Author's response to reviews Title:Video-confidence: a qualitative exploration of videoconferencing for psychiatric emergencies Authors: Marianne V Trondsen (marianne.trondsen@telemed.no) Stein Roald Bolle (stein.roald.bolle@telemed.no) Geir Øyvind Stensland (geir.oyvind.stensland@unn.no) Aksel Tjora (aksel.tjora@svt.ntnu.no) Version:2Date:10 October 2014 Author's response to reviews: see over
To the Editor of BMC Health Services Research Dear Editor, October 10th 2014 for your invitation to revise and resubmit our manuscript (MS: 6556747421291272) entitled Video-confidence: a qualitative exploration of videoconferencing for psychiatric emergencies by Trondsen, Bolle, Stensland and Tjora to BMC Health Services Research, and for the constructive comments and suggestions for improvement from the four reviewers. We have now revised the manuscript in response to these comments, and hope it will satisfy the Editor and the reviewers. The revised manuscript has also been proofread by a professional, native-english-speaking editor to improve the written English. Please find enclosed our revision of the manuscript where we have addressed the comments of the reviewers, and in the following table we will give a point-by-point description of the changes made. for your continued consideration of the manuscript. Please let us know if you require any additional information or if we can be of any further assistance. Sincerely, Marianne Trondsen e-mail: marianne.trondsen@telemed.no Phone: + 47 41 51 07 92
Respons to the reviewers to the manuscript (MS: 6556747421291272) entitled Videoconfidence: a qualitative exploration of videoconferencing for psychiatric emergencies : Reviewer 1: Liam Caffery The authors present an good qualitative analysis on the use of video conferencing for emergency psychiatric consultations. The methods are appropriate. The interview quotes are used well to support the results. The conclusions are important for practice. The manuscript does need some editing to bring up to publication standard English. Authors response Minor Essential Revisions Material and Methods 1. Paragraph 2: The statement 'with very limited research evidence' should not be in the methods. This is justification for doing the study and should go in the Background section. (See Discretionary Revisions Comment 1) 2. Paragraph 3: Descriptive statistics about participants should be included in Results not Materials and Methods. 3. Paragraph 4: 'Because of the large variation regarding VC experience' this statement should be included in Results e.g. Interview varied in length form 34-80 minutes. Reasons for variation in length could be included in Discussion but not Results. This statement is used to argue for the explorative qualitative design of the study (not the theme of research as such) and therefore placed in the methods section. However, we have rewritten some sentences in the Background section (in paragraph 3, 4 and 5) to improve a more stated aim and justification for doing the study, to respond to the Comment 1 in Discretionary Revisions (see more details below) The paragraph 3 is not descriptive statistics on various actors and their use of VC, but an outline of inclusion criteria for participation in the study. We understand that this statement was confusing, and have rewritten the sentence and added more details about the interviews. The variation in length of the interviews was as expected in advance. We used interview-guides of different lengths to each of the group of interviewees (patients, psychiatrists and local health staff). For example, the psychiatrists had naturally been involved in far more VC consultations than the patients as well as the health staff, by working as an on-call doctor for the centres for 1-2 years. Psychiatrists and local health staff were also questioned about clinical, professional and organizational issues that were not included in the interviews with the patients. Based on deliberate differences in length of interviews, we found it adequate to describe the factual information about the interviews in the method section. The variation of the length was not a result of the study, but because of the design, and therefore included in the methods
section. However, we have now divided the description of the length of interviews in three parts, related to each target group to provide the information clearer. Results 4. Paragraph 1 belongs in the Background section not Results 5. Paragraph 2 'Especially this quotes from patient 3...'belongs in Discussion not Results 6. Paragraph 7 'The use of VC was therefore regarded...' belongs in Discussion not Results Discussion 7. Paragraph 1 is repetitive and should be removed 8. A Limitations sections should be included in Discussion. Conclusion 9. The authors draw a very interesting point 'This safety argument is of major interest, because it challenges the idea of frequent uses as a success criterion for technological innovation'. I believe this is a important finding of the study hence, should also be included in the Conclusion. 10. The authors state that 'VC may improve the confidence...' and 'VC can be used for building a decentralise...'. However, it is not just the technology ie.vc but the medical service that is important. The authors should rephrase e.g. 