Health care Professionals' experiences of counselling competence in digital care pathways – A descriptive qualitative study

Abstract Aim Health care professionals are tasked with the role of supporting patients in using eHealth services in their personal care and counselling competence in digital environments to ensure appropriate patient care. Our aim was to describe health care professionals' experiences of counselling competence in Digital Care Pathways. Design A descriptive qualitative study. Methods Interviews with semi‐structured questions were conducted. Twelve healthcare professionals were interviewed. The data were analysed using inductive content analysis. The results were reported according to the Consolidated Criteria for Reporting Qualitative Research. Results The analysis revealed eight distinct areas of competence related to counselling in Digital Care Pathways, namely, counselling competences related to the use of Digital Care Pathways, supporting patients' self‐care, information technology competence, competence in creating an interactive counselling relationship on the Digital Care Pathway, information management, ethical competence related to counselling in Digital Care Pathways, competence to developing Digital Care Pathways services, and change competence. No Public or Patient Contribution Due to the complex and unpredictable circumstances of COVID, people's strict confinement in the hospital prohibited free access to them and the study environment. Therefore, the professionals involved in the study were interviewed through online systems.


| INTRODUC TI ON
The digitalization of health care services is rapidly increasing on a global level. This rapid digitalization has created new opportunities for communication between health care professionals (HCPs) and patients (Koivunen & Saranto, 2018;Odendaal et al., 2020).
For instance, eHealth services can now be implemented remotely and are defined as the utilization of digital technologies to promote health. eHealth is an umbrella term for a range of different technologies, example, remote reception solutions, mobile applications, or various patient portals (Koivunen & Saranto, 2018;Öberg et al., 2018). Thus, HCPs are now able to readily reach patients who live in geographically distant locations and employ effective patient-professional communication to improve care quality and the coordination of services (Koivunen & Saranto, 2018;Odendaal et al., 2020). Furthermore, many patients are now skilled at using eHealth services, and actively search for health-related information and monitor their health records online (Koivunen & Saranto, 2018;Öberg et al., 2018).
The rapid digitalization of health care has transformed HCPs work content and responsibilities (Odendaal et al., 2020). The role of an HCP is to support patients in utilizing eHealth services for their personal care (Jarva et al., 2022;Kinnunen et al., 2019). An HCP's digital health competence is related to their ability to provide patient-centered care through different digital channels, use digital health systems and technology, and interact with the patient through digital means (Jarva et al., 2022). A systematic review performed by Paalimäki-Paakki et al. (2022) concluded that digitalized counselling environments are comparable with standard counselling methods; this suggests that the use of digital counselling environments could accompany standard counselling methods.
The advent of digitalization in health care has made technologyrelated competence critical to nurses' work (van Houwelingen et al., 2016). In other words, the digital health competence of HCPs ensures patient safety (Jarva et al., 2022;Öberg et al., 2018). In clinical nursing, the five most important competence areas are nursing documentation, data protection and security, information and knowledge management in patient care, ethics and information technology, and quality assurance and management (Egbert et al., 2019). In addition to technological skills, a professional's attitudes and beliefs regarding the use technology has is a considerable influence on their competence in digitalization (Konttila et al., 2019). Furthermore, a HCP's competence in eHealth involves the evaluation of eHealth services and combine traditional and digital methods (Jarva et al., 2022). In other words, eHealth services are not necessarily suitable for all patients, and some would also benefit from traditional face-to-face counselling (Koivunen & Saranto, 2018;Odendaal et al., 2020). For example, according to Akinosun et al., (2021), the use of digital health interventions did not lead to improvements in all lifestyle risk factors among cardiovascular patients relative to usual care interventions. Therefore, HCPs should be able to determine patients' skills, attitudes and readiness to use digital solutions when considering counselling via eHealth systems (Koivunen & Saranto, 2018). HCPs need new competences when transitioning to digital environments and counselling patients via eHealth services (Kinnunen et al., 2019;Konttila et al., 2019).
Communication and counselling skills are generally interrelated competences in health care, as well as being statistically significant to health promotion and disease treatment in eHealth services (Konttila et al., 2019). A professional can ensure that a patient understands their situation and the treatment process by asking specific questions and tailoring the counselling on an individual level. Problem-solving skills are also important when clinical experience and technology-related decision-making are combined (van Houwelingen et al., 2016). It has been recognized that a variety of digital counselling environments have potential in motivating selfcare, providing peer support through interaction, and offering reliable, understandable, and up-to-date information to help patients with both their disease management and adherence to self-care (Frederix et al., 2015).
HCPs who show a positive attitude and patience will encourage patients to take an active role in their personal care (van Houwelingen et al., 2016). According to previous studies, HCPs often report negative experiences about using technology in their work; for this reason, certain HCPs have rather negative attitudes to digitalization (Koivunen & Saranto, 2018;Konttila et al., 2019). Therefore, HCPs may feel that they possess insufficient technological skills even if they fluently use digital services in their personal lives (Koivunen & Saranto, 2018). HCPs have also reported insufficient skills in developing digital health services (Öberg et al., 2018).
A professional can improve their digital competence by integrating learning into daily work and highlighting the benefits of technology (Konttila et al., 2019).

