Received: 5 January 2023 | Revised: 22 May 2023 | Accepted: 1 July 2023

DOI: 10.1111/jnu.12925

H E A LT H P O L I C Y A N D S Y S T E M S

Interprofessional collaboration in telemedicine for long-­term

care: An exploratory qualitative study

Apphia Jia Qi Tan BSc (Nursing) (Hons), RN, PhD candidate1 | Wei Ling Chua PhD, RN1 |
Lisa McKenna PhD, MBA, MEdSt, RN2 | Laurence Lean Chin Tan MBBS, MMED3,4 |
4 1
Yu Jun Lim BSpPath (Hons) | Sok Ying Liaw PhD, RN

1
Alice Lee Centre for Nursing Studies,
Yong Loo Lin School of Medicine, National
University of Singapore, Singapore,
Singapore
2
School of Nursing and Midwifery, La
Trobe University, Melbourne, Victoria,
Australia
3
Division of Palliative and Supportive
Care, Department of Geriatric Medicine,
Yishun Health, Singapore, Singapore
4
GeriCare@North, Yishun Health,
Singapore, Singapore
Correspondence
Apphia Jia Qi Tan, Alice Lee Centre for
Nursing Studies, Yong Loo Lin School
of Medicine, National University of
Singapore, MD11, Clinical Research
Centre, 10 Medical Drive, Singapore
117597, Singapore.
Email: apphiatan@u.nus.edu
Abstract
Background: Widespread and sustained adoption of telemedicine in long-­term resi-
dential care is emerging. Nursing home (NH) nurses play a key role in collaborating
with remote physicians to manage residents' medical conditions through videocon-
ferencing. Therefore, understanding of interprofessional collaboration and effective
communication between nurses and physicians is critical to ensure quality of care and
safety during teleconsultations.
Aims: To explore NH nurses' and physicians' experiences of interprofessional collabo-
ration and communication during teleconsultations.
Methods: A qualitative descriptive design was adopted. Purposive sampling was con-
ducted to recruit 22 physicians and nurses involved in NH teleconsultations. Semi-­
structured online interviews were conducted, and data were thematically analyzed.
Results: Three themes were identified: (1) Manner of communication in telemedi-
cine, (2) sociocultural influences in collaborative practice, and (3) role expectations
in telemedicine. Both nurses and physicians recognized the importance of building
and maintaining trust as physicians heavily depended on nurses for provision of ob-
jective information for clinical decision-­making. However, practice differences were
observed between nurses and physicians during teleconsultations. Sociocultural influ-
ences such as power relations and language barriers also affected the nurse–­physician
relationship and interpersonal communication. Additionally, different performance
expectations were identified between nurses and physicians.
Conclusion: Interprofessional collaboration in teleconsultations is challenging because
of lack of in-­person assessment and dependence on nurses for clinical information.
In addition, expectations and communication styles differ among healthcare profes-
sionals. This study called for interprofessional telemedicine training with incorpora-
tion of shared mental models to improve role clarity and communication. Given the
international-­dominated healthcare workforce in long-­term care, the development
of cultural competency could also be considered in telemedicine training to enhance
nurse–­physician collaborative practice.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
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© 2023 The Authors. Journal of Nursing Scholarship published by Wiley Periodicals LLC on behalf of Sigma Theta Tau International.

