Examining digital care relationships of medicaid participants in the pre/postnatal care period: a qualitative study

Abstract

Background

Underserved populations in the United States are at higher risk for poor maternal health outcomes. New models of care, such as telehealth, can offer additional support, including access to care 24/7/365 days a year; however, little is known about their impact on nurse-patient relationships. This study aimed to explore the perspectives of patients and nurses (registered and advanced practice registered nurses) on the relationships established through a telehealth program for pregnant and postpartum women.

Methods

A qualitative, descriptive, longitudinal study was conducted between December 2022 and December 2023. Semi-structured interviews were completed with 28 individuals in the first year after the program’s launch. Among the participants, 23 were pregnant or postpartum women enrolled in a pregnancy and postpartum support program, and five were nurses involved in delivering the program. The semi-structured interviews were conducted remotely using a phone or an online platform. The interviews were analyzed using thematic analysis.

Results

Two major themes, Therapeutic Nurse-Patient Relationships and Programmatic Aspects that Support Virtual Relationships, along with twelve subthemes, were identified. Participants felt that the programmatic aspects allowed them to create meaningful relationships with their care providers. In addition, the digital services offered a nonjudgmental and supportive method for women to receive care and education when and where they need it. From the nurses’ standpoint, they felt that they could personalize the care for women without the time limitations typical in an in-person clinical encounter.

Conclusions

Supporting women through digital models of care can influence their engagement and relationships with their nurses. Findings show that both the women and the nurses reported being able to establish positive relationships, although they described them differently. As a result, women reported feeling comfortable accessing care and asking pregnancy-related questions, suggesting that telehealth programs can foster the development of therapeutic nurse-patient relationships.

Background

The complexity surrounding maternal mortality globally remains a formidable challenge to saving lives, particularly among women who face social and economic issues [1]. Within the United States, increasing maternal health complications and mortality rates have erased decades of progress and are now considered as a “maternal health crisis” [2]. However, these disparities are not evenly distributed throughout the population and disproportionately impact low-income [3] and racial minorities [4]. For example, in 2020, pregnancy-related mortality rates among American Indian/Alaska Native and Black women were almost three times higher than those for White and Hispanic women, with rates of 63.4 and 55.9 compared to 18.1 and 22.6 per 100,000, respectively [5]. While there are many factors as to why this population is at risk, research indicates that limited access to timely, high-quality pre-and postnatal care significantly contributes to their higher morbidity and mortality risk [1, 4].

To increase access to care, many states within the United States expanded their Medicaid programs (joint federal-state health insurance program) so that more women are eligible for preconception to postnatal healthcare, which is associated with prompt prenatal care [6] and improved maternal health outcomes [7, 8]. However, despite increased Medicaid coverage, few providers, transportation barriers, long wait times, and poor patient-provider relationships continue to limit women’s access to quality prenatal care [9].

The use of telehealth in high and low-income countries, including the United States, Australia, and Bangladesh, has shown that it has the potential to improve maternal health outcomes and reduce some of the barriers to care that women face when accessing care [10,11,12]. Yet, a rapid review published by Cantor et al. [10] illustrates the need for further research on telehealth programs and their effectiveness in improving health equity. To address not only health equity, but also access to care, in 2022, OSF HealthCare collaborated with four federally qualified health centers (FQHCs) to implement the Pregnancy and Postpartum Support Program (PPSP). This app-based program provides telehealth services to pregnant women (including adolescents) with 24/7 virtual access to registered nurses (RNs) and advanced practice registered nurses (APRNs).

Addressing maternal health needs in a digital space

Globally, the approach to maternal health has focused on reducing maternal death, with a lesser emphasis on how to deliver services within healthcare systems in a holistic and integrative manner [1]. Within the United States, access to maternal care has been trending downward; in 2022, only 74.9% of all women, and 60.5% (15–19 years) received early and adequate prenatal care [13]. Despite expanded Medicaid coverage for pre/postnatal care over the last decade, the number of counties within the United States with no obstetric providers, hospitals, or birth centers has also increased [14]. Therefore, some women must travel long distances for care, wait later into the pregnancy to receive prenatal care, and potentially receive less prenatal care [15]. Moreover, with the limited number of providers who offer services, when women have a prenatal appointment, they often spend hours in the waiting room for a quick visit that often feels rushed, mechanistic, impersonal, and at times judgmental [9, 16, 17].

