Community nurses’ experiences with digital sensory interventions in remote primary care: a qualitative descriptive study of trust, privacy, and family dynamics
- Open Access
- 13.12.2025
- Research
Erschienen in:
Abstract
Introduction
Remote models of primary care have reshaped where and how community nurses build relationships, assess symptoms, and support families, shifting portions of intimate clinical work into domestic spaces [1, 2]. Within video encounters and remote patient-monitoring workflows, nurses increasingly use digital sensory interventions (DSIs), structured, technology-enabled practices that elicit or interpret assessment cues at a distance. DSIs encompass patient-led symptom narration using standardized scripts, audio-based respiratory and functional cues, invited caregiver observations when appropriate, and streams of data from home devices and wearables [3‐5]. In this study, DSIs are treated as a specific subset of telehealth encounters in which nurses intentionally guide remote sensory assessment (for example, coached respiratory counts, off-camera mobility tests, or alignment of pulse oximeter logs with real-time audio cues). By contrast, teleconsultations limited to general conversation, education, or administrative coordination, without structured sensory tasks, were considered routine telehealth and fell outside our DSI focus [6].
These practices can extend access and continuity; at the same time, they make trust, privacy, cultural norms, and family dynamics central determinants of care quality. Although telehealth is now described as routine, the relational and ethical scaffolding that nurses must construct around DSIs remains under-specified in the literature [7, 8].
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Community nursing has long been grounded in continuity, cultural sensitivity, and family-centred decision-making [9]. Telehealth extends this ethos into the home, where nurses navigate variable lighting, sound, bandwidth, caregiving roles, and spatial constraints while upholding domestic privacy and modesty, and still making safe clinical judgments [10]. Evidence across phone, video, and remote monitoring suggests nurse-led telehealth can add substantial value; however, effectiveness depends on deliberate preparation for rapport-building, environmental awareness without intrusion, and consent practices tailored to domestic settings. Competency statements and practice guidance increasingly emphasize that nurses require technical, communicative, and ethical skills to conduct remote assessments that are both person-centred and safe, considerations that carry particular salience in culturally conservative households where privacy boundaries are tightly held [11‐13].
Existing research documents both promise and strain. Qualitative studies report improvements in access and timeliness, yet al.so highlight barriers for older adults and vulnerable populations, reduced nonverbal bandwidth, variable digital literacy, and the redistribution of workload to families [14‐17]. Findings converge on the fragility of rapport in remote care and the need for slower, explicit, and transparent communication to sustain trust [18, 19]. While data- and device-level protections (platform selection, encryption, authentication) are increasingly well described, situational privacy inside the home is less developed [20]. Without clear, nurse-actionable protocols, remote encounters can inadvertently expose household members, living spaces, or personal circumstances; consent may be assumed rather than refreshed; and “always-on” sensors may blur boundaries between care and surveillance [21‐23]. Public and regulatory guidance tends to remain high-level; frontline nurses need granular micro-protocols for real-time decisions such as which cues to elicit, who should be present, when to pause or switch modality (e.g., audio-first or data-only), and how to document boundary setting [24].
Family participation is double-edged. Caregivers can stabilize technology, translate symptoms, and enact coached assessments; they can also gatekeep, dominate accounts, or disagree about what should be disclosed [25, 26]. Recent studies across rehabilitation, palliative, and home-based care show that caregiver preferences shape the conduct and acceptability of remote visits, yet nursing strategies for orchestrating these roles during sensory-dependent assessments [27, 28], while preserving patient autonomy and domestic privacy, remain under-characterized [29, 30].
Moreover, scholarship often treats the granular techniques that make remote sensing clinically useful, patient-led guided symptom description, coached functional tests that can be performed off-camera, structured verbal environment-safety checklists, and the integration of wearable/device data as generic telehealth tasks [31‐33]. Few studies conceptualize these as DSIs with distinct relational and ethical implications, especially in cultural contexts where visual exposure is exceptional rather than routine, and where opt-in, time-limited, and reversible consent is essential [34]. Guidance on “intentional viewing” usefully notes that technologies both extend and constrain the clinician’s sensing, but operational taxonomies linking specific DSI techniques to trust, privacy, cultural congruence, and family processes in community nursing are sparse [35, 36]. This constitutes a clear gap: a nursing-centred account of privacy-preserving DSIs in remote primary care that explains how nurses balance clinical signal gathering with relational and ethical safeguards under real-world constraints.
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Addressing this gap matters for practice, standards, and equity. For practice, a descriptive map of privacy-preserving DSIs can be translated into micro-protocols: pre-visit briefing scripts that frame consent as stepwise and reversible; option-setting that presents audio-first and data-only pathways before any visual cues; on-call boundary negotiation (what to sense, who may be present); culturally appropriate caregiver role assignment; modality switching when privacy or modesty is at risk; and documentation templates that capture consent refresh, privacy decisions, and trust-repair actions [37]. For standards and education, findings can inform telehealth competencies that move beyond device operation to the relational competencies required for DSIs (narrating purpose, securing assent from all present parties, pausing or switching modalities when needed) [38]. For equity, explicit DSI practices can reduce burdens shifted to families, prevent inadvertent surveillance of living conditions, and guard against moral distress among nurses when intimate cues are clinically relevant but culturally sensitive. In systems where telehealth is standard, these refinements are necessary to ensure safety, consistency, and person-centred, values-aligned care [39].
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Aim of the study
To describe and interpret community nurses’ experiences of deploying privacy-preserving digital sensory interventions in remote primary care, with particular attention to trust-building and repair, domestic privacy protection, cultural congruence, and family role orchestration during digitally mediated encounters.
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Research question
How do community nurses enact privacy-preserving DSIs in remote primary care, and how do these practices shape trust, domestic privacy, cultural alignment, and family role orchestration across audio-first, data-enabled, and selectively visual modalities?
Objectives
1.
Identify the types, components, and workflows of DSIs used by community nurses (audio-first scripts, validated scales, device/wearable data; visual cues only when essential and consented).
2.
Examine nurse strategies to initiate, maintain, and repair trust when DSIs request sensitive cues, including opt-out pathways.
3.
