Healthcare is evolving to better meet patients’ needs, focusing on five key characteristics called P5 medicine: preventive, personalized, predictive, participative, and psycho-cognitive (1). This transformation involves, particularly in the psycho-cognitive dimension, an increased emphasis on
Any condition requiring Pediatric Intensive Care Unit (PICU) treatment can be considered a childhood critical illness (3, 4). Hospitalization and intensive treatment procedures at a PICU during childhood can impair a child’s psychological and social functioning (5), increasing the risk for long-term adverse psychosocial consequences for childhood critical illness survivors (6, 7).
Literature indicates that digital psychosocial follow-ups for childhood critical illness survivors could improve their psychosocial well-being (8,9,10,11). These digital solutions, mainly web applications and virtual reality (VR), are increasingly used (8, 10,11,12). It is important to involve the perceptions and experiences of health professionals in their design to ensure these solutions can be integrated into the current healthcare system (13, 14). While previous research has investigated health professional perspectives on such digital solutions (e.g., (15)), recent studies have focused on their perspectives on solutions targeting survivors of specific medical conditions like cancer (e.g., (16, 17)).
This study aims to explore health professionals’ perspectives on the potential of digital psychosocial follow-up for childhood critical illness survivors in general. Specifically, it will answer the research question: “What are health professionals’ perspectives on the potential of digital psychosocial follow-up for childhood critical illness survivors?” To gain a comprehensive understanding of these perspectives, a case study (18) of health professionals at a Norwegian hospital was conducted. The findings of this study are relevant for informing clinicians caring for critical childhood illness survivors. Moreover, the results can enhance the research and development of effective digital solutions for this vulnerable group.
The Standards for Reporting Qualitative Research (SRQR) (19) are followed to report this study. The Norwegian Centre for Research Data provided ethical assessments regarding collecting, storing, and processing data (Notification Form 477311).
Expert interviews with health professionals with insight into psychosocial follow-up for childhood critical illness survivors were utilized to gather specific knowledge of the digital potential (20). This study design has also been used in a similar study to identify health professionals’ perspectives on the potential for digitalizing a healthcare process (21).
The Division of Paediatric and Adolescent Medicine at a Norwegian public hospital, treating children and adolescents below the age of 18, served as the primary site of recruitment for health professionals who work with childhood critical illness survivors. The first author recruited health professionals through hospital-provided phone numbers and mail addresses, using a combination of snowball and purposive sampling methods to ensure diverse perspectives. The demographic information of the interviewees can be found in Table 1. To enhance the study’s trustworthiness, the interviews were triangulated (22) with stakeholders covering the five most prominent roles concerning the psychosocial follow-up of childhood critical illness survivors. Out of the hospital’s eight departments that interact with children with critical illness, the interviewees worked across three departments; the most relevant departments for the subsequent phase of this research project focuses on a target group from the surgery department. The interviewees provided informed consent to be able to participate in the audio-recorded interviews.
Overview of the interviewees.
I1 | Female | PICU nurse | Intensive Care | 25:34 |
I2 | Female | |||
I3 | Female | Child psychiatrist | Psychiatry | 40:16 |
I4 | Male | Child psychologist | Psychiatry | 35:24 |
I5 | Male | Pediatrician | Surgery | 24:31 |
I6 | Female | Special pediatric nurse | Surgery | 45:10 |
From February to March 2022, the first author collected the data utilizing semi-structured interviews to maintain a general structure while allowing the interviewees to discuss aspects not initially considered (23). The main topics covered in the interview guide included: 1) the current psychosocial follow-up for the childhood critical illness survivors at the hospital, 2) the psychosocial needs of the survivors, and 3) the hospital’s experiences with digital solutions. Different perspectives were gathered through both group and individual interviews. I2 was included in a group interview with I1 at I1’s request, while the remaining interviews were conducted individually. Using an iterative data collection and analysis strategy, interviews were conducted until no new codes were identified. Interviews were conducted in Norwegian and lasted between 24 and 45 minutes. Due to the COVID-19 pandemic, the interviews were performed digitally and audio-recorded on the video communication platform Zoom because it is the preferred and licensed platform for the hospital. The first author verbatim transcribed a total of 2 hours, 50 minutes, and 55 seconds of audio recordings of the interviews in the word processing software Microsoft Word. Moreover, these transcriptions were anonymized for analysis.