J Nurs Sch. 2023;55:1227–1237.  wileyonlinelibrary.com/journal/jnu | 1227

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1228
Clinical Relevance: Telemedicine is increasingly adopted in long-­term care settings,
where multidisciplinary healthcare professionals from different health institutions are
involved in resident care. Interprofessional collaboration should be incorporated into
telehealth education for enhanced clinical practice in this care delivery model.
KEYWORDS
communication, interprofessional collaboration, long-­term care, nursing homes, telegeriatrics,
telehealth, telemedicine
I NTRO D U C TI O N
Telemedicine is increasingly being introduced in community and
long-­term care settings to enhance access to specialist care (Barbosa
et al., 2021), reduce the need for unnecessary transfers to acute
healthcare institutions (Champagne-­L angabeer et al., 2019), and in-
crease cost efficiency (Li et al., 2022). While there has been growing
interest in telemedicine since the early 2010s, the COVID-­19 pan-
demic led to an exponential increase in adoption of this style of med-
icine (Cormi et al., 2020). Beyond the pandemic, telemedicine use
will be sustained as clinicians gain better understanding of its ben-
efits (Thomas et al., 2022). New models of care require healthcare
professionals to adapt to interprofessional collaborative practices on
virtual platforms (Perri et al., 2020).
Multidisciplinary healthcare professionals work together to pro-
vide various services including examination, assessment, management,
interprofessional care planning, and education through telemedicine
(Şahin et al., 2021). In Pappas et al. (2019), extensive interprofessional
communication during telemedicine consultations is highlighted as key
to clinical decision-­making processes between physicians and nurses.
As distance-­based services are more readily available for patients as
they move through various healthcare settings, these telemedicine
interactions have inevitably increased. Healthcare professionals who
work in different healthcare contexts have different practice patterns
and expectations, all of which affect communication and collaboration.
Thus, there have been calls for more emphasis on interprofessional
teamwork and collaboration of multidisciplinary healthcare providers
who can cater to patients' individualized needs through telemedicine
platforms (Powers et al., 2023).
Interprofessional practice has been a longstanding key qual-
ity indicator in healthcare delivery to enhance patient outcomes
and work satisfaction across diverse settings (Guck et al., 2019).
Much research has been conducted to investigate organizational,
team, and individual-­level factors influencing collaborative prac-
tice in healthcare teams (Wei et al., 2022). To ensure a collabo-
rative practice-­ ready workforce at all levels, key competencies
have been developed to augment interprofessional education and
practice. Globally, guidelines for education and practice such as
the Interprofessional Education Collaborative (2016) has been de-
veloped and widely applied across primary care settings and care
models, with domains such as clarifying roles and responsibilities,
augmenting communication and teamwork, and conflict resolution.
However, up until now, limited programs have been implemented to
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INTERPROFESSIONAL COLLABORATION IN TELEMEDICINE
enhance interprofessional practice for both students and healthcare
professionals in telehealth settings (Browne et al., 2022).
In long-­term care telemedicine usage, healthcare profession-
als of different disciplines and often different care settings are in-
volved in providing care for nursing home (NH) residents. Parties
involved could include the NH staff and residents, together with
remotely located physicians and healthcare providers of external
healthcare institutions, such as general practitioners, advanced
practice providers, and allied health professionals (Tan et al., 2021).
While published literature has demonstrated increased access to
care, convenience, and positive impacts for NH residents and staff
through digital technologies, there is a lack of insight into inter-
professional collaboration, communication patterns and behavior
in teleconsultations. Although clear communication and informa-
tion transmission is essential to maintain quality in technologically
mediated care provision (Frittgen & Haltaufderheide, 2022), there
remains little research focus on how providers communicate and
collaborate for clinical decision-­making through video-­mediated
consultations. Greenberg and Gutwin (2016) posit that the aware-
ness required for development of mutual understanding between
individuals is not present in video-­mediated communications, un-
like in face-­to-­face interaction. Due to the lack of environmental
cues and ability to analyze nonverbal language, it is challenging
to maintain awareness and clear intention among healthcare pro-
viders (Eisenberg & Krishnan, 2018) thus leading to a diminishing
quality of interaction. Several studies exploring video-­mediated
communications in telemedicine reported challenges and uncer-
tainty among healthcare providers due to changes in communi-
cation flow and traditional clinical practices (Gomez et al., 2021;
Shankar et al., 2020). This may ultimately affect their overall accep-
tance and satisfaction toward telemedicine services. Considering
these challenges, exploring perceptions of social interaction within
video-­mediated communication increases insight into the relation-
ships, communication, and actions during telemedicine encounters.
This will provide increased insight into the type of the interper-
sonal competencies required for successful and sustained delivery
of care through telemedicine (Thomas et al., 2022). Presently, cli-
nicians are still exploring the interpersonal attributes required to
achieve effective communication and establish therapeutic rapport
to provide quality care remotely (Henry et al., 2017).
Interdependency and shared responsibility among the involved
providers exist as NH nurses provide vital information required for
remote physicians to make clinical decisions regarding residents'