Analyze how nurses anticipate and mitigate privacy risks (stepwise/reversible consent, limited-frame principles, off-camera options, modality switching, and clear data-handling explanations).
4.
Explore how nurses invite and delimit caregiver roles to support assessment quality without compromising patient autonomy or modesty.
5.
Derive practice recommendations for protocols, documentation, and training that support safe, ethical, culturally congruent DSI use in community nursing telehealth.
Theoretical framework
As depicted in Fig. 1, this study integrates the Transactional Model of Stress and Coping with Cognitive Appraisal Theor [40], to conceptualize digital sensory interventions (DSIs) as relationally charged sociotechnical practices enacted within two nested conditions: an inner Trust Ring, which enables clinical interaction, and an outer Privacy Ring, which safeguards personal boundaries. DSIs are shaped by four contextual layers: domestic environment, technological infrastructure, cultural considerations, and regulatory framework, which together determine what can be ethically and practically sensed in the home [41].
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Three actors engage DSIs through distinct roles [42]: nurses function as facilitators and active mediators; patients are care recipients who co-generate clinical data and act as primary consenting agents; and family members serve as co-appraisers who may scaffold technology or, at times, gatekeep access [43]. Guided by appraisal constructs, all parties conduct threat, challenge, and benefit appraisals while evaluating coping resources (e.g., privacy controls, cultural accommodations, gender-concordant staffing, alternative modalities). We specify six privacy-first nursing micro-practices that mechanistically link DSIs to outcomes: boundary negotiation, consent refreshment, transparent narration, modality de-escalation/escalation (audio ↔ data ↔ visual), role assignment, and privacy protection/documentation (Al-Naimi & Alistar, 2024).
A modality hierarchy structures real-time decision-making: audio-first → data-enabled → visual (opt-in, time-limited). Decision gates govern movement across modalities, clinical necessity → refreshed consent → cultural accommodation feasible → proceed/time-limit → document, that preserve autonomy and modesty while securing adequate clinical signal. Through these mechanisms, DSIs influence four outcome domains: care quality, safety and equity, person-centredness, and trust-and-privacy integrity, positioning DSIs not as neutral tools but as intentional, negotiated interventions in remote primary care.
Fig. 1
theoretical framework of digital sensory interventions in remote primary care
Telehealth’s rapid normalization has outpaced nursing-specific guidance for conducting the sensory work of assessment ethically inside the home, particularly where domestic privacy, cultural modesty, and family gatekeeping are salient. By centring privacy-preserving digital sensory interventions, audio-first, data-enabled, and visual only by opt-in and time-limit, and by theorizing their entanglement with trust, privacy, and family roles, this study addresses a defined practice gap. Using a qualitative descriptive approach, we aim to generate operational, culturally congruent micro-protocols and competency elements that community nurses can apply to deliver safe, person-centred remote primary care in Saudi settings and comparable contexts.
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Methods
Research design
This study employed a qualitative descriptive design, situated at the more interpretive end of this tradition, to generate a rich, practice-proximal account of how community nurses implement digital sensory interventions (DSIs) in remote primary care settings [44]. This approach was selected for its suitability in producing clinically usable knowledge directly relevant for the development of protocols and training materials, where a detailed understanding of process enactment is paramount [45]. Within a pragmatic–constructivist stance, the analysis was theory-informed: an a priori conceptual framework (Trust/Privacy Rings and appraisal-based theory) was used as a sensitizing structure rather than a coding template, allowing higher-order constructs and an integrated model (e.g., Tele-Relational Competence) to emerge while remaining closely anchored to participants’ accounts [46]. Reporting adheres to the Standards for Reporting Qualitative Research (SRQR) [47] and was cross-checked against the Consolidated Criteria for Reporting Qualitative Research (COREQ) [48] to ensure methodological transparency and rigor.
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Operational definitions:
Digital sensory interventions (DSIs) are structured, technology-enabled practices that remotely elicit or interpret assessment cues, prioritizing audio-first elicitation (e.g., standardized symptom narration; coached respiratory/voice cues) and data-enabled inputs (e.g., patient-reported measures; vital-sign streams from home devices/IoT; wearable movement/haptic data). Visual cues (e.g., guided checks during video) are used only when clinically essential, are opt-in, and are time-limited, with refreshed consent. DSIs may be synchronous or asynchronous and are documented within secure health systems [49, 50]. For analytic purposes, an encounter was coded as a DSI when the nurse deliberately orchestrated one or more guided sensory tasks (such as coached respiratory counts, voice-based work-of-breathing checks, off-camera functional tests, or review of home device logs alongside synchronous audio assessment). Contacts confined to generic symptom discussion, education, or scheduling, without such guided sensory work, were classified as routine teleconsultations and not analysed as DSIs.
Dynamic consent
Field-of-view negotiation
A privacy-by-default discussion of what, if anything, enters the visual frame, who controls the device, and who may be present, with preference for off-camera alternatives where feasible.
Study setting
The study was conducted within three distinct community nursing services in Al-Majmaah, an urban–peri-urban governorate in Riyadh Province, Saudi Arabia. To maintain institutional confidentiality, these organizations are referred to as Site 1, Site 2, and Site 3. All participating sites had established telehealth programs as a routine component of their service delivery model. The patient population served by these sites encompassed a wide range of socioeconomic conditions, resulting in diverse home environments and variable internet connectivity. This heterogeneity was intentionally leveraged to support the study’s maximum variation sampling strategy, ensuring a comprehensive understanding of DSI enactment across a spectrum of real-world conditions.
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Participants and sampling
Eligibility criteria
Inclusion. Registered Nurses (RNs) licensed in Saudi Arabia who were currently delivering remote primary care at one of the three participating services (Sites 1–3) were included. Participants required ≥ 6 months of continuous telehealth experience that routinely incorporated digital sensory interventions (DSIs) as defined in the Operational Definitions (i.e., use of audio-first and/or data-enabled assessment; visual steps only when applicable per study framework). Eligible nurses reported routine use of at least two modalities, one of which had to be audio or data. Functional proficiency in Arabic or English and active direct patient care (adult or pediatric) in community/home settings were required.