The first author analyzed the Norwegian transcriptions using the software NVivo Release 1.7 and Braun and Clarke’s six-phase framework for thematic analysis (24), applicable in qualitative health research (25). These phases included: 1) familiarizing with the data, 2) generating initial codes, 3) searching for themes, 4) reviewing the themes, 5) defining the themes into a model, and 6) writing the research by including quotes that were the most representative of the findings (24). An inductive approach was utilized to ensure that the generated codes and themes were strongly linked to the data (24). Concurrent data collection and analysis were employed for Phases 1 through 4 to identify emergent themes and construct a model. Following each interview, emergent themes were discussed with the other authors. After interviewing I6, it was observed that this final interview yielded no new codes, leading to the decision to terminate the data collection process. Phases 5 and 6 of the analysis were then completed, and the extracted data and model were translated into English. All authors agreed on the model and the presentation of the research.
The interview findings yielded 84 extracted quotes. A model of 13 codes, four sub-themes, and two main themes was constructed. The model is presented in Figure 1.
Overview of the identified themes.
The first main theme,
Summary of content in the different codes of the affecting demographic factors.
Medical Condition |
– The frequency of psychosocial follow-up for childhood critical illness survivors tends to differ for diverse medical conditions. – There is a tendency for survivors not to be referred to the psychosocial follow-up despite the fact they have experienced trauma during their hospitalization. |
Age |
– The psychosocial needs tend to vary with the child’s age. – The psychosocial follow-up tends to vary in content with the child’s age. |
Gender |
– Compared to girls, boys tend more likely to withdraw from the psychosocial follow-up even though they also could need it. |
Residence |
– The psychosocial follow-up tends to be better the closer the child lives to the hospital. |
Summary of content in the different codes of the affecting environmental factors.
Family |
– The guardians of the childhood critical illness survivor consent to or request the offer of psychosocial follow-up on behalf of the child until the child is 16 years old. – Not all families are aware of the psychosocial follow-up offer. – Immigrant families are more likely to withdraw the psychosocial follow-up compared to non-immigrant families due to concerns about a connection between child and adolescent psychiatry and the Norwegian child protection service. – The family tends to be an essential part of the evaluation of the child’s offer. |
Health Professionals |
– Pediatricians evaluate if the child receives the offer. – The timing of when the pediatrician provides the offer could influence the decision. |
Table 2 summarizes the different codes of the potential demographic factors affecting how and if a childhood critical illness survivor receives psychosocial follow-up. The rest of this section provides a detailed description of each code.
The interviewees indicated that the child’s medical condition is one significant demographic factor affecting the frequency of psychosocial follow-up. For example, an interviewee described the psychosocial follow-up as follows: “A bit random (for different medical
Another interviewee elaborated on this challenge of not capturing every childhood critical illness survivor that needs follow-up:
The child’s age is also an essential demographic factor that could affect the content in the psychosocial follow-up. For example, an interviewee explained how psychosocial needs vary with age:
The gender of the child is another demographic factor of the psychosocial follow-up the interviewees highlighted as potentially affecting. affecting. For example, an interviewee talked about boys as a non-reached group:
Another interviewee elaborated on this concern about boys as a non-reached group:
Lastly, the distance from the child’s residence to the hospital is a demographic factor affecting the psychosocial follow-up, according to one of the interviewees:
Table 3 summarizes the different codes of the potential environmental factors affecting if and how a childhood critical illness survivor receives psychosocial follow-up. The rest of this section provides a detailed description of each code.