INTERPROFESSIONAL COLLABORATION IN TELEMEDICINE
care. Exploring micro-­processes of interprofessional collaboration
and communication during telemedicine will contribute to the ex-
panding knowledge base around telemedicine usage and identify
future training needs to improve collaborative capabilities in tele-
medicine. To ensure longevity of telemedicine usage and quality in
NHs, optimizing interprofessional practice is warranted (Ransdell
et al., 2021; Tan et al., 2022). This study aims to explore NH nurses'
and physicians' experiences of interprofessional collaboration and
communication during teleconsultations. This is part of a larger
qualitative study investigating healthcare provider experiences in
long-­term care telemedicine use (Tan et al., 2022).
M E TH O D S
To obtain a rich description of the phenomenon of interprofessional
collaboration and communication between NH nurses and physi-
cians during telemedicine and present it through a comprehensive
summary, a qualitative descriptive study was rendered appropriate
(Neergaard et al., 2009). Interpretation of data is low-­inferenced
compared with other qualitative methodology such as grounded
theory and phenomenology. This enabled us to stay close to the data
and provide an accurate account of events. The study is reported
in line with the Consolidated Criteria for Reporting Qualitative
Research Checklist (Tong et al., 2007) (Appendix S1). Ethics ap-
proval was obtained from the National University of Singapore's
Institutional Review Board.
Setting and sampling
Our study site was GeriCare, a department in a tertiary hospital
providing teleconsultation services to NHs and its affiliated NHs in
Singapore. In this service, teleconsultations may be scheduled to ad-
dress changes in residents' clinical condition or provide follow-­up
after acute hospitalization (Low et al., 2020). During teleconsulta-
tions, one physician assesses an average of three to four residents. As
the physicians are not physically present in the NHs, trained nurses
are responsible for gathering relevant clinical information, preparing
case presentations, and performing physical assessments before the
session. During teleconsultations, nurses present the resident's case
to the remote physician, participate in discussion on the resident's
care, and perform physical assessments if required by the physician.
Purposive sampling was undertaken to recruit physicians at
GeriCare who had experience in providing geriatric teleconsultation
services to NHs. Recruitment was conducted through invitation via
telephone calls and electronic mail. Nurses from six NHs had already
been recruited in a previous study phase regarding their experiences
delivering teleconsultation services (Tan et al., 2022). Participants
were eligible if they (1) worked as a full-­time registered healthcare
provider with at least 1 year of working experience and (2) were phy-
sicians who had experience in providing teleconsultation services to
NHs or (3) were registered nurses who had experience facilitating
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1229
teleconsultations. None of the participants approached declined to
be interviewed.
Data collection
Individual interviews were conducted in English and transcribed
by one researcher (AT). Interviews were held on the Zoom vide-
oconferencing platform from July to November 2021 and lasted
30–­75 min. Semi-­s tructured guides were developed for both
nurses and physicians (Appendix S2) and were reviewed by both a
physician and a nurse who were experienced in providing telemed-
icine services to nursing homes. Recorded verbal consent was ob-
tained beforehand from participants to audio and videorecord the
interviews. All collected data were anonymized. During the data
collection process, the interviewer asked open questions and used
probing techniques to explore participants' general experiences
and interaction during telemedicine encounters. The interviewer
explored all possible leads from participant sharing to pursue data
saturation.
Data analysis
Thematic analysis was adopted to analyze the data (Clarke
et al., 2015). Thematic analysis was deemed as an appropriate
method of analysis to synthesize findings from both the nurses'
and physicians' interviews and highlight the similarities and differ-
ences of the data from both groups. The researchers familiarized
themselves with the raw interview data through multiple readings
of the transcripts. Initially, data were transcribed verbatim and
inductive, line-­by-­line coding was independently conducted by
two researchers (AT and CWL) to ensure minimal transformation
of data (Kim et al., 2017). Thereafter, AT, CWL, and LSY, a senior
researcher experienced in qualitative methods held two discus-
sions to crosscheck code groupings and develop themes. Iterative
recoding of data was conducted during the period of analysis.
Constant comparative analysis technique was adopted to exam-
ine similarities and differences between physicians' and nurses'
perspectives. The research team considered data saturation to be
achieved after no new codes or themes arose during multiple dis-
cussions. Final themes were reviewed by all co-­authors and agreed
upon.
The researchers were guided by Lincoln and Guba's (1985)
trustworthiness criteria throughout the study. First, credibility
was enhanced by having two researchers independently code
interview transcripts. Second, progress of code and theme de-
velopment was recorded in an audit trail using MAXQDA 12
software for dependability. Third, to enhance confirmability, an
iterative process of initial coding, discussing potential categories
and themes, looking for conflicting data, recoding the data, and
having further discussions for theme formation was undertaken.
Last, to ensure transferability, rich descriptions of the context in
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1230 INTERPROFESSIONAL COLLABORATION IN TELEMEDICINE

which long-­term residential care teleconsultations take place and
participant details were recorded.
R E S U LT S
Twenty-­t wo participants were interviewed (six physicians and six-
teen nurses) (Table 1). All physicians were trained to provide geriatric
care. The six NHs from which nurses were recruited included non-
profit organizations and one private NH. Nurses underwent telecon-
sultation training before being involved in the service.
Three main themes and six subthemes were identified that
framed the nurse–­physician relationship in the teleconsultation en-
counters: (1) Manner of communication in telemedicine, (2) sociocul-
tural influences in collaborative practice, and (3) role expectations.
Themes, subthemes, codes, and additional verbatim quotes are dis-
played in Table 2.
recognized the importance of building trust and rapport through ver-
bal encouragement, which was key to ‘give [nurses] more confidence
to take the lead in directing resident care’ (DR3). Nurses shared that
physicians used informal ways to communicate to them ‘like a friend’
(SN15), which made them less intimidated and furthered rapport build-
ing. As the nurses' frequency of facilitating teleconsultations increased,
they became more confident in communication with physicians:
The doctor, whenever we present, they will appreci-
ate us also. It really motivated and encouraged me to
present more cases to them. (SN15)
However, nurses described some unpleasant experiences with physi-
cians. They encountered physicians who expressed displeasure through
‘unsatisfied facial expression(s)’ or vocal utterances. During these sit-
uations, nurses felt frustrated, or as one participant described, ‘felt so
dumb’ (SN2), because they could not meet physicians' expectations.