Since the onset of the COVID-19 pandemic, there has been increasing national and international interest in using telehealth to improve access and reduce barriers to maternal healthcare [12, 18, 19]. Research has shown that these programs have the potential to lower healthcare costs, make care more accessible, and improve maternal health outcomes [10, 20]. They can vary but often consist of replacing some prenatal visits with virtual visits or supplementing care with additional digitally based services (synchronous and asynchronous) [10, 20, 21].

While telehealth programs have demonstrated some positive outcomes, telehealth’s impact on patients’ relationships with nurses and other providers is mixed. For instance, some studies have suggested that transitioning from in-person visits to virtual can depersonalize the patient-provider experience and make it difficult to form a positive relationship with patients [22, 23]. It has been reported that some women prefer in-person visits because they can develop more trust and rapport than with telehealth visits [24]. Other research has suggested that telehealth can reduce some barriers women face in accessing care and provide tailored, personal healthcare within the home setting. For example, maternal telehealth programs have been shown to provide valuable information [25], lessen feelings of isolation [26], and support nurse-patient relationships [27].

Additionally, women have indicated that they want pre/postnatal healthcare to include emotional support, better communication, adequate and timely education, not to be biased, and to acknowledge their social/cultural needs [25, 28]. Telehealth programs could provide this type of care if they can support the development of strong therapeutic nurse-patient relationships, which consist of trust, professional intimacy, respect, empathy, and the appropriate use of power [29]. These relationships have been documented in maternal home visiting [30] and midwifery programs [31] and are linked to positive patient experiences and perceptions of care. Moreover, positive therapeutic relationships developed through face-to-face encounters have led to better birth outcomes, lower costs, and higher-quality care [31]. As noted in a recent integrative review, evidence is lacking on how relationships between patients and providers, perceptions of support, or trust are affected by virtual visits [21]. Therefore, more information about the impact of telehealth interventions is needed. This study aimed to address the gap in the literature by exploring the perspectives of nurses and patients regarding the nurse-patient relationships established through a telehealth program for pregnant and postpartum women.

Methods

Design

This study used a qualitative, longitudinal, descriptive design [32] to understand women’s experiences from enrollment in the PPSP program until six weeks postpartum. This design was selected because women’s needs and experiences change through pregnancy [33], and it was unclear if or when relationships with the nurses might develop. Topics for the three semi-structured interviews were determined by researchers prior to initiation of the research study (Refer to Table 1). These interviews took place between December 2022 and December 2023. Data were obtained from 23 women enrolled in the PPSP program and five nurses supporting the program’s implementation. The reporting of this study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) [34].

Table 1 Sample interview topics for women enrolled in the pregnancy and postpartum support program by interview

Setting

The PPSP was developed as a remote monitoring and educational app-based program to support mothers in the prenatal and postpartum periods. Pregnant or postpartum mothers in Illinois with Medicaid or secondary Medicaid insurance coverage are eligible to enroll in the program. Various strategies are used to encourage program enrollment: provider referrals, staff outreach directly to patients, posted fliers in offices with “quick response” codes, and advertisements with phone numbers. The PPSP aims to improve access to care, timely assessment, and referrals to needed resources using both responses to social determinants of health (SDoH) questions and digital health workers (DHWs) within a mother’s local community. DHWs provide information and referrals to community resources through in-person visits and phone calls, using interpreters if necessary. Through the app, patients can input their blood pressure, answer weekly questionnaires, message RNs, and schedule virtual visits with nurses. RNs can triage and escalate patients to APRNs who can determine the best treatment course. Enrollment into the program is voluntary, and patients control the frequency of their engagement, including scheduling visits with nurses or APRNs as the program is supportive rather than a replacement for pregnancy-related care. Enrollment may begin as early as eight weeks and continues through a six-week postpartum period with educational content provided that coincides with each trimester and the postpartum period. Within the program, each trimester’s educational content is referred to as a different loop (e.g., loop 1, 2, 3, and postpartum loop).

