Healthcare Professionals' Perceptions of Emotional Intelligence in Remote Counselling—A Descriptive Qualitative Study

ABSTRACT

Aim

In recent years, the significant expansion of remote healthcare services has introduced effective new treatment models. Correspondingly, remote counselling through telephone and digital methods has witnessed substantial growth. The dynamic interaction between healthcare professionals and counselling content is crucial during remote patient consultations, directly impacting outcomes and overall healthcare burden. Our aim was to explore healthcare professionals' perceptions of the use of emotional intelligence in the context of remote counselling.

Design

Qualitative descriptive study.

Method

A snowball method was used to identify potential participants for the study. Six semi‐structured focus group interviews were conducted to capture the perceptions of the participants. Interviewees (n = 16) were healthcare professionals from Finnish healthcare organisations. Inductive content analysis was used to analyse the data.

Results

Two main categories were found related to the use of emotional intelligence during remote counselling. Firstly, healthcare professionals described emotional intelligence as being expressed through dialogue during remote counselling. Emotional intelligence was achieved through realising reciprocity and using emotional intelligence skills during remote counselling. Secondly, they identified factors that shape the use of emotional intelligence. The identified factors included: individual characteristics in the manifestation of emotional intelligence, unique aspects of the remote counselling environment and competencies that enhance emotional intelligence skills.

Conclusion

Healthcare professionals indicated that dialogical interaction with patients enables the use of emotional intelligence in remote counselling. Interpreting patients' emotions and providing emotional support were perceived as challenging in the context of remote counselling. Those challenges may lead to misunderstandings or weaken the quality of counselling.

Patient or Public Contribution

No patient or public contribution.

1. Introduction

Healthcare professionals (HCPs) more often provide counselling to patients in remote environments (Rezaei Aghdam et al. 2020; Nazeha et al. 2020), where communication is limited (Marent and Henwood 2020). In Finland, remote services have been developed to offer counselling for patients, especially in northern regions where long distances between healthcare providers and patients make remote counselling essential (Liljamo et al. 2020). The utilisation of technology‐based devices in communication has transformed the interaction with patients (Odendaal et al. 2020).

In remote counselling, functional interaction, along with the content of counselling, plays a crucial role, directly influencing the counselling outcomes (Paalimäki‐Paakki et al. 2022) and the healthcare burden (Oikarinen et al. 2017). Remote counselling, in this study, is understood as a patient‐centred and goal‐oriented interaction which provides information and support to the patient, sufficient to support their adherence to self‐care and ultimate health outcomes (Kaakinen et al. 2013; Oikarinen et al. 2018; Paalimäki‐Paakki et al. 2022). Counselling helps patients absorb information about the principles and practices of making healthy, informed choices (Dwarswaard et al. 2016). It also respects the patient's right to receive clear and understandable information about their overall health, such as risk factors, treatment options and their effects (Act on the Status and Rights of Patients, 785/1992, section 5). However, effective counselling requires more than just legal or ethical frameworks; it also depends on the clinical and pedagogical expertise of HCPs and their ability to counsel patients while fulfilling their professional duties (Richard et al. 2018). In this study, HCPs refer to doctors, counsellors, nutrition therapists, physiotherapists, prosthetists‐orthotists, psychologists, public health nurses, registered nurses and workability coaches who provide remote counselling.

Remote counselling seems to offer an impressive alternative and supplement to conventional counselling, for instance in treating depression in various population groups (Moshe et al. 2021). Remote counselling has also been found to be effective in youth psychotherapy (Venturo‐Conerly et al. 2022) where it appears to match the effectiveness of face‐to‐face counselling (Paalimäki‐Paakki et al. 2022; Singh et al. 2021). According to Kaakinen et al. (2013), counselling is established as a fundamental element within different sectors of health services, encompassing an essential role in supporting individual patients' well‐being and promoting overall healthcare. Patient‐centred counselling enables active participation in treatment and takes into account each patient's background factors, for example, age, educational level, and gender. As counselling is increasingly offered remotely, it is important to pay closer attention to how remote delivery affects the content and outcomes of counselling (Suonnansalo et al. 2024). Attention also needs to be given to HCPs' competence in supporting patient self‐management and fostering a reciprocal relationship during remote counselling (Kaihlaniemi et al. 2024).

HCPs use emotional intelligence (EI) skills to understand a patient's needs through interaction, and structure their own activities to achieve the desired results (Li et al. 2021). Emotions are a particularly important element of interaction (Olry‐Louis 2018). Remote counselling should always be guided by the patients' needs, keeping in mind that it may not be suitable for everyone. Some patients may also benefit from traditional face‐to‐face counselling (Koivunen and Saranto 2018; Odendaal et al. 2020). In this study, EI is defined due to its abstract nature, according to Goleman's (1995) model. EI comprises self‐awareness, self‐regulation, empathy, motivation and social skills (Odaci et al. 2017). It is defined as a dynamic characteristic (Zeidner et al. 2012), and has been previously studied in various contexts, such as patient counselling within psychology (Pearson and Weinberg 2017) and nurses' occupational well‐being within nursing science (Li et al. 2021).

Existing research has demonstrated that EI promotes nurses' occupational well‐being, facilitates better treatment decisions and positively impacts the care they provide (Al‐Ruzzieh and Ayaad 2021; Li et al. 2021). Studying the HCP's perceptions is essential to develop effective remote counselling services. However, research into EI in the context of remote counselling from the HCPs perspective is still very scarce.

The concept of EI concerns the recognition and regulation of emotions (Abraham and Scaria 2017; Li et al. 2021; Odaci et al. 2017). EI is an individual characteristic which relates to personality and how someone expresses and reacts to emotions (Olry‐Louis 2018). An emotionally intelligent person is empathetic, aware of their own emotions and able to manage them. EI skills can be applied to thinking and problem solving, and various ability and rating scales have been used to measure EI, for instance in studies of academic performance and learning outcomes (MacCann et al. 2020.) EI is defined as a crucial characteristic for HCPs affecting the interpersonal and counselling competence (Rezaei Aghdam et al. 2020). Competence refers to knowledge and skills, values, performance and attitudes (Jarva et al. 2023).