The five Finnish university hospitals have developed Health
Village patient portal, which includes Digital Care Pathways (DCP), to supplement traditional care paths for different patient groups.
DCPs include information about a specific disease, support in selfcare, frequently asked questions, and various relevant assignments and queries. Furthermore, patients who use the service will have the opportunity to self-monitor their progress and assess symptoms.
The patient can also use the service to remotely meet with their HCP, either through secure messaging or video conferencing. Liljamo et al., 2020Liljamo et al., , 2021.
According to a Finnish national health record survey study, nurses demonstrate a satisfactory level of general IT competences, including basic IT competence, data protection and security, and ethical knowledge. On the other hand, expertise related to patient work in a digital environment is at a weaker level (Kinnunen et al., 2019).
Consequently, it is necessary to clarify HCPs' views on the topic. The aim of this study was to describe HCPs' experiences of counselling competence in DCPs. The study answered the following question: Which competences do HCPs need when they are counselling patients in DCPs?  (Tong et al., 2007;Supplementary File S1).
Various occupational groups of HCPs, such as nurses, midwives, rehabilitation instructors, physiotherapists, and occupational therapists, work in DCPs. In this study, a HCP refers to any professional representing these occupational groups. HCPs from one university hospital were recruited using convenience and snowball sampling (Polit & Beck, 2017). To be eligible to participate, the HCP had to have experience of counselling patients during at least the pilot phase of DCP. The participants were recruited with the assistance of the development manager of Health Village, who had access to the administrators of the DCPs, and their supervisors. In addition, the researcher advertised the study during a remote meeting with the administrators of DCPs. Potential participants were approached by an email which included information about the study and the researcher's contact information if an HCP was interested in participating. Following the sending of an email that stated interest to participate, each HCP signed a consent form before the interview was conducted. Participants had the opportunity to ask additional questions at the beginning of the interview.

| Data collection
The first author (blinded for the review) interviewed 12 HCPs from February -March 2021. The interviews were conducted through video conferencing because of the COVID-19 pandemic. Participants were interviewed at their workplace. Data collection was completed when saturation was achieved, that is, no new information of new dimensions or theoretical categories were obtained from the interviews with additional participants, and the data were classifiable . Data saturation was followed by an analysis that was started during the interviews. The semi-structured interviews were completed with each participant. The interview guide included the following nine topics: 1. Counselling competences in digital environment; 2. Patient orientation in digital counselling; 3. Communication skills; 4. Technological skills; 5. Competence in information management; 6. Ethical knowledge; 7. Competence in developing a DCP; 8. Organizational and collegial support; and 9.
Attitudes towards digital counselling. Participants responded to the seventh topic if they had experience in developing DCP. (Polit & Beck, 2017.) The selected topics were based on previous research and the first researcher's understanding about the subject. The content of the interview guide was evaluated by two HCPs before the interviews. Similar sub-questions were deleted based on the findings of the evaluation. Furthermore, one pilot interview was conducted and included in the study data. The interviews were video recorded with the permission of the participants, after which they were transcribed into text format and checked for accuracy. The transcription process generated 94 pages of text (Times New Roman, font size 12, line spacing 1). The interviews lasted an average of 47 min and ranged from 33-84 min. Field notes were made after each interview.

