Experiences of New Zealand nurses using teleconsultation "Caring at a distance"
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Jane Wright, National Nursing Informatics Conference (HiNZ 2015 Conference), Christchurch
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Experiences of New Zealand nurses using teleconsultation "Caring at a distance"
- 1. The experiences of New Zealand nurses using teleconsultation JANE WRIGHT, RGON, MNURS, MICHELLE HONEY, RN, PHD, FCNA(NZ),
- 3. Research aim and question “What are the factors New Zealand nurses consider important to confidently and competently participate in teleconsultation” Aim was to produce a descriptive account of the nurses’ experiences regarding their participation and use of teleconsultation.
- 4. Literature review Teleconsultation is of particular interest to health professionals working in rural settings (Marcin, et al., 2004). Seen as a tool to address health accessibility and equity issues (Jarvis-Selinger, Chan, Payne,Plohman, & Ho, 2008). Teleconsultation may be a useful tool to facilitate and support nurses practicing at more autonomous and advanced levels (Lea, 2006). Supports shared health care between primary and secondary services, and for provision of specialist services in remote communities (George, Ngo, & Prawira, 2014; Sabesan, Simcox, & Marr, 2011). Previous studies (US) noted nurses satisfaction with teleconsultation attributed to increased efficacy, increased specialty access and improved patient monitoring (Reed, 2005).
- 5. Research Methods and Methodology Qualitative methodology Recruitment by purposeful sampling method. Snowball sampling also utilised. Data collection using semi-structured interviews General inductive approach (Thomas,2006) using thematic analysis (Braun & Clarke (2006)
- 6. Participant Clinical Title Years as a registered nurse Time in specialty area (years) Time using Teleconsultation (yrs) Participant 1 Clinical Nurse Manager 25 16 2.5 Participant 2 Clinical Nurse Manager 31 15 3 Participant 3 Staff Nurse 14 4 months 4 months Participant 4 Clinical Nurse Specialist 12 8 3 Participant 5 Clinical Nurse Manager 22 15 8 Participant 6 Clinical Nurse Specialist 15 8 3 Participant 7 Clinical Nurse Specialist 30 4 2 Participant 8 Clinical Nurse Specialist 19 3 3 Participant 9 Nurse Manager 27 15 3 Participant Demographics
- 7. The participants and teleconsultation All used telephone, computer and videoconferencing tools Most used texting to give or receive information and email was frequently used to seek, receive or provide advice. This occurred for most on a daily basis Videoconferencing more variable with use from a few times per month to 10-15 hrs per week Most participants had the use of a mobile phone Videoconference facilities ranged from mobile carts to fixed units with the age of the units varying from two years to five years.
- 8. Theme Sub-Theme Relationships/Connectivity ∎ Communication ∎ Collaborative care and planning ∎ Rapport and trust ∎ Empowerment ∎ The voice of the nurse ∎ Etiquette Sooner, better, more convenient ∎ Timely care and transfer ∎ Accessibility to support and expertise ∎ Convenience ∎ Patient and family focused Journey from novice to expert ∎ Confidence and competence ∎ Specialty experience The roles and responsibilities of the nurse ∎ Advocacy and support ∎ Co-ordination ∎ Information sharing and documentation Can you see or hear me? ∎ Practicalities of offering teleconsultation services Themes and sub themes
- 9. Connectivity/Relationships Communication “Be clear and precise. Be systematic when you are trying to get information across. If you don’t understand or you believe the person at the other end hasn’t heard you correctly, repeat it, ask them ‘”did you hear what I said, “do you understand what I’ve said? "or “did you get that?” (Participant 2)
- 10. Connectivity/Relationships Rapport and trust “I haven’t actually been able to meet every single person I’ve seen on videoconference but when I do meet them it’s a really nice feeling to finally meet that person that you’ve had a close rapport with through V/C. I don’t think that you would get that on audio conference. It’s quite a different rapport when you see each other on the screen” (Participant 8)
- 11. Connectivity/Relationships Collaborative care and planning “I will talk through the patients that are here in the [tertiary centre], how they are, what they are up to and when they may be coming back home etc and then for the [patients] and families that are back home in [remote centre] but are still undergoing some form of treatment then the [remote centre] will report back to us how they are going and we’ll problem solve any issues they’ve got and then make a plan for that following week” (Participant 7)
- 12. Connectivity/relationships Empowerment “I think that the videoconsultations we have done with our patients kind of empowered us with what we are doing and confirming what we are thinking and what we are worrying about” (Participant 1)
- 13. Connectivity/Relationships The voice of the nurse “Because I’m the main person that gives treatment so if the consultant is seeing a new patient or seeing someone that’s on treatment I want to be part of it” (Participant 6)