Manner of communication in telemedicine Discordant communication styles

The participants adopted specific approaches to communicating
with each other through the telemedicine platform. This involved
informal communication and encouragement to build rapport.
However, certain differences in communication were identified dur-
ing the relaying of clinical information.
Building interpersonal relationships
Nurses and physicians focused on building interpersonal connections
and working partnerships with each other to ensure safe delivery of
care through teleconsultations. Both parties emphasized that mutual
understanding and trust had to be present for effective communica-
tion to occur during teleconsultations as physicians were not physi-
cally present and relied on nurses providing information. Physicians
As teleconsultations were conducted remotely, physicians de-
pended on nurses to provide pertinent clinical information for
decision-­making. However, collaborative interactions were impeded
by differences in the way information was relayed by the nurse to
the physician during consultation. While nurses were trained to fol-
low a structured format to relay resident information, physicians
had their own preference in the way the resident's condition was
communicated to them. Some physicians found nurses long-­winded
and preferred if they went ‘straight to the [resident's] problem’.
Consequently, physicians assumed control of the conversation and
nurses perceived this as an interruption to their communication of
information. One nurse mused that a physician ‘did not want to hear
stories about the resident’ and ‘did not provide much time to speak
up about his [sic] recommendations’ (SN13). Disjointed communica-
tion between both parties occurred:

TA B L E 1 Demographic data.

Demographic Physicians Nurses

Gender Male 3 Male 2

Female 3 Female 14
Job position Resident physician 4 Registered nurse 14
Consultant 2 Senior Registered nurse 2
Years of experience in geriatric 1 year 3 ≤1 year 4
teleconsultations 2–­5 years 2 2–­5 years 11
6–­10 years –­ 6–­10 years 1
>10 years 1 >10 years –­
Country of training Singapore 2 Philippines 13
United Kingdom 2 Singapore 1
Others 2 India 1
Malaysia 1
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INTERPROFESSIONAL COLLABORATION IN TELEMEDICINE 1231

TA B L E 2 Themes, subthemes, codes, and quotes.

