INTRODUCTION:

Telehealth encompasses all facets of remote health care including clinical services provided using telemedicine, as well as interactions with automated services, systems, or information resources. It is the integrated use of electronic information and telecommunications technology to support remote clinical health care, patient and professional health-related education, public health, and health administration [1].

Health care systems continue to struggle to provide access to cost-effective quality care.

The dramatic changes in health care reflected by increasing patients with multiple chronic diseases, health care workforce shortages, mandates to decrease costs, and infusion of technology make it necessary for nurse practitioners to embrace telehealth.The use of telehealth technology presents new opportunities for addressing these challenges by increasing patient access to care and decreasing costs, while improving desired care outcomes.

For nurse practitioners to address health care of the future, advanced knowledge and skills in the use and application of telehealth technologies in practice are becoming essential. Preparing nurse practitioners to utilize telehealth technology requires specific and dedicated didactic and experiential telehealth education incorporated within existing curricula. It is important that educational programs focus on the understanding of telehealth and its application as well as skills development. Based on a comprehensive review of the literature, this article provides a multimodal framework for preparing nurse practitioners to utilize and champion the use of telehealth within the complex health care environment.

Telehealth programs have been used to provide content that focuses on defining telehealth, telehealth etiquette, interprofessional collaboration, ethical practice in telehealth, and satisfaction. The following sections address recommended topics that programs might consider addressing when training nurse practitioners in telehealth [2].

DEFINING TELEHEALTH:

Technology has been applied to health care in so many diverse ways that it is not surprising that there is great confusion as to what terms such as telemedicine and telehealth mean and how they are used in health care. Thus, educational programs might begin with a clear understanding of what constitutes telehealth and how it differs from telemedicine. There have been more than 100 definitions of telemedicine in the literature over the past 10 years, suggesting that clarification for practitioners is needed. Telehealth is therefore the use of electronic information, devices, and telecommunication technology to provide direct patient care, remote patient monitoring, and education at a distance. Telephone, audio-only, text messaging, fax, and email communication are not considered telehealth technologies.Telehealth has been called a “disruptive technology”in that it may either replace or supplement the traditional face-to-face patient–provider encounter [3].

TELEHEALTH ETIQUETTE:

An important aspect of the telehealth encounter that must be included in health care professionals’ education is telehealth etiquette. Telehealth etiquette includes the unique behaviors necessary to conduct an effective telehealth visit. These behaviors are similar, yet different from previously learned behaviors necessary to conduct either a traditional in-person visit or a telephone consultation.Telehealth etiquette includes proper camera positioning, elimination of office or clinic noise, the removal of personal objects located within view of the camera, and even the clothing choice made by the provider.¹⁷ Bright or busy clothing patterns can distract from a telehealth encounter. Traditional communication skills must also be adjusted for this type of visit. Students must be taught the subtleties of eye contact during a telehealth visit. Eye contact is made with the client by looking at the camera, not the client’s face on the screen. Looking down or taking notes can be perceived as disinterest or distraction. While empathy can be conveyed during a telehealth visit, it must be carefully constructed. Students must be taught to look and lean into the camera and to nod their head to encourage their client. Rather than using touch, students must be taught to choose the words that they use with their clients carefully to display empathy. When students are adequately prepared to communicate using proper telehealth etiquette, they are better assured that they will have a successful visit. Strategies used to assist students in learning about telehealth etiquette include didactic lectures and visual examples as found in videoed encounters of poor telehealth interactions [4].

INTERPROFESSIONAL COLLABORATION:

Interprofessional collaboration and learning how to accomplish it is now a mainstay of health profession education. Most of the professional organizations representing health-related professions have a mandate to include interprofessional education into their training programs. However, preparing students to collaborate through solely face-to-face encounters is not adequate for the nurse practitioners who will be providing care in rural and underserved areas where many professions do not reside. In addition, hierarchical models must be minimized if interprofessional collaboration is to be effective. Telehealth can serve as a tool to allow nurse practitioners and their patients to gain access to other professions at a distance as well as serving as an equalizer related to professional roles. Educational programs have been developed using didactic lectures and standardized patient experiences as well as intraprofessional projects to successfully teach interprofessional and intraprofessional collaboration using telehealth. These telehealth programs demonstrate effective collaboration in circumstances that would otherwise not be possible [5].

ETHICAL PRACTICE IN TELEHEALTH:

Telehealth practice is governed by the same Codes of Ethics for health care professionals as traditional face to face/same place encounters, yet the intricacies of providing care via this modality can trigger interesting ethical challenges for providers. Mehta outlines four potential ethical “pitfalls” related to telehealth implementation: erosion of the provider/patient relationship, threats to patient privacy, forcing one-size-fits-all implementations, and the temptation to assume that the new technology must be effective. Issues related to patient privacy, confidentiality, and security are addressed earlier, but exploring other areas of concern such as the erosion of the patient/provider relationship is paramount to a balanced and comprehensive advanced practice nursing curriculum. Ensuring that advanced practice nurses possess the moral sensitivity to identify ethical issues in care regardless of the structure and format of the interaction is an important step in advanced practice nursing education.

