of the participants added that people cannot meet all healthcare needs by themselves in virtual care. Families do not have adequate skills to perform some procedures:

Virtual care might not be suitable for all patients with chronic wounds. For instance, those with complicated needs must visit the clinic to be treated in person. (Wound therapist)

6. DISCUSSION

This study was the first study in Iran to assess the barriers to the implementation of virtual care for patients with chronic wounds. Based on the analysis of the data, the barriers can be categorized into five categories, namely the lack of policymaking in virtual care, ethical challenges in virtual information and communication technology, social, economic and cultural issues, IT users' insufficient knowledge and limitation of virtual care scope of practice.

One of the findings of this study was the lack of policymaking in virtual care, which leads to inadequate technological and communication infrastructures. Technology is a key factor in providing virtual care and has a statistically significant effect on patients' ability to access care (Golinelli et al., 2020). According to our findings, Kim et al. studied the evidence published in telemedicine of chronic wounds care before and after the pandemic in their review study. In the mixed care model, in which telemedicine is merged with in‐person care, some of the barriers include low picture quality, poor internet connection, insufficient space for photography equipment at home, patients' concern about the misuse of pictures and photographing the wrong wound, financial problems, the difficulty of directing the patient to the counselling room and problems with equipment transfer (Kim et al., 2022). The present study also reported insufficient budget for purchasing technological equipment, which was in line with the above‐mentioned study. Accordingly, Bokolo et al. reported in a systematic review that organizational (budget availability, educating service providers and patients and integration of work flow), technological (preserving privacy and information security, access to high‐quality bandwidth and Wi‐Fi and IT infrastructures) and social (requirements of permit issuance, the lack of regulations and support, and increasing the patients' and practitioners' willingness through improving individual understanding) factors affect the acceptability of telemedicine among patients and medical practitioners during and after the pandemic (Bokolo, 2021). The results of our study also identified the lack of a legal framework as a barrier to the implementation of virtual care. However, as remote and virtual healthcare services were promoted during the COVID‐19 pandemic to reduce the risks of virus transmission, it was understood that most countries lacked a legal framework to issue permits, merge virtual services with routine care and service cost reimbursement. There was a need for changes in monitoring procedures in countries without integrated services (Oropallo et al., 2021). Therefore, adopting efficient policies at the national level while considering all aspects of virtual care provision to patients with chronic care seems inevitable.

Another notable finding from the group discussion sessions and literature review was addressing the ethical challenges in information and communication technology in the provision of virtual care to patients with chronic wounds. Although new technologies promise improvement in the quality of care, decrease in costs and increase in patient satisfaction, there are some ethical considerations in using them (Hale & Kvedar, 2014). Similarly, Dolan et al. reported issues related to privacy, security, confidentiality of patients' information and conversations, and informed consent as ethical concerns (Dolan et al., 2021). Lambe C reported that concerns about the privacy and security of telehealth systems can negatively affect people's trust in telehealthcare services and threaten the capacity of these systems to improve the quality and effectiveness of health care (Lambe, 2020). People with no specialized training in wound care are providing wound care for patients in care centres or at home (Bokolo, 2021). Based on the findings of our study, there is a concern that wound care might be done by non‐specialist wound therapists, and this model of care provision might be abused by virtual profiteers. Consequently, it is crucial that patients, healthcare providers and managers be aware of these issues and receive guidance on how to deal with them when providing virtual care (Kuziemsky et al., 2018).

The findings of this study suggested that social, economic and cultural issues such as unequal distribution of healthcare services are among the barriers to the development of virtual care services for patients with chronic wounds. In this regard, Hughes et al. stated that from nurses' viewpoint, despite the benefits of virtual care, problems in accessing care have negative effects on patients. Some patients, especially the elders, might be in danger of avoiding technological advances due to the lack of access to technology (Hughes et al., 2022). Appireddy et al. mentioned the challenges of providing virtual care to patients, especially those suffering from cognitive disorders, lacking the skills needed to use technology, and lacking access to mobile phones or other remote communication devices, as the limitations in providing virtual care (Appireddy et al., 2020). Other studies have been conducted on this subject, and issues such as the lack of access to high‐speed internet in rural communities, cultural beliefs and norms, and being below the poverty threshold have been stated as barriers to providing virtual care (Asham et al., 2020; Bokolo, 2020; Mahoney, 2020) The availability of financial resources and associated products and services needed for wound care vary geographically (Kuhnke et al., 2019). Therefore, to overcome inequalities, it is necessary to consider these points when providing virtual care.

Another challenge mentioned in this study was IT users' insufficient knowledge. In this regard, in a mixed‐method study, Birkhoff et al. assessed cardiac failure patients' ability to use and accept virtual nursing visits. They concluded that unfamiliarity with technology was one of the main challenges. Patients need education or other family members' help to use it. The problems in navigating the software and forgetting how to access virtual visits were other challenges reported in this study (Birkhoff et al., 2021). Hughes et al. also reported that patients, especially the elders, are not able to use technology, and this can be a potential barrier if they do not have support systems at home (Hughes et al., 2022). Accordingly, familiarizing clinicians and patients with new technology can solve the problems of using them for assessing and managing wounds (Barakat‐Johnson, Jones, et al., 2022). However, it seems that it is not feasible to provide virtual care to everyone. Therefore, to ensure the provision of virtual care to patients without access to the necessary technology, there is a need for efficient assessments and clear policies (Hughes et al., 2022).