- 14. Connectivity/Relationships Etiquette “I guess there’s little formalities that take place especially tele-video where people go about and introduce themselves and then they kind of get on with what they are talking about in a formal process and bearing in mind that we are still health professionals in that environment even though it can feel very bizarre and unusual…..but we still have to maintain professionalism at that time as well. Just be aware of confidentiality, shutting doors that kind of thing; that your really clear about what you are saying so there cant be any degree of misinterpretation” (Participant 5)
- 15. Sooner, better, more convenient Accessibility to support and expertise “I think it [teleconsultation] actually makes the nurse feel more secure because we’ve only got the GP and they don’t specialise in [specific field]. Their knowledge and expertise in this area is limited but if it’s a [specialty specific issue] or it can be an issue that can impact on the way we treat a patient so we need to speak to a consultant or registrar. Probably a bit like oncology nursing where you need to speak to the palliative care team or the oncologist because the general doctor will have some knowledge but won’t have the knowledge you need as a nurse to deliver that care” (Participant 2)
- 16. Sooner, better, more convenient Timely care and transfer ‘’It allowed immediate access as well if they presented to a [remote area] and were sick. You could do an assessment and make a clinical decision about whether they were clinically safe to transfer” (Participant 9)
- 17. Sooner, better, more convenient Convenience “There’s a huge advantage for patients especially for those that are stable. Rather than drive two or three or even five hours from [remote area] for a 10 minute appointment and everything’s ok we’ll just do it over telehealth” (Participant 6)
- 18. Sooner, better, more convenient Patient and family focus “It means that family can be involved and not having to travel all that distance and that’s great and in the long term helps with client care and integrating family involvement” (Participant 5)
- 19. Journey from novice to expert Confidence and competence “You’ve got to feel confident in what you are presenting and the patient has to feel the same confidence in you otherwise I think the fact that we are [distance] away becomes very apparent” (Participant 6) :
- 20. Journey from novice to expert Specialty experience “You need to be nurse competent in the area you are dealing with. You now its like if you are dealing in [specialty]. I’m jus using that as an example because that’s what I do. You have to have some degree of experience. I had to learn a whole new language very quickly so I could do the job well” (Participant 3)
- 21. The roles and responsibilities of the nurse Co-ordination “It’s not just co-ordinating rooms and co-ordinating with the patient, it’s arranging tests at their [local] hospital and arranging that for the same day that they come in so I’ll try and tee that up so they can have the test on the same day, so I tend to co-ordinate all that”(Participant 4)
- 22. The roles and responsibilities of the nurses Advocacy and support “Sometimes they’re in a bit of a flap so I can remind them ‘now you were going to ask them about such and such’. It’s like opening that discussion. You know the patient is too flippin scared to ask so you can kind of lead them into it a little bit or I can say “Joe Blogg is worried about this and that” (Participant 6)
- 23. The roles and responsibilities of the nurses Information sharing and documentation “You’ve just got to document everything, you just never know when it going to go per-shaped and I think that the documentation for us and the [remote areas], when you make a plan, when a scan is going to be done, who is going to review that scan, who is going to take responsibility……..so that when plans are put in place somebody takes responsibility for following thing through on things (Participant 8)
- 24. Can you see or hear me Practicalities of offering teleconsultation service “Availability is an issue especially here in [tertiary centre] but also other places that have only one or two videoconference capabilities. That can make it really hard to get a booking that suits, finding a doctor to agree, finding out what’s good for the patient , where you can get a room at both sites. So there are certainly some problems“ (Participant 4)
- 25. Key Messages The nurses were strong advocates for teleconsultation to ensure a positive experience for the patient Teleconsultation built on and extended existing skills – especially communication Nurses reported a high level of confidence and competence
- 26. Conclusion Limitations of the study - small sample size and the demographics of the nurses interviewed. Implications for nursing practice - potentially a generation of nurses unprepared and ill equipped to cope with increasing technology. Opportunities for expansion of nursing services, more diverse roles and support for advanced practice Implications for research - nursing research is limited so opportunity to increase knowledge and understanding of implications of an increasingly “mobile future Implications for organisations and policy - careful planning and preparation to ensure smooth transition into clinical services
