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Preparing Nurses for Roles in Telehealth: Now is the Time!

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Carolyn M. Rutledge, PhD, RN, FNP-BC
Tina Gustin, DNP, RN, CNS

Abstract

With the COVID-19 pandemic, the method for delivering healthcare changed overnight. Telehealth became a primary method of delivering care. Suddenly, nurses were expected to utilize technology with very little, if any, training in telehealth. All evidence suggests that telehealth is here to stay. As such, it is now time for healthcare providers to reflect on best practices for telehealth, and for nurse educators to ensure that graduates are prepared to function in the new telehealth arena. This article provides an introductory overview of the history of telehealth nursing; uses for telehealth with the COVID-19 pandemic; new awareness of telehealth challenges, and nursing roles. We also discuss sites that require a telehealth nurse and the Four P’s framework for telehealth education.

Citation: Rutledge, C.M., Gustin, T., (January 31, 2021) "Preparing Nurses for Roles in Telehealth: Now is the Time!" OJIN: The Online Journal of Issues in Nursing Vol. 26, No. 1, Manuscript 3.

DOI: 10.3912/OJIN.Vol26No01Man03
https://www.doi.org/10.3912/OJIN.Vol26No01Man03

Key Words: Nursing, nursing education, telehealth, telehealth education, nurse educator, nursing programs, healthcare technology, nursing faculty, telehealth technologies, telehealth nursing

Spring 2020 created a paradigm shift in healthcare. For years, the healthcare profession, most specifically nursing, has prioritized the in-person relationship with patients in lieu of telehealth visits. Telehealth, as defined by the Health Resources and Services Administration (HRSA), is “the use of electronic information and telecommunications technologies to support and promote long-distance clinical healthcare, patient and professional health-related education, public health and health administration” (U.S Department of Health & Human Services [DHHS], 2020, para 1).

Because of the limited emphasis, few nursing education programs integrated telehealth content within the curriculum. While the National League of Nursing (NLN) provided a vision for preparing nursing students for technology, the focus was on electronic health records (EHR) and informatics, rather than telehealth for the provision of care (NLN, 2015). Even though the American Association of Colleges of Nursing (AACN) essentials for BSN (2008), MSN (2011), and DNP (2006) education addressed technology in broad terms, there was minimal reference to virtual health and no mention of telehealth (AACN, 2020). Because of the limited emphasis, few nursing education programs integrated telehealth content within the curriculum. When the COVID-19 pandemic hit, healthcare professionals, including nurses, were not prepared to pivot to delivering care through telehealth technologies.

Nurse educators had failed to prepare nursing graduates with the needed skills to optimize their role in telehealth delivery. This gap has left the registered nurse (RN), Clinical Nurse Specialist (CNS), Clinical Nurse Leader (CNL), and nurse managers/ directors without the skillset needed to plan, implement, deliver, and evaluate telehealth programs. Even now, emphasis is being placed on providing training in telehealth to primary care providers (PCPs), such as nurse practitioners in advanced practice nursing programs, as opposed to RN, CNS, and CNL programs (Chike-Harris et.al., 2020; National Organization of Nurse Practitioner Faculty [NONPF], 2018; Rutledge et al., 2017; Van Houwelingen et al. 2016). As such, this article will focus on telehealth for nursing to include these overlooked groups of nurses (RN, CNS, and CNL).

It is now time to re-evaluate where the profession of nursing stands regarding telehealth. It is now time to re-evaluate where the profession of nursing stands regarding telehealth. It is time to embrace this new paradigm and prepare nurses to not just support telehealth efforts, but to take the lead in its integration within healthcare. It is time for nurses to promote and optimize the efficiency, effectiveness, and implementation of telehealth. The door has been opened for telehealth as a vital method to provide healthcare. All indications suggest that it is here to stay.

Nurses who utilize telehealth are expected to maintain their same scope of practice, however, with the added use of telehealth technologies. Through telehealth practice, the nurse uses a variety of technologies, such as videoconferencing to communicate with the patient; remote patient home monitoring to collect clinical data (e.g., blood pressure and blood glucose levels); and peripherals such as a Bluetooth stethoscope and a high definition camera to collect and deliver data to providers. The nurse practicing telehealth promotes patient wellness; assesses patients and provides care in remote or disadvantaged settings; manages chronic conditions; provides transition of care; and supports end of life care. The value of telehealth to the patient and healthcare settings is increased when the care is provided by a skilled, empathetic nurse prepared to deliver nursing care through technologies (National Council of State Boards of Nursing [NCSBN], 2014).