| Data analysis
The data were analysed following the guidelines of inductive content analysis . Prior to the actual analysis, the written material was read through several times so that the researcher became familiarized with the data. Next, a unit of analysis was chosen; in this case, the unit of analysis was sentences that corresponded to the research question. These sentences were then classified as open codes. The open codes were analysed and grouped together to form sub-concepts. In the next step of data abstraction, the sub-concepts were categorized into concepts based on similarities in content. In the final step, main concepts were formed from the identified concepts . The main concepts which described HCPs' experiences of counselling competences in DCPs were then reported (Elo & Kyngäs, 2008;Kyngäs et al., 2020). The formation of a sub-concept as an example of content analysis is described in Table 1.

| Ethics
The presented research followed the ethical guidelines of the Helsinki declaration (World Medical Association, 2013). The study protocol was reviewed and approved according to practices of the local hospital district; furthermore, the head nurses gave their permission for the research to be conducted. According to legislation in Finland, Research Ethics Committee approval was not required since the study does not involve minors, direct or indirect physical or physiological harm to the participants, or clinical trials. (Medical Research Act No. 488/1999).
The participants received information about the study and its aims before being asked for written informed consent. The participants were also informed that the interview would be video recorded, and that only their speech would be analysed. Participation was voluntary and the participants could withdraw from the study at any time without consequences. The study also complied with the European Union's General Data Protection Regulation (GDPR, 2016). Only researchers had access to the collected data, which are stored on the first researcher's (blinded for the review) computer in a passwordprotected folder until the data are published. All of the participants' personal information was kept confidential, and their anonymity was ensured when reporting the findings. Participants were treated fairly and equally during the research (Pietilä et al., 2020).

| Study participants
All of the participants (n = 12) were women who were between 36-61 (mean 47) years of age. The participants had work experience ranging from 10 to over 25 (mean 19.4) years; they had a maximum of 2 years of experience in working on the DCP. The participants' demographics are presented in detail in Table 2.

| Health care professionals' experiences of counselling competence in digital care pathways
A total of eight main concepts and 19 sub-concepts describing HCPs' experiences of counselling competence in DCPs were identified through inductive content analysis ( Nursing expertise in content production Technological skills in content production Skills to support the involvement of DCP users Extensive content production expertise related to different patient groups Identifying patient group challenges in content production Multidisciplinary expertise in content production Producing content requires a special type of technological know-how Considering accessibility in content production Skills for patient involvement Skills in the orientation of professionals (A7).
You must know something about medical treatment.
If the patient uses lots of opiates, then you can consider the need for laxatives. (A12).
Involving the patient in their own care requires expertise in supporting the patient's self-care and counselling skills related to health care services. The most common topics in self-care counselling were vaccinations, physical activity, smoking and alcohol consumption, urination and peristaltic action, nutrition, skin care, oral health, sleeping and sexuality. Patients were informed about the available health care services and also encouraged to seek peer support.
One can involve patients in such a way that they follow their daily lives in relation to possible challenges. (A2).
How the patient can receive, for example, more information and peer support, along with the possibility for some forms of rehabilitation.

| Information technology competence
Quite the same motivational skills as in this job anyway. (A7).
HCPs needed skills to meet the patient via the DCPs. Communication on DCPs was considered to be informal, personal, friendly, and polite.
However, this form of communication required reflection because it was impossible to read the patient's facial expressions and gestures.
Communication in the DCPs had to be encouraging, clear and empathetic. The latter was considered challenging even though the participants felt that it was important to emotionally support the patient.
The participants shared that it was useful to ask additional questions related to the patient's coping in order to meet the related challenges and patient's concerns.
You must consider how to write those things, because it is often easier to explain face-to-face (A5).
You need to learn how to produce writing that is easy to read and encouraging, yet also brief.

