An E-Delphi Study to Identify Core Competencies for Managing Chronic Patients’ Needs Through Telecare

1 Evangelos C. Fradelos

2 Ioanna Tsatsou

3 Snježana Čukljek

4 Michela Barisone

4 Emiliano Loria

1 Maria Saridi

1 Ioanna Papathanasiou

1 University of Thessaly, Larissa, Greece

2 Hellenic Airforce General Hospital, Athens, Greece

3 University of Applied Health Sciences, Zagreb, Croatia

4 University of Piemonte Orientale, Novara, Italy Article received: 15.01.2025.

Article accepted: 27.02.2025. https://doi.org/10.24141/2/9/1/7

Author for correspondence:

Evangelos C. Fradelos

University of Thessaly, Larissa, Greece E-mail: efradelos@uth.gr

Keywords: chronic diseases, chronic patients, management, telecare, competencies

Abstract

Introduction. Since there is an increase in chronic disease prevalence, there is a global challenge in the field of healthcare professional education in effec- tively treating chronic patients. Telecare is an effec- tive way of caring for specific populations and situa- tions, but it requires specific competencies and skills from health professionals.

Aim. To recognize core telecare competencies of healthcare professionals for the management of chronic patients, as part of the “BeEmTel: Beyond the Emergency. Telecare for Non-Communicable Diseas- es through Simulation Techniques” project.

Methods. A three-round e-Delphi study was conducted from May to August 2022. A panel of 26 experts from five European countries was asked to approve, modify, or add items and then prioritize each competence.

Results. This e-Delphi resulted in 37 competencies included in 12 domains: laws/normative/ethics, mul- tidisciplinary team, shared decision-making, patient/ caregiver education, relationship, assessment/evalu- ation, planning, knowledge/ability, communication, risk evaluation, psychological and emotional support and family involvement. From the total of 37 com- petencies, experts agreed about the score of 22 of them. The agreement in all competencies ranged from 92.4% to 100% (defined as >75% agreement).

Conclusions. The results of this study will provide the basis for European educational institutions to develop educational programs on telecare in chronic diseases as well as to establish national policies on telecare.

Introduction

The increasing global ageing of the population is de- scribed by the World Health Organization (WHO) as a critically important issue for the socioeconomic and medical community (1). Unfortunately, the number of older people is rising disproportionately and most people are expected to live to age 60 and beyond

(2). Older adults have expectedly higher rates of re- ported chronic diseases (3).

Chronic diseases are mainly non-communicable dis- eases generally lasting at least one year, having slow progression and typically require ongoing medical care (4). The four main types of chronic diseases are cardiovascular diseases, cancers, chronic respiratory diseases and diabetes (5). Chronic diseases manage- ment includes numerous long-term treatments and an increased demand for healthcare services that lead to excessive costs, inadequate access to care, sometimes poor quality of care (due to lack of education and re- sources) (6), and poor quality of life of the elderly (3).

Therefore, chronic diseases have become a major problem for the individual, the communities and so- ciety as a whole. Undeniably, science is galloping as new methods are found to manage chronic diseases in various hospital and community settings. There- fore, new and promising technologies are being used, such as telecare. Telecare is the use of information, communication, and monitoring technologies which allow healthcare professionals to remotely evaluate health conditions, educate, or deliver healthcare in- terventions to patients at home or in community set- tings (7).

Especially during the COVID-19 pandemic, telecare was widely used due to social restrictions. It facili- tates health care, particularly in remote or under- served areas. Telecare can improve patient outcomes through the supplementation of the in-person man- agement of chronic diseases, with approaches such as remote monitoring and patient education (8). The most commonly used technologies are those with a monitoring function and systems with reminders, advice, or self-care instructions. An important factor in these systems is their usability, which can help chronic patients to accept and engage in the telecare monitoring systems, making them more independent in their own homes (9).

Telecare is believed to be a revolution of healthcare systems, so it is essential to reflect on the training of healthcare professionals in order to become skilled to engage into telecare and integrate it into their daily clinical practice (10). Indeed, the growing utilization of telecare practices brings considerations about the training and skills of healthcare professionals to use it both effectively and correctly (11). Major barriers to telecare use among healthcare professionals in- clude the lack of knowledge and competence (12). On the other hand, telecare training induces the will- ingness, readiness, compliance and confidence in us- ing telecare (13).

