Safe and Effective Video Consultations

Safe and Effective Video Consultations A guide for C&I staff on clinical skills and best practice when undertaking online video consultations with service users Dec 2020

Video consultations are consultations with our service users delivered via video technology. This allows patients to receive a face to face consultation without being in the same place as the clinician.

The Trust uses several platforms for video consultations, but our preferred platforms are Attend Anywhere for one to one consultations and Microsoft Teams for group sessions.

Since video consultations were introduced across the Trust in early 2020; largely due to the Covid 19 lockdown, we’ve seen a significant uptake and increase in the number of consultations being held online.

This e-booklet has been compiled by clinicians for clinicians to provide some useful tips and information when conducting your video consultations. Primarily it has been produced to help with one to one video consultations.

MORE INFORMATION For a service user’s view of Attend Anywhere, why not watch this short YouTube video here Check out our useful flow chart which will indicate whether to use Microsoft Teams or Attend Anywhere.

For further information on video consultations, please contact clinical.applications@candi.nhs.uk

Index Training 4 Attend Anywhere

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Before your first video consultation

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Setting up your environment and your tech

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First session

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Guidelines for greeting and setting the scene Other considerations

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Managing your video consultation

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Managing risk 8 Other points to note 8 Disinhibition 9 Screensharing 9 Chat function 9 Inviting another colleague to join an Attend Anywhere video consultation 10 Checking to see participants in an Attend Anywhere consultation 10 Tech troubleshooting 10 Service user trauma or distress 11

Subsequent sessions with same service user

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Finishing the call

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Following your video consultation

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Further help and resources

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Training Attend Anywhere (AA) is an NHS endorsed video consultation service for one to one consultations.

Benefits of the service include: SERVICE USERS • May feel more comfortable / safer / relaxed than in an NHS setting • Less stigma than arriving at clinic and sitting in waiting room • Safety of distance might allow certain affective states, which are usually withheld, to emerge • May be easier for service users to attend than facing transport and travel to onsite location

CLINICIANS • Video consultations can help optimise your time • Client’s physical background/ environment can provide you with insight into their life • Client may be more relaxed, more open and honest in their own environment Attend Anywhere training can be held online and generally the training session for one person will take between 15 and 30 minutes.

For details on our online Attend Anywhere training Click here Those in the iCope team use IAPTUS to help support video consultations. For more info please speak to your Manager.

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Before your first video consultation SETTING UP YOUR ENVIRONMENT AND YOUR TECH • Ensure your environment is clear/tidy and adequately lit • Set up a suitable background image (this is available on MS Teams see here for info on how to set this up) • Ensure that camera angles are clear and ensure that the viewer has a clear image of you (preferably from the waist up) • Ensure that your internet connection is working and test logging in to the video platform chosen for the consultation • Ensure that your internet connection speed is suitable from your location for the platform (preferably, fast broadband or WLAN) • Ensure that you have the right technology in place adequate peripherals such as webcam, microphone) Remember Attend Anywhere works on the following browsers: – Chrome or Safari for those on Apple device – Chrome on a PC – Attend Anywhere does not work on Internet Explorer • If working remotely, ensure technology meets required standard and there is read/write access to the clinical record system • Make contingency plans for what to do if video link fails e.g. clinician will contact service user by phone • Ensure your team have the necessary training and are competent, including any ‘dummy’ consultations in advance, to test the process • Ensure that there is a clear process for updating and cancelling any consultations with service users, for instance, if you are unexpectedly unable to attend eg due to illness.

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First session GUIDELINES FOR GREETING AND SETTING THE SCENE • At your first session with a service user, it’s good to initiate the conversation by calling or inviting the patient to say something such as. ‘can you hear me?’ or ‘can you see me?” to prompt your service user to optimise the technical set-up, then continue with the following; • Your name and role at C&I Trust • A short explanation of the use of video consultations, ie why you’re using this, how it will work from the service user’s point of view and what your service user should do in the case of any technical problems (see page 16 for info guides for service users) • Confirmation on how long the session is likely to take • An explanation as to how you will manage any questions and needing to take a break?

• Confirm the service user’s identity (e.g. if not known to you, ask name and date of birth) • Advise your service user should you expect to type up notes during the session, (eg explain to the service user that they may hear a keyboard in the background during the session) • Confirmation of a suitable telephone number to call the service user on in case of any technical issues online • We assume consent if a service user is attending a video consultation, but would suggest reaffirming this to check they are still keen to go ahead with the appointment • Introduce everyone in the room (even those off camera), and ask patient to do the same or confirm that they are alone • Reassure the patient that the consultation is likely to be very similar to one in person, and that the call is confidential / secure • It’s important to confirm that both parties agree not to record the session/take photographs unless asked for and both in agreement • If there is a valid reason for recording the session (eg supervision), this must be explicitly consented and documented by both parties.