The primary method of health-related communication is app-based, with chat responses and/or phone calls from nurses. Weekly check-ins serve as prompts for participation. Tailored education is also provided to patients via the app. The service is available 24 hours a day, seven days per week. Response times of 30 minutes or less are required if the patient’s check-in response or comment is flagged as a “red alert,” and a 1-hour response time is required for “yellow alert” triggers. High blood pressure readings are an example of a red alert, and a positive depression screening may trigger a yellow alert. Telephone calls from the RN to the patient enable triaging of the patient’s need for appropriate escalation and the type of follow-up care or service needed [35]. Two RNs facilitate the day-to-day flow of patient care, with one managing alerts, triage, and questions and the other managing the tracking of program enrollment and crossover of patients into different pregnancy care loops and postpartum programs.

Participants

A purposeful sampling strategy was used to recruit women for the research study. Eligibility was determined based on enrollment in the program within the past 30 days and if the patient was affiliated with OSF HealthCare or one of the FQHC partners. Each month, from December 2022 to December 2023, program staff sent a list of potentially eligible women already enrolled in the PPSP to research team members. The list was reviewed, and women were selected based on rurality (rural-urban commuting area [RUCA] codes [36]), duration in the program, trimester, source of prenatal care, and town to ensure that the sample included all the regions within Illinois served by the program and that it also included a mix of FQHC and OSF HealthCare patients. In total, 197 women met the eligibility criteria, and patients were texted once or sent a recruitment letter and called up to three times. Of the 197 patients contacted, 164 did not answer their phones or respond to the text message, 33 answered the phone, 23 consented, and 10 declined. Nurses and APRNs were eligible to participate in the study if they worked in the PPSP. They were identified from a list of employees working within the program. Members of the research team reviewed the list and sent recruitment emails, with five of seven consenting to participate.

A total of 23 women were interviewed at least once. Eight women were interviewed twice, and three completed all three interviews. Demographics were collected on 21 of 23 patients (See Table 2). As noted earlier, the residential zip code was used to ensure sampling distribution from across the PPSP’s outreach across the state. The women’s RUCA codes ranged from 1 to 7, indicating that the sample included rural and urban areas. Women enrolled in the program during all trimesters, including one who enrolled only in the postpartum. All the women were enrolled in Medicaid. In addition, five nurses (RNs or APRNs) were also interviewed.

Table 2 Descriptive characteristics of women enrolled in the pregnancy and postpartum support program (N = 23)

Measures

Depending on when the women enrolled in the program, they were interviewed up to three times. The first interview was conducted in their first or second trimester, the second in their third trimester, and the third interview within six weeks of giving birth. Interviews were conducted by three authors: a medical anthropologist, an APRN research scientist, and a doctor of nursing practice candidate with obstetric experience. All patient interviews were conducted using unique semi-structured interview guides developed through a literature review. The guides covered the topics of pregnancy experiences, care preferences, program use, barriers to care, pregnancy management, and birth outcomes. Program staff were interviewed once using a different semi-structured interview guide, including implementation/development, patient experiences, preferences, and caring experiences. The authors initially reviewed each study guide and then again after each of the first five interviews and made changes as necessary, such as rewording questions and adding probes. Interviews were conducted via Microsoft Teams or the phone and lasted between 30 and 60 min. (See Table 3)

Table 3 Semi-structured interview guide question excerpts from patient and nurse interviews

Ethical principles of the study

This research study was approved by the University of Illinois College of Medicine Institutional Review Board (IRB) -1 (1876230). All participants were informed about the study goals and confidentiality, verbally consented before enrolling, and were given a small stipend for their time. To maintain compliance with IRB approval and to preserve anonymity for healthcare personnel, precise demographic data are not reported.