EI has been highlighted as a crucial attribute for HCPs, as it relates directly to the interpersonal and counselling skills, ability to support patients' emotional and social needs and other competencies that they are required to demonstrate (Abraham and Scaria 2017; Rezaei Aghdam et al. 2020; Kaakinen et al. 2012; Kaihlaniemi et al. 2023). This is why research into EI has entered the field of nursing science (Li et al. 2021; MacCann et al. 2020). A healthcare professional's EI skills influence the formation of relationships with patients, affecting the outcomes of their treatment. It has been shown that effective cooperation between HCP and patient promotes positive health outcomes (Rezaei Aghdam et al. 2020; Randine et al. 2022), reducing the social and financial costs of healthcare, while poor counselling increases the burden on healthcare services (Oikarinen et al. 2017).

EI was first conceptualised by psychologists Salovey and Mayer (1999) (Li et al. 2021; MacCann et al. 2020) who suggested that it consists of four main elements: the perception of emotions, connecting emotions to thoughts, understanding emotions and managing emotions (Li et al. 2021; MacCann et al. 2020; Odaci et al. 2017). Bar‐On (Odaci et al. 2017) explains that EI emerges from the personal and social skills with which a person understands themselves and others, expresses their own emotions and thoughts, initiates and maintains social relationships and is able to fulfil others' wishes and meet their needs. EI has previously been studied in the contexts of patient counselling within psychology (Odaci et al. 2017; Pearson and Weinberg 2017; Pellitteri 2010), leadership (Abraham and Scaria 2017; Girardea) and nurses' occupational well‐being (Li et al. 2021) within nursing science. According to these studies, emotionally intelligent leaders utilise EI skills to influence their employees and create trusting relationships between themselves and employees (Abraham and Scaria 2017; Alshammari et al. 2020). Xu et al. (2021) showed that EI skills also have a positive effect on multi‐professional work. In nursing, it has been established that EI promotes nurses' occupational well‐being, enables nurses to manage stress, reduces the effect of negative emotions, supports better treatment decisions and has a positive effect on the care they provide (Al‐Ruzzieh and Ayaad 2021; Li et al. 2021; MacCann et al. 2020).

In this study, EI is understood in line with Goleman (1995) as the ability of HCPs to recognise and regulate their own emotions, recognise the emotions of patients, motivate themselves and patients and build and maintain relationships with patients (Odaci et al. 2017). EI skills are also taken to be a dynamic characteristic that can be strengthened with practice (Li et al. 2021). The prevailing shortage of HCPs makes it essential to pay attention to their occupational well‐being and reduce levels of burnout, which can be achieved by engaging their EI skills (Abraham and Scaria 2017; Li et al. 2021). Providing remote counselling may have negative effects, which employers should be aware of when their employees primarily work remotely (O'Neil et al. 2024). This study provides in‐depth insight from the perspective of HCPs which is relevant to the development of effective remote counselling. However, research into EI in the context of remote counselling is still very scarce. Therefore, before exploring patients' perspectives on their interactions with HCPs it is important to first understand EI from the HCPs perspective (Rezaei Aghdam et al. 2020). The aim of this study was to describe HCP's perceptions of the emotional intelligence in the context of remote counselling. The research question was: “How do healthcare professionals perceive their use of emotional intelligence in remote counselling?”

2. Methods

2.1. Design

The study adopts an inductive and descriptive qualitative approach, employing critical realism to explore the beliefs and experiences of healthcare professionals (HCPs) in real‐world settings regarding the implementation of Emotional Intelligence (EI) in remote counselling. This methodological choice, critical realism, serves as a philosophical framework that enables us to gain insights into HCPs' perspectives and beliefs (Koopman and Schiller 2022). Qualitative research aims to explain certain phenomena and provide an in‐depth understanding of them (Kyngäs et al. 2019). The inductive approach allows us to obtain a multifaceted and broad description of HCPs' perceptions of using EI in remote counselling (Mikkonen and Kyngäs 2019; Žukauskas et al. 2018) In line with this approach, data were gathered through focus group interviews, which enabled us to capture the perceptions and perspectives of HCPS (Tong et al. 2007). In this study, patient counselling refers to interactive and goal‐oriented interactions between HCPs and patients in digital healthcare environments, such as digital health centres or portals. The goal is to address the patient's health in real time through counselling.

2.2. Participants

The sampling strategy was purposive, and the snowball method was used (Kyngäs et al. 2019). The sample was taken from northern Finland, where long distances between healthcare providers and patients make remote counselling essential. In this study, the healthcare professionals (HCPs) included were doctors, counsellors, nutrition therapists, physiotherapists, prosthetists‐orthotists, psychologists, public health nurses, registered nurses and workability coaches, who deliver remote counselling. The inclusion criteria for HCPs were that they (a) had some experience of remote counselling and (b) had carried out remote counselling using the audiovisual or text‐based platforms, such as Microsoft Teams, Zoom or Digital Care Pathway. Digital Care Pathway is a part of the Finnish patient portal where remote counselling can be implemented via secure messaging or video conferencing (Kaihlaniemi et al. 2023; Liljamo et al. 2020). These platforms are limited to secure messaging and video conferencing and do not support counselling via phone calls, email or text messages.

HCPs were recruited from various public and private Finnish healthcare organisations of different sizes, including health centres, hospitals and private sector companies. Potential participants received an email that contained information about the study, a data protection sheet and a link to a form through which they could confirm their consent to participate in the study and submit their background information prior to the interviews. Two prospective participants were excluded due to their lack of experience in counselling patients using appropriate remote counselling platforms.

2.3. Data Collection

Six focus group interviews (with a total of 16 participants) were conducted between November 2022 and March 2023. Due to scheduling challenges and one participant's illness, two of the interviews were conducted as a pair rather than a group interview. The interview guide (Table 1) was developed based on earlier literature on the two themes: remote counselling and EI. The guide was semi‐structured because this allowed participants to discuss the phenomenon flexibly and from their own point of view (Tong et al. 2007). The interview guide was pilot tested with three individuals before being finalised. Interviews were conducted by the lead researcher via Microsoft Teams. Another researcher, the corresponding author, conducted one of the interviews. The interviews were digitally recorded and transcribed verbatim. The researcher concluded that, after conducting five interviews, no additional information pertaining to the study phenomenon could be gleaned through further interviews. This signifies that the data saturation point has been reached. To ensure saturation, the researcher made field notes during the interviews and processed the data immediately after each interview (Kyngäs et al. 2019). The researcher verified the absence of new insights during the categorisation process, confirming that after five interviews, no additional information emerged in relation to the study phenomenon. In total, the interviews lasted 265 min and generated 54 pages of written text (Times New Roman, font size 12, spacing 1).

