Remote working has been widely used in business for many years but before COVID-19, this was not the case within healthcare settings. This article seeks to review the advantages, challenges and solutions which users of remote working in business have experienced, to see what can be learnt as virtual consultations and video conference meetings become integrated into our working lives.
The COVID-19 pandemic and related lockdown forced the NHS to make rapid and significant changes to its traditional model of patient care delivery. This included primary and secondary care consultations, patient diagnostics and management, and providing for those infected with and of increased vulnerability to coronavirus.
Previous barriers and delays to change evaporated quickly and new ways of working and infrastructure swiftly appeared as the NHS adapted to the on-going situation.
As the pandemic progresses the NHS will have a new, perhaps more intricate challenge: how can the full spectrum of clinical services be restored, integrating pre-existing practices with new COVID-19-safe ways of working, to yield a future-proof hybrid model of healthcare delivery?
There are certain aspects of our pre-COVID-19 working patterns that will be welcomed back, others that will need transformation and some that can be confined to history. Equally there will be elements of peri-COVID-19 working that would be useful to continue in the future, but others that were a temporary necessity and represent a degree of compromise that would be unacceptable in the long-term.
One useful element, which was widely embraced from the start of lockdown, is remote working. Trying to continue consultations with patients and meetings with colleagues whilst at a distance, undoubtedly presents difficulties. However, during this period where it has been essential, benefits have also been seen. Remote working is already a tried and tested, integral part of the business world. Indeed, it has gained popularity, with the number of UK workers who have moved into remote working increasing by nearly a quarter of a million people over the last decade . In companies that have embraced flexible working, up to 64% of employees are working from home at least some of the time . The advantages, challenges and solutions that the business world has found are therefore important to review, and are largely transferable to healthcare settings.
What is remote working?
Remote working is defined as “a situation in which an employee works mainly from home and communicates with the company by email, internet and telephone” . It creates virtual teams of workers who are physically and geographically separate, but with technology allowing organisational tasks and relationships to continue . Similar descriptions include virtual working, teleworking, and telecommuting. New technology has facilitated these interactions, specifically the internet and tools such as video conferencing and cloud storage. Since 2014, UK employees have the right to request flexible working hours from their employers and have it properly considered .
Advantages of remote working
The main immediate advantage to remote working during the coronavirus pandemic was, and continues to be, the reduced risk of catching and spreading the virus. There are however multiple medium and long-term advantages to the individual, employer, and wider society that are summarised in Table 1. These benefits do have commonality and create an inter-dependent network (Figure 1).
Figure 1: Word cloud describing workers’ positive perception of remote working.
Working from home (or at a place nearer your home) reduces the time lost travelling to commute. This can be over an hour each day , more in larger cities, often at significant cost funded by the individual. Over half of regular commuters in the UK report that their travel increases stress levels and reduces productivity [6-8]. Productivity is clearly an important factor for both individuals and employers. Remote workers also state that their productivity is higher due to reduced interruptions, distractions and a more personalised environment ; indeed 75% of people who work from home state fewer distractions as their main motivator . Productivity is shown to be higher in those that work remotely, compared to open plan offices [9,10].
Remote working with no commute also enables greater flexibility in working hours compared to the restrictions imposed within traditional workplaces. Being able to define a working pattern increases employee autonomy and provides better work-life balance, which increases job satisfaction and organisational loyalty . Studies show that morale in companies with flexible working is increased by up to 90% .
Further advantages for employers who can support remote working are that physical distance, in the presence of adequate internet services, is no restriction to the spectrum of employees, clients or service users that can be engaged globally . It is a competitive attribute to have as 80% of business employees surveyed would turn down a job that did not offer flexible working, even if it was more prestigious .
A reduced on-site workforce allows a smaller physical footprint to be maintained with the inherent cost savings this brings (up to 77% in some studies ). Coupled with increased productivity of remote workers remote working stands to increase financial viability. Employment security enhances job satisfaction, loyalty and wellbeing, which again positively impacts productivity whilst reducing staff turnover [9,11,12].
Societal advantages of remote working are potentially huge. Reduced stress and enhanced wellbeing could ease healthcare demands and maximise the productive workforce. Environmentally, reduced commuting could take millions of cars off the road, decreasing carbon footprints and pollution. This would reduce pollution-related diseases and protect global ecosystems . A reduced number of people commuting would also reduce congestion and improve travel efficiency for others.
Disadvantages of remote working
The most obvious difference between a traditional work environment and that of the remote worker is the lack of opportunities for face-to-face communication. Whilst all forms of media provide information, understanding and cohesiveness, face-to face interaction predictably provides the most social cohesion and is, without question the richest form of communication  (Figure 2).
Figure 2: Different media formats and their social cohesiveness and media richness (Reproduced with permission from Advanced Workplace Associates Limited. Working AWAy Workshop Summaries 1-4. Advanced Workplace Associates; 2020. www.advanced-workplace.com/awa/services/advanced-workplace-institute/working-away/#more-8271).
Face-to-face interactions facilitate strong and sustainable working relationships and offer teams a sense of community and support [4,14]. Good relationships with colleagues are the most important factor contributing to morale, according to over three quarters of workers . Remote working makes relationships harder to develop and sustain.