- 27. Recommendations ● Incorporate telemedicine principles into undergraduate and post graduate nursing programs to create a heightened awareness of what information and communication technology and telehealth can contribute to health care delivery ● High priority from organisational bodies to the introduction of technical support and education for nurses around information technology in the workplace. ● Develop and implement competencies to support safe and effective nursing practice in teleconsultation. ● Strong representation from nursing should be included in the development of evidence based practice standards, guidelines and the system design and management that encompass teleconsultation. ● Advocacy from nursing is important to ensure patients’ needs continue to be met in a holistic and patient-centred manner within teleconsultation services. ● Develop standards and protocols for the use of teleconsultation in the workplace. ● A formal generic approach to the documentation of teleconsultations utilizing electronic patient records should be considered a priority to complement and safeguard the practice of teleconsultation
- 28. Acknowledgements Participants School of Medicine & Health Sciences, Auckland University Canterbury District Health Board Health Workforce NZ
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- 33. Pellegrino, L., & Kobb, R. (2005). Skill sets for the home telehealth practitioner: A recipe for success. Telemedicine Journal & e-Health, 11(2), 151-156. Pope, R. (2013). The electronic age: using teleconsultation. Nursing & Residential Care, 15(8), 561-563. doi10.12968/nrec.2013.15.8.561 Radhakrishnan, K., Jacelon, C., & Roche, J. (2012). Perceptions on the use of telehealth by homecare nurses and patients with heart failure: A mixed method study. Home Health Care Management & Practice, 24(4), 175-181. doi:10.1177/1084822311428335 Reed, K. (2005). Telemedicine: Benefits to advanced practice nursing and the communities they serve. Journal of the American Academy of Nurse Practitioners, 17(5), 176-180. doi:10.1111/j.1745-7599.2005.0029.x Richards, H., King, G., Reid, M., Selvaraj, S., McNicol, I., Brebner, E., & Godden, D. (2005). Remote working: Survey of attitudes to eHealth of doctors and nurses in rural general practices in the United Kingdom. Family Practice, 22(1), 2-7. doi:10.1093/fampra/cmh716. Sharpe, K., Elcock, M., Aitken, P., & Furyk, J. (2012). The use of telehealth to assist remote hospital resuscitation and aeromedical retrieval tasking: a 12-month case review. Journal of Telemedicine and Telecare, 18(5), 260-266. doi:10.1258/jtt.2011.110906 Sevean, P., Dampier, S., Spadoni, M., Strickland, S., & Pilatzke, S. (2008). Bridging the distance: Educating nurses for telehealth practice. The Journal of Continuing Education in Nursing, 39(9), 413-418. 4.2011.02537. Whitten, P., & Love, B. (2005). Patient and provider satisfaction with the use of telemedicine: Overview and rationale for cautious enthusiasm. Journal of Postgraduate Medicine, 51(4), 294.
Editor's Notes
- As a nurse working in rural health I was very interested in the concept of provision of health care from a distance using information and communication technologies ie teleconsultation. The context into which this fits is around my role as an oncology nurse providing an outreach oncology service and as demonstrated by the photo above my research masters journey. Hence why I am standing here terrified today. The service is based within our small hospital, an approximately ninety minute drive from a large tertiary hospital. This small hospital provides a day patient chemotherapy service and monthly clinics with a visiting oncologist Care of the patients is predominantly nurse-led with remote access to specialist oncologists and local medical support by specialist rural health physicians. Although comfortable communicating via telephone and computer based technology, my first V/C was fraught with anxiety and technical issues This personal experience prompted my desire to gain more knowledge about teleconsultation as a health provision modality and to explore how nurses could better be prepared for this in their practice
- 3
- The review was extensive but as a bit of a background have highlighted some findings from the literature
- Demographic data - the group consisted of nine NZ registered nurses who were employed by district health boards across NZ. They defined themselves as caring for patients with complex needs across the following specialties: Oncology, paediatrics, renal, respiratory and mental health. A component of their role involved provision of outreach or shared care services
- Thematic analysis was undertaken using the phases described by Braun and Clarke (2006) and the following themes and subthemes were reported in relationship to the research topic. There were 5 themes and 16 subthemes. Each slide will now represent a theme with a quote that best describes the link or importance of the subtheme.
- The telephone was used frequently to communicate between nurses, consultants and patients and continues to be the mainstay of communication remotely for most of the nurses. It was found to be the most effective when advice or information was needed urgently. Being able to seek advice in a timely manner was important for the nursesto be able to carry out their roles effectively. Whilst most acknowledged that physical face to face encounters were the ideal, all but one felt V/C could also be a very effective form of communication. This though, was dependant on the both patient and health professional feeling comfortable with the process of communicating remotely. All nurses felt T/C demanded a high level of communication skills, both verbal and written, for communication to be as effective as face to face encounters and verbalised that communication needs to be succinct, clear and professional: in what ever form it took.