Exclusion. Non-clinical roles (e.g., administration, scheduling, technical support); contacts limited to logistics with no assessment content; telehealth work without any DSI activity; < 6 months telehealth experience; inability to provide informed consent; extended leave without active telehealth practice; or active disciplinary investigation specifically related to telehealth practice.
Sampling strategy and sample size
We employed purposive, maximum-variation sampling to obtain a practice-proximal range of DSI enactments across modalities (audio-first, data-enabled, and selectively visual/opt-in), patient populations (adult and pediatric; acute and chronic conditions), and domestic contexts (e.g., private vs. shared living spaces; variable bandwidth/connectivity). To identify niches of practice (e.g., data-only monitoring workflows, audio-led coaching in low-bandwidth homes), we supplemented recruitment with snowball sampling, inviting participants to recommend colleagues with distinctive telehealth experience [53].
Sample size was guided by information power, with a focused aim, conceptually coherent framework, and participants’ high DSI involvement; fewer interviews were required to achieve analytic adequacy [54]. We planned 20–30 interviews and completed 24 (Site 1: n = 9; Site 2: n = 8; Site 3: n = 7). In total, 41 nurses were invited; 11 declined, 27 scheduled, and 3 did not attend. We monitored information power iteratively (after every 3–4 interviews/site) and closed recruitment once additional cases yielded redundant codes without expanding the modality–privacy analytic matrix. A participant flow diagram is provided in Fig. 2.
Fig. 2
Sampling strategy and participant flow
Recruitment and data collection
Recruitment
Following institutional ethics approval, recruitment proceeded via designated gatekeepers at each participating service (Sites 1–3). An IRB-approved invitation describing aims, eligibility, risks/benefits, and contact details was circulated to all eligible nurses. To mitigate managerial influence, the notice directed interested nurses to contact the research team privately through a study email/phone; managers were not informed about who inquired or participated. Those who expressed interest received an information sheet and consent form, with at least 48 h provided for consideration and questions. Electronic informed consent was obtained before scheduling any interview. Participation was voluntary with no incentives, and declining carried no professional consequences.
Data collection
Data were generated via semi-structured, one-to-one interviews conducted between March and June 2025, using a study-specific interview guide (Supplementary File 1) aligned with the study’s core objectives, trust-building/repair, privacy protection, family-role orchestration, and DSI workflow. The guide employed open-ended questions and non-leading probes to elicit practice-proximal accounts of DSIs across audio-first and data-enabled modalities; visual scenarios were considered only hypothetically (no demonstrations), consistent with the study’s privacy-preserving stance.
Interviews were conducted in Arabic or English on a secure, encrypted platform with the camera off by default; an audio-only telephone was offered to participants who preferred low bandwidth or greater privacy. Sessions lasted 45–75 min and were audio-recorded with explicit permission (video was not recorded). The privacy protocol required interviewers to be in a private room, use a headset, prohibit screen capture, and avoid any request to show homes, family members, or devices. Participants were reminded they could pause, skip questions, or withdraw at any time without penalty; dynamic re-consent was sought before exploring potentially sensitive topics (e.g., boundary breaches, trust repair).
The guide was pilot-tested with two non-participant community nurses, leading to clearer probes on field-of-view negotiation as a policy decision (not a live camera practice) and a brief vignette to explore trust-repair actions. Pilot data were excluded from analysis.
Recordings were transcribed verbatim and de-identified. Arabic interviews were translated and back-checked by bilingual researchers for semantic equivalence; discrepancies were resolved by consensus. All files were stored on encrypted, access-restricted drives, using only study IDs. Closing reflections captured participants’ final views; member feedback on a brief thematic summary informed minor clarifications but was not treated as validation.
Data management and analysis
Data management
Audio recordings were saved locally and immediately uploaded to a secure, encrypted, access-controlled repository. All files were transcribed verbatim. For Arabic interviews, a certified bilingual translator produced the Arabic transcript and an English translation; a second bilingual nurse-researcher verified fidelity through time-anchored spot checks (every ~ 10 min) and logged discrepancies for consensus resolution. All transcripts were de-identified using unique IDs (e.g., N08-S2) to protect confidentiality [55]. Version control tracked edits to transcripts, memos, and analytic files. Data handling and retention were in accordance with IRB-approved policies, with access restricted to the study team.
Data analysis
We used reflexive thematic analysis [56], supported by NVivo 14 (QSR International). Analysis followed a hybrid deductive–inductive path [57]. A preliminary codebook, anchored to the theoretical framework, included parent nodes for trust, privacy, family-role orchestration, DSI components/workflows, and documentation [58]. Inductive coding was then elaborated, and new child nodes were created as needed to provide data-driven insights (e.g., field-of-view negotiation, situational crowding). Framework-external themes were presented alongside framework-aligned themes; we did not retrofit novel content into pre-specified categories.
To enhance dependability within a reflexive TA design, two analysts trial-coded 25% of transcripts (n = 6) using codebook v1.2 as an early calibration exercise to surface interpretive differences and tune the analytic lens. The observed overlap of provisional codes (86%) was treated solely as a training/diagnostic indicator, not as a validity or reliability test. Analysts met to adjudicate, refine definitions (codebook v1.3), and record decisions in the audit trail. A second calibration check on additional transcripts (n = 3) indicated greater overlap (90%). The remaining transcripts were single-coded by the primary analyst, with weekly peer-debriefings to sustain reflexivity and consistency. Analytic work included iterative memoing, thematic mapping, and targeted challenge by disconfirming cases [59]. A theme was retained if coherent across ≥ 2 sites and supported by multiple participants and contexts; the team reached a reasoned consensus on the final thematic structure.
Data sufficiency
Data sufficiency was guided by information power [60], operationalized in terms of the study’s five objectives. Recruitment continued until no new (a) DSI steps or roles, (b) trust-building/repair strategies, (c) privacy safeguards, (d) family-role configurations, or (e) actionable practice recommendations emerged across two consecutive interviews. This point was reached at Interview #22, where the saturation grid and analytic memos showed only repetition and elaboration of existing codes across all five domains, with no creation of new nodes. Two additional interviews (Interviews #23–24) were then conducted as a planned confirmatory check; line-by-line coding and memoing indicated that all segments mapped onto the existing codebook without further code expansion, at which point the team agreed that information power was sufficient and recruitment ceased.
