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| ARTICLE |
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| Year : 2015 | Volume
: 16
| Issue : 1 | Page : 11-16 |
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Telenursing in contemporary practice
Dorothy D Theodore1, Priyadarshini L Byrappa2
1 Principal, Narayana Hrudayalaya College of Nursing, Bengaluru, India
2 Assistant Professor, Narayana Hrudayalaya College of Nursing, Bengaluru, India
| Date of Web Publication | 10-Jun-2020 |
Correspondence Address:
 Source of Support: None, Conflict of Interest: None
Advancement in healthcare system is booming with information technology at the forefront. Nursing being a major part of the healthcare system cannot lag behind. Nurses need to be adequately equipped with the required knowledge and skill in contributing to the utility of the technological advancement. Telenursing is one such advancement which is developing at a fast pace. Telenursing is becoming an essential means of providing care due to factors such as affordability, accessibility of services to the unreached and immobile sections of the society such as elderly and chronically ill, and shortage of specialists among healthcare professions. This article discusses various aspects of telenursing such as history, scope, and its use. It also presents a framework applicable to telenursing. The various challenges faced by nurses in implementation of telenursing alongside legal and ethical aspects are discussed.
Keywords: telemedicine, telenursing, principles, organization, nursing competencies, ethical issues, ethical challenges
How to cite this article:
Theodore DD, Byrappa PL. Telenursing in contemporary practice. Indian J Cont Nsg Edn 2015;16:11-6 |
| Introduction | |  |
As medicine advances in leaps and bounds, nurses also need to keep in pace with their practice. Telenursing is one such leap the nurse needs to take. Telenursing is booming at a large rate in many countries due to many factors such as increase in chronically ill patients and aging, and the increase in coverage of health care to distant, rural, and small regions. But awareness regarding telenursing is very limited as assessed by a study conducted by James and Priyadarshini (2012) in a reputed tertiary care centre. The study reported that 50% of the nurses had average knowledge and 43% had poor knowledge.
| Definition | | |
Telenursing is the practice of nursing over distance using telecommunications technology (National Council of State Boards of Nursing, 1997). According to College of Registered Nurses of Nova Scotia (CRNNS) (2008) telenursing is a component of telehealth that occurs when nurses meet the health needs of clients using information, communication, and web based systems. The precursor of telenursing was telemedicine.
| Historical Development | | |
In ancient days, Africans used smoke to signal illness in the village. In 1870’s, the first telephonic call was made by the inventor of telephone (Graham Bell) for the purpose of management of battery acid burns. In 1912, Australian Inland Mission established nursing cadre for nurses posted in remote areas. In 1929, Traeger pedal radio processed communication between the outpost nurses and the flying doctor services. This was the first telenursing service (Bywood, Raven, & Butler, 2013). National Aeronautics and Space Administration (NASA) in 1960 invented telemedicine to monitor the health of astronauts. During 1970’s, health maintenance organizations used nurses to give telephone advice (Dasgupta & Deb, 2008). In 1974, Mary Quinn documented the care provided to patients in Logan airport from Boston through telemedicine. In 2005, international telenursing survey conducted by International Council for Nurses (ICN) revealed that 719 telenurses responded positively (Schlachta-Fairchild, Varghese, Deickman, & Castelli, 2010).
In India in 1997, the Apollo group of hospitals was the first to start outreach through the use of communication technology via telemedicine in Aragonda, Andhra Pradesh. Currently it is the oldest and largest provider of telemedicine in South East Asia. Following that in 2003, a certificate course in telehealth technology was started by Apollo group of hospitals and Annamalai University with an intake of 30 students in each batch. This course was discontinued after 6 batches due to lack of job opportunities. Apollo group of hospitals has also been conducting a pilot study in home telecare systems and nursing. As part of the distant healthcare advancement, Apollo hospitals with Philips medical systems, Indian Space Research Organisation (ISRO), and Development of Humane Action (DHAN) foundation started hospital on wheels. In 2005 there were 2 telenurses working in India (ICN, 2010). First telenursing training centre was introduced in India in Mysore. Telenursing training centre was set up at Viswabharati School and College of Nursing in Mysore, in association with Chaithanya Medical Foundation, Bangalore (The Hindu, 2008). Some of the agencies that provide training in telehealth or telenursing are Apollo group of hospitals, Chennai, Anna University, Chennai (certificate course), School of Telemedicine and Biomedical Informatics. Luknow, Teleradiology Solutions, provider of teleradiology services - Teleradiology training center at Rad Gurukul, Bangalore. Tele-training centre at National Institute of Health and Family Welfare, New Delhi proposes telenursing to be introduced throughout India.