- Despite not meeting in person a sense of rapport was identified by being able to visualise the person and through the frequent contact made possible via T/C : The nurses described that by using V/C when they finally met the person they had been dealing with they had already established a greater rapport than they would have if communication had been by phone and email only. Acknowledgment was made by specialist nurse in a tertiary centre of the confidence and trust that had built up between the remote areas and tertiary centre through their regular meetings via V/C and acknowledged the considerable amount of experience and expertise that those working in remote areas were also able to offer:
- T/C provided many opportunities for more collaborative planning of care for patients being cared for. All nurses were involved in the shared care of patients between a tertiary centre and a remote centre where the patient resided and they acknowledged T/C allowed a more collaborative approach to care. Two nurses coordinated weekly V/C meetings with the nurses working in the remote area to discuss and plan patient care: Multidisciplinary team meetings in tertiary centres held by V/C enabled health professionals in the remote areas to attend and contribute to the planning and care of the patient:
- One of the advantages of using teleconsultation was a sense of empowerment for those nurses working in remote areas namely around education and participation. Nurses working in remote areas spoke of the difficulty in being able to participate in further education, particularly in their practice specialty. This was related to the practicalities of having to travel long distances for often a relatively short education session. V/C provided nurses with both formal and informal learning opportunities they would not have otherwise had. An example was described by two nurses where facilitation and presentation of these sessions was a shared responsibility between themselves and the remote centres which occurred on a regular basis. The fact that distance education was carried out by V/C also had the added benefit of providing the nurses with ‘V/C experience’ Formal education sessions by V/C were a regular occurrence for most participants: Improved and more equitable access to the nurse educators in the tertiary or base hospitals has increased learning opportunities and professional support, with all nurses seeking advice using telephone and email, and some via videoconference One nurse saw a V/C as an opportunity for an evaluation of her own professional practice through interaction with her colleagues. She saw this as affirming and an opportunity to improve her practice. Telecommunication tools enable more frequent interaction between the nurses and their colleagues. This appeared to have an impact on the confidence levels of the nurses, with one believing this was empowering to her colleagues: A nurse working from a tertiary hospital, felt an important part of her role was to empower the nurses working in remote areas. Providing specialty support and education from a distance was not only essential to ensure safe patient care, but was designed to also develop the expertise and confidence within the local team:
- Specialty healthcare often necessitates the need for patients to travel to a tertiary or larger centre for the delivery of care. This has made it difficult in the past for health care providers in the patient’s own community to have an involvement or a voice in the planning of care, despite often being responsible for the provision of that care. T/C has provided a platform for nurses working in remote areas to be actively involved in decision-making around care. The nurses working remotely felt it was important and beneficial to patient care that nurses have their say:
- The word ‘etiquette’ featured in a number of the nurses interviews. They spoke of the need to have a heightened awareness of their communication skills and simple courtesies can be problematic due to the delay in voice transmission resulting in people speaking over the top of each other; background noise is amplified through the speakers so movement of people and objects can be distracting. The importance of behaving in a courteous manner was deemed important to successful communication and to maintaining professionalism. They warned when undertaking V/C it can be easy to forget that there are others present who are not physically in the room.
- Accessibility to support and expertise relates to both the nurses and their patients. With V/C, patients and staff working in remote areas have access to the support and expertise of specialist consultants without the necessity of having to travel to tertiary centres. This level of convenience was seen as a significant advantage and contributed to the reported high level of satisfaction from patients and their families The nurses working in remote areas identified that the use of T/C was extremely valuable in providing a sense of security when providing care to patients’ with complex conditions. Whilst the local medical staff [doctors] were acknowledged as important members of the multidisciplinary team, participants felt in some situations a higher level of knowledge and expertise was required: The ability to be able to ring, email or arrange a patient review by specialist staff was deemed a crucial aspect of providing safe patient care: Another example exemplifies this: I know they are only a phone call or email away. I don’t ring [consultant] very often because I know he’s extremely busy and I know he will always reply to my emails. It might not be till ten o’clock that night. If it’s something urgent I will ring them, I couldn’t do my job without that. I wouldn’t sleep. (Participant 6)
- Some nurses reported they were able to have their patients seen sooner by the consultant via V/C if the patient was unwell or they had concerns regarding the patient’s health status and felt by being able to visualise the patient over V/C, a more informed decision could be made regarding patient transfer to a tertiary centre: Nurses felt that better decisions around the safety of patient transfer could also be made. The nurses described situations where transfer of an unwell patient was averted and care of a patient was able to be provided locally by staff supported remotely by the medical specialist: T/C was not exclusive to the management of patients in an acute episode of care. Telehealth clinics via V/C have been introduced as clinical demand outweighed available consultant time for physical face to face clinics.
