The Covid-19 pandemic led to a new way of developing guidelines around the world because meetings needed to be held virtually. Virtual meetings can replicate physical meetings regarding structure and duration (Rasburn et al. 2021) but might need additional training and support resources to allow patients and the public to participate in virtual guideline development activities. This new way of working has benefits, such as allowing individuals with disabilities, long-term health conditions or specific symptoms, and those with caring responsibilities to participate. But virtual meetings also pose challenges, such as having an impact on committee dynamics and making it harder to provide support for patient and public members. This section will discuss recruitment to virtual guideline development groups and the effect of virtual meetings on their group dynamics.

Recruitment of patient and public members for virtual guideline development groups

Advantages of recruitment to virtual guideline development groups

Virtual meetings can remove some of the known barriers to participating in guideline development groups, such as geographical distance and the time-burden of travelling to a physical meeting space (Chambers 2021; Rasburn et al. 2021). Notably, evidence shows that virtual working can expand the reach to a wider demographic and foster inclusivity or accessibility (Chambers 2021; Rasburn et al. 2021; Snowdon et al. 2023). Guideline developers, such as NICE in England and RNAO in Canada, often find that virtual working makes it possible for patients or the public to apply for roles when they otherwise would not be able to attend physical guideline development group meetings.

Recruitment to virtual groups can have the following advantages: 

• Virtual meetings can remove geographical barriers and encourage participation from individuals living in rural areas. Potential guideline development group members who live further away from the location of physical meetings could be more motivated to apply because there is less of a time commitment for virtual meetings.
• Individuals with disabilities, long-term health conditions or specific symptoms, such as fatigue, can participate. Virtual working reduces the physical fatigue, some of the recovery time and the time-burden associated with travelling to physical meetings. This provides guideline developers the opportunity to hear from individuals who could be excluded from physical guideline development group meetings when a health condition or disability would prevent them from attending in-person.

Comment on the advantage of virtual meetings “I find travel very difficult for health reasons. Doing it virtually works well and allows me to exercise influence without 8-hour round trips and overnight stays – and the seven day recovery that comes with that.” NICE Lay member

• Allows patient and public members to better manage or organise other commitments, such as work or caring responsibilities, so they can attend virtual guideline development group meetings.
• Less travel removes a possible financial burden, which improves accessibility of meetings and supports equal opportunity. Although some organisations provide expenses for travel and accommodation, payment may only be made after the meeting. Up-front payment for meals might prevent some individuals from participating in guideline development work. Virtual working can remove a financial barrier associated with travel, accommodation or meal costs.

Barriers to recruitment to virtual guideline development groups

Some individuals might not have access to suitable technology or the internet, might have low digital literacy, or may not able to use virtual meeting platforms (Rasburn et al. 2021). Patient and public members might not have access to the appropriate technology to participate in virtual meetings and may feel excluded compared with attending face-to-face meetings (Chambers 2021). To address these barriers, guideline developers could secure a budget or provide loanable IT stock (for example, laptops) to their patient and public members who need technology to participate fully during meetings. Additional software or digital training can be provided (Rasburn et al. 2021), as well as having a key contact person to provide technological support. This is especially important for guidelines with a topic that affects a population who typically do not have access to technology, for example. a guideline on the health of individuals who experience homelessness. Potential applicants can be made aware of the support available to them by including information about it in recruitment materials. 

Other barriers to recruitment include not having a quiet space or one that protects confidentiality when holding lengthy meetings, or having complex caring arrangements or childcare responsibilities (Rasburn et al. 2021). The Australian Living Evidence Collaboration overcame such a barrier by allowing women to attend virtual meetings with their children while developing the Australian Pregnancy and Postnatal Care guideline.

Guideline development groups and virtual group dynamics

NICE collected feedback in exit-surveys from patient and public members involved in guideline development groups during the initial rollout of virtual working (see Chambers 2021). The feedback highlighted that some patient and public members had positive and negative experiences of the virtual meeting format, and how it influenced to group dynamics, which is consistent with other evidence (Snowden et al. 2023). (The section on managing group dynamics explains how understanding group dynamics can help guideline development groups to be more effective.)

Advantages of virtual meetings for group dynamics

Virtual meetings can make working in guideline development groups feel less daunting for some patient and public members because they take part in the meetings from their own homes (Chambers 2021). The familiar surroundings help individuals to feel at ease or relaxed, and consequently more confident to participate in guideline development group discussions (Chambers 2021; Stefanik-Guizlo et al. 2024).

Virtual meetings using software like Zoom or Microsoft Teams can also help to foster a culture of equality among guideline development group members. Some participants have reported that meetings can be less influenced by hierarchy or dominant contributors because the ‘raise hand’ function places participants in a queue (Rasburn et al. 2021). This has been described as having a ‘democratising’ effect (Snowdon et al. 2023). Meeting software can also create more opportunities to contribute, for example, the chat function can allow minor points or agreements to be made and acknowledged without interrupting the ‘flow’ of the meeting (Chambers 2021). However, some participants experience the chat function as increasing inequality.

Comment on chairing and using software in virtual meetings “The chair made effective use of the tech and I liked being able to use the chat to ask questions and comment without having to put my hand up or interrupt.” NICE Lay member

Challenges of virtual meetings and solutions

Relationship building

A common theme from NICE’s exit survey responses was that patient and public members found it harder to build relationships in a virtual meeting environment compared with in-person meetings (Chambers 2021). Research by Stefanik-Guizlo et al. (2024) also supported this finding. The difficulty in building relationships is mainly because the social aspects of a face-to-face meeting are absent, such as refreshment breaks. Breaks provide an opportunity for all group members to form working relationships and for patient and public members to ask informal questions that can aid their understanding of guideline development processes or build confidence to speak up during meetings.

