Telenursing: The Virtual Nursing Practice

Advances in information and telecommunication technologies are revolutionizing health and education services throughout the world, including the provision of nursing services. By lessening distance and time, these technological advances significantly improve access to health and healthcare, most particularly among underserved populations and those living in rural and remote areas. These advances help research and education activities, assure more efficient utilization of health and human resources and facilitate managing demand for services. Health for All is a global health movement undertaken by the World Health Organization (WHO) in the late 20th century which seeks to ensure that basic health care is made accessible to all people and that resources for health are evenly distributed. It seeks to ensure that health begins at home, in schools, and at the workplace. It also encourages people to utilize more efficient ways to prevent and alleviate diseases and disabilities. In the report of Tejada de Rivero, the final Declaration of Alma-Ata in the International Conference on Primary Health Care:

Primary health care is based on practical, scientifically sound and socially acceptable methods and technology made universally accessible through people’s full participation and at a cost that the community and country can afford. It is the central function of the health system and its first level of contact, bringing health care as close as possible to where people live and work. It is the telenursing that answers the goal and vision of WHO in primary health care. (25)

Telenursing is a novel approach to nursing care provision through the use of information and telecommunications technology in circumstances where there are significant physical distance between the nurse and the patient.

As a field of nursing, telenursing is a part of telehealth that is gaining significant growth rate in numerous nations due to several factors. These include the rise in coverage of healthcare in far-flung or less-populated areas, an increase in the number of aging and chronically ill population, and the widespread endeavor to bring down health care costs. Employment in home health care in the U.S. is anticipated to go up by 36 percent or more over the next seven years with around 46 percent of the traditional (on-site) nursing visits could probably be replaced by telenursing (Wooten et al. 83). Replacing half or more of the US on-site home visits with telehomecare nurse visits, agency costs may be brought down by fifty percent (Britton et al. 12). Research conducted in Europe indicates that a large number of patients could benefit from in-home telecommunication services (Valero et al. S91). Actually, telenursing is not an entirely new health care system, a significant number of nurses have provided nursing advice and health information over the telephone for several decades. However, at present, it is now a rapidly-growing service. Teledelivery of health promotion and disease prevention services—including nursing education, treatment and diagnosis—are rapidly developing.

Telehealth and Telenursing

Telemedicine is a health care delivery system that uses telecommunications (such as Internet connections, interactive television systems, dedicated line connections and satellite links) and communication information technology (such as voice, images, elements of a medical record and commands) that help provide healthcare services, clinical care, and physician examination for medical diagnosis to individuals who are at some distance from the provider (Grigsby et al. 32). The innovative uses of emerging information and technologies are realizing new approaches in providing health care—such as providing the capability to move the caregiver and information to where the patient is instead of moving the patient to centralized places to deliver health services and information. Today’s telemedicine model is evolving to become “teleconsultation,” a process where a medical doctor consults with a patient or other specialists through the use of high-quality video-conferencing, with that consultation enabled by online information access (Coiera 1367). Teleconsultation is complex system of high-tech health care provision that covers a myriad of health related processes, activities and systems, conducted over a distance through information and communications technologies, for the goal of research, management and education for health, healthcare, disease control and, ultimately, worldwide health promotion (WHO).

Telemedicine is the combination of computer and telecommunications technologies to enhance the effectiveness and efficiency of healthcare services by setting caregivers free from conventional limitations of time and place and by allowing consumers to make informed choices in a highly competitive market (Bauer and Ringel 25). According to ANA (200), telehealth is the elimination of the conventional barriers of time and distance for the provision of health care activities or pertinent health care services. Several of the technologies used in telehealth include computers, teleconferencing by telephone or video, transmission of images, interactive video transmissions, telephones, direct links to health care instruments, etc. Telenursing is a division of telehealth in which the focal point is on nursing practice through telecommunication technologies.