| Information management competence related to counselling in digital care pathways
HCPs need to be able to document counselling in the patient health record and utilize patient information in counselling. The participants also felt that certain data searching skills were relevant to counselling.
HCPs need to document contact-related matters and changes in the treatment of a disease in the patient's health record. Patientsubmitted data must also be transferred to the patient health system and documented in the patient report. Information regarding counselling provided via DCPs was documented in the patient health record using the following structure: the needs; goals; implementation; and results. The participants acknowledged that documentation in the patient information system was more formal than communication via DCPs.
If I write on the patient health record, that is where I should emphasize the essential health information issues related to the contact (A3).
You must document any cases in which the patient has consulted the doctor to change the medication. (A8).
The participants felt that utilizing data in the patient health record helped HCPs answer the patients' individual questions. Expertise was also needed to assess patient data available in DCPs. Professional skills were significant in the assessment of symptoms or problems reported by the patient.
HCPs must be able to retrieve information from the information system. (A10).
The messaging that comes from patients can be descriptive. We may also prepare ourselves to respond to certain kinds of issues at the appointment. Then the patient would also be heard better. (A2).
I can react to whatever needs to be handled. For instance, what I must do or clarify if the child has diseases or some health-related issues. (A5).
Evidence-based information was utilized in counselling via DCPs.

| Ethical competence related to counselling via digital care pathways
In the context of DCPs, ethical competence comprised data protection, security knowledge, and ethical knowledge related to counselling.
HCPs relied on the data security of DCPs. However, awareness of data privacy and security challenges were considered important.
The participants mentioned that in some cases it was difficult to ascertain where the information was coming from; hence, when a matter was sensitive and/or intimate, they may personally contact the patient by phone. Thus, communication skills were essential to ensuring data protection. HCPs were aware of the risks associated with the processing of personal data, and reported that each professional had to be particularly careful when processing these type of data. Another aspect of ensuring patient safety was the ability to transfer data obtained via DCPs to the patient health record.
After all, we are given individual login IDs. It should not be accessible to unauthorized people, but to those who go there, (sign in) because of their profession. To take a stand on something, that you don't go there out of curiosity. (A7).
If it feels that they are asking questions about a private matter, you can always call. There must be a tactile element involved when the person posing the questions is someone other than this patient of ours. (A2).
Us professionals must be accurate when connecting the patient to the right care path. That we don't accidentally do it incorrectly because there might be a security risk. (A3).
HCPs were aware that use of the digital service was completely voluntary for patients. The participants considered respecting the patient to be important and, as such, counselling via DCPs had to be confidential and individual. The use of evidence-based information was also important because several professionals were participating in the counselling. The HCPs reported several common practices that were in place to overcome challenging situations.
We have patients who have never gone there. And they do not want to go. Well, then we will take care of things in another way. (A11).
It would create that feeling for the patient, he will be cared for, and his case taken care of. I'm sure that's the goal, but that the human voice would remain there. (A2).

| The implementation of digital care pathways requires development competence in developing services
Nursing expertise and technological skills were emphasized when discussing the production of content for DCPs. Skills to support the involvement of users were also necessary.
Expertise for content production was related to the patient group (professional skills), illness-specific knowledge, and selecting the correct treatment processes. Identifying challenges related to the patient group was an important part of content production. This required a positive attitude towards change, and an awareness of the significance of counselling via DCPs.
HCPs were motivated by the changes brought about by DCPs.
Counselling via DCPs required continuous and wide-ranging learning. A positive attitude towards learning new things made the change easier.
I am a very optimistic character. I believe that developing will continue and then there will be these new patient groups. That is what we are waiting for. (A7).
However, I've already used so many of these, and got used to using different kind of programs and applications. It doesn't have anything to do with the fact that I probably won't learn it or that it's probably very difficult. (A9).
HCPs were aware of the importance of DCPs for health care from both the patients' and professionals' perspectives. Counselling via DCPs was considered useful because it was a new method for contacting and sharing information. As such, this service allowed easy communication between the patient and the professional. The participants also realized the benefits of remote appointments, although most of the respondents had no experience of them.
It motivates us to practice and participate. Because you know, it is increasingly the future. (A10).
There are links which we can guide the parents to explore. So, I can take advantage (of them) in counseling. (A6).
You can participate in some counseling even if you come from somewhere 200 kilometers away. That (the traditional approach) makes no sense when it can be handled in this way. (A12).