'an emergency psychiatric service delivered by VC' or ' a decentralised psychiatric service enable by VC' or similar How VC is used in relation to other technologies (like telephone) is part of the study and therefore in Results section. Quotes are normally presented in the Results section (quite often termed Analysis section) in qualitative interview-based studies. This structure makes sense because the analysis (results) is presented through the interview quotes and interpretation. Same argument as above. This paragraph is now removed. A limitation section is now included at the end of the Discussion. The safety argument is an important finding and now included in the Conclusion. We have rephrased these two sentences. Discretionary Revisions 1. I believe the paper could be improved with a We have rewritten the paragraph 3, 4 and 5 in more clearly stated aim and justification. the Background section to improve a more clearly stated aim and justification for doing the study. In accordance with yours suggestion, we have also removed the sentence Both in psychiatric and somatic medicine,. (Comment 3 below) from the Discussion to the Background. 2. I believe it is better in scientific publications We have replaced the word mentioned with
to use the word reported rather than mentioned e.g. some of the psychiatrists reported... 3. The sentence 'Both in psychiatric and somatic medicine, these are characterised by complexity, uncertainty...' is included in the Discussion section. This sentence provides clear and strong justification for performing the study and may be better used in the Background section.(see Comment 1 above) Minor issues not for publication 1. videoconferencing and video conferencing is not used consistently Abstract 2. paragraph 1: to areas with lack of psychiatrists -> to areas which lack psychiatrists or to areas with a lack of psychiatrists 3. paragraph 1: I believe the use of 'situations characterised by uncertainty' should be omitted from abstract or put in a separate sentence 4. paragraph 3: I believe the use of 'also when VC is not used' should be omitted from abstract as it causes confusion. reported, said, emphasized e.g. We have removed the sentence to the Background (see our answer to comment 1 above). We are now using consistently videoconferencing. We have omitted this part of the sentence. We have rewritten this sentence. deinstitutionalisation not used consistently 8. paragraph 3: regarding to consult a psychiatrist is not clear and should be restated. Level of interest: An article whose findings are important to those with closely related research interests Quality of written English: Needs some language corrections before being published Statistical review: No, the manuscript does not need to be seen by a statistician. Background 5. paragraph 1: out-patient -> outpatient 6. paragraph 1: day-treatment -> day treatment 7. paragraph 1: de-instituionalisation and We are now using consistently deinstitutionalisation. We have restated the sentence in paragraph 3. Reviewer 2: Natalie Bradford The title is informative and clear Abstract The abstract is concise. I found the statement in Authors response.
results regarding finding number 4) as a safety net, also when VC is it used a little confusing in the abstract. I was unsure from the abstract how it could be a safety net if it was not used. Perhaps for the abstract it may be easier for the reader to allude to the use of the safety net of VC and leave the explanation of it being a safety net when not used for the main text. Background The background is well structured and presents the justification for the analysis of emergency psychiatric care via VC well. Methods The methods used are clear and appropriate to answer the research question. The authors have presented the research undertaken in line with many of the COREQ guidelines (guidelines for reporting qualitative research)., although now specific mention is made of adhering to these guidelines, and some items in the guidelines checklist have not been addressed. Results The results are informative and plausible. The illustrative quotes used highlight are appropriate and highlight the results. Discussion The discussion is well structured and provides a nicely rounded reflection on the findings in this study which are supporting by the data. The authors clearly acknowledge the work they are building upon and provide indications of areas for further research. Minor essential revisions There is no limitations section in the manuscript. This should be included at the end of the discussion. Discretionary revisions The abstract could be modified as suggested above. The authors could present the findings according to the COREQ guidelines. While the writing is acceptable, there are some grammatical errors which are likely due to English being a second language. However We have rewritten the statement in number 4, and hopefully it is now clearer.. The article is authored by an interdisciplinary team of experienced researchers, from medicine and the social sciences. While consolidated criteria for reporting qualitative research are useful, especially the social sciences do report such studies without COREQ. A limitation section is now included at the end of the discussion. See argument above (methods).