- The convenience of T/C also featured as a positive aspect for health professionals. Time saved in travelling also benefited the staff travelling from tertiary to satellite areas: The nurses working in tertiary centres provided support and care to patients over very large geographical areas. The use of V/C substantially reduced the need for physical visits to the satellite areas. : All the nurses were unanimous in feeling that the use of T/C provided a higher level of convenience for patients. Depending on location many patients travelled long distances for a relatively short consultation: All the nurses reported that one of the main reasons for the high level of satisfaction from patients was the reduced travel times:
- The ability to consult and seek advice remotely was often not only more convenient for the patient but in some situations provided a more patient and family focused delivery of care: One example from one of the nurses captured this well , a palliative care patient we wanted to stop [type of treatment]. We had multiple family meetings but it came to the crunch and we had to say stop, and go home, set hospice up and everything else along those lines. We arranged a family meeting so they didn’t have so far to travel. We were able to be there and hear what the consultant said, what the patient said, what the family had to say. The patient was able to leave here and say goodbye to all the patients, which they wanted to do. It was a lot less stress even though it was very sad and tearful for everyone. It was a really good way of dealing with it and they respected that and it kept their dignity throughout instead of going in to an unfamiliar place, to a cold clinical examination room which is like 100 kilometres away to be told the worst news, that they are going to stop and not have any of the nursing staff who know them with them. (Participant 2) Other nurses agreed and felt opportunities for family involvement in consultations were more enhanced through local access: Opportunities to reduce travel when patients felt unwell or it became physically difficult were also welcomed by the patients and their families along with significant socioeconomic benefits.
- Most of the nurses were initiated into videoconferencing with little or no training or guidance, resulting in some less than positive experiences. All recognised the value of technology and its benefits to clinical practice so were determined to ensure its success into their practice. However they recognised that for practitioners not fully committed to the concept of T/C these type of experiences or perceptions could be harmful to the future of teleconsultation: One nurse described her initial experiences as “baptism by fire “. She started doing V/C in response to an urgent clinical need resulting in little planning or opportunity for training. This experience was echoed by other participants who felt that to ensure nurses were prepared for teleconsultation there needs to be much more support and education for those starting out. The opportunity to observe the teleconsultation process before participating was a recommendation by all. Mentorship by those experienced in teleconsultation was a strong recommendation and .the ability to receive training on equipment operation and practical hands on use of the equipment before having to use it in a clinical situation was also seen as paramount by the nurses: The experience of one nurse was different than most. The organisation she worked for was committed to the telehealth concept and provided a lot of support and resources for the implementation of V/C: The nurses were asked to rate their level of confidence in using teleconsultation Most participants identified themselves as now being very confident using with teleconsultation. Their level of confidence was generally reflected in the length of time they had been practising teleconsultation with nearly all having at least 2-3 years’ experience with V/C, and much longer with telephone and email based consultations. All described initially feeling very self-conscious about being viewed on a television screen. This revolved around their physical appearance and how well they were able to communicate during the videoconference: What also contributed to the levels of confidence included being fully prepared for the meeting by such things as ensuring equipment working, results and information on hand that may be required. To be able to confidently participate in V/C was deemed important by participants to ensure patients felt comfortable during the consultation The relationships between those involved in a T/C also impacted on the level of confidence. The more collegial and supportive the relationships were the more comfortable nurses were with using the modality. Competence can be defined as a cluster of related abilities, commitments, knowledge and skills that enable a person to act effectively in a situation. The nurses were asked to rate their perceived level of competence with teleconsultation using Patricia Benner’s (2000) terms .describing levels of competence Most rated themselves as proficient or expert at this point in their practice of teleconsultation. Whilst most acknowledged their introductions to videoconference had been a steep learning curve, all adapted quickly: identified a lack of formal protocols and processes and believed if they had been in place the transition would have been smoother:
- In order for there to be a smooth transition when embarking on teleconsultation most nurses felt the nurse needed to have advanced nursing skills and some experience of the specialty: All the nurses were very experienced registered nurses as reflected in their current senior positions. They believed that this experience enabled them to adapt quickly to adding T/C n to their practice and felt this contributed to their high levels of confidence and competency. Specific skills identified by the nurses were advanced communication skills both verbally and written, advanced clinical assessment and critical thinking skills. They felt they were often the eyes and the ears for the consultants and the level of trust and autonomy given to them was reliant on demonstration of these skills. Most nurses felt that T/C not appropriate for a beginning nurse due to the current lack of support and infrastructure related to providing T/C services and the need for advanced skills and expertise in the area they were working in However they did recognise the role of teleconsultation in future health care and believed an awareness of this needed to be incorporated into undergraduate programmes,