Analytic strategy

The interviews were recorded using Microsoft Teams or via telephone using an audio recorder and transcribed verbatim. Interview summary sheets and notes were composed after each interview and uploaded into NVivo 14, a qualitative data analysis program. Transcripts, notes, and interview summaries were deidentified and inductively coded using the process for text analysis as described in Ryan and Bernard [37]. At least two of the authors met weekly to review the transcripts using open coding, a collaborative process of dividing the transcripts into conceptually meaningful segments (phrases, sentences, or clusters of sentences) and assigning them a code word or phrase that describes each chunk of data. After co-coding the first five transcripts, the research team reread and recoded them to eliminate redundant codes by collapsing multiple codes into fewer codes, renaming, further defining codes to improve their conceptual meaning, and organizing them into a hierarchy [38]. The team members then used the codebook to analyze the remaining transcripts independently. To improve the interrater reliability of the coding process, the team met weekly to review the coded transcripts and refine the codebook. During this phase, the interview guides were also slightly modified to address emergent themes by revising questions and adding probes to elucidate additional details on topics (e.g., PPSP usage and patient experience). Memos, comparing codes across positive and negative cases, were used to refine the themes further and develop the conceptual framework [38].

Results

While enrolled in the PPSP, patients primarily interacted with RNs in the program via text messaging. Depending on their level of need (or interest), some women also participated in phone calls and virtual visits, but those options were not used as frequently. Analysis of their discussions about their relationships identified two major themes and twelve subthemes (See Table 4). The first major theme, Therapeutic Nurse-Patient Relationships, consists of six subthemes that explain how nurses, other healthcare providers, and patients describe the nurse-patient relationship. The second major theme, Programmatic Aspects that Support Virtual Relationships, focuses on the aspects of the program that impacted or shaped how relationships developed.

Table 4 Results from thematic analysis of interviews (N = 28)

Therapeutic Nurse-Patient relationships

Throughout the interviews, patients and nurses described the close, personal, and intimate relationships they developed. The closeness that developed resulted from the nurses communicating in a non-biased, emotionally supportive manner that patients interpreted as a caring relationship that was, at times, akin to a friendship.

Effective communication

Nurses and patients mentioned that effective communication was important. Nurses commented that they communicated differently with the women than in a clinic. For instance, instead of giving women a lot of information all at once (at a prenatal visit), the nurses learned that the best way to communicate was by texting “after 9 am” and not,

…sending all this information and asking all these questions. It’s got to be much shorter because that’s how the moms handle it better. And it has to be very to the point. And they will ignore any question that they don’t want to answer…and they’ll answer the question that they want to answer. (Nurse 1)

Overall, the patients found nurses to be excellent communicators and that nurses adapted to texting very well. As one woman explained, “They have been nothing but understanding… [nurses] put things in a way I can understand. It’s just an overall great experience.” (Patient 1)

Non-judgmental

Patients also mentioned that they felt “like they [nurses] listen,” and it made them feel as if they could ask questions without feeling uncomfortable or criticized. As one patient explained,

I feel like all females that are going through a pregnancy or afterward, they shouldn’t feel embarrassed. To use the OSF resource, or like talk to a nurse, it’s very helpful and we are all females and shouldn’t feel embarrassment, if they do, it’s very helpful. (Patient 2)

Others mentioned how they felt they could ask any question without worrying about what the nurse would do or say.

Like, whatever question of any silly thing that you need some of them for, they’re there and they answer you with so much care…like they’re family…You know, they don’t ever make [send] a message that makes you feel judged. (Patient 3)

Emotionally supportive

Patients repeatedly mentioned that the nursing staff supported them when they had questions and concerns about their pregnancy, especially when they did not have anyone else to talk with. One woman explained, “I definitely love the support…. even if I’m home alone all day or have been for a few days and haven’t really talked to family or anything.” (Patient 4) Another patient explained that she just wanted to know that everything with the pregnancy was going okay, but she did not have anyone else she felt she could talk to about her concerns. Nurses in the program acknowledged the importance of providing emotional support and being there for patients when they needed them.