TABLE 1.

Interview guide.

Theme one: Remote counselling

1. Please describe what remote counselling is like, in your opinion.

Theme two: Emotional intelligence

2. What do you think emotional intelligence means?

3. How do you recognise a patient's emotions during remote counselling?

4. How do you convey emotional support to the patient during remote counselling?

5. How do you recognise and regulate your own emotions during remote counselling if, for instance, you feel frustrated, tired or sad?

6. How does remote counselling affect your motivation to provide counselling?

7. How do you motivate patients during remote counselling?

8. If you think about forming a social relationship with a new patient, what is it like developing a relationship with a patient in remote counselling?

9. How have your emotional intelligence skills developed during remote counselling?

Additional information

10. Does anyone want to add anything else related to emotional intelligence or remote counselling?

2.4. Ethical Consideration and Statement

Research ethics and the Declaration of Helsinki guiding nursing research were strictly followed whilst conducting this study (World Medical Association 2013). Research approval was granted by the (University of Oulu). According to legislation in Finland, no ethical approval was needed because the study does not involve minors, direct or indirect physical or physiological harm to the participants or clinical trials (Medical Research Act No. 488/ 1999).

European Union General Data Protection Regulation (GDPR 2016) was followed in the collection of personal data. Risks were assessed by completing a GDPR form before personal data was collected. Collected data (personal data and written interviews) were stored on the password‐secured computer of the first researcher. The anonymity of the participants was ensured. Following data collection, all personal data were removed from the transcripts to ensure participant anonymity. Beauchamp and Childress's four ethical principles were maintained to protect participants autonomy and justice, and promote non‐maleficence and beneficence (Pietilä et al. 2019). Participation was voluntary. Participants were given appropriate information about the study and opportunities to request further information were provided. Each participant provided their individual written consent for the interview and recording. Participants were able to withdraw from the study at any time without negative consequences.

2.5. Data Analysis

Given the fragmented nature of studies on EI in the context of remote counselling, we employed an inductive content analysis approach as outlined by Kyngäs et al. (2019) to analyse the data. The interviews lasted for between 37 and 52 min. Only the manifest content was analysed, not the latent content. The analysis process was tabulated in a word file. The data were analysed by the leading researcher (University of Oulu) as follows: First, the researcher read the data through several times to become familiar with it. The data were then read through sentence by sentence to determine whether or not each sentence related to the research question. All the relevant sentences were designated as “open codes” (selected units). These open codes were then organised into subcategories (n = 17), and further grouped into categories (n = 5) and main categories (n = 2) based on similarities and differences in their content. Appropriate names were assigned to these categories to represent their thematic significance. An illustration of the data analysis is given in Table 2.

TABLE 2.

Illustration of the data analysis process.

Unit of analysis	Open code	Sub‐category
…then, when I got over those problems, I felt like I didn't have to focus so much on those technical things anymore, it was much easier to focus on the patient and the therapy. (A15)	Technology in interaction	Interaction via virtual and remote communication technology
…technology is also important to me, because it brings me stress, that I usually ensure the functionality of the technology as much as possible in advance, it's a way for me to reduce the stress in the situation itself. (A2)	Technology as stressor
And the technical challenges are definitely the biggest challenge… (A14)	Technical challenges
…if the connections are struggling or something else, there's really nothing to be gained from communicating. (A2)	Internet connection problems
And then just as I said the material, you can make better use of internet links, for example… (A10)	Utilisation of technology in remote counselling
…if there is a technical challenge and we have to switch from video reception to a phone call, then we might have lost a moment of insight or something. (A13)	Switching the model of counselling during counselling session

2.6. Rigour and Reflexivity

Rigour was assessed according to Lincoln and Guba's model of trustworthiness: credibility, confirmability, objectivity, transferability and authenticity (Kyngäs et al. 2019; Polit and Beck 2017). Credibility was strengthened by pre‐testing the interview guide and using a broad sampling strategy to capture the perceptions of a variety of HCPs. The participants were recruited from a wide range of healthcare settings and came from different healthcare professions. To increase confirmability, the research team (comprising four researchers) met regularly to review the analysis process and discuss the results as the analysis proceeded. The results were also discussed with one study participant. These discussions promoted objectivity on the part of the researcher with regard to the results of the study. Transferability was supported by transparent reporting of the results, and relevant citations were reported to ensure authenticity. The categorization process was reported using tables (Kyngäs et al. 2019.) The study phenomenon was not familiar to the researcher beforehand, and it is notable that, as a working physiotherapist in Northern Ostrobothnia, she knew few of the study participants. To ensure methodological integrity, methods and findings were reported in line with the Consolidated Criteria for Reporting Qualitative (COREQ) research principles (Tong et al. 2007). The researcher employed the COREQ checklist during the study planning phase and referenced the page numbers of the conducted study when addressing the guide questions/descriptions in the checklist. This meticulous approach facilitated the promotion and maintenance of study quality throughout the research process.

3. Findings

In total 16 HCPs from different fields within the health sector participated in this study. Demographic information about the study participants is presented in Table 3. Participants' perspectives on the use of EI in remote counselling can be divided into the following two main categories: (1) emotional intelligence as expressed through dialogue during remote counselling and (2) factors which shape how emotional intelligence is used. The results are shown in Table 4 and Figure 1. The categories are described in the following section and illustrated with quotes from the participants.

TABLE 3.

Demographic information about the study participants (n = 16).

Characteristic		All (n = 16)
	Average	Range
Age (years)	38	35–56
Gender	Female	13 (81%)
	Male	3 (19%)
Education level	Vocational education	1 (6%)
	Bachelor's degree	11 (69%)
	Master's degree	4 (25%)
Profession	Doctor	2 (14%)
	Counsellor	1 (6%)
	Nutrition therapist	1 (6%)
	Physiotherapist	4 (25%)
	Prosthetist – orthotist	1 (6%)
	Psychology	1 (6%)
	Public Health Nurse	1 (6%)
	Registered Nurse	4 (25%)
	Workability coach	1 (6%)
	Average	Range
Work experience (years)	12	2–25
Remote counselling education	Yes	10 (62%)
	No	6 (38%)
Remote counselling	Daily	4 (24%)
	Weekly	6 (38%)
	Monthly	6 (38%)

TABLE 4.

