Training primary care staff in delivering the primary care consultation remotely: a systematic review

Background Remote consultation is widely used in primary care, and its use has increased greatly since the onset of the COVID-19 pandemic. Despite this, primary care clinicians lack formal training in delivering remote consultation. There is a need to understand how training might best be delivered, and what evidence there is to support this. Aim To summarise existing published literature about training primary care staff in conducting primary care consultation remotely, to outline which models of training may be effective, and to identify unanswered questions for future research. Design & setting Systematic review of English language studies in primary care included in Medline (Ovid), Cochrane Database, PubMed, Embase (Ovid), Web of Science, and CINAHL from 2010–2021; and in Google results from 2010–2022. Method Databases were searched using a predefined search strategy. Title, abstract, and full-text screening was conducted to identify eligible studies for inclusion in the review. The quality of included studies was assessed, and findings were synthesised to answer the research questions. Results We included 10 studies. Seven examined training on remote consultation with trainee GPs or residents, and three examined training on remote consultation with qualified primary care clinicians. Training described led to positive change overall, including increased confidence and self-efficacy in delivering remote consultations. Furthermore, trainees reported increased use of remote consultation, increased efficiency, and increased engagement from patients. Studies where training involved workshops or didactic learning alongside experiential learning resulted in more positive feelings and more confidence about how technology could aid consultations. Conclusion There is limited evidence on training primary care staff in conducting remote consultation. Available evidence indicates that training has a positive impact on the ability of clinicians and staff to deliver remote consultation.


Introduction
Telephone consultation is an established means of delivering consultations to patients in primary care settings. 1,2Its use has increased dramatically since the onset of the COVID-19 pandemic, 3 making appropriate training in remote consulting vital to ensure adequate patient care is delivered.][6][7] Primary care staff are required to organise and deliver remote consultation, and while written support has been developed, 8,9 a lack of formal training has been identified as a barrier to successful implementation and use of remote patient consultation. 4,10,11ithin postgraduate medical training, consultation skills education has focused on face-toface consulting. 12,13By contrast, medical schools are increasingly training students in using remote consultation. 14Primary care clinicians are expected to train medical students in delivering remote consultation 15 despite not necessarily being supported to develop these skills.There is likely a knowledge gap for the cohort of primary care clinicians currently training and practising.Some steps have been made to integrate remote consulting into more specialised training, including supervised clinics, training days, and standardised guidance. 16,17Work on this integration is limited, however, and more understanding of primary care clinician training is needed.
Local, national, and international guidance on remote consulting has emerged from the COVID-19 pandemic. 8,9,18Although this guidance can assist primary care clinicians, it is not a substitute for official training, and may not be evidence-based.As the demand for staff training in primary care increases, we conducted a thorough analysis of empirical research.The objective of this review was to provide an overview of effective training models for primary care staff in conducting remote consultation, and to highlight areas that require further research.

Method
This systematic review was conducted following a predefined protocol (unpublished).The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in reporting. 19

Inclusion and exclusion criteria
This study focused on primary care, and included any primary care staff as participants.Training related to conducting remote consultation, including telephone, text, video, or email communication where patients were examined.
Empirical studies of any design, including unpublished research, was included.Review articles, conference abstracts, discussion and commentary articles, and letters were excluded.
We included studies published in English from 2010 onwards, owing to low level of remote consultation use with patients in primary care before this date.Studies that were conducted in nonprimary care settings, or those that focused on student training, were excluded.

Outcome measures
The review explored models of training and the content of curricula.Outcomes relating to training (type, provider, participants, completion rates), effects on healthcare professionals (impact on confidence, practice, satisfaction with training) and health service-related outcomes (impact on levels of remote consulting) were examined.

Information sources
The following electronic databases were searched in December 2021: Medline (Ovid), Cochrane Database, PubMed, Embase (Ovid), Web of Science, and CINAHL.Additionally, Google was used to search for eligible published and unpublished studies in June 2022.Reference sections and citations of included studies were screened to identify further eligible studies.

Search strategy
Search terms for the main search strategy included all terms relating to 'remote consultation,' 'training', and 'primary care'.The full search strategy can be found in Supplementary Box S1.
We searched the first 100 results in Google for studies using a combination of terms.Search one was for the terms 'general practice', 'remote consultation', and 'training'.Search two was for the terms 'primary care, 'remote consultation', and 'training'.

Data management and screening
Search results were combined and duplicates eliminated using Endnote X9 and Covidence software.Eligibility of studies was assessed by screening titles and abstracts.Studies that met the inclusion criteria were further screened by full text by two researchers.In case of discrepancies, a third reviewer was consulted.Relevant data were collected using a data extraction template.