Having someone send these messages that say this is what’s normal and you may feel like this and that’s okay, and we’re here for you at, you know, 1:00 [o’clock] in the morning when you can’t sleep because you’re replaying it all in your mind. Here’s someone that you could talk with. (Nurse 1)

Intimate

Nurses and patients also described their relationship as close and more personal. Nurses juxtaposed these relationships to other nurse-patient encounters in clinic settings. As one nurse explained,

And even that small kind of relationship that…[patients] have with that nurse [in the clinic] is not the same as the relationship that we have with the patients through the loop. I think it’s just a much more intimate close. They ask us questions that I know they would not have asked in the office… And I think it’s intimidating to share that [sensitive personal information] with your provider. But the relationship that we have with them through the [PPSP], I think that is tailor made for that kind of sharing that, you know, can you just give me information on resources in my area in case I need it? (Nurse 1)

Another APRN mentioned that patients viewed frequent communication through the use of the PPSP as a safe medium for sharing personal, detailed information.

And I mean, I feel like we connect. I worried when I went digital that I wasn’t going to connect with patients. But I actually feel like I connect more with my patients digitally because I talk to them every day. You know, when you work… in the floor [hospital] or even the office like, you don’t see them…as much as you do now. (Nurse 2)

For example, another nurse described a recent patient text,

‘I’d wanted to reach out before my depression got too bad.’ That was the message we got in the chat. It wasn’t because of a PHQ-2 [2-item depression screening questions]. It was ‘I’m reaching out before my depression gets too bad.’ (Nurse 3).

Patients explained this closeness with the nurses as people they could talk to “when emotions get deep.” Those emotions could be anxiety, depression, sadness, or the joys that they felt during and after the pregnancy. As one expectant mother noted, “When you feel lonely and stuff like that, that they’re there for you, that they just take care of every concern that you have.” (Patient 4)

Another woman explained the relationship further,

Obviously [it is] still like a professional relationship, but like a good like doctor-patient relationship. They’re comfortable bringing up my issues and discussing them. And I actually I feel like I’m heard and it’s not just, you know, this is the standard of care and this is what we’re going to do. (Patient 13)

Transferable relationships

When patients talked about the nurses they interacted with, most could not name the person; instead, they referred to the positive feelings that they had toward the nurses in general terms: “[nurses] were like family to me.” One woman explained it as, “It’s nice to have a little check-up, even if I don’t know the nurse in person.” (Patient 4) This implies that when one nurse, or a team of nurses, establishes a relationship with the patient, it is transferable to any other member of the nurse care team. A nurse commented,

I think a lot of our patients think of us as one single nurse. They rarely use our name, which I think is interesting when they interact with us in the loop [text messaging]. We always use their names, and they rarely use our names back, even though our name is right on the screen. So, in my perception is that they think of us kind of as they have some imaginary nurse…and that’s who they’re interacting with. (Nurse 4)

Programmatic aspects that support virtual relationships

Aside from the characteristics of the nurses that the patients liked, they also reflected on specific programmatic characteristics of the PPSP that influenced the development of their relationships.

24-hour access

Around-the-clock access to nursing staff was a common theme that patients appreciated. It was frequently stated that the 24/7 real-time access to care gave them peace of mind. One woman stated, “If I needed something after hours, that’s nice to know that you’re just a message away.” (Patient 5) Another patient similarly stated, “It’s easily accessible anytime I need it, which is really nice…any questions, comments, concerns.” (Patient 2)

Action-oriented care

Implementing healthcare interventions supported the nurse-patient relationship by ensuring that something beyond emotional support and education was achieved for the patients when concerns arose. As one patient explained, “When I had a sinus infection, they gave me an antibiotic for that because it was a weekend, and I couldn’t get into my doctor.” (Patient 6) According to interviews, this program ensured patients were given assessments, evaluations, care coordination, and prescriptions when treatment was indicated. Patients felt their complaints were being heard and addressed, which nurtured their trust in staff.