- .All the nurses had some degree of coordination involvement around the V/C process. Some took full responsibility for the booking of appointments and V/C facilities whereas others had clerical support for this: Some preferred to be responsible for the co-ordination to ensure the smooth running of the sessions by ensuring all relevant tests and information was available: The desire by the nurses for the T/C process to be successful, from both the patient and health professional point of view was evident in all interviews and all expressed a strong sense of responsibility to ensure this happened: All participants felt appropriate patient selection for teleconsultation was an extremely important and required careful assessment. Nearly all the nurses ensured that the patients had had at least one face to face consultation prior to commencing V/C. Prior to considering V/C patient education about the process and gaining their informed consent was deemed crucial in ensuring good outcomes and patient satisfaction:
- Patient support and advocacy during a V/C was seen as one of the most important nursing roles. Advocacy was demonstrated in a number of ways throughout the interviews. Examples include: subtle highlighting of a patient’s symptoms that the nurses were aware of but were not being reported to the consultant or the initiation of discussions that patients were reluctant bring up with their consultant: Advocacy also included clarification and ensuring patients understood discussions that were taking place The nurses all involved in patient V/C g all agreed that giving bad news to patients at a distance was not an ideal situation, however, there were occasional times that this was unavoidable. Patients were generally already familiar with V/C and had established relationships with the health professionals: Provision of emotional and psychological support was described by most nurses as their responsibility during a patient V/C. Often it is only the nurse present with the patient and family at the remote end and their physical presence was seen as mandatory to provide psychological support and act as the link between patient and consultant
- Consultation by distance has bought about its unique challenges around information sharing and the documentation of the processes. Different patient management systems between tertiary and remote areas create difficulty in sharing documentation. The introduction of electronically stored and shared patient documentation was seen as crucial to the success and safety of T/C by the participants. Documentation of a patient V/C consultation was similar to that of face-to-face for most participants. Often a clinic letter would be dictated by the consultant but due to the delay in a letter being transcribed and then reaching a remote area most participants also wrote notes in a patients’ clinical record, on paper or electronically. Emails were generally either cut and pasted or transcribed into the patient’s clinical record, while outcomes of phone call conversations were also added into the clinical record. All participants were acutely aware of the need to protect their professional practice and undertook a variety of processes to ensure this. Two nurses followed up any verbal discussions around patient treatment with emails outlining the discussion to reduce the risk of mis-interpretation: Some nurses were clearly the key link in ensuring that those involved in the patient’s care were kept fully informed of management plans between tertiary and remote centres. They were also proactive in searching for ways to improve communication processes:
- The theme practicalities emerged, as the nurses discussed the issues undertaking an actual T/C, and what needs to be considered by those embarking onT/C. Their experiences offered valuable insight into what was required from a technical and infrastructure perspective to provide a quality service. Most of the frustrations and disadvantages around the use of teleconsultation identified by the nurses centred on day to day practicalities of providing consultations by V/C. and revolved around equipment and facilities. The success of T/C appears to very much depend on the infrastructure surrounding its use. Technology continues to develop at a rapid pace and the age and sophistication of the technological tools used varied. Many of the nurses encountered difficulties in accessing V/C facilities and rooms suitable for the consultation. Room size, location and availability were often described as barriers to successful consultations: The ability to upgrade equipment was seen as another barrier to reaching the full potential of teleconsultation. The perceived reasons for this were fiscal constraints and telehealth being seen as a low priority. Remote areas often lacked the resources and key people to drive and champion the telehealth vision: The nurse who had been using V/C for the longest period of time had seen a succession of equipment introduced and agrees that the increasing sophistication of technology has improved the quality and was able to provide a clarity that was more closely akin to face-to-face consultation: Room setup was deemed very important by nurses as some were working in adhoc facilities with poor lighting and an inability to examine patients by proxy: The areas that had teleconsultation facilities attached specifically to their units reported the most satisfaction and the least difficulties in being able to access and use the equipment: All involved were in agreement that for V/C to provide the same quality and equitable service as face-to-face consultations individuals participating needed to be committed and comfortable with the process. The level of technology available to use for T/C was variable. Some areas were well resourced, particularly in tertiary centres, or areas where personnel were strong advocates for telehealth.