Based on Miller’s pyramid of clinical competence, tel- ecare provision by healthcare professionals requires knowledge on the basis of telecare practices as well as competencies including theoretical knowledge, the basic understanding of telehealth, its tools and its applications, practical skills, and attitudes (14, 15). Also, having knowledge on issues of confidenti- ality and data protection is of great importance (16).

As shown by two recent reviews, there is no system- atic approach regarding the incorporation of telecare in healthcare professionals’ training curricula (17, 18). Nevertheless, standards and guidelines for the creation of telecare courses are increasing and they mainly focus on organizational, ethical, clinical, tech- nical and soft skills instead of the specific needs of healthcare professionals (15). Nowadays, there is growing body of literature on teaching and training of telecare competencies, but the methods of their implementation still lack in the academic field. Tel- ecare competencies are being more and more recog- nized – they are included into the regulations – but still, the application of telecare curricula is complex

(19). The most cited competency frameworks are

those published by the Accreditation Council for Graduate Medical Education (ACGME) (20) and Asso- ciation of American Medical Colleges (AAMC) (21).

The European Union has established a number of initiatives and directives since 1999 and throughout the years so as to increase the use of telemedicine in Europe. Additionally, telemedicine presents peculi- arities and challenges resulting from its own nature, like the use of complex technologies, thus demand- ing some specific qualifications from the healthcare professional. Many European countries still do not have a regulation regarding telecare, but even if they did, the regulation includes general considerations instead of specific standards of care or competen-

cies. Lastly, they are mostly developed by a profes- sional and scientific association of each country

(22). European Telehealth has created the European Code of Practice for Telehealth Services “TeleSCoPE”, which mentions the need for an accreditation and a certification for healthcare professionals engaging in telecare (23). Nevertheless, there is no agreement on common competences in the European Union, and each Member State should have its own competences or requirements for telecare delivery (22). Therefore, there is a lack of a standardized telecare competency framework in Europe, especially for chronic diseases.

As part of the “BeEmTel: Beyond the Emergency. Telecare for Non-Communicable Diseases through Simulation Techniques” project, a literature review was conducted and a list of 35 core competencies for the management of chronic patients’ needs through telecare was identified. These 35 competencies were grouped in eight main categories, that is clini- cal knowledge, critical thinking skills, technological skills, clinical skills, communication skills, implemen- tation skills, professionalism and professional eth- ics, evidence based practice and others (e.g. cultural and social skills). Therefore, healthcare professionals must have a variety of skills in order to meet their chronic patients’ needs through telecare practices (24).

Aim

Driven by the above, an e-Delphi study was con- ducted to recognize core telecare competencies of healthcare professionals for the management of chronic patients as part of the “BeEmTel: Beyond the Emergency. Telecare for Non-Communicable Diseas- es through Simulation Techniques” project.

Methods

e-Delphi study

The Delphi technique is a research methodology used to achieve consensus concerning real-world knowledge solicited from experts on topics where no agreement previously existed. The Delphi meth- od is based on the assumption that group opinion is more valid than individual opinion (25), describes it as a method to obtain the most reliable possible consensus from a group of experts through a series of questions with controlled feedback, organized in various rounds. At the end of each round, the results are summarized so that they can be evaluated by the expert panel, thus enabling the ‘systematic emer- gence of a concurrence of judgment/opinion’ (26). The number of rounds usually ranges between two and four, depending on the complexity of the topic and the time available.

In order to identify and map the skills needed to meet the profile for future health professionals in chronic disease management through telemedicine, the e- Delphi technique was adopted, because it is quicker to implement and ensures higher response rates. The Delphi technique does not use a random sample, but a selected group of experts, defined as a group of in- formed individuals (27). The inclusion criteria for the panel of experts were: working in a country of Eu- rope, a scientist working directly or indirectly in the care of chronic patients and be willing to participate.

Taking as a starting point, the results of the literature review in which 35 competencies were identified (24), a three-round e-Delphi study was launched on the 16th of May 2022. At the end of each round, the par- ticipants gave their opinion on the identified compe- tencies and a consensus was reached. Once the Delphi study participants provided their opinion on the iden- tified competencies, the responses were summarized and redistributed to the panel in the next round. Only those competencies which reached 75% of the agree- ment were included in the next round. Through a con- vergence process that identifies points of agreement and disagreement, a consensus was reached.