Advantages of Telenursing

Telenursing can be considered as cost-effective in minimizing the need for, or the length of, hospital stays. It also allows increased access to services to widely dispersed populations. Furthermore, it helps expand high-quality home care services. According to Britton and colleagues (14), telenursing allows more timely information to patients and families—thus reducing the use of high-cost health care services. Despite limited resources, therefore, telenursing can benefit a large population spread over a wide geographical area. The result is a decline in total health care costs and better access to health care with more proper use of resources. In Denmark, WHO reported that nurses working in an outpatient clinic for people with back problems continued regular telephone contact with patients. As a result, the number of hospital admissions and “bed days” were reduced by around fifty percent. Among the widely dispersed population of Iceland, a telephone-based nursing intervention is being provided to support mothers with difficult infants, which helped reduced distress and fatigue (Thome and Adler 129).

Innovative programs use telenursing to allow women with pregnancy-induced hypertension to remain at home (Britton et al. 15). Clinical information can be shared with other professional colleagues including national and international experts. A nurse in Northern Ireland established a telenursing scheme for patients with leg ulcers resulting in improved quality of service for patients on both sides of the Irish border and the development of enhanced nursing roles (Moore 14). New and emerging technologies also facilitated much better access to nurse education, specifically continuing education which covers teaching online learning, video-conferencing, multi media systems, and other off-campus distance education programs (Russo 35). Utilizing patient simulation modeling, clinical skills can be learned and practiced (35). Telenursing also offers experienced nurses the chance to bring back their years of service to the clinical arena without bearing the physical burden of ‘floor’ nursing in clinical areas. Among its numerous benefits, telenursing can directly address the rising shortages of nurses. It can also keep patients out of the hospital as well as minimize distances and save travel time.

Barriers to the Growth of Telenursing

There are several likely impediments that can prevent the further development of telenursing. These include the effects of the disadvantages of telenursing in health care. Telemedicine has the potential to level the playing field, creating new relationships between medical practitioners and patients, and achieving authentic empowerment of consumers (Bauer and Ringel 25). Historical definitions of telemedicine fail to include pertinent changes that are happening in other areas of healthcare delivery. Most efforts to explain telemedicine are relegated either implicitly or explicitly in the framework of a doctor-patient relationship. Furthermore, it can be said that the birth of telenursing can lead to the death of the most potent traditional caring tools, including therapeutic touch, therapeutic communication and therapeutic relationships between patients and care providers specifically the nurse-patient interaction.

It may be harder to create a therapeutic relation as a result of the physical separation from the patient. This may require nurses to develop innovative communication skills as well as technological competency. Though it alters the means in which professional nursing services are delivered, telenursing does not fundamentally alter the nature of nursing practice. Registered nurses engaged in the telenursing still employ fundamental nursing processes to assess client’s needs and plan, implement and assess nursing care through follow-ups. Instead of creating in-person therapeutic nurse-client relationships, these relationships, however, are forged through the use of computers, the Internet, telephones, and other emerging communication technologies.

On the other hand, oppositions to telepractice are fearful that the absence of direct hands-on assessments or face-to-face interactions will decrease the quality of health care and, in turn, increase liability risks by being dependent on the artificial intelligence of computer technologies. Other considerable concerns that have been raised include the likelihood that nurses to step outside of their areas of practice and the heightened risks to the confidentiality and security of patient’s health records and information. While special certification and licensure are not typically required, systems must be in place to ensure the delivery of quality of care and safe practice. The use of technology has paved the way for the development of International Classification of Nursing Practice (ICNP). This is a long term project that will provide a structured terminology and a classification that can be employed to describe and organize nursing data, which can in turn be integrated into multidisciplinary health information systems in the near future.

Applications of Telenursing

According to ICN, telenursing applications are available in the home and hospital, through telenursing centers and through mobile units (65). Home care is one of the most distinctive telenursing applications available. Telephone triage and home care are the rapidly growing applications today. In home care, nurses employ systems that enable home monitoring of physiologic parameters such as blood glucose, blood pressure, weight measurement and respiratory peak flow all through the World Wide Web. Via interactive video systems, patients contact on-call nurses 24-7 and organize for a video consultation to deal with any problems. These consultations may include, for instance, how to give an insulin injection or change a dressing, or discuss increasing shortness of breath (Russo 36). This instantly-accessible assistance is particularly helpful for adults and children with debilitating illnesses and chronic conditions.