these errors do not detract from the meaning or readers understanding of the manuscript. Reviewer 3: Peter Yellowlees Major revision 1. There is a lot of repetition between the results and discussion section on the major findings - suggest that the results section be focused only on the actual data, and that discussion of the implications of the data be in the discussion section. Doing this will considerably shorten and focus the paper making it stronger. The authors might like to consider putting the quotes in a separate table under the four main themes that they discovered. 2. A natural English speaker should review the paper as there are many linguistic improvements that could be made throughout to improve the readability. Level of interest: An article of importance in its field Quality of written English: Not suitable for publication unless extensively edited Statistical review: Yes, but I do not feel adequately qualified to assess the statistics. Authors response Repetitions between the results and discussion section are removed (for example paragraph 1 in the Discussion). To be able to tie analytical interpretations to empirical details based on the qualitative approach, quotes need to be placed in the floating text. The article is based on a qualitative study drawing on interviews, and there is not used statistical data. Reviewer 4: Chi-Wai Lui Authors response Major Compulsory Revisions 1. The conclusion the authors drawn is not consistent with the aim of the study and also not supported by the findings. It needs to be tune down and revised. The use of VC may have increased confidence in the 4 dimensions as suggested by the authors. It is however a big jump to claim in the Conclusion that 'Use of VC can also strengthen collaboration... increase their competence... This study therefore suggests that VC can be a tool to ensure quality in a decentralised psychiatric service for emergency care.' The authors seem to treat 'confidence' and 'competence' or 'quality of service' as equal, which are not the same thing. We have now rewritten the Conclusion to make it clearer and consistent with the aim and the findings. 2. The paper will be strengthened if further Even with a difference in basic training, the two
details regarding the 19 health staff participants are provided. The readers were told this group consists of specialist nurses and social educators but their role (and contexts) in using the VC technology is unclear. Having this information (and how VC is actually conducted in the emergency practice) will increase our understanding of how the technology helps reduce uncertainty/develop shared responsibility among the staff members. It will also be good if job title (nurse, educator) is specified in quotes of the staff. 3. Related to point 2, the authors argue that one of the 'main mechanisms generating stronger confidence' they identified is the 'use of VC for collaborative problem-solving across professional levels' (third paragraph of Discussion). However, their discussions on how VC facilitates collaboration or shared responsibility on decision making remain a bit thin. Further elaboration on these points with concrete examples will substantially improve the quality of the paper. Minor Essential Revisions 1. The authors suggest data analysis 'followed a stepwise-deductive inductive (SDI approach' (second paragraph of Data Generation and Analysis). The inductive angle of the methodology is clear but the 'stepwise-deductive' component needs more elaborations. 2. Further explanation is needed on why 'the four themes in our analysis are related to various aspects of confidence that are not related to technical qualities' (the seventh paragraph of Discussion). Not sure why the first three aspects of confidence have nothing to do with technical qualities. 3. The meaning (and their relation to the findings of the study) of the last few sentences in the last paragraph of the Discussion section is unclear: 'While health service provision is becoming more interdisciplinary... when handling especially vulnerable mentally ill patients'. Need further elaboration and explanation of the claim made here. 4. Abstract: Results section, point (4), 'as a safety net, also when VC is not used'. Will it be better if 'ALSO' is replaced by 'EVEN'? [Same issue in second paragraph of the work categories «specialist nurses» and «social educators» perform the same work. After further consideration of translation of the Norwegian job titles, we have decided that the word «nurse» best translates the competence and tasks performed by the health staff at the regional psychiatric centres. We have therefore changed the paper accordingly, and hope this helps to reduce the possibility for confusion. We found the use of VC for collaborative problem-solving across professional levels as a part of our findings. We have elaborated on to make it clearer that it means collaboration between psychiatrists in the on-call system and the nurses at the regional centres. We have also added a sentence to this paragraph referring to previous studies which explains this in more detail and with more examples. The stepwise-deductive control strategy of SDI is elaborated on. The formulation is edited. The argument is elaborated on. We have rewritten this statement and the word also is replaced by even.
Results section] 5. Background: first paragraph, 'Maintaining life in patients own community...' should be 'PATIENTS' own community...' 6. Background: third paragraph, delete 'with' from 'advanced consultative services to areas with lack of psychiatrists'. 7. Material and Methods, first paragraph, '2,5 to 4 hours away...' should be '2.5' or...? Level of interest: An article whose findings are important to those with closely related research interests Quality of written English: Needs some language corrections before being published Statistical review: No, the manuscript does not need to be seen by a statistician.