For the conduction of the e-Delphi study, it wasn’t re- quired to obtain an ethical approval. The panel of ex- perts participated voluntarily and the study did not present any potential harm to individuals or patients.

Results

A multidisciplinary panel was formed. Thirty-five

(35) European experts in the fields of chronic diseas- es and telecare (nursing academics, regulatory board members, nursing service directors and experts on chronic diseases) were invited to participate. For this purpose, a template was specifically designed to collect information about the experts. Out of the 35 invited experts on a voluntary basis, 26 of them agreed to participate in all rounds of the e-Delphi study. The panel of experts was derived from five European countries (Romania, Croatia, Germany, Greece and Italy), but were external to the BeEm- Tel project consortium partners. In fact, to ensure an objective evaluation, none of the experts knew who the other experts were. The formulation of the panel of experts is depicted in Table 1.

In the first round, the panel of experts was asked to rate the 35 competencies (Table 2), according to their importance in a 5-point Likert scale where 1 corre- sponded to not important to 5 that corresponded to very important. The first round of the e-Delphi study ended on the 10th of June 2022. The participants were asked to rate the competencies according to their importance, to rephrase them if needed and to propose any competency which, in their opinion, is needed but wasn’t included. The first round gave the following results. The highest value was observed for the competency #27 “Act according to laws, regu-

lations and ethical standards while practicing” with a mean score 4.93 and the lowest values for the com- petency #10 “Apply knowledge and practices of data management and analysis” with a mean value 3.82.

From the initial 35 competencies, eight had to be removed in order to reach the consensus of 75% re- quired by a Delphi study. Furthermore, the panel of experts proposed a list of 34 additional competen- cies which, after merging similar proposals, led to the creation of a list of 53 competencies that was distributed for evaluation in the second round (Table 3). Taking into consideration the results of the first round, the second round was prepared and launched on the 27th of June 2022. In the second round, the panel of experts was once more asked to rate the list of derived competencies according to the importance in a Likert scale from 1 to 5. The second round ended on the 8th of July 2022.

The second round of the Delphi study resulted in 37 competencies, as shown in Table 4, divided in twelve areas. Again, in this round, the highest value was ob- served in a competency in the area of professional ethics and it was in the competency “Respect for hu- man dignity, self-determination, informed consent, and patient confidentiality, which are only a few of the moral norms and processes, ethical questions, and obligations unique to healthcare jobs” with a mean value 4.89. On the other hand, the lowest score was observed in the competency “Provide second opinion for chronic patients” with a mean value 3.86.

Finally, the third round was launched on the 19th July of 2022 and ended on the 13th of August 2022. Then, experts were asked to provide their agreement or disagreement on the score of the 37 competen- cies that resulted from the second round (Table 5). The agreement in all competencies ranged from 92.4 to 100%. From the total of 37 competencies of the third round, the experts agreed at 100% for the score of 22 of them. For the rest of the competencies, the agreement was noted from 92.4% to 96.2%. These percentages are fulfilling the percentage for the con- sensus of a Delphi study.

29. Guaranteeing a prompt response to patients’ needs through a telecare system (according to the severity of the patients’ issues).

Planning

28. Plan, implement and assess personalized-individualized health care to meet the needs of chronic patients by using telecare technology.

30. Apply specialized knowledge related to chronic diseases.

31. Integrate scientific findings into practice in an evidence-based manner; introduce research findings into decision-making by formulating a specific clinical inquiry in response to a known information need; look for the most relevant evidence to meet that need; examine the evidence that has been retrieved critically; synthesize the evidence into an action plan, and assess the consequences of any acts or actions taken.

32. Demonstrate flexibility and open-mindedness to changes in healthcare conditions.

33. Knowledge of technical aspects of telecare devices to be able to support the patient in overcoming difficulties with utilization of the monitoring equipment.

Knowledge/ability

34. Use mobile health technologies and e-health (online applications and services) in order to enhance the provided health care.