Theme Subtheme Codes Quotes

Manner of Building interpersonal Mutual trust; trust and rapport ‘And it's all about trust right, so if I trust you to actually
communication in relationships give me a good history and you're very thorough with
telemedicine your clinical examination then I am going to take your
word for it. And generally, it's about building that
rapport, not just with the patients, but with the nurses
as well.’ (DR1)
Mutual trust; reliance on ‘The trust is very, very important. Because we do rely on
nurses' information for them to conduct the physical assessment, and to come
decision-­making up with the findings. Our clinical decisions rely on
that.’ (DR2)
Maintaining trust ‘That's why we try to give them a very legitimate kind of
assessment so that at least we will still maintain the
trust with the doctors, that our assessment is correct.’
(SN1)
Discordant Different way of approaching ‘It depends to the doctor… in our training we need to
communication teleconsultations report the background of the resident first before the
styles situation. But some of the doctors want you to tell the
situation first before the background.’ (SN9)
‘We notice some doctors, when we start to present, they
will just ask us to go straight away to the problem. In
our practice we always present step by step, following
the teleconsultation form. But this doctor always asks
to report the problem. So, we get stuck, and we feel
lost.’ (SN15)
‘Different doctors have different styles; they have
different personalities. The way they approach cases is
totally different.’ (SN16)
Adjusting to individual ‘Because of the long-­term relationship you have with the
physician's consultation nurses, they know your style of doing things.’ (DR4)
style ‘I think generally we have a certain structure when you
present a case, but some doctors… every doctor has
their own way of doing things la. And for the nurses,
its standard, as long as… it's a general skeleton but you
insert information here and there.’ (DR1)
Sociocultural Power relations Hierarchical culture ‘I think culture plays a part too. Some nurses from less
influences in developed countries… they don't dare to speak up
collaborative because they see the physician… they feel that cannot
practice speak casually…’ (SN7)
‘I have been to United States, I find that uh that ownership
is more… or that power is more equal? Whereas in
local and working with the nursing home nurses, they
sometimes feel that the doctors know best, but we
don't necessarily know best (laughs).’ (DR3)
‘Doctor knows best’ mindset ‘Sometimes, to be honest, I think nurses have the intuition
that the patient needs to go to hospital… but they are
just waiting for us (the doctor) to say so and give the
instruction.’ (DR4)
Language barrier Communication challenges; ‘I think a lot of the nurses who work in the nursing homes
strong accent, difficulty are foreigners. So language, sometimes. Can be a bit of
expressing oneself an issue.’ (DR1)
‘I need to know more… have better choice of words.
Sometimes I lose my words, I don't know what I'm
saying…’ (SN11)
‘The accent was very strong… It took a while… and there
was a lot of…’can I just clarify…’, ‘is this what you're
telling me…’ you know, ‘what you're trying to say’…
takes a while to get accustomed.’ (DR3)
(Continues)
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1232
TA B L E 2 (Continued)
Theme Subtheme Codes
Role expectations in Self-­imposed Performance stress
telemedicine expectations
Setting realistic Competency of nurses;
expectations expectations for physical
examination
Competency of nurses;
differences in training and
practice scope
A lot of newer nurses who present … they tell you
incidents that happen in 1992 since resident was
admitted … And I will ask, ‘So why do you want me
to see the patient today?’. Because you suddenly cut
their script they will be flabbergasted and say, ‘I don't
know’, and continue. Ultimately, they will just request
for a medication top up. For goodness sake, just tell
me you want to top up the medicine. (DR4)
The disjointed communication resulted in physicians taking on a
more active role in steering and shaping the conversation to convey in-
formation in a manner that suited their preferences. Nurses eventually
adapted to the ‘physician's style of doing things’ and that ‘became the
way the … [presentation] was done’:
When nurses start to present, they [nurses] jump in
… I pull them back and say no … Start with this, go on
to this and then tell me what the problem is. When I
keep doing that, they get into the habit of how they
need to present the case. (DR1)
Sociocultural influences in collaborative practice
The physician-­nurse relationship was also affected by sociocultural
factors such as asymmetrical power relations and language barriers
during teleconsultation encounters.
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INTERPROFESSIONAL COLLABORATION IN TELEMEDICINE
Quotes
The doctor will be disappointed if the nurse presenting
doesn't know anything. Waste both our time. (SN16)
‘They will question your answers like, “why do you think…”
and sometimes I cannot answer, because these are the
only data that we gathered and we really don't know
what else, but the doctor wants to know more. (SN2)
‘Uhh, as long as they know their facts. If they do not
know they can look up, it's fine. I don't have high
expectations… I don't expect them to be perfect.’
(DR5)
‘We just expect them to pick up things like wheezing…
that's quite easy, wheezing, crepitations… I don't
expect them to pick up heart murmurs. I mean you
can hear the murmurs, but don't have to decide which
valves…’ (DR6)
‘The examination for the abdomen I just need to make
sure it's not an acute abdomen, but I don't expect
them to tell me is it tinkling, is it this or is it that… (DR4)
But they are not trained in a more in depth as to like… how
do you use the signs to elicit and come to a diagnosis.
We can't expect them to give us the diagnosis of what
is wrong with the patient, but they can help us by
saying the patient is very uncomfortable, the abdomen
is vey soft, there are no signs of tenderness. (DR3)
Power relations
A sense of unspoken hierarchy and power imbalance between
nurses and physicians was identified from the data. Foreign-­
trained nurses expressed that they were not acclimatized to com-
municating with physicians in telemedicine settings back in their
home countries. This led to feelings of anxiety and fear of being
reprimanded:
I think I focused more on … what if they scold me?
(SN2)
Physicians echoed this sentiment, mentioning that nurses were
‘fearful of speaking up’, which reduced opportunities for shared
decision-­making:
Unfortunately, the Asian culture is about hierarchy. If
you look at Western countries, you are on an equal
platform. So that's where we need to get to. If you
want to work in a team, there cannot be a hierarchy.
(DR1)
Physicians called for nurses to take ‘equal ownership’ in
‘being the resident advocate’ (DR3). They acknowledged nurses
as valuable contributors as nurses had the most contact time
with the residents and were, therefore, more familiar with their
conditions.