| Organization of Telemedicine in Healthcare System | | |
According to telehealth resource center (American Telemedicine Association, 2008) telemedicine is organized at two levels namely telenursing within a healthcare system and between healthcare systems. In organization within single healthcare system, the consultation services are offered internally particularly by making better use of provider time through reducing the amount of travel time to physically see the patients at different clinics and hospital locations within the organization. They may be further subdivided into inpatient services provided to other hospitals in the system and outpatient services that typically are directed to clinics within the system. In the context of organization between healthcare systems, telemedicine consultation services are organized with a concentration of medical specialists to offer their services to other healthcare facilities or organizations that may not have the same access to specialists.
| Principles of Telenursing | | |
Several principles of telenursing guide the administrators to plan and offer such service. Principles outlined by CRNNS (2008) are given below:
- Augment existing healthcare services
- Enhance optimum access and where appropriate provide immediate access to healthcare services
- Follow position descriptions that clearly define comprehensive yet flexible roles and responsibilities
- Improve and enhance quality of care
- Reduce the delivery of unnecessary health services
- Protect the confidentiality and security of information related to nurse-client interactions
| Scope | | |
Telenursing can be implemented in nursing education, service, administration, and research. According to World Health Organization (2007) the scope of telenursing is as follows:
- Emergency response system
- Disease surveillance and control
- Human resource coordination, management, and supervision
- Telenursing diagnostic and decision support at point of care
- Remote patient monitoring
- Health promotion and community mobilization
- Health related learning/health education
- Training and development of health personnel
For clear understanding, the scope of telenursing is discussed under the following headings:
Nursing education: Nurses can be trained by using telenursing in remote areas and may be used in continuing nursing education.
Nursing service: In nursing service telenursing can be practised in various situations. They may be broadly classified to include (Schlachta-Fairchild, Elfrink, & Deickman, 2008):
- Teletriage: Using information technology and the principle of triage management emergency situations from a distance can be handled. For example, during an emergency like accidents, in remote places teletriage method can be used to save lives.
- Telecare: Audio and video conferencing consultations with healthcare providers or between healthcare providers and clients are facilitated (e.g., In rural clinics, the health status of the clients living with chronic illnesses such as congestive heart failure can be assessed).
- Teleconsultation: Questions can be answered that are received by remote web conference consultations. This is similar to that mentioned above. For example, nursing care can be provided via teleconsultation for soldiers at the battle field.
- Electronic discharge planning: This involves monitoring the status of clients in their homes specially those who have taken an early discharge with the use of telecommunication techniques.
- Telenursing in therapeutic nurse-patient relationship (TNPR) development: Here, the TNPR is developed using telecommunication techniques and technology.
- Telenursing for health education: This involves promoting self care through health education using telecommunication technology. The areas that may be handled primarily are promotion of health and prevention of diseases and tertiary care in terms of home management of the residual effects of the disease. It can also address the home management of minor illnesses.
- Telenursing help-lines: These are operated by nurses and they can provide disease specific information, counseling and guidance through the use of technology.
Nursing administration: Nurses can use the advanced technology for collaborating and mentoring nurses around the globe, they can share their experiences, and bring down the cost of healthcare services.
Nursing research: The scope of using telenursing in nursing research include sharing of information with other professional colleagues (national and international), promotion of evidence based practice, and consultation with experts in the specific field.
| Framework of Standards and Guidelines | | |
The framework depicted here is related to telemedicine which can be applied to telenursing also. The framework by Manamel and Sarkar (2009) is adopted for telenursing framework (see [Figure 1]. | Figure 1: Framework of guidelines and standards applicable to telenursing (Source: Manamel & Sarkar, 2009)
Click here to view |
Infrastructure includes a telenursing consultation room and a specialty center. The telenursing consultation room is where the consultants/specialist converse with the peripheral centers. The telenursing specialty centre is linked to peripheral centre located in the suburban and rural areas from where the patient or healthcare worker can consult. Equipment and technology required for telenursing are high resolution video camera, web camera, document camera, microscope, personal computer, microphone, telephone, fax machine, faxes and modem to deliver service to the patients. Technologies used in telemedicine are internet, digital imagery, trans telephonic electrocardiogram monitoring.
| Nursing Competencies | | |
The prerequisites for a nurse who should be involved in telenursing are multifaceted personality, competence and enhanced communication skills, technology awareness and competence in its use, critical thinking skills, multi state registration, and skill of management. According to the ICN (2010), the competencies required for telenursing are listed as follows:
The nurse should be able to
- establish a duty of care and collaborate with team members
- use computer based approach and advocate for technological innovations
- provide advice and counsel in the context of available medical data
- participate in development, implementation and evaluation, improvement review and modification related to nursing practice
- comply with existing organizational policies and guidelines related to privacy and confidentiality, informed consent, information security, and documentation
- provide services consistent with standards for nursing practice, code of ethics, registered nurse act, and other relevant acts
- use standardized protocols and guidelines
- protect confidentiality and security of client information
- assess own competencies, identify areas for learning, and address knowledge gaps related to technology used
- support evidence based practice
- establish therapeutic nurse-client relationship and document nurse-client interactions
- give details of one’s identity
- assess cognitive ability, hearing and vision to use the system
- encourageclient to call back if needed
| Implementing Telenursing | | |
Telenursing can be implemented in various phases. CRNSS(2008)suggests four phases and they are outlined in [Figure 2].