| DISCUSS ION
The results indicate that HCPs experienced counselling competence in DCPs as a multifaceted entity which requires diverse competences.
The performed analysis identified eight areas of competence related to counselling in DCPs, namely, counselling competence related to the use of DCPs, supporting patients' self-care, information technology competence, competence in creating an interactive counselling relationship via DCPs, information management, ethical competence related to counselling via DCPs, implementation of DCPs requires competence in developing services, and change competence.
Existing digital competence frameworks focus on the development of basic information technology skills, the management of data in electronic patient information systems, digital communication skills, along with awareness of the ethical, legal, privacy and security implications of technology (Nazeha et al., 2020). These competences were also emphasized in the results of this study. Sufficient information technology competence facilitates counselling via DCPs, and HCPs must understand how to manage the information resulting from counselling. Previous studies have confirmed this result. For instance, HCPs with strong IT skills were more likely to utilize digital technology in their work (Nazeha et al., 2020), be positive about online interaction, know how to use patient portals and understand when it was suitable to contact patients (Laukka et al., 2020). It should be acknowledged that HCPs need special technological skills to successfully participate in the development of DCPs. In conclusion, counselling via DCPs requires HCPs to be both professionally and technologically adept.
Ethical competence was another subject that was reflected in both the implementation of counselling via DCP and the development of the service. Ethical challenges related to the digitalization of health care have been identified in previous literature reviews. Nittari et al. (2020) (Alam et al., 2019;Jokinen et al., 2021) and motivation to familiarize themselves with the service (Jokinen et al., 2021). Patients need certain equipment to access the service (Jokinen et al., 2021), and a functional Internet connection (Alam et al., 2019;Jokinen et al., 2021). If the patient's readiness to use eHealth services is not considered, inequality among vulnerable patient groups may increase within health care (Alam et al., 2019;Jokinen et al., 2021).
Furthermore, investments must be made into the training of HCP to ensure patient-oriented counselling in the use of digital services (Jokinen et al., 2021). Moreover, the way in which health care organizations implement eHealth practices, along with the usability of the service, may strongly impact the use of patient portals. The support targeted at HCPs will work to increase the amount of counselling available through eHealth services (Hörhammer et al., 2021).  (Lee et al., 2020). Previous studies also found that challenging situations require counselling at the health centre or by phone (Laukka et al., 2020;Lee et al., 2020), and multidisciplinary competences have been highlighted (Laukka et al., 2020). The assessment of the data required professional skills to ensure appropriate counselling and to avoid possible malpractice. The use of patient information improved the quality of counselling via DCPs because this practice made the process more patient-oriented. According to previous research, it is necessary that HCPs understand the purpose, infrastructure, use and storage of electronic health information (Nazeha et al., 2020). Therefore, awareness of data protection and security challenges is essential. The data protection of eHealth services is influenced by the underlying technology and the HCPs' activities (Nittari et al., 2020), which was also reflected in the results of this study.
Thirdly, the implementation of DCPs requires change competence and skills related to the development of services, both which involve considering the needs of professionals and patient groups.
This requires strong professional competence from HCPs. Moreover, HCPs working in digital environments need technological skills related to content production. According to Hulter et al., (2020), the implementation of patient portals in a hospital environment requires not only technological implementation, but also diverse interaction between users. Implementation includes three steps, namely, informing patients and professionals about the portal, incorporating a portal into the practices of professionals, and addressing the needs of patients in the ongoing development of the service. The phases were also shown in the results of this study because HCPs were found to be key to counselling patients in how to use DCPs and introducing other professionals to the service. Patient involvement was considered important, but adapting patient portals to meet patient needs was considered challenging in a hospital environment (Hulter et al., 2020). In this study, the involvement of patients in development was also perceived to be important, but nevertheless limited in practice. Feedback was collected from patients who had tested the DCPs but, for example, workshops were not carried out. It remained unclear whether the reason was a lack of resources, challenges in networking or a lack of know-how.