INTERPROFESSIONAL COLLABORATION IN TELEMEDICINE
Language barriers
Another challenge in nurse–­physician online interactions was the
presence of language barriers such as differing first languages and
strong accents. It took repeated interactions for both parties to
get accustomed to each other. Physicians attributed this to foreign
nurses having varying training in their home countries. This impeded
mutual understanding during teleconsultations. This was supported
by nurses who admitted that they may not possess the language flu-
ency and medical terms required to effectively communicate the
residents' cases:
Some nurses are not from the traditional recruitment
source, so English might not be their first language.
They do speak English, but some terms we use may
be different, or the way we express it. It takes a while
to get used to how they report certain things. (DR3)
Role expectations in telemedicine
Nurses had much performance stress due to their self-­imposed
expectations and fear of disappointing the physicians. However,
physicians seemed to set realistic expectations in terms of nursing
performance during teleconsultations.
Self-­imposed expectations
Nurses expressed that they had to perform in certain ways to match
up to the expectations they perceived physicians' had for them, dur-
ing the teleconsultation. It seemed that nurses placed a lot of pres-
sure on themselves to be well-­prepared and have all the answers
that physicians needed as they wanted to ‘maintain the trust’ (SN1)
established with the physicians and prevent disappointment. This
resulted in increased feelings of anxiety, stress and self-­blame for
nurses in situations where they were not able to provide accurate
assessment findings or the information the physician requested.
Nurses perceived that their style of delivery and expressed confi-
dence to provide recommendations were also important factors to
engage the physicians and earn their right to be part of the clinical
decision-­making:
I felt so stressed when doing teleconsultations. My
assessment is lacking sometimes, then when doc-
tor asks question and I cannot answer, I feel very
ashamed. (SN12)
Setting realistic expectations
While physicians expected nurses to provide accurate clinical in-
formation, they were realistic in their expectations in terms of
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1233
assessments that could be performed within nurses' competency
and practice scope. The physicians had a common sentiment that
they did not expect the nurses to be able to perform higher-­level
physical assessment such as picking up heart murmurs or abdomi-
nal tinkling sounds. Although nurses were able to verbalize potential
causes of residents' presenting clinical conditions, physicians still
held the main responsibility in identifying a diagnosis through analy-
sis of the relevant medical history, laboratory investigations, clinical
presentation of the resident, and other vital information:
They are taught certain things to look out for, what
are the common, most probable causes … But we
have to understand that their training is not the same
as doctors’ training, so we don't expect them to …
they can come up with a probable diagnosis, but it is
our duty to run through the assessment, to clarify the
findings. (DR3)
Additionally, another notion that was put across was that physi-
cians may not fully understand what the nursing home nurses' roles
and capabilities are. For instance, one physician expressed that if
nurses were still inexperienced in teleconsultations, ‘the questioning
becomes even more thorough to tease out the details from the nurse’
(DR1). Due to the differences in competency levels and practice scope,
they shifted their expectations and adjusted their practice to elicit ap-
propriate and relevant clinical information to contribute to their clinical
decision-­making.
DISCUSSION
Our study findings revealed insights into the nurse–­physician rela-
tionship and collaborative practices during nurse-­facilitated geriat-
ric teleconsultations in NHs. Overall, nurses were acknowledged as
key players as they supplemented in-­person assessment and pro-
vided pertinent clinical information. The increased interdependency
between nurses and physicians was a main driver for relationship
building. Nurses were more receptive toward physicians who dem-
onstrated acknowledgment, and appreciation in teleconsultations.
Actions of mutual respect, trust, acknowledgment, and appreciation
for nurses which improves interprofessional cooperation with physi-
cians has been demonstrated in similar studies (Collette et al., 2017;
Müller et al., 2018). Additionally, informal talk between healthcare
professionals enhances rapport development, contributing to effec-
tive teamwork (Mitzel et al., 2021). Although interpersonal connec-
tions were developed through telemedicine, challenges in practice
differences, underlying sociocultural influences, and unaligned ex-
pectations between both parties influenced the nurse–­physician
relationship and collaborative practice.
The differences in practice and approach to the teleconsul-
tation was highlighted during the communication of resident in-
formation by the nurses to the remote physicians. This was not
a surprising finding, as healthcare professional education and
 |
1234
socialization into professional practices are mostly isolated from
other relevant disciplines (Meleis, 2016). Nurses and physicians are
immersed in their own professional culture and patterns of prac-
tice, which leads to ‘profession-­centrism’, a fixed worldview de-
veloped and reinforced through their training. The result is unique
and differing approaches to care, which poses as a hindrance to-
ward communication, trust and, therefore, effective collaboration
(Pecukonis, 2020). This was evident in our study, where physicians
were keen to gather objective data using targeted questions and
probing techniques from the start, while nurses were more inclined
to share further background details and on the NH residents, which
created friction in communication. While physicians may focus on
objective data and evidence-­based approaches to care, research