The interviewees indicated the child’s family as the most significant environmental factor for the psychosocial follow-up. For example, an interviewee pinpointed the challenge of not capturing every childhood critical illness survivor that needs psychosocial follow-up when it depends on the family’s initiative and awareness for all children below the age of 16:
The family’s culture also affects the psychosocial follow-up as immigrant families are another group the interviewees considered hard to reach. For example, an interviewee explained:
Further, the interviewees talked about how they evaluated how a child’s psychosocial offer should be mainly based on the family. For example, an interviewee said:
Additionally, the child’s pediatricians are affecting the psychosocial follow-up. For example, the pediatrician was informing how he evaluated if a child needed psychosocial follow-up:
Moreover, one interviewee pinpointed the importance of the timing of when the health professionals are telling about the psychosocial follow-up offer:
The second main theme,
Summary of content in the different codes of the limitations for digital usage.
Lack of Digital Solutions |
– The hospital currently tends to lack the use of digital solutions. – The hospital lacks uniformity and guidelines for the use of digital solutions. |
Relationship Building |
– Video communication could hinder relationship-building for the child compared to face-to-face communication. |
Children’s Screen Time |
– Many children tend to have high screen time and are so obsessed that they forget their necessary needs. |
Summary of content for the different codes of the opportunities for digital usage.
Digitization of the Hospital |
– The whole hospital is undergoing a digitization process. – Forced video communication with Skype during the COVID-19 pandemic tends to be beneficial for children with bowel problems, children aged 15–16 years, and children living far from the hospital. |
Existing Digital Solutions |
– The digital platform “HC And” is successfully used in other hospitals. – There exist many promising digital solutions the hospital could use (e.g., telehealth, apps, VR, technology in procedures, and technology to socialize). |
Children’s Digital Skills |
– Children generally tend to have high digital skills. |
Creating an Artifact |
– The hospital is in the process of creating its own mascot to help children feel better in hospital settings. |
Table 4 summarizes the different codes of the potential limitations of adopting digital solutions in psychosocial follow-up for a childhood critical illness survivor. The rest of this section provides a detailed description of each code.
The interviewees indicated that the hospital’s lack of integration of digital solutions in their practice is the most significant limitation for digitizing psychosocial follow-up. For example, an interviewee described the digital usage for the psychosocial follow-up as follows:
Moreover, the same interviewee pinpointed that a limitation of this video communication is that it can weaken the relationship building:
Lastly, one interviewee expressed concern regarding the potential limitation of the high amount of screen time:
Table 5 summarizes the different codes of the potential opportunities of adopting digital solutions in psychosocial follow-up for a childhood critical illness survivor. The rest of this section provides a detailed description of each code.
The interviewees indicated that the digitalization of the hospital presents the most significant opportunity to digitize psychosocial follow-up. For example, an interviewee was excited about the ongoing digitalization:
Moreover, another interviewee experienced the forced digitalization of the hospital with video communication during the COVID-19 pandemic as beneficial for groups of children harder to reach because of their medical condition, age, or residence:
The interviewees also discussed the ability to use existing digital solutions relevant to psychosocial follow-up for survivors of childhood critical illness. They were enthusiastic about the reported benefits of the existing Danish digital platform “HC And”. For example, an interviewee said:
Further, one interviewee was optimistic regarding existing digital solutions in general:
The interviewees also highlighted the digitalizing opportunities lying in children’s generally high digital skills. For example, an interviewee said:
Lastly, one interviewee mentioned an opportunity to digitalize psychosocial follow-up by exploiting the hospital’s child and adolescent psychiatry’s ongoing work on creating an artifact:
In addressing the research question, expert interviews with six health professionals at a Norwegian hospital revealed their perspectives on the potential of digital psychosocial follow-up for childhood critical illness survivors. The interviews identified a model of four affecting demographic factors (medical condition, age, gender, and residence) and two affecting environmental factors (family and health professionals) that need to be considered.
Related to the potential of digital usage, the model identified three limitations (lack of digital solutions, relationship building, and children’s screen time) and four opportunities (digitalization of the hospital, existing digital solutions, children’s digital skills, and creating an artifact). The results indicated the benefits of a digital solution for psychosocial follow-up for survivors of childhood critical illness to reduce their issues after hospitalization in the context of the psycho-cognitive, preventive, and predictive dimensions of P5 medicine (1).
