Table 3 Summary of NASSS framework domains and key quotes

The condition

Disappointed with diabetes in pregnancy diagnosis

“So when I got diagnosed with it this second time, I wasn’t surprised, but I think you’re always disappointed you know, you’re always a bit, not devastated, but obviously wish you didn’t have it” (Participant #3)

“I was really disappointed that I have it. Because I knew from my friend, that it’s a little bit difficult… I am also scared of needles” (Participant #6)

The technology

Technology challenges using videoconferencing

“So I ended up how to just under normal phone call. So yeah, I think video chatting would be good but their internet connection wasn’t good. A little bit annoyed me. It was kind of like moving the car and something because you don’t know”. (Participant #8)

“It took an hour and a half trying to figure out how to get on to the meeting. It would have been easier if they would have just called me” (participants #1)

Value proposition

Greater access to care and convenience

Safety

Share clinician load across various health care sites

Time efficiency and economic benefits

Meaningful employment

“Telehealth is helping if they don’t have to do any measurements or anything, like it saves you from travelling, they give you the same information. If you’re sitting in the room, you don’t have to, like the waiting room in that hospital” (Participants #5)

“Because of this COVID pandemic, there are so many points [advantages], like what should I say during pregnancy your immunity it low. So it’s better to have a telehealth appointment, because we don’t need to go there and exposing other patients and getting that infection” (Participant #2).

“The other best benefit of it, I think is, if someone is running behind, we could actually help them offsite. For example, if I work in the Dandenong Clinic and they tell me that Monash Link and Clayton, they are running behind. I can actually say, “That’s okay. I’ll call the patient from Dandenong”(Endocrinologist).

Regarding the general flow, I do find that phone consultations are a lot smoother. The reason being, when patients come in face to face, they usually bring in their other children, sometimes they’ve got their family members or support person there with them, which is lovely, but the waiting room becomes extremely crowded. And waiting for patients to go from one end of the clinic, of the waiting area, to go into your clinic room, that sometimes takes a while.” (Endocrinologist).

“It feels good to be getting to do something important and providing care to people that need it even despite what’s going on in the world. I guess you feel like you’re doing something that’s still very meaningful and I think when restrictions were tight and so I think patients were clearly grateful that we were providing the service that we needed” (Endocrinologist).

Adopters: women with diabetes

Positive telehealth experience

“It has been really great. I’ve only had telehealth appointments for my gestational diabetes. And they’ve been totally fine. Diabetes, I think it’s the thing we can check and discuss over the phone. So it’s not that difficult. But Maternity care should be like, it is better to have face-to-face. (Participant #7)

“They just said you’ll need to get your blood pressure done and I was like how the hell am I going to do that? And they were like just go to your GP. And that’s a bit silly, because I’m still gonna go to a doctor anyway. My GP measured my tummy and she did the foetal heartbeat and my blood pressure” (Participant #3).

Adopter: clinicians

Initial phase of pandemic was challenging

Increased administration workload

Perceived reduced value of telehealth

Telehealth is not ideal model for all pregnant women

“The initial phase was quite a time of uncertainty. Uncertainty with the processes, with the procedures, with the co-ordination and communication between the teams, the diabetes educators, the endocrinologist, the administration.” (Dietitian).

“The most time-consuming part for the doctors at this point is sending out a script, or sending out pathology forms to the patients. We have to print out the patient’s script, phone up the patient’s usual chemist, which some patients know, some patients don’t know, and they would Google it…Then we write it down, and our admin staff will have to email that script to the chemist. So that is very time consuming.” (Endocrinologist)

“Clients are not valuing the consultation as much as they previously had…. So maybe seeing it as not as important or seeing as the optics are different, you know you’re with someone you don’t know, you haven’t seen, particularly with a telephone consult you don’t see face to face. Some person you’ve never heard of is just calling you” (Endocrinologist).

“There are patients who are illiterate and can’t document their sugar levels down and we tend to just go through the Glucometer ourselves. And during over the phone, they really can’t tell us what their sugar levels are. They also heavily rely on families or friends to help them document and email through and I think that’s extra stress for them. I don’t know what is the best way to help this to, but illiterate... Illiteracy patients I think will need some extra support” (Endocrinologist).

Organisation

Professional isolation

“You know if I really needed help or wanted to a second opinion I could always seek it. But I think there’s less of the kind of corridor conversations that were really good with colleagues both in terms of advancing clinical knowledge, working out management plans for patients, but also just making sure that your colleagues are okay. Just small talk and how are you and that sort of thing. So, I think that has fallen away quite a lot. And I think that’s a real shame… I do at times feel a bit lonely in clinics” (Endocrinologist).

“Many of my colleagues are working from home. So I think there’s a less of a team – you lose that sense of a team when you’re normally in a clinic there’s a few clinicians, there’s that sense of working as part of a team and there are clinicians available that you can discuss tricky cases with very easily. It lends itself to that because if someone’s physically there. You can knock on the door and have a chat about it” (Endocrinologist).

Wider system

Cultural factors

“I think because you don’t have the confidence to listen to the English on the phone. More hard. There is no body language involved. Yet so yeah, I think they might prefer to face to face or they can even bring something to play with.” (Patient #12)

“For less health literate patients…I think visual or cues from body language and so on are more important and I think for that situation face to face appointment is necessary” (Endocrinologist).

Embedding

Future scale-up: delivery of a hybrid diabetes in pregnancy model with initial session and insulin education delivered in person

“If I am a patient, my ideal scenario would be your first appointment will be face-to-face, so you can ask a little bit more questions. And some patients are very anxious when they’ve got gestational diabetes (Endocrinologist).

“Like if someone like myself has never had a sugar check-up and that machine and feels the needle and all that ….it will be I think better for the face to face. And they can talk to someone and have the confidence back. I got stuck on the first one, like the blood wasn’t coming. Maybe I was scared that I wasn’t pointing to the right spot. But then she came and showed me how to do it.” (Participant #10)

“Face-to-face delivery if starting insulin. That means that she can come in, see us and then see the diabetic nurses, all in the one hit, That would work for her, save her a trip to pharmacies, save the calling her and have to do a separate consultation. And I think with COVID pregnancy which is pretty terrifying for some women. It’s a lot better done face to face (Endocrinologist).