Telenursing: Is It In My Future? Case Studies Example
Chamberlain College of Nursing
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The primary goal of telenursing is delivering nursing care with the use of telemedicine technologies in the environment where the participants are geographically separated. The studies show telenursing is used in chronic, pediatric, coronary, psychiatric, obstetric, orthopedic, neurologic, rehabilitative and newborn care (Grady & Schlachta-Fairchild, 2007), with impressive results like improved glucose profile of diabetes’ patients, symptoms’ reduction in cancer care, minimal requirement for intravenous infusions in ICUs (Williams, Habbard, Daye & Bardenn, 2012; Lashkari et al.,2013;Petitte et al.,2014). Telenursing is appreciated by patients for continuous monitoring, psychological support, reduction of anxiety and other symptoms (Grady & Schlachta-Fairchild, 2007; McCann et al., 2009; Annadale & Lewis, 2011). However, nurses demonstrate a wide range of opinions, from a high degree of satisfaction\ better care delivery (Grady & Schlachta-Fairchild, 2007; Snooks et al., 2008), to concerns raising from “dehumanizing” effects for patients (Lorentz, 2008), additional stress, fatigue, multitasking (Röing & Holmström,2015) and diverse ethical and legal issues (Hebda,Czar,& Mascara 2005). In the same time, there is a growing number of Home Health Agencies (HHAs) providing telecare (Greenberg 2000), with a patient-to-registered nurse (RN) ratio higher than in nontelehealth agencies (Peck, 2005) which can be a possible indicator of professional nurses’ interest in telenursing jobs. The author, a nursing home RN, has been recently contacted with an offer of job in telehomecare for patients with chronic illnesses. In this essay, the author evaluates advantages and disadvantages of telenursing for professional nurses and the impact on their patients, considering implications for practice for nurses in chronic care.
Advantages of telenursing
The importance of telenursing is promoted by healthcare officials due to its increasing meaning to public health. 2004-2005 survey in 36 countries of the world (Grady & Schlachta-Fairchild, 2007) showed that majority of patients treated by telenursing were those from chronic care, especially in older people. In chronic care, telenursing can be effective way to decrease both general and inpatient costs of treatment. The same survey demonstrated that nurses consider the reduction of the nurses’ shortage one of the most important advantages of telenursing. The undoubtful benefit for a professional nurse is equal opportunities guarantee: even nurses restricted by their physical (old age, disabilities) or working (senior nurse) capacities can provide advice and monitor patients via telehealth technologies (Grady & Schlachta-Fairchild, 2007).
The nurses also believe telenursing has enhanced the focus on the patient centered care as the main concept of nursing (Grady & Schlachta-Fairchild, 2007). It is proved by the experience of U.S. Department of Veterans Affairs (telenursing programs for about 35,000 chronically ill veterans) which shows that telenursing substantially reduces the patients’ discomfort and inconvenience of travel and hospital visits, wait time for next visits and the overall number of hospitalizations as acute conditions and emergencies can be prevented (Hebda et al.,2005). Even the increased technology costs of the program are lower than in-patient admission costs. These results are confirmed by international surveys and data from other countries (Lorentz, 2008; Snooks et al., 2008). The benefits for patients, with 85% of them being completely satisfied (Hagan, Morin, & Lepine, 2000; Bratton & Short, 2001), positively impact the public health. The telenursing experience only in one state (Texas) and one centre of diabetes-related care shows reduction of charges to $747 per patient per year compared with hospital-based services, and patient-to-registered nurse (RN) ratio raise up to even 495:1 (Peck, 2005).
Professional nurses can use the teleahealth technologies to increase their level of autonomy and tasks span to cover the underestimated needs of the patients (Grady & Schlachta-Fairchild, 2007). The nurses believe that here telenursing has dual advantage both positively influencing their professional status and increasing the patients’ satisfaction (Grady & Schlachta-Fairchild, 2007) in spite of the opinion about “dehumanizing the patient” (Lorentz, 2008). This can be explained by feeling of “doing not being” of the patient as an active member of videoconferences and the health team, and by the nurse being sure of her capacity to prepare, troubleshout and estimate the patients’ needs (Hebda et al. 2005; Grady & Schlachta-Fairchild, 2007). From nurses’ perspective, telenursing also allows them to realize both the principles of improved quality and continuity of care through constant follow-up and monitoring of the patient (Hebda et al. 2005). Most nurses prefer the concept of telehealth to that of telenursing, as a broader notion emphasizing the individual's long-term wellness and self-management, thus reflecting the intention to provide a patient-centered care as a core principle (Peck 2005). Nurses have excellent opportunity to train the patients, with repetition of the instructions and relevant explanations, e.g. in wounds dressing (Peck, 2005). Finally, this results in the increased levels of job satisfaction (Grady & Schlachta-Fairchild, 2007). A postal survey conducted among 111 telenurses working for NHS Direct Wales in 2002 revealed that two thirds of them reported job satisfaction resulting from possibility to moving from crisis intervention to prevention (Snooks et al.,2008).
Two factors nurses marked as additional advantages for them in 2004-2005 survey were also the level of pay and the improved organizational structure. Most nurses admitted that interaction, or promotion of collaborative working which is crucial in chronic care, is a core factor telenursing brings (Grady & Schlachta-Fairchild, 2007). The UK review of telenursing in palliative care (11 papers) showed multiple benefits from good communication pathways, technical support and workable protocols elaborated as a result of professional teams’ work (Kidd, Cayless, Johnston, & Wengstrom, 2010). The centralized healthcare record facilitates the time of elaborating the protocols of care for patients in complex settings, and simultaneously improves both professional nurses’ decision making and quality of their records (Hebda et al. 2005).