Immobilized patients, or those who live in far-flung or hard-to-reach areas, or clients with chronic ailments, disabilitating and communicable diseases may simply just stay at their residences and be virtually “visited” and assisted regularly by a nurse through the internet, videoconferencing, videophone, etc. Other applications of home care telenursing include the care of patients in immediate post-surgical situations, the care of wounds, ostomies, handicapped individuals, and many more.

In a typical home health care setting, one nurse is able to visit up to 5 to 7 patients a day.

But through telenursing, one nurse can “visit” more than a dozen patients within the same period of time. Telenursing assists patients and families to be active participants in care, particularly in the self-management of chronic illness. It also allows nurses to provide timely and accurate information and support online. Continuity of care is improved by encouraging regular contacts between health care providers and individual patients and their families.

A typical application of telenursing is also used by call centers operated by health maintenance organizations (HMOs), which are staffed by registered nurses who function as case managers or perform patient triage, information and counseling as a way of regulating patient access and flow and reduce the use of emergency rooms. Telenursing can also include other activities such as assistance to physicians in the implementation of medical treatment protocols, examination of results of medical tests and exams, patient education, and nursing teleconsultations.

Regulatory Issues of Telenursing

Telenursing is burdened with regulatory, ethical and legal concerns—similar to what is happening with telehealth. In many nations, interstate and intercountry practice of telenursing is not allowed (the attending nurse must be licensed in both her/his state/country of residence and in the state/country of origin of the patient receiving telecare). In one issue of MedHunters (1), Lois Scott, one of the minds behind this innovative and successful form of nursing, details five skills that a telehealth nurse must have to be successful. These are comfort with technology, critical thinking, excellent communication skills, ability to multi-task and strong clinical judgment. Nurses must finish one month of training. This include orientation to telehealth’s computer system, listening to sample calls, handling incoming calls with a coach, and receiving coaching on recorded calls.

It should be noted that most of the issues normally seen as barriers to provider-patient telemedicine consults are equally essential to a discussion of telephone triage nursing. One instance is the interstate licensure for nurses who interact with patients across state lines (Jacobsen and Selvin 430). As one means for approaching resolution of these questions, the Boards of Nursing and Nurse Examiners in a number of American states have been working with the National Council of State Boards of Nursing (NCSBN) to determine models for regulation of nurses across state lines, and have focused on a ‘mutual recognition’ or reciprocity model. However, as a new emerging field, telenursing may need additional education or specialty to allow practice competency.

Privacy, Confidentiality and Security Issues of Telenursing

In general, the competencies necessary for safe, competent and ethical telenursing practice mirror the competencies required of all registered nurses. However, nurses practicing telenursing should also have competencies related to the emerging technologies being employed and the capability to identify if equipment and other appurtenances are properly working. Additionally, the nurse must be able to know if the technology is applicable to the client to assure safe and effective nursing practice. Issues on who should be accountable, client choice and decision making with informed consent, documentation, security and confidentiality, and liability protection are of specific value in telenursing, not only in terms of interactions with clients but also in ensuring that the technologies themselves are safe, functional and secure.

Conclusions

Telenursing can be said to offer a handful of interesting and promising advantages to the delivery of healthcare information and disease monitoring at a distance. However, it also presents particular challenges. Based on the merits of the above discussion, telenursing has the potential to significantly increase access to care for those in distant or underserved regions, enhance the accuracy of health evaluations, and improve the availability of information, research and patient education. In providing care from a distance, policy makers, by working hand-in-hand with medical practitioners, need to ensure that there are appropriate systems in place for the regulation and management of telenursing. Policies and standards must be implemented to ensure safe, professional and ethical practice as well as security, privacy and confidentiality of information. Finally, telenursing activities must be comprehensively and seamlessly integrated into the overall policy, strategy and standards for the growth of nursing practice, the provision of nursing services, and the continuous education and training of nurses.

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