Outcomes
The outcomes of interest were training (type, provider, participants, completion rates), effects on healthcare professionals (impact on confidence, practice, satisfaction with training) and health servicerelated outcomes (impact on levels of remote consulting).

Quality assessment
We assessed quality of the included studies using the Mixed Methods Appraisal Tool (MMAT) 2018, 20 appropriate for studies using a range of methodologies.Each study was assessed using five assessment points, and given an overall quality rating (for contextual purposes) based on the number of positive or negative scores received.Studies achieved an overall rating of high quality if four or five criteria were met, moderate quality if three criteria were met, and low quality if two or fewer criteria were met.

Data analysis
Included studies were analysed using narrative synthesis owing to their heterogeneous nature, enabling those with different designs to be analysed systematically, with similarities and differences being considered. 22etails of included studies and analysed outcome data were grouped according to characteristics and, where possible, into themes.Findings are presented using text and tables, with results of the quality assessment presented alongside to contextualise the synthesis.

Results
In total, 1382 results were screened, resulting in the inclusion of ten studies in the review.The screening process and numbers and reason for exclusions can be found in the PRISMA flowchart (Supplementary Figure S1).
Seven studies examined training on remote consultation for trainee GPs or residents, 23,[26][27][28][29][30][31] while three examined training of fully qualified primary care nurses. 24,25,32Participants were at varying stages in their careers and presented a heterogenous sample for analysis.

Training style
The articles presented a range of training styles.Six studies 24,25,27,[29][30][31] collected data after implementing workshop or didactic learning followed by experiential learning, using either real or simulated patients.In contrast, two studies 23,32 involved training with no practical elements attached, and the remaining two 26,28 collected data either after an assessment of a remote consultation (as a workplace-based assessment or observed structured clinical examination [OSCE]) or after experiential learning without any previous teaching.Not all articles clearly stated whether their training, particularly with didactic elements, was online or in-person, and there were no consistent training methods between them (see Supplementary Table S2).

Impact on healthcare professionals
All ten included studies report outcomes relating to healthcare professionals following training for remote consultation.Six studies reported increased confidence and self-efficacy when delivering consultation remotely, 23,24,27,30,31,33 including improved knowledge of technology use. 23,33Participants reported positive responses about training on remote consulting across all studies; however, some highlighted that further training was probably needed. 27,29here was a heterogenous sample of trainees across and within articles, but many focused on preparedness for independent practice and confidence in remote methods.Only one article 26 explored UK GP trainees' experiences of training in remote consulting, solely telephone consulting, and highlighted the experiential nature of current training with assessment primarily through workplacebased assessments.Senior trainees reported more positive experiences with remote consulting, but all agreed that further training was needed.
The US studies employed a wide range of educational methods across diverse trainee groups and differing consultation modalities.Two articles did not state which year groups were examined, 23,28 and one compared OSCE outcomes between postgraduate year 1 and 3 trainees after training (no discernible differences were identified). 29There was a wide range of remote consulting modalities for, with one study focusing on email only, 23 and the rest a mixture of synchronous and asynchronous consulting.29]31 In one study, residents' rated competence in remote consulting increased from 2% (n = 2/89) to 41% (n = 24/58) after training. 31Many studies, however, reported a need for further training.
Three studies explored outcomes for a mixed sample of primary care nurses across varying consultation modalities. 24,25,32Two UK-based studies 24,25 evaluated outcomes for nurses in band 6 and advanced practitioner roles, but did not differentiate between the groups, with one focusing on consulting with patients with respiratory conditions. 25Across all three studies, training focused on electronic written communication with patients, either through a web-based platform or an app, with the addition of video consulting in the UK articles.
Training improved reported knowledge of remote consulting, with median knowledge rated immediately after training increasing from 2.9 to 3.7 out of 5. 32 Nurses reported that training in, and subsequent use of, remote consulting was beneficial for use with patients and improved care. 24,25

Type of training
The studies assessed a wide range of training and pedagogical methods, including didactic teaching, workshops, and online learning.However, there was inconsistent delivery and lack of clarity within the studies.Two studies referenced online learning, one lecture-based learning, and the other 'modules' with associated discussion forums. 23,31Other studies described 'didactic small group sessions' but lacked details on their delivery. 27,30,32Additionally, the amount of teaching varied from one-off sessions to a 3-year curriculum, and experiential learning ranged from simulation to real patients at different stages of training.
0][31] Those studies that employed only one type of training (that is, lecture-based or experiential) particularly highlighted knowledge gaps and a desire for further training. 26,28,29In one study, after receiving lecture-based training, more participants stated they were 'not sure' about their comfort levels in using email communication with patients (0-17.5%,P = 0.003). 23