| Study strengths and limitations
The trustworthiness of the presented research was evaluated based on the criteria of Lincoln and Cuba. The model comprises concepts such as credibility, dependability, confirmability, authenticity, and transferability Polit & Beck, 2017 both of these decisions improved credibility. The use of direct quotes also increased the credibility of the research. To ensure confirmability, the researcher kept a research diary during the research and field notes after each interview. The transferability was improved by using convenience and snowball sampling and reporting the demographic information of the study participants. A detailed description of the analytical process improved the dependability of the data analysis, while the results of the analysis were reviewed together with the last author (blinded for the review).
Even though the sample size was small, the collected data represented the topic well because data saturation was achieved. The study also had some limitations, especially regarding the sample.
Most of the participants worked in long-term care DCPs so there were limited descriptions of the competences necessary for shortterm treatment or therapy DCPs. Furthermore, most of the respondents were registered nurses, which means that the views of other occupational groups remain unclear. The fact that interviews had to be remotely conducted due to the ongoing COVID-19 pandemic also caused some limitations, as the researchers were more familiar with face-to-face interviews and may have missed certain subtle body language. Moreover, it is important to note that the researcher knew some of the participants, but sought to act objectively during the interviews.

| CON CLUS ION
This study provides new information about which counselling competences HCPs need to participate in DCPs. HCPs play an essential role in the execution of counselling via DCPs and in the continuous development of this service. In addition to supporting patients' selfcare, HCPs must clearly understand how to use the implemented DCPs. This is a cornerstone of patient-centered counselling, which is widely regarded as the most appropriate form of patient care.
Professional expertise and digital competence are required when HCPs provide counselling via DCPs. Competence in fostering interactive counselling relationships and information management skills are also necessary in patient-centered counselling. When discussing ethically challenging situations, the participating HCPs emphasized interaction skills, the utilization of evidence-based information, and multidisciplinary competence. The development of DCPs requires innovation and the consideration of different user groups so the service can provide patients with the maximum benefits.

| RELE VAN CE TO CLINI C AL PR AC TI CE
At its best, counselling via DCPs benefits the work of HCPs and the everyday lives of patients. However, to reduce inequality, vulnerable patients must be identified. HCPs must have sufficient competence to ensure effective and safe counselling for different patient groups.
The present study provides ample evidence that this topic must be included in the basic education and practical training of HCPs.
Furthermore, adequate resources must be allocated to health care in order to ensure adequate competence among HCPs. In addition, HCPs must have sufficient time to provide counselling via DCPs and develop effective, patient-centered services. Cooperation between different user groups, including patients, is significant, but without competent HCPs it would be impossible to develop and implement counselling via DCPs.

AUTH O R CO NTR I B UTI O N S
Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data: JK, AO, PL; Involved in drafting the manuscript or revising it critically for important intellectual content: JK, AO, PL, PK, MR. Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: JK, AO, PL, PK, MR. Given final approval of the version to be published: JK, AO, PL, PK, MR.

ACK N O WLE D G E M ENTS
We would like to thank the HCPs who participated in this study for their immense contribution. We also wish to acknowledge Sees-Editing Ltd (http://www.seese diting.co.uk) for improving the language of this manuscript and helping us to communicate our findings to readers of the journal.

FU N D I N G I N FO R M ATI O N
No funding.

CO N FLI C T O F I NTER E S T S TATEM ENT
No conflicts of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
All the data have been used in this study.

CO N S ENT S TATEM ENT
The research involved no patients and any invasive intervention on human participants for whom a special ethical consent was required.
However, all the study participants had to agree to and return a consent form for participation.