Patient communication preferences

Patient preferences were supported by allowing them to control the frequency of communication with program staff and communicate via text messaging. One nurse mentioned in an interview, “the amount of participation is completely open to the patients so they can check in as often as they’d like or as infrequently as they’d like.” (Nurse 3) Moreover,

It gives that patient ownership to reach out when they want to reach out and respond when they want to respond - doesn’t mean we’re not going to bug them if they don’t respond. But we try and be gentle when we respond. (Nurse 2)

Pregnant women preferred text messaging and liked that they could interact as much or as little as they wanted in the program. However, some women still valued their in-person prenatal visits, “it’s just. It’s more, um, comforting. It’s a lot more comforting to do it in person versus over your phone screen.” (Patient 7)

Quick and responsive

Relationships were strengthened with the timeliness of the nurse’s text responses to patient questions. The ability to have access to nurses and other providers at their fingertips made patients feel supported and at ease. One patient stated, “I get my questions answered right away without waiting for the doctor or nurse to call me back.” (Patient 8) The speed of responses by the nurses in the program not only showed respect for patient time and an acknowledgment of their concerns but also felt more like a real-time conversation with staff as opposed to leaving a message on an asynchronous platform such as MyChart.

Anonymous

Patients mentioned that the PPSP allowed them to feel more comfortable talking with nurses (RNs and APRNs). Some explained that texting was easier for them to communicate their feelings, and others mentioned that it was easier to talk about certain things via text. An APRN suggested that it was “being anonymous with the nurse that you’re talking to that allows them to be more open about what they’re experiencing. Because it is not a face-to-face interaction…they’re more open about what they have knowledge deficits around.” (Nurse 4) Another nurse further explained, “I just feel like having worked both sides of it, like in-person versus digital, I just feel like so many more of these patients open up to us about those things than I saw [with patients] when I worked in the clinic.” (Nurse 5)

Not time-limited

Patients and nurses alike appreciated that their conversations were not time limited as they would be in a clinical setting. The way the program was developed, conversations between nurses and patients could last indefinitely. An APRN stated, “So in terms of the quality of care that we can produce virtually, I think it’s equivalent, if not better, because I think we have the opportunity to spend the time with the patient, respond much quicker and to follow up either via telephone or video.” (Nurse 2) Another nurse explained,

They don’t have that comfort [in the office] because it’s ‘we got to get to the next patient…hurry, hurry, hurry’. But with us, we could carry on a chat for most of the day with multiple patients at the same time and they never have that rushed feeling. (Nurse 3)

Patients like this feature because it allows them to think about the information provided and ask questions whenever they have one at the most convenient time for them. Some women also compared the time that was spent with the PPSP nurses to the care that they received from their OB provider,

Sometimes when she [OB provider] kind of rushes in the room and tries to rush out and I try to ask her questions. And sometimes it just kind of seems like she doesn’t really want to answer my questions. Um, which kind of sucks. But, I mean, what can you do? I get it. She’s a busy woman. And she just kind of seems like she just kind of doesn’t care to do too much. (Patient 12)

Trusted source of information

Patients described the educational resources provided by the program, in contrast to internet resources, as reliable. “Whatever resources they were willing to give me, I was willing to take. I usually go to the APP or ask a doctor. I try to avoid the internet, sometimes the internet can never really be trusted.” (Patient 11) Furthermore, the program developed trust in the nurses, “I trust. I trust whoever is on the other line from OSF because I trust OSF.” (Patient 13) Some patients also indicated that because the information was tailored and provided when they needed it, they were more likely to contact program nurses when they needed information.

Discussion

This research demonstrated that maternal telehealth programs can enhance the development of therapeutic nurse-patient relationships, offering women an additional healthcare option to in-clinic obstetric care only. With high rates of maternal morbidity and mortality worldwide, it is crucial to enhance the care provided to expectant and new mothers. In many instances, public health and policy solutions have concentrated on increasing access to care, which many in the United States have interpreted as expanding insurance coverage. However, research has shown that insurance coverage alone does not always translate into increased access to high-quality and timely care [9]. Recently, though, within the United States and in other countries, telehealth has emerged as a new strategy to expand access to maternal care [10, 39, 40].

While maternal telehealth programs vary globally, they have been shown to reduce some barriers to care by increasing access to healthcare providers, decreasing the need for transportation, and delivering patient education remotely [12, 25]. Participants in our study reported that being part of the program improved their access to quality education, decreased their reliance on primary or urgent care for acute issues (such as sinus infections), and provided them with nurse support whenever needed. In addition to reducing barriers, some research on maternal telehealth programs has shown that they can increase overall healthcare usage and reduce racial disparities in postpartum healthcare usage [41].