Those particularly at a disadvantage are those not as familiar and adept with communication technologies as they risk not being able to utilise their experience and skills properly . Also, new members joining virtual teams, without existing relationships and shared knowledge to build on, will not function or collaborate as efficiently. Lack of face-to-face interactions has also been shown to limit creativity within virtual teams . This is because effective communication and knowledge sharing are crucial to the generation of new and unique ideas within teams .
A large study by Nuffield Health showed that although the impact of remote working is generally positive for employees it needs to be consciously planned and carried out, as individuals will have differing requirements . Loneliness is reported as the hardest aspect of remote working to deal with (affecting around 21% of workers ). A large survey of UK employees working remotely during lockdown found that 97% wouldn’t take steps to seek out help from their employer if they were struggling with working from home . Managers and colleagues need to monitor and support their teams to help with personal and professional issues that may arise .
The traditional workplace has a schedule incorporating work hours, socialisation and breaks, which are important for wellbeing and team functionality; a remote worker needs to ensure they set an appropriate schedule so as not to miss meeting basic needs, as ensuring adequate sleep, nutrition, hydration and exercise will enhance performance and reduce stress . Self-discipline is as important as access to a physical space away from distractions.
It has also been shown that those working remotely can overwork, possibly because they feel obligated because of their flexibility. Concerns that remote working might equal reduced employee contact seem unfounded , with reports demonstrating increased availability compared to office colleagues, working on average 15% more hours per week . Balancing working hard versus working too much to compensate for the flexibility the employer has allowed can be an issue requiring the setting of realistic goals and regular reviews with colleagues .
Appropriate infrastructure and support is a prerequisite for successful remote working. This includes the correct media technology, adequate staff and service user training, and back up plans in case of technology malfunction. Technical support available is essential with negative encounters potentially leading to a permanent loss of faith in the working methods. There will be a financial outlay required initially to put systems in place however this is likely to be recouped in the long-term as the advantages discussed above materialise.
What can we learn?
Despite the barriers, remote workers can forge good relationships and be innovative. Communication is significantly enhanced by highly functioning media platforms that allow video consultations and data sharing in real time. Employees and teams have to ensure robust preparation, clear team structures and responsibilities, and strong, supportive leadership [4,14]. Reassuringly, a global survey of workers during national lockdown showed that existing relationships with colleagues were being maintained in 90% of cases . Ideally, a combination of face-to-face interactions, certainly at the start of new teams or projects, alongside regular wellbeing reviews, will support those in flexible working and enhance its benefits [4,14].
The majority of healthcare workers are adept at navigating electronic systems and have been trained in face-to-face interactions. Virtual meetings or consultations however, need to be approached differently to ensure maximum communication. Useful considerations for each remote interaction are shown in Box 1. Avoid relying on a single media format to guard against fatigue and promote collaboration alongside singular working to provide variation. It is also prudent to consider whether a large meeting is necessary, with half of workers agreeing that interactions during the second national lockdown have been streamlined for the better .
Figure 3: Factors that contribute to building trust within in a team.
Trust is the key to the success of relationships regardless of team members or their physical location  and so its cultivation must be a priority (Box 2). A number of factors can help build trust within in a team (Figure 3). It is important that there is a clear, shared vision and team structure, with well-defined team roles and outcome measures. Teams that have clearly defined roles and responsibilities are able to handle strategic decisions and conflict more efficiently and effectively . This is particularly important if a new way of working is established, if change occurs or if new members join the team. Team members are encouraged to appreciate the strengths and weaknesses of all individuals in an effort to maximise efficiency and need to be visible and communicate regularly with co-workers, and take responsibility for and deliver on their allocated goals.
To further encourage relationships, it is important to spend time communicating about personal issues not just work. This is often done naturally during face-to-face interactions in the workplace but can be forgotten in the virtual setting.
Using video media maximises non-verbal communication and increases interaction but again, combining remote working with an element of face-to-face will strengthen relationships .
Remote working challenges a team leader to work and engage differently. Monitoring morale and productivity cannot rely on face-to-face catch-ups in the workplace, either pre-arranged or spontaneous. Research and models of leadership and teamwork are increasingly looking at those virtually but not physically connected [16,24]. Measuring productivity has to rely heavily on outcome delivery rather than time in the workplace. Morale requires a multi-faceted assessment, likely based on communication at different time points, mediums and both one-to-one and group discussions. Team members have to be encouraged to discuss issues with colleagues and seniors, but leaders will need to be proactive too. Leaders also need to be aware of the risk of bias against those team members who work remotely and so have more limited opportunities to discuss and develop relationships .
Despite the advantages, it is highly unlikely that there will be a large, permanent shift of NHS staff to complete remote working. Although some roles may easily adapt to it, the vast majority still need a significant presence in their healthcare workplace for face-to-face patient contact. It is clear from other industries though, that if done well, remote working or a working pattern that includes it, brings positive advantages including productivity and increased staff wellbeing. Given this, the development of a hybrid-working pattern surely deserves encouragement and effort. Sessions such as administration, outpatient consultations, research, audit and teaching could continue successfully online post-COVID19. This would also help to future proof the NHS in case of a similar crisis arising again. If the NHS, its leaders and staff can continue the evolution that has been started during this pandemic, a change from traditional working structures and ethos may be possible, for the better.
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