Trustworthiness
Trustworthiness was addressed using Lincoln and Guba’s criteria (as summarized by [61], operationalized to a reflexive thematic analysis design.
Credibility. We combined prolonged engagement across three sites with maximum-variation sampling to capture diverse DSI enactments. Credibility was further strengthened through iterative memoing, peer debriefings (weekly), and systematic attention to disconfirming cases (at least two per major theme logged and discussed) [62]. We collected participant feedback on a two-page bilingual thematic brief with a subsample (n = 10; 8 responses). The feedback informed minor clarifications (e.g., “dynamic consent”) and was treated as interpretive input rather than validation, consistent with reflexive TA. Bilingual translation fidelity checks (time-anchored spot-checks) supported the accuracy of Arabic→English materials. In keeping with reflexive TA, we did not treat coder agreement as a quality criterion; early overlap figures are reported only as training heuristics to refine the analytic lens.
Transferability. We provide a thick description of the setting, services, participant roles, and DSI workflows, alongside the modality hierarchy and privacy safeguards, enabling readers to protect domestic privacy granularly yet non-identifyingly.
Dependability. An audit trail documents all major analytic decisions: dated codebooks (v1.2→v1.3), adjudication logs, decision memos, versioned thematic maps, and NVivo project histories [63, 64]. Early coding calibration outputs (overlap of provisional codes: 86% → 90%) were used formatively for training only; we did not compute inter-coder reliability metrics, consistent with reflexive TA.
Confirmability. Quote→code→theme matrices ensure that claims are traceable to raw data. The team maintained reflexive journals to make researcher assumptions explicit, and an external methods audit by a senior qualitative scholar reviewed the audit trail and final thematic structure for methodological neutrality [65].
Ethical considerations
This study adhered to the Declaration of Helsinki and received approval from the Majmaah University IRB (MUREC/COM-2025/244). Participation was voluntary and unrelated to employment. After a bilingual information sheet, electronic written consent was obtained; participants could withdraw at any time without penalty. Transcripts were de-identified (unique study IDs) and stored on AES-256-encrypted, access-controlled servers with access limited to named investigators under confidentiality agreements.
Given the telehealth context, privacy safeguards distinguished platform security from situational privacy: interviews were conducted camera-off by default (audio-only option), no video was recorded, no demonstrations of homes/family/devices were requested, and a privacy checklist (private room, headset, who can overhear) was used. Dynamic re-consent preceded sensitive topics; participants could pause/skip/stop at any point, and gender-concordant interviewers were offered when feasible. Risks were minimal; de-escalation and referral information were available. Data will be retained for five years post-publication, then securely destroyed. No monetary incentives were offered; participants received a certificate of contribution.
Reflexivity
We adopted an explicitly reflexive stance consistent with reflexive thematic analysis, recognizing the research team as co-producers of knowledge. The lead interviewer (community health nursing academic with telehealth implementation experience) brought an “insider” understanding of DSI practice; a second interviewer (clinical nurse specialist with limited telehealth exposure) contributed “fresh eyes” sensitivity. To minimize power dynamics, no participants had supervisory/assessment relationships with interviewers. Team positionality statements and reflexive journals documented assumptions about privacy, cultural modesty, and family gatekeeping, and how these values might shape data generation and interpretation [66, 67].
Analysis was conducted by a qualitative methodologist (primary) and a community nurse educator (secondary). Rather than “bracketing,” we used iterative reflexive memoing, dialogic debriefs, and decision memos at codebook development and theme finalization to surface and work with subjectivity [68, 69]. Given the bilingual dataset, a certified translator prepared Arabic→English materials; a bilingual nurse-researcher performed fidelity checks, attending to clinical/cultural connotation. We co-developed a glossary of key terms and cross-checked all theme-defining quotations against original Arabic audio to preserve conceptual integrity. Reflexive dialogues and translation decisions were logged in the audit trail [69, 70].
Findings
Participant characteristics
The study included 24 community nurses from three community services in Al-Majmaah, Saudi Arabia. Table 1 summarizes demographic and professional characteristics. The sample was predominantly female (91.7%) and largely mid-career (45.8% with 11–20 years as Registered Nurses). Half of the participants (50.0%) reported ≤ 2 years of telehealth experience, consistent with the rapid local expansion of remote services. Participants reported routine use of digital sensory interventions (DSIs) across modalities, with audio-first and data-enabled cues forming the core workflow and visual steps used selectively, only when clinically essential and consented. As one nurse put it, “I start with voice and device data; video is optional and only if it adds something important” (P15, Site 2, 12 years). Another highlighted domestic privacy realities: “In the home visit, I control the environment; online, families control what I can access” (P08, Site 3, 7 years). These accounts illustrate typical practice but are illustrative rather than prescriptive and should be interpreted within the study’s privacy-preserving, audio-first framework.
Table 1
Demographic and professional characteristics of study participants (N = 24)
Characteristic | n | % |
|---|---|---|
Gender | ||
− Female | 22 | 91.7 |
− Male | 2 | 8.3 |
Age (years) | ||
− 25–35 | 10 | 41.7 |
− 36–45 | 9 | 37.5 |
− 46–55 | 5 | 20.8 |
− Range: 26–54 | — | — |
RN experience (years) | ||
− 4–10 | 8 | 33.3 |
− 11–20 | 11 | 45.8 |
− > 20 | 5 | 20.8 |
− Range: 4–28 | — | — |
Telehealth experience (years) | ||
− 0.5–2 | 12 | 50.0 |
− 3–5 | 8 | 33.3 |
− > 5 | 4 | 16.7 |
− Range: 0.5–8 | — | — |
Primary population | ||
− Adults | 14 | 58.3 |
− Older adults | 7 | 29.2 |
− Mixed adult/pediatric | 3 | 12.5 |
Site distribution | ||
− Site 1 | 9 | 37.5 |
− Site 2 | 8 | 33.3 |
− Site 3 | 7 | 29.2 |
Thematic analysis
Reflexive thematic analysis identified four central themes that address the research questions and capture the procedural, relational, and ethical dimensions of DSI enactment. Across cases, nurses followed a stepwise hierarchy of actions: pre-brief/environment setup → field-of-view (FoV) negotiation (if needed) → coached, audio-led tests with data alignment—with consent refreshed at each escalation. Trust moves (transparent narration; repair) and privacy moves (FoV zoning; modality switch/pause) were activated at boundary crossings (e.g., room changes, more intimate cues). This architecture explains when and why family role orchestration becomes necessary. Themes and subthemes are summarized in Table 2.