Healthcare professionals' perceptions of emotional intelligence in remote counselling–the results by category.

Main category (n = 2)	Category (n = 5)	Sub‐category (n = 17)
Emotional intelligence as expressed through dialogue during remote counselling	Realising reciprocity by using emotional intelligence	Establishing rapport Patient‐centredness in building rapport Facing the patient Understanding and communicating understanding Attitudes in developing rapport
	Utilisation of emotional intelligence skills	Recognising and regulating the professional's own emotions Recognising the patient's emotions Providing emotional support
Factors which shape how emotional intelligence is used	Individual characteristics in the expression of emotional intelligence	Uniqueness of the professional Uniqueness of the patient Motivation of the professional Motivation of the patient
	Special features of the remote counselling environment	Interaction via virtual and remote communication technology The environment of remote counselling
	Competencies which strengthen emotional intelligence skills	Professional's competencies Supporting competencies for remote counselling Development of emotional intelligence skills

FIGURE 1.

Using emotional intelligence during remote counselling—Healthcare professional's perceptions.

3.1. Emotional Intelligence as Expressed Through Dialogue During Remote Counselling

According to HCPs, EI is expressed through dialogue during remote counselling. This involves realising reciprocity by using EI skills during remote counselling. Reciprocity includes establishing rapport with patients, patient‐centredness in building that rapport, facing the patient, understanding and communicating that understanding and the attitudes demonstrated while developing rapport.

Rapport was perceived as the professional's ability to react to the patient's expressions and consider different channels of communication in interpreting them. HCPs often use small talk to establish rapport with patients, but in remote counselling, there was less scope for small talk or it was carried out in different ways than in face‐to‐face counselling.

…it depends on counsellors' ability to use different channels, to verbalize the exercises in a different way, but also depending on the patient's own learning channels. (A1)

…there is more of the same when we are in the same place, like small talk. We talk about the weather or whatever, but maybe here it isn't so easy getting to know the patient. In traditional counselling you get to know them in other ways than just around the thing itself. (A11)

The absence of physical positioning in a shared space was perceived to affect rapport, reducing the scope for professionals to position themselves on the same level as the patient. Utilising body language was described as challenging or impossible, and this influenced the interpretation of the patient.

…when the patient is in a different space physically. Somehow that common position is different. It affects how we are connected and positioned. (A14)

…it isn't mandatory to keep the camera open, you can't observe what it is, emotions, and whether the patient is there and whether things are understood, you can ask clarifying questions, there won't necessarily be the same truthful answer…(A6)

Reciprocity was perceived as patient‐centred in nature. Patient‐centredness had a bearing on how the professional spoke to the patient, listened to them and prepared for the counselling session.

…you are interested in what the patient is telling at that moment, that it would be conveyed that I am listening, and this matter is important, and I absolutely want to be there for him…(A15)

…it's probably good that there is some kind of contact, at least the nurse or counsellor has some preliminary information about where to start. (A6)

During remote counselling, professionals aimed to make patients feel safe by showing empathy and being well‐informed about the patient. This was intended to compensate for the lack of physical contact. Although at first the professionals did not believe that counselling patients remotely, without touch, would work, they felt that actually it was possible. However, they found it intense and mentally draining to counsel patients using remote audiovisual methods.

…you have to accept patient's feelings, that if you feel this awkward, it doesn't matter, it's part of this, if it's first time we are remotely, you can calm down the patient for making him feel good…(A2)

…I feel that it's a bit more difficult, counselling remotely compared to a phone call, because you don't have to control expressions or you don't have to show empathy, maybe with expressions so much. (A13)

Eye contact was perceived to promote a sense of connection when facing the patient remotely. However, it was felt that audiovisual communication did not enable true eye contact with the patient, and this was perceived to affect their rapport. The intangibility of remote counselling added to the uncertainty and challenge of interpreting a patient's emotional state during a session.

…in a way you have to look at that camera and you can't see the other person's eyes from that camera, then you don't have eye contact in the same way…of course it will somehow affect. (A14)

I agree that…when there are messages on the Digital Care Pathway and the patient hasn't directly said how they feel, then it's the same as guessing how they feel now…(A8)

Real understanding of the patient's situation and communicating that understanding were described as a significant part of establishing reciprocity.

…that you really understand what you're being told that you don't read anyone's expressions or gestures between the lines…(A9)

Professionals understood patients through their words, facial expressions and tone of voice. The professional communicated their understanding by repeating the words used by the patient and making sure that they had understood the patient correctly. Professionals described that it was easier to understand patients through an audiovisual connection than through text‐based counselling.

Even though you can't see the whole body all the time, but…the tone of voice and gestures and all that…and then that when you said this, what did you mean by that, did I understand correctly…(A4)

Professionals explained that using clear and simple language in remote counselling strengthened their patients' understanding.

…it isn't able to make sure, at least through the patients' face, that the information has been understood, sometimes, I repeat again at the end what has been said. (A16)

The attitudes of the HCP and the patient were also perceived to influence the formation of reciprocal relationship. For instance, a patient's willingness to accept remote counselling affected the formation of a relationship, and could take time from the counselling itself.

If it's forced, then I have a bigger job as a professional to get the patient to turn a little to my side and convince them that this also works and that I'm here just the same as if I were present. If, on the other hand, the patient has been able to choose that remote counselling is the way for me, then we are more on the same page and perhaps have a similar understanding. (A1)

According to HCPs, using EI skills in remote counselling includes having the ability to recognise and regulate one's own emotions, recognise the patient's emotions and provide emotional support to the patient.

HCPs were able to successfully recognise and manage their own emotions during remote counselling. Understanding how and why particular emotions arose helped them do this, as did regulating their mental resources, for instance by setting rules and boundaries in the counselling situation.

…I've clearly accepted my own emotions and their formation in a certain way. And then, if emotions arise and when they (emotions) arise, recognizing them makes it easier. Understanding that hey, this is a limited situation for us, there can be misunderstandings, and we may not all reach the exact same level of interaction…(A5)

I've had to say…don't talk bad at me, don't swear at me… that even professionals don't have to put up with everything, that being a spittoon, there is a danger of burning out. (A7)

HCPs also regulated their own emotions by using physical and psychological techniques such as inhabiting the role of a professional, maintaining distance from their own emotions, focusing on the patient and keeping quiet.