| Challenges Including Ethical and Legal Issues | | |
According to Bywood et al. (2013) nurses face a variety of challenges in the implementation of telenursing. They are:
- absence of direct “hands on” assessment and face to face interaction
- increase in liability risks
- financial investments
- likelihood of technology failures
- risk for problems related to confidentiality and security
- practice beyond their scope of nursing
- inability to provide adequate information to the client to make an informed consent and
- lack of license if the client is from another province which is beyond the scope of practice for the registered nurse
The nurse needs to take several precautions to overcome the above mentioned challenges. Some of the ethical and legal issues have to be handled very carefully. The various liabilities related to telenursing will include the type of health professional involved with their qualification and licence, specific technology and its uses, organizations and institutions involved and human resource training.
The legal issue that nurses face is related to accountability and malpractice, multistate registration, and nature of phone calls. In accountability and malpractice, the nurse needs to practice only within her scope or licence. Where multistate registration is practised and when teleconferencing crosses the border of the state, the nurse needs to have the license in both the states. At the time of receiving phone orders confirm whether the person giving the order is a registered practitioner within the jurisdiction. The nurse must be aware of law of the state in terms of practice and specifically telenursing (Hutcherson, 2001).
In case of documentation, institutional policies have to be adhered to. With regard to dealing with ethical concerns, confidentiality and safety of client data have to be maintained. The following are some of the special considerations that the nurse needs to follow:
- Protect the client data adequately (hacker safe)
- Be cautious while using social networking sites such as facebook and twitter
- Ensure compliance with legislation and regulations designed to promote confidentiality
- Inform clients that they have the right to use other methods and media for their care
- Get consent for this method of nursing from the client. The consent must be voluntary, informed, made by one who is mentally capable to give the consent, and with the client’s knowledge of who is in the room while giving the consent
- Keep telehealth equipment under lock when not in use
- Use keys and passwords for security
- Soundproof the rooms and headsets
Ethical Competence Building in Telenursing
Ethical competence is both an individual and an organisational responsibility in the healthcare system. In order to be able to identify if a dilemma is truly ethical in nature, as well as to be able to judge and act upon it, high ethical competence is needed among nurses. One way to achieve this could be to work with so called ethic rounds which is a form of institutionalized and inter-professional ethics discussions. In addition to the increased ethical competence that might come out of such ethic rounds, a decrease in moral uncertainty and moral distress might also follow (Hoglund & Holmstrom, 2011).
| Conclusion | | |
Telenursing can help in providing care where there is shortage of nurses. With the advancement of technology nurses have to move out of the traditional role of care provision only at the bedside and need to become technology savvy in order to meet the demands of the ever changing medical advancement and technology. In India, telenurse education is used by Indian Nursing Council for the contact classes for Ph D nursing students where teleconference is used as a method of teaching. These technologies are rapidly moving into the governmental and nongovernmental hospitals and the nurse needs to equip herself in order to meet the demands of her profession. Telenursing needs to be incorporated in the nursing curriculum to make the future nurses competent.
Conflict of Interest: The authors have declared no conflicts of interest.
| References | | |
| 1. | American Telemedicine Association. (2008). Telehealth nursing. Retrieved from www.americantelemed.org/docs/default-document-library/telenursingwhitepaper_ 4-7-2008.pdf?sfvrsn=2.  |
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| 4. | Dasgupta, A., & Deb, S. (2008). Telemedicine: A new horizon in public health in India. Indian Journal of Community Medicine, 33(1), 3-8. doi: 10.4103/0970-218.39234 |
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| 8. | James, S., & Priyadarshini. (2012). Descriptive study to assess knowledge on telemedicine among staff nurses of a selected hospital, Bangalore. Unpublished project under RGUHS. |
| 9. | |
| 10. | National Council of State Boards of Nursing. (1997). Telenursing: A challenge to regulation. National Council, Position Paper. |
| 11. | Schlachta-Fairchild, L., Elfrink, V., & Deickman, A. (2008). Patient safety, telenursing, and telehealth. In R. G. Hughes (Ed.), Patient safety and quality: An evidence- based handbook for nurses. Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved from: http://www.ncbi.nlm.nih.gov/books/NBK2687/ |
| 12. | Schlachta-Fairchild, L., Varghese, S. B., Deickman, A., & Castelli, D. (2010). Telehealth and telenursing are live: APN policy and practice implications. The Journal for Nurse Practitioners, 6, 98-106. |
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| 14. | World Health Organization. (2007). Towards development of health strategy 2007. Retrieved from www.ehidc.org/…/ 199-white-paper-towards-the-development-of-an- mhealth |
[Figure 1], [Figure 2]
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