Table 2
Emergent themes and subthemes of digital sensory interventions (DSIs) in remote primary care
Theme | Subtheme (with micro-descriptors) | Prevalence (participants; sites) |
|---|---|---|
1. Staging DSIs as Stepwise Workflows | 1.1.Pre-briefing & Environment Setup (purpose; assign roles; check light/noise/bandwidth) | 20/24; Site 1–Site 3 |
1.2. Field-of-View (FoV) Negotiation (tight framing; patient/device-holder control; pause to reposition) | 21/24; Site 1–Site 3 | |
1.3.Coached Tests & Data Alignment (audio-led maneuvers; cross-check with device logs) | 18/24; Site 1–Site 3 | |
2. Trust-Building and Repair in Mediated Spaces | 2.1. Transparent Narration (reasoning aloud; pacing to patient energy) | 19/24; Site 1–Site 3 |
2.2. Repair & Vulnerability Management (owning glitches; ceding control; reschedule option) | 17/24; Site 1–Site 3 | |
3. Privacy as Ongoing Boundary Work | 3.1. Dynamic Consent Refresh (checkpoint at each escalation/context change) | 22/24; Site 1–Site 3 |
3.2. FoV Zoning & Presence Management (who is present; what is seen; private-space prompts) | 20/24; Site 1–Site 3 | |
3.3. Modality Switching/Pausing (audio-only; defer visual; pause capture; document) | 14/24; Site 1–Site 3 | |
4. Family Roles in Digitally Mediated Care | 4.1. Role Assignment & Scaffolding (technician/translator/device-holder; protect patient voice) | 19/24; Site 1–Site 3 |
4.2. Gatekeeping & Competing Agendas (redirect; patient-first talk time; alternative view path) | 16/24; Site 1–Site 3 |
Theme 1: Staging DSIs as stepwise workflows
Nurses enacted DSIs as structured, stepwise workflows rather than single actions. Encounters typically began with pre-briefing and environment setup, progressed, only if clinically needed, to Field-of-View (FoV) negotiation to manage what, if anything, should be visible, and integrated coached, audio-led tests with device data. Consent was refreshed at each escalation, keeping patient control central. Visual steps were offered selectively and only when they added clinically material information beyond audio/data. This theme addresses Objective 1 by specifying types and workflows of DSIs in community nursing.
Subtheme 1.1: Pre-briefing and environment setup
Most participants (20/24) opened visits with a deliberate pre-brief that framed the encounter and checked context (purpose, roles, privacy, bandwidth/light/noise). One nurse explained:
We’ll do three short steps—talk, [if needed] look, then plan—who’s with you now? (P03, Site 1, 8 years).
Pre-briefs included privacy prompts (who can overhear, preferred language, who should stay/step out) and quick environment adjustments. Skipping setup produced a clinical risk:
I skipped the setup once; the TV was on and I misjudged the wound color (P14, Site 2, 11 years), underscoring that environmental conditions can alter perceived clinical signal.
Subtheme 1.2: Field-of-view (FoV) negotiation
Central to privacy-preserving DSIs was FoV negotiation (21/24): agreeing what, if anything, enters view, who holds the device, and when to pause or reposition. Nurses emphasized tight framing and patient-held control to protect autonomy:
Only the elbow in frame—no background pan (P21, Site 3, 12 years).
When a family member was the device-holder, nurses paused the video to allow private repositioning:
We paused so she could adjust privately (P19, Site 3, 15 years). Screenshots or other captures were used only where local policy permits and after a verbal consent refresh; otherwise, nurses de-escalated to audio-only if privacy or comfort was threatened.
Subtheme 1.3: Coached tests and data alignment
Nurses frequently used coached, audio-led assessments (18/24), for example, counting breaths together or guiding a brief functional maneuver, and then aligned these cues with home-device logs:
I count breaths with them, then compare to yesterday’s upload (P12, Site 2, 6 years).
In a disconfirming case, a synchronous cue suggested risk despite normal device trends:
Device history looked normal, but live cues showed labored breathing, trend was misleading(P04, Site 1, 14 years).
In such instances, real-time cues (audio and, when consented, visual) appropriately outweighed asynchronous data.
Balancing signal quality and autonomy was ongoing: FoV limits and patient/device-holder preferences sometimes narrowed the clinical view, prompting modality switches (e.g., to audio-only), time-limited visual steps, or deferral, each change preceded by a consent refresh and documented in a dedicated privacy-actions field.
Theme 2: Trust-building and repair in mediated spaces
As encounters progress, nurses made credibility visible to sustain cooperation, especially when requests might feel more intimate. Strategies are clustered around two key practices: transparent narration, which explains purpose and next steps in plain language, and repair work, which acknowledges glitches or discomfort and restores control. This theme maps to Objective 2 (initiating, maintaining, and repairing trust during DSIs) within the study’s audio-first → data-enabled → visual (opt-in) hierarchy.
Subtheme 2.1: Transparent narration
Participants (19/24) used transparent narration as a primary trust move: reasoning aloud, previewing the next step, and checking assent before any escalation. One nurse explained,
I’m comparing to your photo from last week; I’m checking the edges (P11, Site 2, 7 years).
Narration was scaled to patient energy:
I trimmed explanations when the patient looked fatigued (P02, Site 1, 16 years), to avoid cognitive overload.
Nurses paired narration with consent refresh (“Is it okay to continue with this step?”) and choice framing (offer audio/data alternatives first), reinforcing that the patient controls what is shared and when.
Subtheme 2.2: Repair and vulnerability management
Trust was also maintained and repaired when disruptions or sensitivities arose (17/24). Nurses owned technology failures and recapped missed content:
Connection froze; I recapped what we might have missed before proceeding (P18, Site 3, 12 years).