…you just have to try to forget your own and focus on that patient…, usually then your own irritation is also forgotten…(A15)

…it's good to be quiet for a while and think about what to say next. Then you won't say anything stupid. (A12)

Patients' emotions were identified through the words they used, their voice (tones, emphasis, tempo), body language, facial expressions and actions. The means for identifying a patient's emotions varied with the counselling method used (audiovisual/text‐based). Patients' age and which patient group they belonged to also affected professionals' ability to identify their emotions.

…facial expressions and gestures and tone of voice, and whether she's crying or somehow feeling nervous or whatever…(A14)

…quite often they are in the grip of such a strong emotion, there they cut off the connection or turn off the camera and there is nothing for a moment…(A3)

Being present, listening and interviewing made it easier for the professional to identify the Patient's emotions. The interpretation of the patient's emotions in text‐based counselling was perceived challenging because it was difficult to recognise emotions from the text.

…when you're genuinely present in the situation and listen…, and not like when many people know that even when you're in Teams, everything else is done there on the side…(A10)

And written counselling is like factual and it doesn't show the emotions… and the personality of the professional. (A17)

Professionals felt that they succeeded in providing emotional support by being present and giving the patient time to reflect on their emotions. Emotional support was also provided through eye contact, facial expressions, tone of voice, words, talking, listening, showing their understanding and providing information. HCPs perceived that the nature of text‐based counselling was not as emotional as in other counselling methods.

By being ourselves and being real and just that we are listening to [them]… and then of course that our expressions and energy and the way we use our own voice…(A4)

…it's true that in those Digital Care Pathway messages, maybe they've been more about factual things being things and ignoring the emotions to the corner then. (A8)

3.2. Factors Which Shape How Emotional Intelligence Is Used

According to HCPs, several factors shape how they use emotional intelligence. These include categories named as individual characteristics in the expression of emotional intelligence, special features of the remote counselling environment and competencies that strengthen emotional intelligence skills.

Relevant individual characteristics include both the HCP's and the patient's uniqueness and motivation. HCPs perceived that they had a unique way of interpreting patients during remote counselling. A HCP's personality affected their communication and ways of interacting with patients. Each HCP's EI skills were perceived as unique. For instance, there might be differences in how HCPs interpret patients' expressions, leading to varying conclusions about the patients' situation and resulting in entirely different counselling outcomes. Patient expressions could also be interpreted in diverse ways, potentially leading to misunderstandings that impact patient satisfaction. The importance of being on the same level as the patient was consistently perceived.

…depends on the temperament of the person, I think that it probably depends on the characteristics of the nurse, that some act differently than others. (A10)

But if the patient doesn't directly express his emotional state, it can be very challenging, it really depends on the person how you interpret those things. One might think that hey it was a concise message and the other thinks that help me, he is very angry now. (A7)

HCPs aimed to implement remote counselling according to the patient's unique situation. This was reflected in how a patient's individual needs were identified and how their needs and wishes were fulfilled. The HCPs explained that considering the individual needs of the patient could be challenging when there were extensive information packages and official forms that had to be used for counselling. The patient's individual way of interpreting the HCP's messages and expressing their own emotions during remote counselling varied.

…if there is someone elderly or so, then I don't suggest remote counselling. But usually if you know that it has the technology under control, then it's not a problem…(A11)

…that the professionals in this kind of electronic environment, professionals ensure their own background by providing comprehensive information packages, and then it becomes robot‐like, for example extensive information packages are less often targeted at that particular person…(A5)

HCPs' motivations for remote counselling were varied and individual. These motivations included the opportunity to work at home, challenge themselves or show the patient that remote counselling could work for them. The participants in this study expressed motivation to engage in remote counselling but expressed concerns regarding patients' commitment to the process. HCPs perceived a potential for patients to multitask during counselling sessions, which could weaken their commitment to remote counselling. Additionally, HCPs voiced concerns about some patients lacking sufficient motivation to fully engage in remote counselling, especially amid busy schedules or in restless environments.

Well, at least I like it and…it also challenges myself and gives so many new opportunities and ways to do the work in a different way, so it motivates. (A10)

The patient can take part in the counselling during a day off, but on the other hand, there is perhaps also a downside, that some people are a bit like, well, let's take care of this quickly, and maybe he won't deal with it just like that, everything is so individual…(A13)

The ways in which HCPs motivated patients varied according to the patient's situations and adherence to self‐care, making it an individualised approach. HCPs perceived challenges in monitoring treatment progress in remote environments. They suggested that a more human‐like approach to monitoring could enhance patient motivation and adherence to self‐care more effectively. Additionally, HCPs noted challenges in how information is shared and explained to patients, directly influencing patient motivation. Nevertheless, the methods of motivating patients were perceived to be very similar to those used in face‐to‐face counselling.

…that how motivated those patients are to take care of themselves. I try to motivate in such a way that I bring up the things that can happen, even if, for example, if blood pressure is not treated, what will it lead to and in the light of health issues…(A16)

Mentally, of course, motivation happens in exactly the same way as at a face‐to‐face‐counselling…, some things can even be easier in concrete matters, but not always, it depends on where the patient is remotely. (A2)

According to HCPs, special features of remote counselling include information‐ and communication technology (ICT) and the environment in which remote counselling takes place.

Virtual and remote communication technology was perceived to enable new ways of counselling the patient and to offer versatile tools for counselling. However, connection problems had been experienced to break meaningful situations, meaning that sensitive, important moments could be lost. For instance, there were several situations in which unstable internet connections caused interactional problems. In some cases, healthcare professionals (HCPs) had to switch the counselling method mid‐session due to these connectivity issues. Additionally, internet connection problems consumed time during counselling sessions and had an impact on the emotions of both HCPs and patients. Rebuilding a sensitive situation after a connection problem was felt to be frustrating and problematic, challenging the use of EI. The relationship with a patient was perceived to remain more distant, particularly when technical problems occurred during the counselling session.

If there is a technical challenge and you have to switch from video counselling to a phone call, then you might have lost a moment of realization. (A13)

…sometimes there's a feeling of being somehow more distant…And then when it's like emotional things in general, it's especially sad if you're interrupted…(A14)

HCPs felt that the use of a technical device between themselves and the patient made counselling feel cold, because it did not allow them to get to know the patient so deeply. The HCP's ability to be fully present could also be interrupted when their attention was diverted to the technological device and its functions rather than the patient. The technical competencies of healthcare professionals (HCPs) were perceived to improve with experience, allowing them to allocate more time to focus on the patient.