The findings further demonstrated the detriment and unintended harm that can come to survivors because of a lack of such digital solutions. It is important to stress that not every traumatized child at the Division of Paediatric and Adolescent Medicine at the Norwegian hospital needing psychosocial follow-up got an offer. These results broadly align with previous relevant qualitative research regarding health professionals’ perspectives, pinpointing how the digitalization of psychosocial follow-ups could increase this lacking accessibility for unreached groups (16, 17, 26). The adoption of digital solutions for psychosocial follow-up should focus on reaching all survivors of childhood critical illness, addressing the global call of psychiatry access lack (27).
The interview findings indicated that different demographic factors affect the current psychosocial follow-up. The interviewees expressed that the psychosocial follow-up could vary with both age and medical condition in terms of content and frequency. These findings expand on previous research, which emphasized medical condition (28) and age (17, 29) as affecting factors for psychosocial follow-up, by underscoring the significance of both factors in the same study. Furthermore, this aspect points to the importance of the personalized dimension of P5 medicine (1) in a digital solution for psychosocial follow-up. Similar qualitative research also reflects this need for tailored solutions (17, 26, 30), and a review of personalized intervention for youth mental health further supports this idea by calling for tailored treatments to optimize patient outcomes (31).
Regarding the gender of the child, the interviewees indicated boys are more likely to withdraw from the psychosocial follow-up. This tendency is in line with a systematic literature review of factors associated with males’ low medical and psychological help-seeking rates that identified that adherence to traditional masculinity norms like emotional control reduces males’ willingness to seek help (32). One interviewee also outlined that the child’s residence is another factor involving a tendency for increased risk of less psychosocial follow-up for a specific group: people living far from the hospital. This observation of residence as an affecting factor for psychosocial follow-up is directly in line with other related studies (17, 28), and a recent literature review finding people’s probability of using psychiatry services decreased as the distance to the offer increased (33). Thus, adapting of digital solutions should prioritize solutions including boys and children living far from the hospital.
Moreover, the interview findings revealed that a child’s current psychosocial follow-up is affected by environmental factors— family and health professionals. This points to the significance of considering the participatory dimension of P5 medicine (1) in a digital solution for psychosocial follow-up, as seen in a German expert interview study targeting a similar population about psychosocial follow-ups for survivors of rare diseases (29). To ensure the adoption of such a digital solution, family and health professionals, important stakeholders in the child’s psychosocial follow-up, should be involved in the design process along with the child. Health professionals’ support is especially essential for implementing such digital solutions into their practice (13).
Research on patients’ willingness to adopt telehealth during COVID-19 found that their health professionals’ attitudes could impact this willingness (34). Similarly, a meta-analytic literature review on dropout in child and adolescent psychiatry found higher effect size on factors related to the child’s health professionals as a dropout predictor compared to factors related to the family (35). The interview findings highlighted that medical doctors primarily determine whether a child should receive a psychosocial follow-up offer, and the timing of when the health professional gives this offer could also affect the decision. This finding is broadly in line with a qualitative Australian study on health professionals’ perspectives on digital psychosocial follow-up for childhood critical illness survivors, highlighting a need to offer such solutions early (17).
Regarding the child’s family, the interviewees explained that it is not the child but its guardians or parents who get or have the authority to request the offer until the child is 16 years old. Moreover, the whole family plays a crucial role in the health professionals’ evaluation of how the child’s offer should be. The cultural background of the family also influences the utilization of psychosocial follow-up, with immigrant families tending to use it less than non-immigrant families due to a fear of the child protection service in Norway. The fear of a connection between the Norwegian welfare system and the child protection service has also been reported in the literature (36). This resonates with literature reviews finding a medium effect size on minority status and cultural barriers as dropout predictors for psychosocial follow-up (35, 37). Thus, the adoption of digital solutions should prioritize the inclusion of diverse cultures.