- The Ministry of Health in New Zealand has a focus on ensuring health services are delivered sooner, better and more conveniently and priorities include care closer to home and making the best use of information technology). Emerging from this study were examples that health services could be delivered sooner, better and in a more convenient way through the use of T/C The advantages of T/C for those living in remote areas are identified in the literature by (Mitchell & Disney, 1997; Sharpe et al., 2012. Both noted patients were seen sooner and complex situations able to be managed by T/C. Similarly patients were able to be monitored at a distance, thus negating the need for transfer. The advent of communication technology has for some specialties both here and internationally allowed accessibility to a higher level of support and expertise previously unavailable in remote centres. Patient satisfaction was an important concept the nurses in this study used to assess the effectiveness of their T/C with high levels of satisfaction reported. Maintaining, or even increasing patient satisfaction was noted in the literature too (Gund et al., 2013; Kitamura et al., 2010). Nesbitt et al. (2005) found that the availability of telemedicine may increase perceptions of local health care quality and importantly a greater level of confidence in the abilities of local health care practitioners. This finding was confirmed in the present study with the nurses reporting a greater level of confidence and reassurance amongst patients whose care was managed between tertiary and remote areas. The study demonstrates the shift of some aspects of more complex health care back into local communities supported by telecommunication technologies which fits with the philosophy of patient and family centred care This study supports other literature by (Moffat & Eley, 2011; Al-Qirim, 2003) who that found that T/C offers a solution to addressing the socioeconomic difficulties encountered for patients’ often travelling long distances for health care The use of T/C as a strategic element to address the health care challenges and inequities for those in remote areas is well documented in existing literature with some positive results (Pope, 2013; Sharpe, Elcock, Aitken, & Furyk, 2012). According to (Broens et al., 2007 & Jennett et al., 2005). User acceptance is considered a strong determinant for the success of T/C This study showed an acceptance of T/C into the nursing practice of the participants. It is perhaps the vision, commitment and engagement of the nurses that contributed to the positive outcomes of T/C for their patients and their nursing practise that their interviews demonstrated. Other literature examining nurse’s experiences of using telemedicine found similar findings, where technology was viewed generally positively and although nurses experienced frustration in the beginning, this did not deter them from participating and they enjoyed the expanded role T/C offered them (Dansky et al., 1999; Radhakrishnan, 2012). T/C and the loss of face to face contact challenges the ability to establish meaningful relationships posing a potential threat to relationships with patients and is cited by Helm (2005) as a common reason for health care professionals’ skeptism and reluctance to engage in T/C. Historically the nurse knowing the patient and establishing therapeutic relationships has been associated with physical presence and close proximity. Nagel et al. (2013) discuss the concerns of nurses becoming reliant on technology, along with their ability to know and convey caring to patients without the usual forms of expression such as touch and other non-verbal communication particularly when T/C is used. However, the nurses in this study felt this could be mitigated by careful attention and specific strategies such as ensuring relationships were established before instigating T/C , along with alternating face to face clinic appointments. They believed in most situations the quality of the relationship could be enhanced by T/C and increased communication. Nagel et al. (2013) concur with the findings of this study in that it is the quality of the relationship rather than the modality of communication that is important and also considered communicating effectively and managing a T/C well could demonstrate caring. This corresponds with other literature that has found it is possible to build a therapeutic alliance with patient’s via T/C The advanced practice level of the nurses meant most already had highly honed assessment skills and were very knowledgeable in their field of specialty. Notwithstanding this, all recognised and described the feelings of inadequacy and nervousness when they began T/C These findings are consistent with other literature examining nurse’s experiences of T/C (Austen & McGrath, 2006; Dansky et al., 1999). All the nurses , on reflection, felt that with more education and opportunity for practise and observation would have contributed to reduced levels of anxiety and increased levels of confidence at the outset. This is also suggested consistently by others (Radhakrishnan et al., 2012; Richards et al., 2005). There is interesting debate in the literature as to the level of nursing practice required to participate in T/C. (Grady & Schlachta-Fairchild, 2007) believe that is not an area for a new graduate nurse and the basic curriculum should be focusing on face to face care with telenursing a form of advanced practice. Others however, support the inclusion of telehealth concepts and clinical experiences within the undergraduate programme. The consensus of the nurses in this study was given the advanced level of communication, critical thinking and advanced assessment skills required, a level of post graduate education and experience contributed to a high level of confidence and competence practising T/C.