Providers have also voiced concern about the potential for patients to “shop” for providers and abuse the system in search of practitioners who will provide expedient care and desired prescriptions. Exploring how this is achieved within the ethical and legal landscapes that vary from state to state requires close review and understanding of the laws and regulations that govern provider scope of practice and the practice of telehealth. Kaplan and Litewka call for providers to thoughtfully explore the ethical issues of informed consent, autonomy, and empowerment within the context of an exploding technological shift toward telehealth and ehealth modalities. Thoughtful examination of what these cornerstone ethical concepts mean in the context of telehealth is an important part of the ethical trainings of nurse practitioners [6].

SATISFACTION WITH TELEHEALTH:

Of high importance in education is the need to increase the student’s positive attitudes toward the topics presented, and telehealth is no exception. In fact, students are often resistant to engaging in telehealth activities stating that they will never use it or that their patients will not like it. Data must be presented to students on the importance of having an open mind toward telehealth. One approach is to present data on patient and provider acceptance [4].

ROLE OF NURSES IN TELEHEALTH:

One of the evolving roles of nurses as they take on new responsibilities of providing nursing service in home settings is the use of information technology (IT). Telehealth nursing focuses on patients’ long-term wellness, self-management, and health. According to the American Telemedicine Association, this IT solution provides nursing care across a distance, empowering the care providers with the ability to monitor, educate, follow-up, collect data, and provide multidisciplinary care including remote interventions, pain management, and family support in an innovative fashion. It has been reported that agencies using telehealth have an average patient-to-nurse ratio of 15:1, as compared with non-telehealth agencies having a ratio of 11:1. Therefore, telehealth nursing can make a tremendous difference in providing patient care, particularly in rural or underserved areas in states such as Nebraska, where there is generally a shortage of nurses and health care services, as well as resources can be limited. In addition, in rural areas, many patients do not receive timely health care interventions because of the lack of specialist services. Home health agencies with telehealth capability caring for patient populations with chronic diseases can take care of patients in their home setting and therefore fill this gap. This provides convenience and a sense of security to the patient, allowing timely nursing interventions under supervised physician care [5].

CONCLUSION:

Telehealth has forever changed health care. Nurse practitioners educated in telehealth can make strong contributions to nursing and health care as they emerge from programs as future nursing leaders. The issues facing health care and health care resource allocation can be improved with telehealth systems of care developed and implemented by nurse practitioners. It is essential that nurse practitioners become empowered with telehealth knowledge and hands-on skills so that they can be a creative force for innovations in telehealth within practice and health care systems. Schools will be at the forefront of health care as they develop telehealth education programs and prepare to respond to the challenges ahead by promoting innovation through nurse practitioner telehealth education.

REFERENCES:

1. Brewster, L., Mountain, G., Wessels, B., Kelly, C. and Hawley, M. (2013) Factors affecting frontline staff acceptance of telehealth technologies: a mixed‐method systematic review. Journal of Advanced Nursing 70 (1), 21– 33.

2. Steventon, A., Bardsley, M., Billings, J., Dixon, J., Doll, H., Hirani, S., Cartwright, M., Rixon, L., Knapp, M., Henderson, C., Rogers, A., Fitzpatrick, R., Hendy, J. and Newman, S. (2012) Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. British Medical Journal (344).

3. Greenhalgh, T., Procter, R., Wherton, J., Sugarhood, P. and Shaw, S. (2012) The organising vision for telehealth and telecare: discourse analysis. BMJ Open (2).

4. Joseph, V., West, R., Shickle, D., Keen, J. and Clamp, S. (2011) Key challenges in the development and implementation of telehealth projects. Journal of Telemedicine and Telecare 17 (2), 71– 77.

5. Segar, J., Rogers, A., Salisbury, C. and Thomas, C. (2013) Roles and identities in transition: boundaries of work and inter‐professional relationships at the interface between telehealth and primary care. Health and Social Care in the Community 21 (6), 606– 613.

6. Hanley, J., Ure, J., Pagliari, C., Sheikh, A. and McKinstry, B. (2013) Experiences of patients and professionals participating in the HITS home blood pressure telemonitoring trial: a qualitative study. BMJ Open (3).

Received on 26.05.2019 Modified on 12.06.2019

Int. J. Nur. Edu. and Research. 2019; 7(4): 598-600.

DOI: 10.5958/2454-2660.2019.00133.9