For potentially sensitive cues, nurses ceded control and emphasized boundaries:
You hold the phone and show only what you want—tell me when to stop (P09, Site 2, 10 years).
A negative case illustrated risk: proceeding with a poor-quality image was perceived as unsafe, leading the nurse to institute a minimum clarity threshold and offer earlier reschedule/in-person follow-up (P05, Site 1, 12 years). Repair sequences typically included acknowledge → apologize (if warranted) → offer options (de-escalate to audio-only, time-limit any visual) → consent refresh → document.
Over-narration can overload patients; under-narration can erode confidence. Nurses managed this by pacing explanations, checking understanding, and documenting key trust actions (e.g., consent refresh, de-escalation) in a dedicated field, ensuring traceability without prolonging the encounter.
Theme 3: Privacy as ongoing boundary work
As intimacy escalates, consent shifts from a single event to a sequence of checkpoints linked to explicit, recordable privacy actions. Whereas Theme 2 focused on relational credibility (how competence is made visible and ruptures are repaired), Theme 3 centers on documentable boundary decisions—what can be sensed, by whom, for how long, and in what modality. Nurses described privacy not as a fixed, pre-consented state but as dynamic negotiation aligned with the study’s hierarchy (audio-first → data-enabled → visual, opt-in) and decision gates (necessity → consent refresh → cultural accommodation → proceed/time-limit → document). This theme addresses Objective 3 (anticipating and mitigating privacy risks during DSIs).
Subtheme 3.1: Dynamic consent refresh
The most prevalent practice (22/24) was dynamic consent refresh at critical junctures, for example, transitioning to a different body area, moving rooms, inviting a family member to participate, or proposing any capture (e.g., screenshot) where local policy permits. Typical phrasing signaled stepwise choice:
Before we enter the bedroom view—are you okay to continue? (P06, Site 1, 9 years).
A disconfirming case (P17, Site 2, 14 years) involved a screenshot taken without real-time consent, prompting a personal rule to “ask explicitly every time” and to document the action in the record.
Subtheme 3.2: Field-of-view (FoV) zoning & presence management
Participants (20/24) practiced FoV zoning to limit exposure, deciding what, if anything, enters view and who may be present. Nurses used privacy-first prompts (“Private space with good light; we’ll keep faces out of frame”) and rapidly re-assessed presence when others entered unexpectedly (e.g., children), adjusting topic, sequence, or modality accordingly (P22, Site 3, 6 years; P01, Site 1, 18 years). FoV zoning operationalized limited-frame principles and kept patient/device-holder control central.
Subtheme 3.3: Modality switching & pausing capture
When risks rose (e.g., sensitive content, unanticipated observers, narrow space), nurses (14/24) de-escalated modality, switching to audio-only, pausing capture, or deferring visual steps, and logged the decision:
Neighbors arrived; I went audio-only and resumed later (P24, Site 3, 8 years).
A negative case (P10, Site 2, 8 years) in which a pause was not documented led to adding a dedicated “privacy actions” field to templates (e.g., pause/resume time, reason, consent wording).
Privacy-safe framing can constrain clinical view, requiring trade-offs (FoV limits, shorter windows) and countermoves (time-limited visuals, alternative audio/data cues). Nurses managed this by anchoring to decision gates, refreshing consent, and documenting each boundary action so that the ethical rationale is traceable alongside the clinical judgment.
Theme 4: Family roles in digitally mediated care
Family participation functioned as an operational lever that could stabilize or destabilize signal quality, consent, and trust in real time. Family members often enabled DSIs by providing technical and interpretive support; at the same time, unmanaged involvement risked gatekeeping or over-speaking. This theme maps to Objective 4 (how nurses engage, delimit, or redistribute caregiver roles during DSIs) within the study’s audio-first → data-enabled → visual (opt-in) hierarchy.
Subtheme 4.1: Role assignment and scaffolding
Nurses (19/24) deliberately assigned roles to preserve the patient’s voice while stabilizing the encounter, e.g., technician (connectivity, device checks), translator/clarifier, and device-holder when a visual step was clinically essential and the patient consented. One nurse described a clear division of labor:
Mom—device; Dad—positioning; Sarah—describe pain; patient stays central (P10, Site 2, 8 years).
When scaffolding drifted into over-speaking, nurses re-balanced participation by redirecting tasks:
I moved the relative to device duty so I could hear from the patient (P23, Site 3, 15 years).
Role assignment was typically pre-briefed, time-limited, and documented to signal boundaries and accountability.
Subtheme 4.2: Gatekeeping and competing agendas
Family members could also gatekeep access or introduce competing agendas (16/24). Nurses protected autonomy through gentle redirection and choice framing:
Let’s prioritize what your mother wants to discuss today (P13, Site 2, 10 years).
When a relative proposed revealing more of the home than the patient had consented to, nurses offered an alternative view path—“hallway only, not the bedroom” (P08, Site 3, 7 years) or de-escalated modality to audio-only. A negative case in which a spouse dominated the conversation led one nurse to institute ‘patient-first talk time’ at the start of subsequent encounters (P07, Site 1, 11 years), making space for the patient’s account before inviting family input.
Without bounded tasks and structured turns, helpful scaffolding can slide into gatekeeping. Nurses mitigated this by staging roles, refreshing consent when participants or FoV changed, and documenting role decisions and any modality switches (e.g., audio-only) to maintain both clinical signal and patient autonomy.
Comparative analysis across contexts
Patterns varied by site constraints, patient populations, and nurse experience, illustrating context-contingent activation of DSI controls to preserve both clinical signal and ethical safeguards within the audio-first → data-enabled → visual (opt-in) hierarchy. At Site 2, variable bandwidth prompted tighter Field-of-View (FoV) negotiation (Theme 1.2) and more explicit role tasking (Theme 4.1) to maintain a usable signal. Older-adult panels required more frequent consent refreshes (Theme 3.1) and family scaffolding (Theme 4.1) due to hearing/vision barriers, with nurses favoring audio-led coaching and de-escalation to audio-only when privacy or fatigue was evident (Themes 1.3, 3.3). Experience gradients were evident: nurses with > 10 years of RN experience articulated a stepwise “hierarchy-of-ask” with serial consent and timely modality switches (Themes 1.1–1.3, 3.3), whereas those with ≤ 2 years of telehealth experience more often displayed binary accept/decline patterns and fewer switches, relying on simpler scripts until confidence developed. Together, these differences demonstrate that FoV limits, consent checkpoints, and role orchestration were adjusted according to bandwidth, household composition, sensory access, and clinician experience—ensuring signal sufficiency while protecting privacy and autonomy.