Finally most nurses even regarding telenursing as secondary to their mainstream responsibilities believe that it allows them to realize a tailor-made approach to the clients, as an extra advantage for the patients, community and their own professional development (Grady & Schlachta-Fairchild, 2007).
Disadvantages of telenursing
The nurses’ expectations and telenursing realities may differ. Apart from nurses’ predominant satisfaction with job, the abovementioned postal survey of Snooks et al.(2008), demonstrated a gap between desirable and actual working hours, level of complexity of expected tasks and routine monotony, and stress level anticipations. Peck (2005) admits that nurses often perceive telenursing as delegating authorities to machines supporting the Welsh nurses’ view of missing 'hands on' nursing (Snooks et al.2008). However multinational surveys report quite the opposite attitude, with participants’ desire “to reach out the hearts through technology.’’ (Grady & Schlachta-Fairchild, 2007).
Legislation and policy issues are of particular concern for US telenurses. (Hebda et al., 2005; Peck, 2005, Lorentz, 2008) Telenursing is not recognized as a distinct service for Medicaid program, and reimbursement is left entirely on discretion of individual states (Hebda et al., 2005). Licensing issues remains a serious limitation as multistate licensure policy is still a subject for debate (Peck, 2005) In accordance with U.S. Nurse Licensure Compact the nurse is accountable to the regulations of the state where she provides telenursing services, delivery of which may be illegal for some states (Hebda et al., 2005). Practicing telenursing across state borders can require obtaining legal advice meanwhile obtaining the Interstate Compact licensure can be a way out (Lorentz, 2008).
Malpractice complaints are one of the main concerns for those engaged in telenursing. They frequently arise due to specific factors associated with use of teletechnologies (Röing & Holmström, 2015). The situations of disputes due to the client’s misinterpretation or misunderstanding are most common in malpractice lawsuits (Röing & Holmström, 2015). Some authors suggest nurses should avoid chat rooms as increasing those risks (Lorentz, 2008), but others propose careful planning of such chats taking into considerations all contingencies that may lead to client’s dissatisfaction and misunderstanding(Peck, 2005).
The privacy concerns in telenursing are connected to another ethical issues which may create difficulties e.g. in obtaining informed consent or identification of the patient and the patient’s mental status. In using telephonic or electronic communication, patients’ autonomy and privacy should be safeguarded (Lorentz, 2008). Security and confidentiality of health sevices requires application of both proper technology\IT controls and e-health standards (Hebda et al. 2005). The professional standards like ANA Core Principles on Telehealth (1999) or AAACN\ANA Practice Standards (1996) stipulate the rules of conduct for nurses; however the technical personnel organizing the sessions may be unaware of such rules (Hebda et al. 2005). The collaborative work of IT\teleservice providers and nurses in ethics area can resolve the challenges (Greenberg, 2000).
Finally, the most significant disadvantage is a rather high level of technology skills required from nurses. They have to be not only professional users of basic programs, but experts in complex applications to access the client’s biometric data\medical records, often with responsibility for the set-up and the basic support of telehealth devices (Hebda et al., 2005). The absence of skills to support such devices can lead to emergencies e.g. in the critical care setting when a sudden outage in service leads to the loss of accessibility to the information. Grady & Schlachta-Fairchild (2007) show that majority of nurses estimate their technology skills as satisfactory to perform their current job duties in hospital setting, but acknowledge a lower level of proficiency in operating more advanced tools. The nursing informatics education can lead to a shift and improvement in this potentially important area (Greenberg, 2000).
In majority, clinical trials demonstrate both nurses’ and patients’ satisfaction with psychological support, continuity of care and active participation in the process which telenursing provides (Hagan, Morin, & Lepine 2000; McCann et al., 2009). The nurses feel it ensures a better, tailor-made patient-centered system of care delivery which can reduce the nursing shortage and the care costs. It provides nurses with a higher level of autonomy and professional status, improves interdisciplinary interaction and thus the quality of their own decisions (Grady & Schlachta-Fairchild, 2007; Lorentz 2008). The qualitative findings suggest that telehomecare proposed to the author as a potential career development path, can give her a possibility to enhance clinical excellence providing more focused and interdisciplinary approach to the patients in home setting. The author concludes that her experience in geriatric nursing and chronic care can be beneficial for HHA as well as telenursing experience could enhance her performance. However a number of concerns remain unaddressed in case if HHA where the author is invited to work practises across the country, in more than one state. The absence of multistate licensing, along with the difference in reimbursement policies, can increase the risk of malpractice suits. The ethical issues such as protecting patients’ privacy and confidentiality require the deep understanding of principles of work of many teledevices and IT applications to ensure the relevant controls are in place. The implication for the clinical practice is the need for training in teledevices and relevant PC applications for any nurse applying for the job including the author. If such training is provided, the position within HHA could satisfy the author’s career needs and be mutually beneficial for the parties.
Nurses’ professional organizations should work in cooperation with other relevant bodies to resolve the potential ethical challenges (Greenberg, 2000). The knowledge of applicable professional standards and legal awareness or obtaining the Interstate Compact licensure will be helpful. Structuring the work with patients, preparing individual plans to tackle multifaceted tasks such as goals of care, technical skills, compliance with standards and laws, reimbursement, and strategies to handle telecommunication breakdowns, can also be useful for the professional nurses to address the challenges .
Telenursing can provide an improved standard of patient-centered care, at the same time reducing the health care costs and increasing nurses’ job satisfaction if all the associated risks are properly addressed and managed. That’s especially relevant for care given to elderly individuals the author has been providing in her clinical practice.
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