- The limitations of this study relate to the small sample size and the demographics of the nurses who participated. The vast life and clinical experience of the nurses practicing teleconsultation meant their level of competence and confidence was relatively high resulting in a lack of representation from more inexperienced nurses who might be beginning to use teleconsultation. The use of individual interviews however allowed for depth of data that was rich in content and the participants were able to recollect vividly their beginning experiences. With the participants all working in a similar shared care environment the data was also not reflective of other types of telenursing consultation, such as nurses practicing solely in telephone triage. Recruitment of more participants was difficult as little is known regarding numbers and whereabouts of nurses practicing teleconsultation in New Zealand. The extent of nurse participation in teleconsultation in New Zealand is an area that would be worthy of further research. If there had been sufficient numbers a quantitative approach with a survey might have provided the possibility of increasing sample numbers therefore involving more nurses in the study. However this would not have met the objectives of the study, where more depth of understanding of their experiences was required. Polit et al., 2001 considered the vulnerability of the qualitative paradigm for bias with the validity of the research dependent on the researcher’s skills. While all measures were taken to ensure the collection, interpretation and analysis of the data was accurate the inexperience of the beginning researcher needs to be considered. Despite the scale of the research being small, it is the first study of the experiences of nurses using teleconsultation in New Zealand and gives some insight into what will be required in the future to support nurses who undertake teleconsultation. Clearly the explosion of information and communication technology within healthcare is beginning to gain momentum, with potentially a generation of nurses who are unprepared and ill equipped to cope with this increasing technological aspect to healthcare. For teleconsultation to embed itself in the repertoire of nursing skills and practice, nurses will need to embrace this technology and recognize the advantages to patient care and their own practice. This begins with the need for nurses to become computer and technology literate, to not only consult remotely, but as more patient management systems and documentation of patient care becomes electronic. Whilst many undergraduate and post graduate programs require nurses to use computers to study strategies will need to be developed for experienced older nurses with limited information technology exposure to make this transition. New technology can provide opportunities for expansion of nursing services, more diverse roles and support advanced practice, as demonstrated by participants in this study. Nurses undertaking teleconsultation need to recognise that with increased opportunity comes the increased responsibility of ensuring they demonstrate high levels of assessment and communication skills to protect both the safety of the patient and their own practice. The use of teleconsultation brings changes to the dynamics of the nurse-patient relationship. The challenge for nursing is to adapt and demonstrate our unique and precious capacity for caring, in a non-physical way. Strategies for demonstrating caring when using technology in patient interactions will be required by nurses to assist in developing their information and communication technology and remote communication skills. Although the body of research around the use of teleconsultation in healthcare continues to expand there remains gaps in knowledge and a need for further research. Whilst there is a small body of evidence in certain areas to suggest the benefit in health care delivery, many authors, while cautiously optimistic, were unable to conclusively demonstrate the benefits or effects of teleconsultation to the delivery of health care. Despite this, the use of teleconsultation continues with increasing numbers of patients and health professionals involved in this modality of care resulting in larger subject numbers for potential new research. It is therefore timely to consider opportunities for more rigorous, robust and collaborative research to be undertaken. This will assist in future planning and direction of the role teleconsultation has in the provision of health services from a distance. Teleconsultation research will also provide more information to assist with evidence based practice decisions. The findings from this study support the use of teleconsultation within the specific area of shared patient care between remote and tertiary services. However, further investigation is warranted in assessing teleconsultation in other situations as a useful patient management tool for improving accessibility to services and cost savings where distances creates inequity. Nursing research, specifically related to teleconsultation is very limited therefore the opportunity to increase the knowledge and understanding of the implications of teleconsultation to nursing practice and patient care outcomes should be a priority as we move forward in this increasingly ‘mobile’ future. While lessons can be learned from international research and adoption of findings can be incorporated into national practice, each country and health service is unique and warrants its own pursuit of research to ensure best outcomes in the health of its own people. Careful planning and preparation prior to implementation of teleconsultation services is needed to ensure the smooth transition in clinical practice. The need for consultation, with all stakeholders, education to engage use and facilitation to support participation in teleconsultation should not be underestimated. This requires commitment from organisational bodies to provide support, both fiscally and logistically, to teleconsultation initiatives and programmes. Another priority is the development of policies and procedures to ensure the safety and efficacy of patient care and to protect the practice of healthcare organisations and individual health professionals involved in teleconsultation. 6.6 Recommendations A number of recommendations have been identified from this study and these are listed: ● Incorporate telemedicine principles into undergraduate and post graduate nursing programmes to create a heightened awareness of what information and communication technology and telehealth can contribute to health care delivery ● High priority from organisational bodies to the introduction of technical support and education for nurses around information technology in the workplace. ● Develop and implement competencies to support safe and effective nursing practice in teleconsultation. ● Strong representation from nursing should be included in the development of evidence based practice standards, guidelines and the system design and management that encompass teleconsultation. ● Advocacy from nursing is important to ensure patients’ needs continue to be met in a holistic and patient- centred manner.within teleconsultation services. ● Develop standards and protocols for the use of teleconsultation in the workplace. ● A formal generic approach to the documentation of teleconsultations utilizing electronic patient records should be considered a priority to complement and safeguard the practice of teleconsultation