Comment on the challenges of virtual meetings “[…] never as good as face-to-face, although obviously far more convenient and easier to manage. I still think lay members are particularly disadvantaged by Zoom, because it’s hard to gauge the ‘feeling in the room’ – we are more dependent on following the conversation at the meeting than clinical members, partly because the papers are so lengthy and detailed. Online meeting is still do-able, and probably the best option for a short meeting, but such meetings still don’t feel ‘real’ enough. And the opportunity for true teamwork is terrible.” NICE Lay member

It is possible that virtual working can alter committee dynamics. At NICE, guideline development group members and NICE staff, have reported that discussions could more quickly become more difficult compared with in-person meetings if committee members:

• had never met in person but only worked online in their guideline development groups
• worked online for prolonged periods without any in-person meetings.

This could possibly be explained by online social regulation processes as described by Roos et al. (2020), who compared face to face discussion with online text-based discussion. Online social regulation may be relevant to guideline development group dynamics. For example, when meeting in-person, individuals rely on non-verbal cues, social rules and diplomatic skills to regulate interaction and avoid conflict. But during virtual discussions, there are less non-verbal cues and synchronicity, with more ambiguity. This could lead participants to perceive being ignored, isolated and less able to find common ground with other guideline development group members, similar to the Roos, et al. (2020) findings. This could lead to a lack of consensus building during meetings. 

To partially address these issues, developers could create ‘social moments’ to avoid the virtual meeting being silent. For example, before the meeting starts they could include an icebreaker, or simply ask the group to share what they did at the weekend. Stefanik-Guizlo et al. (2024) devoted the first 15 to 20 minutes of a meeting to facilitate relationship building using icebreakers or personal updates. Guideline developers can find that some patient and public members need permission to speak amongst themselves at specific points, so offering encouragement to do so can help.

Other strategies could include:

• having at least one of the guideline development group meetings in person, ideally at the start of the process, because this allows you to pick up on people’s personalities and communication styles more easily
• training the chair in online psychological safety and active listening skills, which could help form bonds or repair minor disputes
• encouraging patient and public members to use technology to their advantage (for example, a WhatsApp group for patient and public members can facilitate communication and peer-support before, during or after meetings)
• organising virtual meetings before the guideline development group meeting to encourage relationship building and social connection, for example, create virtual coffee mornings or informal catch-ups (McGrath et al. 2023).

Support for patient and public members

It is important to contact patient and public members to provide support throughout the guideline development group meeting. RNAO in Canada found, from experience, that it can be harder to support individuals in virtual meetings. Chairs and guideline developers can also find it more difficult to detect non-verbal cues and nuances of all guideline development group members, which can affect how useful group discussions are in a virtual setting. To address this, RNAO has encouraged panel members to contact RNAO staff individually if they have any questions or concerns. 

Training and support are essential for all committee members, including guideline development group staff members and chairs for effective virtual working using software and increasing digital literacy. The same support and training strategies outlined in the section on supporting individual patient and public members also apply to patient and public involvement in virtual guideline development groups, but should be adapted to include virtual working. For example:

• Provide a person-centred needs assessment that should include an assessment of digital literacy or technology requirements so that practical support or technology and software training are available (Rasburn et al. 2021).
• Provide a named contact person who can offer patient and public members technological support or discuss their concerns. During guideline development group meetings, it is also beneficial for an appointed person to check in with patient and public members through direct online messages or emails.
• Hold debriefing meetings with patient and public members to invite feedback on their virtual meeting experience, and provide ongoing support. This can ensure any issues with the technology or the guideline development group are addressed.
• Offer training for guideline development group members on how to participate in a virtual meeting, including training on how to use any software. NICE produced a guide to making an impact at virtual meetings for patient and public members (see resource file 1.) This includes how to work with digital meeting papers alongside having the virtual meeting open at the same time.

Negative impacts on meeting discussions

Some patient and public members at NICE found the discussion flow was poor when using the ‘raise hand’ function because guideline development group members make their points in the order in which they raised their hand, which can lead to a disjointed discussion (Chambers 2021). RNAO also reported that guideline development group members can miss important discussions if they need to leave meetings temporarily to join another meeting.

These issues can be mitigated by an effective chair in the following ways:

• ensuring that all points relating to a discussion have been made before it moves on
• asking guideline development group members to be present and to have their video turned on during the discussions
• specifying when comfort breaks are scheduled and the conditions for it being acceptable to leave the meeting, for example, to manage fatigue or symptom flare-ups
• having a discussion with guideline development group members who multi-task during a meeting, before or after the meeting to resolve the issue
• if members have declared a hearing impairment or visual disability, ask all members to ensure that they are in a setting with good lighting, are seated in a position where the camera can detect lip movement for individuals who lip read, and that the sound is adequate (Rasburn et al. 2021); technology checks before the start of the meeting can help. 

Maintaining long-term virtual guideline development groups

Research has found that a preferred format for maintaining long-term virtual working is a hybrid of both in-person and virtual meetings (Stefanik-Guizlo et al. 2024). Guideline developers also support this approach. A hybrid format allows those who can travel to come together in person but does not exclude those for whom travel poses a health risk or are geographically dispersed. Generally, it appears to work best to hold meetings at the start of guideline development to set the tone and scene for future working and dynamics. Alternatively, hybrid meetings can be arranged when it is useful to have face-to-face conversations either when conflict or disagreement arises between guideline development group members or if engagement is poor.

Comment on offering both virtual and face and face meetings “Meetings held online worked very well, but the experience would have been more rounded if at least one had been able to take place face-to-face, for the opportunity to better network and chat with the other committee members during meeting breaks.” NICE Lay member

---