Summary of negative and disconfirming cases
To enhance trustworthiness, negative and disconfirming cases were systematically logged and examined. Divergences from dominant patterns helped refine thresholds, sequences, and documentation fields, converting narrative lessons into explicit, auditable practice rules traceable in adjudication and documentation logs. Table 3 summarizes pivotal cases and the resulting adaptations, illustrating reflective practice among participants.
Table 3
Analysis of key Negative/Disconfirming cases and resulting practice adaptations
Theme | Disconfirming case summary | Resulting practice adaptation reported by participant(s) |
|---|---|---|
1. Staging DSIs as Stepwise Workflows | Normal device log contradicted by real-time cues indicating labored breathing (P04, Site 1). | Prioritize real-time clinical cues (audio and, when consented, visual) over asynchronous device trends when safety is at stake; trigger escalation pathway. |
2. Trust-Building and Repair in Mediated Spaces | Proceeding with low-quality, pixelated imagery perceived as unsafe; trust eroded (P05, Site 1). | Minimum clarity threshold established; offer earlier reschedule or in-person follow-up when threshold not met; document decision and rationale. |
3. Privacy as Ongoing Boundary Work | Screenshot captured without real-time consent, prompting objection (P17, Site 2). | Mandatory verbal consent refresh for any capture (where local policy permits); add privacy-actions field to record consent wording and capture details. |
4. Family Roles in Digitally Mediated Care | Caregiver-dominated talk, suppressing patient input; discomfort disclosed later (P07, Site 1). | Implement patient-first talk time at the start; re-task the caregiver to a technical role (e.g., device-holder); document role assignment and any modality changes. |
Integrated model of DSI enactment
Figure 3 presents an integrated model linking the four themes. Stepwise DSI Workflows (Theme 1) provide the procedural backbone; Trust-Building/Repair (Theme 2) and Privacy Boundary Work (Theme 3) act as dynamic regulators via transparent narration, consent refresh, FoV zoning, and modality switching/pausing. Family Roles (Theme 4) modulate enactment through role scaffolding or gatekeeping, influencing both signal quality and ethical safeguards.
Bidirectional relationships are explicit. For example, a privacy risk (Theme 3) can prompt a modality switch (Theme 1/3); this is explained through transparent narration (Theme 2) to preserve trust. The figure locates key operational elements: pre-brief scripts and consent checkpoints (Themes 1 & 3), clarity thresholds and narration pacing (Theme 2), and role-tasking templates with privacy-actions documentation (Themes 4 & 3). The model operationalizes the study’s modality hierarchy—audio-first → data-enabled → visual (opt-in, time-limited)—and decision gates (necessity → refreshed consent → cultural accommodation → proceed/time-limit → document).
Trustworthiness note. Coding disagreements were resolved through reasoned consensus (adjudication log). Data sufficiency was defined as the absence of new DSI steps, roles, or trust/privacy actions across two consecutive interviews (reached at Interview 22); two additional interviews confirmed no further expansion. Bilingual quotes were cross-checked against the original Arabic audio to ensure semantic fidelity.
Fig. 3
Integrated DSI Model: Relationships across workflow, trust, privacy, and family roles
Discussion
This study reframes digital sensory interventions (DSIs) as nurse-led sociotechnical work in which clinical judgment, relational choreography, and ethical vigilance are inseparable. Community nurses did not merely conduct “video visits”; they staged DSIs as stepwise workflows beginning with deliberate pre-briefing, proceeding, only when clinically necessary, to Field-of-View (FoV) negotiation, and culminating in coached, audio-led assessments aligned with device data [71]. Within this scaffold, trust was made visible and repairable through transparent narration and explicit recap after technological interruptions, while privacy was safeguarded as ongoing boundary work rather than a one-time signature. Family participation emerged as a pivotal force that could stabilize the encounter through technical scaffolding or destabilize it via dominance and gatekeeping [72]. The integrated model clarifies these bidirectional relations: when privacy is threatened, modality switching/pausing restores boundaries; when switching is transparently narrated, trust is repaired; when trust is restored, the workflow can safely escalate to more intimate sensory requests if indicated. Two practice heuristics carry immediate translational value. First, when signals conflicted, nurses prioritized real-time clinical cues (audio and, when consented, visual) over asynchronous device logs, clarifying how epistemic risk is managed at the bedside. Second, consent functioned as a verb, refreshed at threshold moments (new body areas, room changes, and any capture where local policy permits) and documented as a standard element of the tele-note [73].
The findings align with contemporary nursing research, which positions telehealth as relational labor under technical constraint, yet they move from principle to protocol. Prior qualitative work highlights preparation, pacing, and transparent communication for sustaining rapport [74]; this study specifies concrete micro-practices, reasoning aloud, post-glitch recap, and permissive choice-framing at intimate junctures, that render trust work observable and teachable. Platform/connectivity scholarship advanced implementation but underspecified the bedside heuristics nurses require when real-time cues diverge from device trends; here, the decision rule privileging synchronous observation provides a defensible, safety-first standard [75, 76].
Beyond nursing-specific work, these findings also extend the broader telehealth literature, which has largely focused on access, satisfaction, and technical reliability in video or telephone encounters rather than the granular ethics of sensory guidance within domestic spaces. Prior telehealth studies rarely detail how consent is refreshed in real time, how FoV is negotiated to protect modesty, or how family presence is actively bounded to preserve patient voice. By specifying consent-in-action, FoV zoning, and role assignment as core relational tasks, our analysis addresses this gap and reframes telehealth encounters as privacy-critical, ethically mediated workflows rather than neutral channels of information exchange. In doing so, the study positions DSIs as an evolution of telehealth practice that explicitly links relational work to safety, dignity, and documentation.