The interviewees pointed out the lack of digital solutions incorporated into the Norwegian hospital, which could make it challenging to introduce a new digital solution for psychosocial follow-up for childhood critical illness survivors. Digital solutions for mental health have low uptake in healthcare despite the potential to decrease cost and increase accessibility (13). The interviewees mentioned the digital platform “HC And”, VR, and telehealth as successful examples of digital solutions that could inspire a solution for digital psychosocial follow-up and persuade skeptical stakeholders. Digital transformations in healthcare are traditionally considered slow because of healthcare’s complex organization, high amount of sensitive data to handle, high resistance toward digitalization, and low degree of user-friendly digital solutions (38). It is important to design, assess, and certify widely available training programs for health professionals to address their most essential needs in implementing digital mental health interventions in their practice (13, 14). Therefore, the digitalization process of a solution for digital psychosocial follow-up needs to be as long as necessary to train health professionals’ adaption. However, children’s current digital life with high digital skills, pinpointed by the interviewees, could make it easier to introduce them to digital solutions compared to the stakeholders in other age groups.
The interview findings pinpointed that the ongoing digitization of the entire hospital and the rapid digitization with video meetings during the COVID-19 pandemic can also aid in adapting digital solutions for psychosocial follow-up. The latter digitization process was beneficial for some children who are harder to reach physically, such as those with medical conditions that make social settings challenging, older children, and those living far from the hospital. This positive experience of telehealth as more accessible aligns with previous research about specific groups responding positively to the forced digitalization of psychosocial follow-up during the COVID-19 pandemic (39, 40). Qualitative research on health professionals’ experiences with digitalization during the COVID-19 pandemic also found that digital solutions could address communication challenges related to the transition between hospital and home that existed before the pandemic (41). Therefore, the present study adds to the current hope in psychiatry and psychology that this pandemic-driven digitalization process with telehealth could transform psychosocial follow-up (40, 42,43,44). Besides, exploiting the continuous development of child and adolescent psychiatry in hospitals can enhance children’s engagement in digitalization. This development can involve incorporating a hospital’s artifact in a digital solution for psychosocial follow-up for childhood critical illness survivors.
However, one interviewee pointed out that relationship-building can be worse with video communication compared to face-to-face for some children. These findings are consistent with similar research where health professionals are concerned about missing non-verbal cues in digital solutions (15, 26). Thus, digital psychosocial follow-ups should be hybrid solutions that also includes children who struggle with video communication.
Previous research regarding the health professionals’ and patients’ experience of the pandemic-driven digitalization of telehealth highlighted that telehealth mostly worked well if the patient and health professional had previously met face-to-face (40). Regarding web-based psychological treatments for adults, health professionals also preferred hybrid solutions (13). One interviewee also pinpointed the importance of a hybrid solution, stating that children’s screen time is already high and obsession with the digital world could cause them to forget real-world necessities.
This study’s single-site design may restrict the generalizability of the results to other hospitals. Conducting a multi-site study involving hospitals with varying psychosocial follow-up and digital situations could help explore the broader applicability of these findings. The present study concluded with six interviewees because the last interview yielded no new codes. This sample size aligns with Braun and Clarke’s recommendation of a minimum six interviewees for small research projects utilizing thematic analysis (45). Furthermore, prior qualitative health research has demonstrated that six interviewees could be sufficient to achieve saturation in thematic analysis (46, 47), particularly for expert interviews (48, 49).
Further research may build upon the study’s indications of a potential for a hybrid solution that integrates all dimensions of P5 medicine (1). Future work could investigate a larger and more representative sample of health professionals, possibly from multiple hospitals. A multi-site study on hospitals with different psychosocial follow-up and digital usage could further investigate the generalizability of the findings of the present study. Additionally, these findings should be explored more in-depth with other stakeholders, particularly the target group of childhood critical illness survivors. In particular, the authors plan to use the results of this study to design a digital psychosocial follow-up solution for a specific target group of child survivors of Hirschsprung’s disease or anorectal malformation at the Norwegian hospital.
In a clinical context, the significance of this findings lies in its potential impact on psychosocial follow-up for childhood critical illness survivors. Increased knowledge of demographic and environmental factors that affect children may help health professionals caring for critical childhood illness survivors offer better psychosocial support, ultimately enhancing the quality of life for vulnerable children. This knowledge can also ensure that child and adolescent psychiatry services do not overlook those at risk of not receiving necessary support. The findings of this study and further research can also be used as a starting point for developing digital solutions for psychosocial follow-up at hospitals, guiding designers and developers to create appropriate tools that lead to better solutions for psychosocial follow-up for childhood critical illness survivors.