Impact on health services
Four studies reported health service outcomes related to the use and impact of remote consultation.Of these, three reported increased use of remote consultation and technology to deliver healthcare post-training, 24,27,32 with one study reporting 89% (n = 17/19) of practices surveyed using three or more remote services. 24tudies involving fully qualified staff reported that participants felt training on telehealth or remote consulting and subsequent integration into practice would increase efficiency.Nurse participants in two studies 24,25 reported increased clinician productivity, improved communication with patients, and fewer missed appointments after training.In one study, the number of remote consultations carried out by the nurse participants increased from 2 to 12. 32 Eight the studies were conducted pre-pandemic, before primary care was forced to rapidly implement a wholly remote approach to consultation delivery.This increase in use has only reinforced the need for more evidence on training needs of primary care staff on remote consultation.

Strengths and limitations
This review is necessary to assist with providing remote consultation in general practice, and includes up-to-date evidence, including information gathered during the COVID-19 pandemic.
The review only included studies published in the English language.This may have led to missing relevant evidence published in other languages.It is also possible that searches may have failed to identify studies that are poorly indexed or traverse disciplines.
The included studies were inconsistent in their approach, methodology, participants, settings, and aims, reflecting the novelty of this field, but making summary and comparison of training difficult.Some bias can occur when comparing the effects of training with no training, as changes in behaviour may occur due to the awareness of being observed.
This review aimed to examine models of training and the content of curricula, but limited published evidence that included these details was identified.

Comparison with existing literature
A recent Cochrane review highlighted the need to train healthcare professionals in remote consulting. 13hile it was uncertain as to whether a training intervention would improve telephone consulting skills, the review only included one study.
Studies show that clinicians' confidence levels can vary when conducting remote consultation, but with proper training, their confidence can improve, as seen in this review. 3There has been hesitancy to integrate training into practice owing to a lack of perceived benefits, especially before the COVID-19 pandemic. 11However, this review has identified studies that demonstrate the positive outcomes of training in, and integration of, remote methods, such as increased work efficiency and better patient engagement.
These views are not limited to primary care; recent articles have recommended integrating remote consulting into dermatology and neurology training, and suggest options including supervised clinics, training days, and standardised guidance. 16,17Further evidence is needed to identify the best educational methods for this training, integrating the body of work with medical undergraduates in primary and secondary care settings. 15,33While postgraduate training needs may differ, these studies highlight the potential methods for, and benefits of, training in remote consulting.

Implications for research and practice
Out of the studies conducted, only one examined the possibility of training non-clinical primary care staff members, with most of the studies focused on training GP trainees and nurses.It is crucial to further explore the training needs and effects of training for remote consultation among primary care staff members.
The recent surge in research indicates a rising demand for evidence on how primary care can effectively provide remote consultation.Staff members require training in this area, with the level of training needed varying depending on the staff's experience.Training methods such as workshops and hands-on learning have been shown to positively impact the confidence and perceived skill of recipients, and should be included as significant components in this type of training.
Studies on training for remote consultation for primary care staff are few.Therefore, we are a long way from the necessary evidence-based curriculum and learning outcomes for training suitable for different types and grades of staff.Given the urgency and the current state of general practice, this educational programme requires proactive funding.Provenance submitted; externally peer reviewed.

Table 1
Characteristics of included studies England General practice in Staffordshire; 24 general practice nurses from 19 practices Quantitative design using survey.Pre-involvement, immediate post-involvement, and 2 months post-involvement surveys on competence/confidence/knowledge.Reflection on individual action plans for implementing TEC, including video consulting.LCAV questionnaires.Chambers, 2019 25 England General practice in Staffordshire; 40 local general nurse practitioners Quantitative design.Mix of feedback after workshops/learning conference of personal experiences.Individual practice reports from CCG with relevant TEC, including video consulting, to support outcomes.Use of TEC 6 months after programme.Chaudhry, 2020 26 England General practice in London; GP trainees in NCEL London at any stage in their specialist GP training at one of the NCEL vocational training schemes Mixed-methods design.Mainly quantitative using questionnaire.Also used semi-structured interviews.Reviewed experiences of GP trainees with remote consultation.US 56 first and third-year internal medicine residents in ambulatory block at a universitybased residency programme in Stony Brook, New York (each session had 10-12 participants) Quantitative design using survey before first session, after first session, and after second session.CCG = clinical commissioning group.LCAV = Leading Change, Adding Value.NCEL = North Central and East London.TEC = technology enabled care.