The results of this study indicated that limitations in Limitation of virtual care scope of practice for patients with chronic wounds are among the main barriers in this field. Bondini et al., in a review study, assessed telehealth adjusted for chronic wound care during the COVID‐19 pandemic. Their findings revealed that using telehealth is not suitable when a direct physical examination is required to support decision‐making or clinical diagnosis (Bondini et al., 2020). In this regard, in a study in Manitoba, the most prominent challenge of providing virtual care in Prairie Mountain Health was that it was unknown which healthcare services could be provided through phones or video conferences. For instance, healthcare providers are not able to perform a physical examination, and providing some services is impossible without in‐person visits (Asham et al., 2020). Like face‐to‐face contact, taking a proper history and doing a comprehensive evaluation of wounds are the necessities of clinical decision‐making in wound management planning (Milne, 2021). Therefore, to provide remote wound care services without jeopardizing the quality of care and patient satisfaction (Barakat‐Johnson, Kita, et al., 2022), patients must be visited by a wound care specialist before using any kind of virtual wound care programme (Shelton & Reimer, 2018). Moreover, it seems that to continue providing virtual care, a wound therapist must evaluate if in‐person visits are necessary before receiving virtual care to ensure patients' healthcare needs are met using a telehealthcare model.

6.1. Strength and limitations of the work

We consider it as strength that we obtained information from healthcare professionals with different educational levels and job positions. The majority of participants were wound therapist nurses, as they were considered the most important group in terms of care and management of patients with chronic wounds. In addition, we believe that the close collaboration and reflection of our research team at all stages of the research process is a strength of this study.

This study faced some limitations that need to be considered. In this study, the views of patients with chronic wounds regarding the barriers to providing virtual care were not investigated. Wound therapists' unwillingness to take part in group discussion sessions due to lack of time was another limitation of the present study. However, we tried to increase their cooperation by explaining the objectives and usefulness of the results and holding virtual sessions.

6.2. Recommendations for further research

As no virtual care has been provided to patients with chronic wounds in Iran, it is suggested that a study be conducted on the barriers to the use of virtual care from patients' perspectives to increase knowledge in this field. Also, there is a need for further research to identify the concerns of patients with chronic wound care and determine the services that can be virtually provided.

7. CONCLUSION

The findings of the present study identified different barriers and challenges in the implementation of virtual care for patients with chronic wounds. Therefore, the collected information can be used as a starting point for the development of virtual care programmes for patients with chronic care. In order to successfully develop a virtual care programme as a new approach for these patients, it is necessary to adopt suitable policies regarding information and communication technology, provide the necessary legal frameworks, assign an adequate budget at the level of the Ministry of Health, employ healthcare specialists who specialize in this field, and consider the ethical, cultural, economic and social issues of the Iranian society. Furthermore, determining the type of services, which can be virtually provided based on the healthcare needs of patients with chronic wounds and involving patients and their families in making the policies for virtual care are among the most important strategies for policymakers to solve these challenges in virtual wound care.

Moreover, the findings of this study can help policymakers formulate instructions to develop virtual care for patients with chronic wounds, decrease the concerns about virtual care and adopt policies to improve the quality of virtual care provided by wound therapist nurses.

AUTHOR CONTRIBUTIONS

Nasib Babaei involved in conceptualization, data curation, formal analysis, investigation, methodology, visualization, writing the original draft, review and editing. Vahid Zamanzadeh involved in formal analysis, methodology, review and editing. Leila Valizadeh involved in methodology, review and editing. Mojgan Lotfi involved in conceptualization, formal analysis, investigation, methodology, project administration, resources, supervision and writing the original draft. Ahmad Kousha provided the resources, review and editing. Taha Samad‐Soltani involved in methodology, review and editing. Marziyeh Avazeh involved in investigation, review and editing.

FUNDING INFORMATION

This work was supported by the Research Deputy of Tabriz University of Medical Sciences.

CONFLICT OF INTEREST STATEMENT

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

ETHICS STATEMENT

This study was approved by the Ethics Committee at Research Vice‐chancellor of Tabriz University of Medical Sciences (IR.TBZMED.REC.1400.771). The informed consent forms were obtained from all participants. The work was conducted following the Declaration of Helsinki. We confirm that all methods were performed in accordance with the relevant guidelines and regulations.

EXPLANATION ABOUT THE NUMBER OF REFERENCES

There are more than 25 references in our article, because this study was a part of a complete action research related to a Ph.D. dissertation in nursing education. It was conducted in two phases, in the first phase, a literature review was done, and it was necessary to refer to some studies.

Babaei, N. , Zamanzadeh, V. , Valizadeh, L. , Lotfi, M. , Kousha, A. , Samad‐Soltani, T. , & Avazeh, M. (2023). Barriers to the implementation of virtual care programmes for patients with chronic wounds: Qualitative empirical research. Nursing Open, 10, 7301–7313. 10.1002/nop2.1983

DATA AVAILABILITY STATEMENT

The datasets generated and/or analyzed during the current study are not publicly available due to the confidentiality of the data of participants but are available from the corresponding author at reasonable request.