Speak to your team manager to access the correct Trust approved consent form, which you will need to upload in the Electronic Patient Record

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• Enquire and reassure about how the service user feels about being on camera. If they are self-conscious, it may be a good idea to suggest that they turn off their camera, so they don’t see their own image. They may wish to do so some way through the session – or alternatively they could place a sticker over their own image on the screen Essentially, a video consultation should follow the same format and etiquette of a face to face consultation, hence ensure that you greet your service user as you would normally during a face to face consultation.

OTHER CONSIDERATIONS • Make sure that you are on time for the consultation • Keep in mind your background, particularly if you are holding the consultation at your home (see ‘setting up’ section on page 5) • Ensure your mobile device is on silent (disable notifications) • Close other popups, programmes and emails on your PC or laptop for duration of session to avoid accidental screensharing of sensitive information • Inform the service user when you are otherwise occupied (e.g. taking notes or reading something on another screen) • Make written records as you would in a standard consultation

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Managing your video consultation MANAGING RISK • It’s good to discuss this with your service user, for instance – how they should let you know if they are not feeling safe or need a break eg they could use a hand signal or ask your service user to use the chat function if they cannot speak aloud • Check with your service user that they have a safe and comfortable space to undertake their video consultation and check if they will have access to this for any future session/s • It’s important to reassure on interruptions and how these will be handled, eg – in the case of the clinician (eg called away for an emergency) – in the case of the service user (eg their partner or family relative walks in during the video consultation) • Options could be to halt the call for a few minutes and redial in at an agreed pause of 5 or 10 minutes. There could be additional agreement that if the interruption extends beyond a certain amount of time, then the video consultation will be rescheduled due to lack of time • It may be that you wish to set up a code word to be used by your service user should they find themselves in an intimidating situation during their video consultation.

OTHER POINTS TO NOTE • Nonverbals can be a useful pointer when gauging the wellbeing of a service user, just as in a face to face consultation. Remember that the service user will be following your nonverbal pointers too, so be mindful when on screen with body language, tonality of voice, posture etc.

CLINICIAN TIP Remember the three C’s; confidence, competence, and consent. Preparation is key so ensure you feel confident in holding a video consultation (eg by holding a simulation session beforehand with colleagues) and you feel competent in managing the technology.

Ensure your service user feels at ease and is comfortable with the facilitation of an online session.

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• Pauses in conversation may be more frequent, depending on connection • Using an online format for a meeting; it’s likely that you may talk over each other. This is to be expected • The amount of eye contact may be a little different in an online setting • Also remember that a lot of non-verbal information may be missing, due to the online nature of the session, eg image blurry, incomplete body on view, or no image at all, sound is delayed etc

DISINHIBITION Disinhibition is a lack of restraint manifested in disregard of social conventions, impulsivity, and poor risk assessment. When handling disinhibition in a video consultation setting, this could be important in the context of setting the right conditions for the session to take place.

This should be a conversation to have before a session, but may well be a conversation during a session, as well. Pointers could include: • Encouraging the service user to be dressed appropriately, (eg ensuring that they are dressed for the session and not in pyjamas or bathrobes), positioned appropriately and within a space where they can talk privately (where possible) without distractions – as if they were attending a session face to face • Having a direct conversation with the client about the boundaries of what is appropriate, i.e. is it ok for the client to: – smoke/vape during a session (for instance in some settings, but certainly not in the case of doing trauma work and dissociating, which could be a fire hazard if the cigarette falls somewhere) – drink during the session eg tea and coffee to calm their nerves but not consuming alcohol

SCREENSHARING If you wish to share your screen during an Attend Anywhere video consultation, see our useful guide here

CHAT FUNCTION You’ll know, from attending a Microsoft Teams meeting, that there is a ‘chat’ function on the right-hand side of the screen, which is visible during a meeting. There isn’t a ‘chat’ function in Attend Anywhere, but clinicians can send messages to service users waiting in the waiting rooms. See guide here.

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INVITING ANOTHER COLLEAGUE TO JOIN AN ATTEND ANYWHERE VIDEO CONSULTATION Here’s a useful guide on inviting a participant to your Attend Anywhere video consultation

CHECKING TO SEE PARTICIPANTS IN AN ATTEND ANYWHERE CONSULTATION Before joining a call, please ensure you are entering the correct consultation, as there may be other on-going consultations or callers with the same name as your client in the shared waiting room. You can check who is currently in a consultation by clicking on the ‘Participants’ tab, as seen below.

John

John...

John Smith (Provider)...

TECH TROUBLESHOOTING Here’s a useful guide for handling Attend Anywhere technical issues here If you still experience problems using Attend Anywhere, then please email the team at clinical.applications@Candi.nhs.uk Options in case of technical difficulties • Give it 5 mins and redial into the call • Aim to telephone the service user if you experience persistent issues • Suggest the service user emails you if they have any issues • Consider changing the bandwidth of the consultation, and also switch off video if needed (switch off camera and use audio only)

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SERVICE USER TRAUMA OR DISTRESS If your service user becomes distressed, angry or confrontational during the video consultation, you will need to use the skills and training you’ve developed for handling those situations in a face to face ‘live’ consultation.