…it's a bit cold like this…remotely, it's much easier for me, it's easier to start a conversation when you're present in that situation, but it's somehow terribly difficult. (A11)

…a big disadvantage in remote counselling is that when there are several systems that need to be used at the same time, you often can't look at that patient all the time, rather you just hear the talk. (A3)

HCPs perceived that environmental issues affected the counselling. HCPs observed that being in their own environment seemed to make patients feel safer and be more aware of their own situation. HCPs also gained information from the patient's environment, which might be their home or workplace, and were able to utilise it during counselling. In contrast, the HCP's environment had to be neutral, so that it would not provoke the patient in any way.

…I see only positive things regarding the perception of emotions in a remote counselling, precisely because it (remote counselling) is almost always a safer situation for the patient than if he were present at the reception…(A3)

…can feel safe…, he has not arrived in the role of a patient in some reception situation, but he is in his own environment and more aware and a little on top of his own situation …, maybe he knows the situation better at that point. (A1)

According to HCPs, competencies which strengthen emotional intelligence skills include professional competence, supporting competencies for remote counselling and development of emotional intelligence skills. Professional competence was seen as professional knowledge, demonstrating professionalism to the patient and maintaining professionalism in a remote counselling situation. Professionalism was developed by supporting remote counselling skills.

…in the role of counsellor, someone you must be very aware of how you they present it (question), because it must be so that the answer is also constructive. (A10)

…it is professionalism that we just must stay calm and listen to those situations and be sorry and try to understand. (A8)

Competencies for remote counselling were supported through community learning, sharing situations with colleagues, mental support and concrete help from the work community.

… we break down those pressures and those patient contacts and go through and also learn and share information and skills among ourselves, that if everything is just the way it is (remotely)…it will be pretty much the same, like a tube, and then everyone will work so maybe quite narrowly…(A9)

In difficult remote counselling situations support was also received from the foreperson.

…the support of the foreperson, the physician, the colleague, and then I ended up with one of my colleagues formulating the message so that my frustration wouldn't be seen in it. (A7)

It was noted that the development of EI skills varied between individuals, and it was generally difficult for HCPs to assess how developed their own EI skills were. However, HCPs described their EI skills and remote counselling skills developing through being involved in remote counselling.

I can't say how I would have developed either. (A12)

But it has been developed very much here, if the camera is open, how you can see the person's movements and expressions and whether you can see what's around there…(A6)

HCPs recognised their need to develop their own EI skills and felt that they needed relevant education which they could draw on during challenging interactions in remote counselling situations. HCPs perceived their EI skills to develop in remote environments where communication was challenging. Limited interaction was seen as an opportunity for HCPs to find new ways of interacting and enhance their EI skills. Additionally, HCPs emphasised the importance of making discussions related to EI more visible in education, workplaces and broader societal conversations.

Body language is difficult, … from where you receive those messages, often only the face is visible. But…you just have to develop this emotional intelligence for yourself, learn to read facial expressions and other things. (A3)

…as a wish for education…about how to receive the patient's emotional states, precisely this one related to communication. (A7)

…it is important that it (EI) is discussed and made visible… (A25)

4. Discussion

This study offers new insight into the use of EI during remote counselling, a phenomenon about which there is little existing evidence. The prevalence of remote counselling for patients (Cheng et al. 2022; World Health Organization 2021) and the identified interactional challenges in remote environments (Odendaal et al. 2020) underscore the importance of understanding how EI is employed in this context. Two main categories were identified from the interviews: (1) emotional intelligence as expressed through dialogue during remote counselling and (2) factors that shape how emotional intelligence is used.

Based on this study, EI is expressed through dialogue between HCPs and patients. Dialogue is defined as goal‐oriented interaction between a healthcare professional and a patient, where both participants are active and engaged in the situation (Artigas Miralles et al. 2020). To be realised, it requires reciprocity between the HCP and the patient, as well as the HCP's ability to utilise EI skills. Several factors shaped the use of EI during remote counselling: individual characteristics, special features of the remote counselling environment and competencies which strengthen EI skills.

Patient‐centred interaction in remote counselling requires good communication (Laukka et al. 2020; Li et al. 2021; Suonnansalo et al. 2024). According to Lee et al. (2020), the relationship between HCP and patient can be described as reciprocal, two‐way and context‐dependent. Our finding that EI is expressed through a dialogue in remote counselling supports this view.

Individuals' uniqueness is highly significant to counselling interactions, because interpreting and responding to someone's expressions leads to different actions and, ultimately, different counselling outcomes (Lee et al. 2020). Accordingly, in this study, both HCPs' and patients' uniqueness and personality influenced reciprocity and how EI was used. Perceptions varied depending on both patient group and profession and by whether audiovisual or text‐based communications were used, which aligns with the results of Keenan et al. (2021). Remote counselling was described as intensive, especially when audiovisual methods were used, which may have effects on the emotional and mental resources of HCPs. The literature suggests that HCPs can regulate their emotional and mental resources by utilising EI skills and that this may support their occupational well‐being (Li et al. 2021).

HCPs also experienced remote counselling as intensive and mentally draining. Looking more closely at this point, it appears that remote counselling consumes HCPs' mental energy and may negatively impact their occupational well‐being. This, in turn, could be mitigated by applying emotional intelligence (EI) skills during counselling to manage stress and reduce negative emotions (Al‐Ruzzieh and Ayaad 2021; Li et al. 2021; MacCann et al. 2020). Additionally, HCPs reported experiencing emotional distance from patients, hiding frustration due to technical issues and struggling to focus on the patient rather than the technology. They also mentioned burnout in the context of remote counselling, aligning with Løberg and Egeland (2021), who suggest that working in remote environments may introduce new challenges and competence requirements for nursing performance. It seems that HCPs must actively regulate and manage their emotions—core aspects of EI—to overcome challenges related to EI use in remote counselling sessions. In doing so, they strive to establish and maintain a high‐quality counselling relationship, even when facing difficulties. Based on these findings, it can be concluded that there are also new competence areas to consider in managing and leading processes.