Privacy/security literature has emphasized encryption/authentication; this analysis centers situational privacy in domestic spaces, operationalized through dynamic consent refresh, FoV zoning, and narrated modality switches that protect dignity without sacrificing clinical signal [77, 78]. Family-engagement research documents the double-edged nature of caregiver involvement; our data show how nurses assign bounded roles, preserve the patient’s voice via patient-first talk time, and redirect over-speaking toward technical tasks, transforming diffuse participation into governed collaboration [79]. Finally, primary-care studies describe bandwidth and environmental variability; the cross-site patterns here translate those observations into conditional activation: tighter FoV under low bandwidth and more frequent consent checkpoints with sensory impairment, linking context to action in ways that are readily implementable [80, 81].
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Theoretical and practical implications.
Theoretical implications
The integrated model extends appraisal-based frameworks by conceptualizing DSIs as appraisal-sensitive requests whose acceptability hinges on perceived controllability, predictability, and boundary integrity. The stepwise DSI workflow enhances perceived control; transparent narration attenuates ambiguity; and privacy boundary work restores person–environment fit when domestic conditions threaten modesty or safety. From this synthesis, Tele-Relational Competence emerges as a programmatic construct encompassing sensory coaching, boundary negotiation, and rupture–repair. Because these elements are observable in practice, amenable to simulation and assessment, and traceable in documentation, Tele-Relational Competence is well-positioned for integration into competency frameworks, continuing professional development, and quality assurance in remote primary care.
Practical implications
The model directly maps to four domains of actionable change. At the service-design level, it supports formalizing clarity thresholds for audio and, when consented, visual inputs, with explicit contingencies and escalation rules when real-time clinical cues diverge from asynchronous device logs, and embedding a stepwise modality hierarchy (audio-first → data-enabled → visual, opt-in and time-limited) into protocols. For clinical documentation, it indicates the need for structured “privacy-actions” and “consent-in-action” fields in electronic records, supported by smart phrases for consent refresh, room changes, pauses, modality switches, and any capture permitted under local policy, so that boundary decisions are visible in the clinical trace. In education and training, the model underpins integration of Tele-Relational Competence into curricula through simulation and tele-OSCE stations that require FoV zoning, dynamic consent refresh, bounded family role assignment, and trust repair after glitches or boundary breaches, with structured rubrics and debriefing to consolidate language, pacing, and boundary-marking skills. At the governance and quality level, it calls for recognising consent-in-action and modality switching/pausing as safety behaviours rather than inefficiencies, and for configuring audits, indicators, and feedback systems to reward privacy-protective pauses, rescheduling when fidelity is inadequate, and thorough documentation of trust and privacy actions.
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Strengths and limitations
Strengths. A principal strength of this study is its operational specificity. Beyond thematic labels, the analysis delineates concrete practices, thresholds, scripts, role assignments, consent checkpoints, FoV rules, and documentation elements that translate qualitative insight into implementable micro-protocols. Maximum-variation sampling across three community services, combined with systematic use of negative and disconfirming cases, strengthened credibility and analytic transferability by converting narrative lessons into explicit practice rules (e.g., clarity thresholds, privacy-actions fields, patient-first talk time). The design maintained a privacy-preserving alignment with the modality hierarchy (audio-first → data-enabled → visual, opt-in), and bilingual fidelity checks supported conceptual equivalence across Arabic–English materials.
Limitations. The study was conducted in a single region with distinct norms around domestic privacy, modesty, and family presence; findings, therefore, reflect context-shaped enactments and should be transferred cautiously to other systems. Data derived from nurse self-reports may introduce recall and social-desirability biases, particularly regarding sensitive boundary and consent practices. Reflexive thematic analysis privileges depth and interpretive richness over quantification, so coder overlap figures were used diagnostically rather than as reliability metrics. Patients and family members were not interviewed, limiting insight into their perceived burden, acceptability, and autonomy. In addition, rapid evolution in telehealth platforms and home devices may shift the salience of clarity thresholds, modality switches, and role configurations over time, underscoring the need for periodic protocol review and stakeholder triangulation in future work.
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Recommendations and future research
Future work should build on these findings in four main directions. First, effectiveness–implementation studies using hybrid designs are needed to examine fidelity to consent-in-action prompts, privacy documentation, and the DSI safety bundle, and to test associations with trust, patient-reported safety, rescheduling patterns, and adverse events. Second, equity-focused research in bandwidth-limited, crowded, or otherwise constrained domestic environments should refine FoV zoning, audio-first strategies, and modality switching to preserve privacy without exacerbating access gaps. Third, measurement work is required to develop and validate a Tele-Relational Competence instrument and to link scores to therapeutic alliance, clinical safety endpoints, and documentation quality in remote primary care and related settings. Finally, co-design and policy evaluation studies should extend perspectives through patient and family interviews and co-designed DSI scripts/templates, and assess policy levers, including reimbursement alignment and workload recognition, for the additional time and cognitive effort associated with consent refresh, privacy-preserving pauses, and diagnostic rescheduling, ensuring that ethical DSI practice is sustainable and adequately resourced.
Conclusion
This study reconceptualizes digital sensory interventions as nurse-led, appraisal-sensitive workflows in which clinical signal gathering, trust work, and domestic privacy protection are tightly intertwined. Community nurses staged DSIs through stepwise pre-briefing, FoV negotiation, coached audio-led tests aligned with device data, and documented consent-in-action, while actively governing family roles to preserve patient voice. By articulating an integrated model and the Tele-Relational Competence construct, and by translating these into concrete implications for service design, documentation, education, and governance, the study offers a practicable route to ethically robust, culturally congruent remote primary care. As telehealth continues to normalize and diversify, these insights provide a foundation for systematically building and evaluating competency assessment, quality improvement, and system-level accountability for privacy-preserving DSIs.
Acknowledgements
Not applicable.
Declarations
Consent for publication
Not applicable.
Institutional review board
This study was conducted in accordance with the Declaration of Helsinki and received approval from the Majmaah University IRB (Approval MUREC/COM-2025/244).
Informed consent
All participants reviewed a bilingual information sheet and provided electronic written informed consent prior to interview; participation was voluntary with the right to withdraw at any time.
Competing interests
The authors declare no competing interests.
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