has shown that nurses tend to provide more anecdotal information
and communicate less assertively (Curtis et al., 2011). Additionally,
this communication mismatch may be further exacerbated because
of the lack of nonverbal cues when communicating via technology
(Barbosa & Silva, 2017).
Besides being accustomed to different professional practices,
the existing imbalance in nurse–­p hysician power dynamics had a
negative impact on communication within the relationship. The
expressed power imbalance could be attributed to the fact that
the majority of nurse participants in our study received nursing
training in countries where cultural attitudes of subserviency and
hierarchal status toward physicians are stronger than in Singapore
(Amudha et al., 2018). Being conscious of this belief could hinder
nurses' abilities to engage proactively and participate in decision-­
making regarding resident care. Nurses may choose not to assume
the role of patient advocate, self-­restrict, or withhold certain in-
formation from the physician because of concerns of overstep-
ping their professional boundaries (Susilo et al., 2022). On the
other hand, we realize that physicians were interested in build-
ing a more equal partnership with the nurses because they rec-
ognized the value of the nurses as the primary caregivers of the
residents. In the telemedicine context, nurses are telepresenters
and key contributors of clinical information for decision-­making.
Therefore, this reveals a pressing need to rewire physicians' and
nurses' role perceptions in delivering this service through champi-
oning partnership-­based communications. Further, due to differ-
ent training backgrounds and native languages of the international
educated long-­term care workforce (McGilton et al., 2016), nurses
struggle with assimilation and local healthcare professionals may
fail to demonstrate understanding of cultural differences toward
them (Balante et al., 2021). This is yet another obstacle in allowing
healthcare professionals to build relationships and form mutual
understanding, hence impeding the development of collaborative
practices (Hull, 2016).
The lack of alignment in physicians' and nurses' role expecta-
tions in teleconsultations was also evident. Physicians had existing
expectations set according to their perceptions of nurses' com-
petency and scope of practice, while nurses had their own set of
self-­imposed expectations. The combination of self-­imposed ex-
pectations in practice and uncertainty of physicians' expectations
15475069, 2023, 6, Downloaded from https://sigmapubs.onlinelibrary.wiley.com/doi/10.1111/jnu.12925 by Nat Prov Indonesia, Wiley Online Library on [18/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
INTERPROFESSIONAL COLLABORATION IN TELEMEDICINE
is known as a self-­reported stressor and poses a negative influence
on nurses' confidence in interprofessional collaboration (Pfaff
et al., 2014). Currently, many telehealth programs are nurse-­led
(Crouch et al., 2022). There is a shift in traditional roles and task
reallocation for this remote service. In teleconsultations, NH nurses
undertake a newly expanded role and greater responsibility in pre-
senting cases and performing more in-­depth physical assessment on
behalf of the remote physician (Tan et al., 2021). Thus, role clarifica-
tion is essential in interprofessional telemedicine training to ensure
awareness and understanding of work scope for collaborative read-
iness and clear team functions (Canadian Interprofessional Health
Collaborative, 2010).
The issues above reveal a need to reach a consensus on interpro-
fessional telemedicine communication competencies and develop
structured programs which are contextualized to the telemedicine
service. Farrell (2016) proposed embracing interprofessionalism by
establishing shared values and promoting an inclusive clinical cul-
ture in healthcare training. Crucial elements of interprofessionalism
that can be integrated into telemedicine training include discussions
around type of information exchange, clarification of values and
preferences, openness to options, preferred and actual choices.
Strategies such as adopting the use of standardized communica-
tion practices in telemedicine (Schmidt et al., 2021), or developing
customized reporting structures agreed on by the interprofessional
team may be included during the early phases of telemedicine ser-
vice implementation. These can be simulated with high-­fidelity pa-
tient encounters in clinical learning environments during the training
and induction of healthcare professionals for telemedicine services.
Additionally, while telemedicine is an excellent opportunity for in-
terprofessional care delivery across healthcare settings, it can also
contribute as a training platform. Using telemedicine platforms for
virtual cross-­training and brief team interventions involving role-­play
of case studies and adequate debriefing and reflection can improve
interdisciplinary communication skills and enable increased clarity
of healthcare team roles, and function (Hovaguimian et al., 2022).
Focusing on closing differences in profession-­centric and cultural
gaps and providing opportunities for collaborative interaction may
effect changes in patterns of professional interactions in the clini-
cal setting (Mahboube et al., 2019). Through integration of interpro-
fessionalism elements to foster open communication at the outset
of clinical training for interprofessional teams, the care setting can
reap benefits such as enhanced healthcare quality delivery, health
outcomes, and work satisfaction among healthcare professionals
(Berwick, 2019).
Next steps include formation of professional telemedicine
standards and related educational tools to ease workplace learn-
ing (Groom et al., 2021). Currently, a lack of interprofessional tele-
medicine competencies exist. Nochomovitz and Sharma (2018) and
Palesy et al. (2022) strongly suggest the development of collabo-
rative communication competencies and honing of interpersonal
skills in telemedicine as key inclusions in developing future curric-
ula for virtual care delivery. Developing appropriate competencies
and task expectations may smooth the collaborative process during