HCPs may face challenges in communicating with patients during remote counselling (Jarva et al. 2023). Providing emotional support to the patient has been described as important (Rezaei Aghdam et al. 2020; Kaakinen et al. 2012; Suonnansalo et al. 2024) but difficult to implement remotely (Kaihlaniemi et al. 2023; Laukka et al. 2020). In this study, HCPs were aware of the limitations of the counselling environment and the communication challenges associated with it. Even when audiovisual connections were used, observing the patient was compromised. HCPs described how the physical separation between themselves and patients during remote counselling affected their use of EI during the interaction.

For instance, body language was described as one way of interacting, which was weaker or impossible to use in these circumstances. Lack of proper eye contact was also described as weakening the interaction with the patient. The risk of misunderstandings was, therefore, higher, and HCPs highlighted real understanding as a key factor in successful counselling. Understanding (Hogan et al. 2018; Laukka et al. 2020) and the clarity of the words used (Kaihlaniemi et al. 2023) have both been highlighted as factors by earlier studies as well. Also, from the perspective of patients (Suonnansalo et al. 2024).

The competencies and emotional skills of HCPs significantly impact the outcomes of counselling. Expressing emotions has positive effects, and therefore, it should be encouraged (Olry‐Louis 2018). Our study results indicate that HCPs hope for more discussion on EI and emotions, especially in the context of patient services in the health sector. The ability of HCPs to respond to patients' emotions greatly influences their interaction (Olry‐Louis 2018). HCPs who can regulate their own emotions and understand those of others react more constructively and positively when addressing emotional problems and social relationships (Odaci et al. 2017). In line with this, HCPs in the study emphasised their ability to respond to patients' expressions in rapport building.

According to Odendaal et al. (2020), HCPs experience that technology can cause both trust and scepticism among patients, and attitudes can change during counselling when utilising technological devices. Accordingly, in this study, HCPs described situations in which patients were not willing to participate in remote counselling as the means for receiving counselling. Therefore, their attitudes towards it were negative from the start. HCPs had to work to achieve the patient's trust, which took time and space from the counselling itself and affected the formation of the patient relationship. In line, Keenan et al. (2021) have highlighted that HCPs must work to win the trust of the patients when interacting in remote counselling environments. Research by Konttila et al. (2019) indicates that a positive attitude on the part of HCPs is also needed to implement remote services.

In this study, healthcare professionals (HCPs) perceived that the ability to regulate their own emotions and utilise emotional intelligence (EI) skills, such as identifying and managing emotions, was beneficial during challenging interactions in remote counselling. EI is described in the literature as a trait that can be leveraged in problem‐solving situations (MacCann et al. 2020), which is particularly helpful for HCPs in challenging remote counselling contexts. Additionally, individuals with high EI are able to regulate their emotions to achieve desired counselling outcomes (Zampetakis and Mitropoulou 2024). High EI skills also predict a person's ability to be flexible and adapt to various situations (Double et al. 2022), which is advantageous for HCPs working in constrained environments. Consistent with this, the ability to respond to patients' expressions was identified as a critical competence for healthcare professionals in this study.

According to Warmoth et al. (2022), there are surprisingly numerous areas of nursing work that can be done via remote counselling, although the help of a physically present person may sometimes be valuable, for instance when counselling elderly people. In this study, interaction via virtual and remote communication technology was described as enabling new opportunities and means for implementing counselling remotely, even though it also posed challenges. However, it is important to consider that for some patients, not being seen in person can be beneficial, especially when discussing difficult topics, while for others, meeting in person is necessary.

The challenges mentioned in this study related to technical problems and devices coming between the HCP and the patient. Firstly, it was problematic and frustrating when internet connections did not work properly or, in some cases, were lost entirely. HCPs described that such situations disrupted interaction with the patient. Connection breakdowns, therefore, had a significant impact on the use of EI during counselling and its success. Warmoth et al. (2022) similarly note that poor internet connections lead to poorer quality interactions.

Secondly, HCPs described the counselling relationship as cold, due to the technological device sitting between the HCP and the patient. HCPs felt that this made it harder to get to know the patient as deeply as they would in face‐to‐face counselling. The same phenomenon has been noted by Keenan et al. (2021). Small talk, which HCPs utilised while establishing a relationship with patients, was also different as it felt difficult to come up with something to talk about. Further, HCPs noted that they could not focus on the patient and show empathy towards them, for example, by using eye contact, because they had to pay attention to the technical functions. Empathy is understood as the ability to comprehend others' personal experiences and emotions (Odaci et al. 2017). In this study, empathy was demonstrated by understanding and calming the patient, as well as through the professional's own expressions. It has been suggested that showing empathy enhances patients' satisfaction with the care they receive (Nurfadhillah et al. 2022; Suonnansalo et al. 2024). In line, earlier studies have highlighted HCPs' concern about concentrating too much on the technology rather than the patient (Odendaal et al. 2020). This suggests that HCPs' level of virtual and remote communication skills may have an impact on their ability to use EI during remote counselling. A lack of confidence in using technology can undermine confidence in a professional's other competencies (Laukka et al. 2020). Further, even if the results of the study did not highlight this, it is important to ensure that healthcare professionals engage in self‐care and receive support when needed, especially when they are dealing with emotionally demanding situations in counselling contexts.

Keenan et al. (2021) and Jarva et al. (2023) 1 suggest that healthcare professionals (HCPs) are concerned about losing the ‘human touch’ when counselling patient in remote environments. Under these conditions, getting to know the patient can be more superficial, even though providing emotional support is critical to patients' adherence to self‐care practices for managing their diseases (Keenan et al. 2021). However, Laukka et al. (2020) have suggested that HCPs can create more profound relationships via remote counselling when they have more contact with the patient. This insight did not exist in this study even though HCPs described a profound relationship to be possible in remote counselling. To maintain the human touch in healthcare services, remote counselling methods should be used as a supplement to, rather than a replacement for, face‐to‐face care (Moshe et al. 2021; Suonnansalo et al. 2024).

HCPs described the support from colleagues and managers as well as professional competencies to strengthen their EI skills. Collegial and organisational support have also been highlighted as factors supporting HCPs' digital competence in the study of Jarva et al. (2023). Further, Laukka et al. (2020) suggest that interaction, particularly on text‐based platforms, requires both time and support from the professional community. At the same time, the motivation and willingness to use remote systems promote the development of professional competencies. Therefore, in line with our findings, Konttila et al. (2019) suggest that organisational and collegial support is needed.