35. Be able to do some basic troubleshooting due to the use of technical equipment.

36. Know how to choose whether to apply telemedicine services and which services to use according to the need of the patient.

37. The ability to evaluate the need to change a telecare service into ‘in office’ service.

38. Apply up to date guidelines and medical scores when taking medical decisions.

39. Adherence to protocols and systematic recording of collected information.

40. The awareness of telemedicine value, capabilities and limitations. Devotion and responsibility so as not to underestimate the value of telemedical sessions.

41. The application of the quality control assessment methodology implementation principle with the aim of improving the clinical outcomes of telemedicine treatment for patients with chronic diseases.

42. Take measures that ensure adequate resources for people with chronic diseases (availability and quality of the Internet, computers, smartphones, etc.).

45. Be able to initiate, maintain and close a conversation in a telecare session in order to draw and provide information related to health information.

Communication

43. Use and apply communication techniques, specifically adapted to the telehealth context, for therapeutic reasons in order to support patients during a telecare session.

44. Identify and assess the health status and health needs of chronic patients by interpreting verbal and non-verbal expressions during video conferencing.

Risk evaluation 46. Develop prevention plans remotely to avoid potential risks for health and safety of chronic patients.

1. During telecare sessions, provide psychological and emotional support to patients and their family members.

2. Through a telecare session, show empathy to ensure careful attention to patients and family members.

   Psychological and emotional support

3. Awareness of benefits and limits of telecare provision.

4. Consider motivation for treatment and the patient’s stage of change in order to offer support as needed.

5. Offer palliative care, including emotional support using telecare systems.

6. Be aware of the implications of chronic disease as far as caregivers’ burden is concerned, and consider the involvement of patients’ caregivers.

Family involvement 53. Involve the family in the care process to facilitate communication.

Discussion

In this study, a total of 37 healthcare professionals’ competencies for telecare in the management of chronic patients are established. These competen- cies focus more on the part of the management with detail and clinical relevance of chronic diseases with the use of telecare, rather than on the simple use and application of telecare services.

Similarly, in 2016, Van Houwelingen et al. conducted a four-round Delphi study for telehealth competen- cies in nurses working in the Netherlands. There, 32 competencies were identified. The most significant competencies for nurses that provide telehealth were coaching skills, the ability to combine clinical experience with telehealth, communication skills,

clinical knowledge, ethical awareness, and a support- ive attitude (28). Also, in 2019, Arends et al. devel- oped 22 telehealth provider competencies based on the relevant existing literature for telehealth practi- tioners. They used these competencies to educate and train nurse practitioner students in telehealth and were mostly associated with operational is- sues (29). Rutledge et al. (2021) conducted a modi- fied Delphi study to recognize, develop, and assess telehealth competencies for nurses. The research- ers used the four P’s of telehealth framework, per se, planning, preparing, providing, and performance evaluation. In detail, planning for the implementa- tion of a telehealth program, the process of readying for telehealth implementation, delivering telehealth services, and evaluating the impact and outcomes of the telehealth program (30). There are indeed studies from different countries that have identified skills and competences for healthcare professionals

telecare sessions.

chronic patients by using telecare technology. to enhance the provided health care.

experience.

technologies. needs accordingly.

for telecare of chronic diseases. A recent systematic review grouped the competences as follows: clini- cal knowledge, critical thinking skills, technological skills, clinical skills, communication skills, implemen- tation skills, professionalism and professional ethics, and evidence-based practice (29).

The Association of American Medical College (AAMC) Telehealth Competencies includes six domains: pa- tient safety and appropriate use of telehealth, access and equity, communication, data collection, technol- ogy, ethical practices and legal requirements for tele- health. The ethical part surrounds issues on under- standing the federal, state, and local setting practice requirements to meet minimal standards to deliver telecare, maintain patient privacy, prioritizing the pa- tient’s interest, and sustaining the professional-pa- tient relationship (21, 31). The results of the present e-Delphi study revealed that ethics in telecare is put first with the competencies “Act according to laws, regulations and ethical standards while practicing” and “Respect for human dignity, self-determination, informed consent, and patient confidentiality, which

are only a few of the moral norms and processes, eth- ical questions, and obligations unique to healthcare jobs” having the highest values. The Telescope code, the European code of practice for telehealth services has a section on ethical principles. This section un- derlines that having an understanding of the ethical context of telehealth services is a required skill and knowledge of healthcare professionals and that com- pliance with the ethical principles is mandatory for all telecare services (23).