INTERPROFESSIONAL COLLABORATION IN TELEMEDICINE
teleconsultations as healthcare professionals gain clarity on their
roles, context of care and availability of resources, and execution of
respective clinical work.
Limitations
Only six physicians were interviewed because of the availabil-
ity of a small pool of key informants of geriatric physicians de-
livering teleconsultations on a weekly basis. However, important
insights were gleaned from their experiences, which were trian-
gulated with the data of nurses from multiple NHs to support or
dispute the experiences of interacting with one another through
videoconferencing technology. Additionally, only interviews were
used to understand the collaborative processes during teleconsul-
tation. Future studies could adopt multiple qualitative methods,
such as ethnographic observations or conversation or discourse
analyses, for richer insights into nurse–­p hysician interactions in
telemedicine.
I M PLI C ATI O N S FO R PR AC TI C E
Clinical leaders and educators may consider future development of
interprofessional telemedicine training programs that jointly involve
nurses, physicians, and other allied healthcare professionals involved.
In these telehealth training and curricula, cultural awareness and a
shared mental model of taskwork, team roles and structured com-
munication for telemedicine settings should be incorporated. This
promotes a shared body of knowledge and mutual understanding
between healthcare professionals during telemedicine encounters.
Additionally, creating opportunities for informal communication be-
tween nurses and physicians during small-­scale team training may
strengthen interpersonal relationships. Standardizing expectations
through interprofessional competency development for all healthcare
professionals involved may enhance understanding of individual roles
and responsibilities in this service and strengthen clinical partnership
in care provision.
CO N C LU S I O N
Interprofessional collaboration is integral to patient safety
and quality, especially so in telemedicine services where com-
munication may be affected by technological limitations. This
study presents findings which warrant the need to enhance
effective collaboration and communication of clinical informa-
tion between healthcare professionals during telemedicine en-
counters. As telemedicine programs are more readily integrated
into care delivery, development of interprofessional telemedi-
cine training and professional telemedicine standards is key to
contribute toward the normalization of this service delivery.
Future studies may include analyzing the complex dynamics
|
15475069, 2023, 6, Downloaded from https://sigmapubs.onlinelibrary.wiley.com/doi/10.1111/jnu.12925 by Nat Prov Indonesia, Wiley Online Library on [18/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1235
of communication and collaborative practices in telemedicine
services through other qualitative methods. The impact of in-
terprofessional collaboration on quality of care indicators may
also be explored.
CLINICAL RESOURCES
Interprofessional education and collaborative practice.
https://www.who.int/publi​c atio​ns/i/item/frame​work-­for-­actio​
n-­on-­inter​profe​ssion​al-­educa​tion-­colla​borat​ive-­practice
Core competencies for interprofessional collaborative practice:
2016 update.
https://ipec.membe​rclic​ks.net/asset​s/2016-­Update.pdf
Telemedicine for care homes implementation guide.
https://wesse​x ahsn.org.uk/img/proje​c ts/Telem​e dici​n e%20for​
%20Car​e%20Hom​e s%20Imp​l emen​t atio​n%20Gui​d e%20Pub​l icat​
ion-­15971​51168.pdf
Role of a telepresenter.
https://nrtrc.org/educa​t ion/downl​o ads/webin​a rs/2013-­S ep-­
Roleo​f theT​elepr​esent​er.pdf
AC K N OW L E D G M E N T S
We would like to express our gratitude to the nurses and physicians
who took valuable time to participate in our study. We would also
like to thank Elite Editing (Australia) for providing language editing
services for this manuscript.
F U N D I N G I N FO R M AT I O N
No funding has been received.
C O N F L I C T O F I N T E R E S T S TAT E M E N T
The authors declare no conflict of interest.
DATA AVA I L A B I L I T Y S TAT E M E N T
The qualitative data generated during and/or analyzed during the
current study are available from the corresponding author upon rea-
sonable request.
ORCID
Apphia Jia Qi Tan https://orcid.org/0000-0002-2422-1591
Wei Ling Chua https://orcid.org/0000-0002-4870-2728
Lisa McKenna https://orcid.org/0000-0002-0437-6449
Laurence Lean Chin Tan https://orcid.org/0000-0001-8835-7175
Sok Ying Liaw https://orcid.org/0000-0002-8326-4049
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S U P P O R T I N G I N FO R M AT I O N
Additional supporting information can be found online in the
Supporting Information section at the end of this article.
Appendix S1.
Appendix S2.
How to cite this article: Tan, A. J. Q., Chua, W. L., McKenna, L.,
Tan, L. L. C., Lim, Y. J. & Liaw, S. Y. (2023). Interprofessional
collaboration in telemedicine for long-­term care: An
exploratory qualitative study. Journal of Nursing Scholarship,
55, 1227–1237. https://doi.org/10.1111/jnu.12925