As an overall conclusion, HCPs identified the need for EI‐related education to support their ability to use EI in remote counselling. HCPs described difficulties with implementing counselling remotely, indicating that this had a direct effect on the interaction and relationship with the patient. In alignment with our findings, Keenan et al. (2021) suggest that establishing a confidential and respectful atmosphere remotely can be challenging, especially during the initial meeting between the (HCP) and the patient. This underscores the importance of strengthening HCPs' emotional intelligence skills, as forming relationships is one aspect of EI (Odaci et al. 2017). Consistent with recent systematic reviews, it has been found that HCPs require more training and education on interaction to effectively support the implementation of remote counselling in the health sector (Konttila et al. 2019; Nazeha et al. 2020; Warmoth et al. 2022).

5. Conclusion

EI is expressed through dialogue between the HCP and the patient. To be realised, it requires reciprocity in the HCP–patient interaction and that HCPs are able to use EI skills. HCPs perceived that it is challenging to interpret a patient's emotions and to give them emotional support in a remote environment. Our study results suggest that dialogical and safe interaction promotes the use of EI, such as communicating understanding and showing empathy. HCPs perceived individual characteristics, special features of the remote counselling environment and competencies that strengthen EI skills to shape their use of EI. The results of this study highlight the influence of individuality and its effects on counselling results. Together with the challenges identified in using EI in remote counselling, it is suggested in this study that EI‐related education is needed.

5.1. Implications for Policy and Practice

The results of this study describe that HCPs need and are willing to develop their EI skills to promote their use in remote counselling. The results also suggest that new aspects of competence in care may require further study to understand their potential impact on both the delivery and reception of care.

To achieve effective dialogical interaction in remote counselling, it is crucial to focus on HCP's ability to form and maintain relationships in constrained environments. If rapport building fails at the outset, achieving meaningful dialogical interaction becomes difficult, which can negatively impact counselling outcomes. HCPs in this study emphasised the importance of understanding the patient, recognising their emotions and knowing how to respond appropriately. Additionally, HCPs' ability to motivate patients remotely plays a significant role in how well patients adhere to self‐care practices, underscoring the need to enhance motivational skills among HCPs. Moreover, participants in the study highlighted the importance of possessing strong emotional regulation skills during remote counselling sessions.

As remote services rapidly expand and develop, EI competence should be recognised as a crucial professional competency in the health sector. Therefore, EI‐related education should, perhaps, be incorporated into the curriculum of various healthcare institutions. This approach could facilitate the implementation of EI in remote counselling and, consequently, ensure more equitable counselling from different HCPs. Additionally, establishing common counselling standards would support more consistent counselling quality and greater equality between patients.

The healthcare managers would promote the use of EI in remote counselling by implementing established standards and continually evaluating their application in the workplace. Furthermore, introducing patients to remote counselling methods may enhance the utilisation of EI during such sessions. This introduction could be facilitated through national advertising, sharing information with citizens, and providing practical support for the use of various remote counselling methods.

Consideration of patients' unique characteristics is crucial when selecting an appropriate remote counselling method. HCPs can benefit from support provided by colleagues and frontline leaders, enhancing the use of EI and promoting patient‐centred counselling. Allocating space for discussions among colleagues in the workplace is essential. However, it is important to note that remote counselling is not suitable for all patients or patient groups (Kaihlaniemi et al. 2024).

In our study, HCPs identified a need for a broader discussion on EI and emotions. The anticipated increase in remote counselling as a method, driven by the prevailing healthcare staff shortage and the cost‐effectiveness of remote counselling, underscores the importance of these discussions. To ensure effectiveness, patient‐centredness and the quality of counselling, societal discourse on the significance of interactional issues should be integrated into policymaking. This includes the development of new remote counselling methods for the health sector. By utilising EI skills, HCPs can regulate their mental resources and improve their capacity to work. Therefore, high EI skills are beneficial both to HCPs and the organisations they work for.

5.2. Recommendations for Further Research

The results of this study highlight the importance of HCPs having EI skills and implementing them during remote counselling. This phenomenon is new and, therefore, further research is needed to gain more understanding of it. Currently, there is no structured data available on how HCPs utilise EI in remote counselling. To assess HCPs' EI competence and its various levels, it is crucial to develop and test an instrument tailored to measure the realisation of EI in remote counselling within the healthcare context. Additionally, it is important to study EI from the patients' perspective, especially in the development of health services. To comprehend patients' experiences, qualitative research should be the initial step. Once an adequate understanding of the study phenomenon is established, the use of statistical methods can facilitate the collection of generalizable data. By building knowledge about EI and how to use it in remote counselling, steps towards improving HCPs' EI skills can be taken and put into practice.

5.3. Limitations

There are some limitations to this study which should be taken into consideration. The purposive sampling method used means that it is possible that the participants had positive attitudes about remote counselling, which may have affected the results. At the same time, purposive sampling ensured that only those HCPs with the best knowledge of the topic were included (Kyngäs et al. 2019). There were 16 participants in this study which may be considered a small sample. However, this number of participants is not exceptional in a qualitative study. The data was quite rich overall. In total, the interviews lasted 265 min and produced 54 pages of written text. Data saturation, which is also important in qualitative study design, was ensured (Kyngäs et al. 2019). One interview was conducted with a second interviewer, which may have influenced the content of the interview. To ensure consistency across interviews, the same interview guide was employed and the interview practices were thoroughly discussed with the interviewers beforehand. This approach ensured the objectivity of the researcher and the use of identical interview questions throughout. The researcher's own assumptions may have influenced the study results: such bias was minimised by holding regular discussions with the research team and by discussing the results with one study participant (Kyngäs et al. 2019). In addition, this study is reported in English, which is not the first researcher's native tongue. The quotes from the participants have been translated from Finnish into English. These factors may have some influence on the content.

Author Contributions

Have made substantial contributions to conception and design, or acquisition of data or analysis and interpretation of data; M.L., A.O., O.K., J.K., O.A. Been involved in drafting the manuscript or revising it critically for important intellectual content; M.L., A.O., O.K., J.K., O.A. Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; M.L., A.O., O.K., J.K., O.A. Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. M.L., A.O., O.K., J.K., O.A.

Ethics Statement

According to legislation in Finland, Research Ethics Committee approval was not required since the study does not involve minors, direct or indirect physical or physiological harm to the participants or clinical trials (Medical Research Act No. 488/1999).

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

No data available. All the data has been used to this study.