Furthermore, the aforementioned competencies from AAMC take account of the data collection in telecare provision, which refers to performing examinations or taking clinical history in digital format and putting this information in the care plan (32). Nevertheless, the collected data management and analysis are not included in these competencies and in the present study, the competency “Apply knowledge and prac- tices of data management and analysis” had the lowest value. Common barriers in the use of telecare services by healthcare professionals are barriers re- lated to hardware and software used for data collec-

tion management and analysis as well as the lack of knowledge in using these technology and technol- ogy literacy barriers (33).

Additionally, one of the last scored competencies was “Offer palliative care, including emotional sup- port using telecare systems”. Palliative care is an approach that helps patients and their families deal with the challenges of a life-threatening illness. Early detection, accurate diagnosis, and treatment of pain and other issues – whether physical, psychological, or spiritual – prevent and alleviate suffering (34). Since palliative care is considered a specialty that puts a great emphasis ńn communication between patients, caregivers, and the healthcare team dealing with dif- ficult situations and advanced care planning, there is a misperception that it cannot provide the same degree of personal contact and empathy by using telecare. However, there are studies, especially in the United Kingdom and the United States of America, that used and evaluated telecare palliative services with positive results for both patients and caregiv- ers. Therefore, a possible explanation of this find- ing could be the feeling of potential awkwardness of telehealth medium that healthcare professionals feel, and this should be acknowledged in order to provide proper palliative care and support and have both time and space to discuss questions or concerns

(35). Although there is growth of telecare services,

there remains insufficient evidence regarding the clinical application of telecare in palliative care (36).

Successful development and implementation of telecare services needs the trust of healthcare pro- fessionals, patients and caregivers. The European Commission has made this call for such trust to all Member States (23). However, in European countries, there are varying socioeconomic statuses and major differences across and within countries in the way healthcare professionals currently provide telecare especially in chronic diseases. Eventually, much still needs to be done to ensure equal high-quality stan- dards and training of healthcare professionals in the management of chronic diseases through telecare services.

Limitations

Out of the 35 invited experts on a voluntary basis, 26 of them participated in all of the rounds of the e-Delphi study, being unevenly distributed across Eu- rope. So, the results might have been characterized by a stronger influence of the healthcare systems and cultures of Southern European countries.

Recommendations

Recommendations surface from these results. At first, telecare competencies should be included into undergraduate and postgraduate healthcare profes- sionals’ curricula in Europe to educate the future generations. Chronic disease management is difficult and complex, so in order to meet the patients’ needs and to effectively and sustainably integrate telecare, it is necessary for telecare to be included into the curricula of future healthcare providers (15).

After that, the existing workforce should be trained with continuing education training programs, possi- bly organized by the scientific or professional associ- ations of each country. Also, healthcare organizations should have a role in supporting their employees in ongoing professional development, engaging in com- petency integration and telecare practices.

Conclusion

This study’s findings are essential for enhancing tel- ecare delivery in European countries in the midst of a digitalizing world. There is a proposed competence framework of 37 competencies across 12 domains that present a basis for training of telecare practices in Europe. This result can help and guide not only the educational process within the BeEmTel project but, if they can communicate properly, it can assist educational organizations that want to train health- care professionals in chronic patients’ care through telecare.

Author contributions

Conceptualization (ECF, MB, EL); Formal Analysis (ECF, IVP, MS, IT); Investigation (ECF, MB, EL); Methodology (ECF, SC, IVP); Software (ECF); Supervision (IVP); Vali- dation (IT, SC, MS, IVP); Writing – Original Draft (ECF, IT); Writing – Review & Editing (IT, SC, MS ECF, EL, MB, IVP).

Conflict of interest

The authors declare no conflicts of interest.

Acknowledgments

Authors would like to thank all of the experts for their participation in this study.

Funding

This study was funded through the “BeEmTel: Beyond the Emergency Telecare for Non-Communicable Dis- eases through Simulation Techniques”, by the Euro- pean Commission under the Erasmus+ Program, refer- ence number 2021-1-IT02-KA220-HED-000027572.

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