As these programs become more popular, it is increasingly important to ensure that they provide quality care and include how to seek a trusted source [42]. To this end, some studies have explored outcomes [39] and patient satisfaction [25] but there is little in-depth research on the impact that it has on patient relationships [21]. One notable exception is Baron et al. [27], who found that pregnant women felt more connected to nurses because of the frequent communication. Our study also confirmed that patients developed positive relationships with their nurses in the virtual environment that allowed them to feel comfortable sharing sensitive personal information. In addition, our discussion of nurse-patient relationships included different types of nurses who interacted with the patient (RNs and APRNs) since the patients sometimes just used the more generic term nurse to describe the nurses they interacted with. Interestingly, when asked about their relationships, nurses and patients in our study described them using four of the five characteristics of a therapeutic relationship (trust, professional intimacy, respect, and empathy) [29, 43] and added a new component, transferrable relationships, which could be a unique aspect of telehealth programs. Some patients even mentioned that they considered their nurse more than just a healthcare provider, but someone they can feel comfortable talking to, confiding in, and sometimes a friend. Landy et al. [30] noted that “friend” in this context is a colloquial way to describe the therapeutic relationship that developed.

Implications

While therapeutic relationships have often been conceptualized as occurring within clinical or in-person settings, some research has shown that telehealth programs can create digital intimacy [44]. In this context, intimacy arises from patients feeling cared for, that they are more than just data, and through developing a collaborative partnership between patient and provider, which provides the foundation for developing therapeutic relationships. Our study illustrates that digital intimacy can be developed between patients and nurses using a telehealth program that communicates with patients primarily through texting. This relationship was fostered through programmatic aspects such as 24/7 access to nurses, the program’s ability to offer continuity of care, personal attention, and support of collaborative decision-making. Interestingly, women preferred using text messaging due to its convenience, allowing them to ask questions, articulate problems, and provide thoughtful responses more easily. It also allowed them to talk to nurses more frequently, which has been linked to the development of better relationships [27]. Moreover, this study illustrates that nurse-led telehealth programs can develop positive patient relationships, the cornerstone of quality maternal healthcare. Finally, while this paper does not report patient health outcomes, other research on the positive impact of patient-provider relationships has shown that they can influence positive health-related outcomes [45]. Our research suggests that maternal telehealth programs, when they incorporate the aforementioned characteristics, can foster positive relationships similar to clinical visits and potentially increase access to quality prenatal care.

Limitations

Several limitations are noted with this study, including its sample size, low response rate, loss of patients to follow-up, and women from one state in the United States. Additionally, our sample mainly consisted of unmarried women, which aligns with the overall enrollment in the PPSP program [35] but may suggest that they have greater needs than their married counterparts. Previous researchers have described the challenges of recruiting and retaining pregnant women in research studies [46]. Despite using several recommended strategies [47, 48], access to this population remained challenging. The sample also does not include patients who did not like the program, were disengaged, or did not respond, therefore affecting the representativeness or diversity of opinions and experiences shared in the interviews. Additional research is needed to incorporate these individuals’ perspectives [42]. Nevertheless, this research provides insights into the roles of nurses in digital health, with an emphasis on the importance of a patient-centered focus, which may serve as a medium for improving pregnancy-related care delivery in under-resourced areas globally [49].

Conclusion

Our study suggests that a new maternal telehealth program can support a therapeutic nurse-patient relationship via selected programmatic characteristics. These relationships are meaningful to patients and nurses. While there are differences in how telehealth programs are developed and operated, they need to consider the impact on therapeutic nurse-patient relationships. This is especially important because these relationships have been linked with improved patient outcomes. As telehealth becomes more widely adopted as a strategy to address barriers to accessing maternal healthcare, focusing on programmatic characteristics that support the development of these relationships can improve both patient and nurse experiences and can help address the maternal health crisis. Further research is needed to examine women’s experiences with telehealth in the postpartum period.