Remember in a video format: • Your tone of voice can help de-escalate a distressed and angry service user. This is referred to as the ‘emotional contagion effect’, where your emotional state can affect how another person feels. If you approach a distressed and angry service user, raise your voice and use a forceful tone, you run the risk of escalating the service user distress and anger • Remember to try and reassure by using their name in your responses • Once you notice significant changes in your service user’s behaviour, it’s best to prepare by detaching yourself from the situation. Keeping cool will let you answer their questions as best as you can and can help avoid further comments or anger • Practice active listening; sometimes, service users get angry because they feel like they’re not being heard or understood. The best way to combat this is through active listening, so for example, listening to what they have to say, and repeating it back to them to demonstrate that you do, indeed, hear and understand them • Acknowledge rising frustration with verbal and non-verbal cues. On a video call, this will include the use of providing positive statements and encouragement • Get support; dealing with difficult service users sometimes requires backup, and there may be instances where you need to ask a colleague to join you on the call • Encourage the service user to ground themselves, e.g. Ask them to feel their feet on floor, where they are sitting. Ask them to describe their environment (e.g. the room they are in) • Ask service users to name: 5 things you can see - 4 things you can touch - 3 things you can hear - 2 things you can smell - 1 thing you can taste • Breath with them by stating for example, ‘Let’s take some slow deep breaths together’ • If service user sounds confused and disoriented remind the person that they are speaking to you, that they are safe and that nothing bad is happening. Remind them of the date e.g. ‘It’s Thursday the XX November 2020’ • For more grounding strategies, see here

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If the service user becomes angry • Remain calm and non-defensive – avoid confrontation • Let the client ventilate feelings (e.g. around technical difficulties or otherwise) and acknowledge their feelings: ‘I understand that you are feeling really frustrated’ • Encourage problem solving and offer reassurance • If service user becomes aggressive/abusive towards staff, explain that meeting can’t continue without cooperation • If impossible to continue, end call and postpone in non-judgemental way

If you become concerned for the service user’s safety • Ask about client’s safety – is someone at home with you?

• Encourage them to reach out for support at end of call. Ask: – Who/what makes you feel better when you’re upset?

– What could you do after the session to calm down (e.g. engaging in a soothing ritual, go for a short walk, listen to a piece of music, watch a distracting video)?

• Make sure service users are in possession of crisis numbers • Make a plan to call back and/or review crisis plan • Discuss any issues with your line manager/clinical supervisor • See section on managing risk page 8

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Subsequent sessions with same service user These may be easier as you have already ‘met’. It would be worth reiterating some of the points mentioned in the ‘first session’ page 6.

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Finishing the call • Be particularly careful to summarise key points, since it’s possible something could have been missed due to technical interference • Ask the service user if they need anything clarified • Indicate clear ‘next steps’ (eg another appointment, medication, prescription etc) • Confirm (and record) if the service user is happy to use video again • Inform them of the anonymous link to a short online user survey that will appear on Attend Anywhere afterwards and that feedback is greatly welcomed • Say goodbye (before closing the connection) • If you leave a Microsoft Teams meeting before the end of the meeting and no longer wish to receive the Teams chat messages taking place after you’ve left, here’s how to leave a meeting chat room: can; – To leave a meeting chat room – Click the Chat icon on the left side of your Teams window.

– Find and click on the desired chat / meeting room.

– Click the Participant icon at the top right, then from the menu that appears, select Leave.

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Following your video consultation • Ensure any notes are shared with relevant clinical colleagues and entered onto relevant clinical applications • Ensure that the call has actually ended (the connection is not live) • Ensure any follow up video sessions are booked into relevant calendars

CLINICIAN TIP Put a reminder sticker next to your webcam to remind you to make eye contact with the camera

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Further help and resources Video consultations – guide to an online session for service users here Video consultation page on the Trust’s intranet site here Here’s a useful document on supporting digital inclusion in services users together with an informative and reassuring one-page document for you to share with your patients which outlines how to prepare for an online session.

We held an all staff webinar on 11 November about video consultations. Our guest speakers were Dr James Woollard, the National Specialty Advisor for Digital Mental Health at NHS England, and Dr Laurine Hanna, Consultant Psychiatrist and CCIO at C&I. Here are the questions raised by staff during the webinar, together with answers here Here are the notes from Dr Woollard, which give an interesting insight into the use of video consultations across the NHS in the UK.

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WHAT OUR SERVICE USERS ARE SAYING ABOUT THE USE OF VIDEO CONSULTATIONS Here are some comments generated via our service user questionnaire.

I am so grateful for this service; it has truly made such a difference to my mood and my life.

I think that the online system works really well and will continue to do so after the pandemic.

During lockdown, I didn’t have to take time off to attend CBT and it still meant that I was able to get lots of help remotely. Thanks!

Always feel so much lighter after speaking to the clinician, never any problems with sound or picture so makes the video consultation stress free and easy.

The clinician was really kind and approachable and makes it very easy to talk to him.

The service was also really easy to use.

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