Most telehealth preparation for nurses occurs not during their academic training, but during clinical orientation for jobs...Most telehealth preparation for nurses occurs not during their academic training, but during clinical orientation for jobs or during a nurse residency program (American Academy of Ambulatory Care Nursing [AAACN], 2018). As a result, when society needed to embrace telehealth in response to COVID-19, healthcare professionals, including nurses, were caught without the needed training. Currently, the AACN supports the use of telehealth in nursing practice, but the organization has yet to mandate that telehealth be incorporated into nursing curriculum (AACN, 2020).

As seen with the COVID-19 pandemic, telehealth delivery is practiced in all settings and requires the support of many professions. The nurse has a vital role in much of this delivery. As such, nursing programs must begin to integrate this content into their curricula. The purpose of this article is to provide insight into: 1) the history of telehealth nursing, 2) roles in telehealth available to nurses, and 3) education that is needed to prepare the nurse to participate in and advocate for telehealth.

Introductory Overview

History of Telehealth Nursing
It is believed that telehealth began with the telephone in the late 1800s.It is believed that telehealth began with the telephone in the late 1800s. The story is told that Alexander Graham Bell spilled battery acid on himself; then called a doctor friend to help with care for the injury (Genes, 2017). By the mid-1900s, the National Aeronautics and Space Administration (NASA) had begun utilizing telehealth to assess the astronauts’ biometric data while in space (Schweichert, 2020). In the 1970s, it was accepted that nurses could handle healthcare questions over the phone, thus being considered telehealth users (Mataxen & Webb, 2019).

Over the last decade, the nurse’s role has expanded beyond phone triage. The term “telehealth nursing” has emerged to describe nursing professionals who care for patients from a geographical distance via audio or visual modalities. Some telehealth nurses function as “telepresenters,” working in the same room with patients who are participating in telehealth consultations with healthcare providers who are physically located elsewhere. Nurses also provide nursing care for patients at a distance relying solely on audio and video modalities. Telehealth includes the use of remote patient monitoring to assess patients at a distance. Telehealth nurses work in a variety of settings that include, but are not limited to, large healthcare institutions, Federally Qualified Health Centers (FQHCs), patient homes, and communities (American Telemedicine Association [ATA], 2018).

Telehealth includes the use of remote patient monitoring to assess patients at a distance. With the expansion of telehealth nursing, the ATA developed a Special Interest Nursing Group (SIG). To date, this SIG has an active group of only 57 members who represent entry level nurses to those with doctoral degrees. The ATA has defined telehealth nursing as nursing care and practice that is delivered remotely; they have further identified nursing via telephone or any other type of technology as telenursing (ATA, 2018). The ATA describes the telehealth nurse as not only the person who presents patients to a remote clinician but also as designers, developers, implementers, administrators, educators, and researchers of telehealth services (ATA, 2018).

In 2019, the American Nurses Association (ANA) updated the 1998 ANA Principles on Connected Health. The 2019 update leveraged leaders in telehealth nursing to revise the Principles of Connected Health to reflect the current lens and transformation of healthcare. These 13 principles were designed to guide nursing practice. Principle 5 specifically speaks to nurses developing their own competencies to ensure safe, effective, and competent delivery of care through technology (ANA, 2019).

Uses for Telehealth with the COVID-19 Pandemic
Nurses who had not been previously prepared to deliver care through technologies were thrust into this space.With the emergence of the COVID-19 pandemic, healthcare shifted immediately from brick and mortar care to virtual care. Healthcare clinics and agencies closed, companies transitioned to remote work, and healthcare professionals had to quickly and dramatically shift how they functioned day-to-day. Digital health exploded. Nurses who had not been previously prepared to deliver care through technologies were thrust into this space.

Tablets were taken to the beside to connect patients with providers and family members; hospice and palliative care visits became digital; and remote patient monitoring use increased, moving into the pediatric space for the first time (Hollander & Carr, 2020). Nurses were called to not only deliver this care, but to educate patients about how to use telehealth technologies, such as videoconferencing platforms (e.g., Zoom, Webex™) and remote home monitoring equipment (e.g., communication dashboards, Bluetooth blood pressure machines, scales, and Holter monitors).

As a result of the pandemic, telehealth has become a household word. As a result of the pandemic, telehealth has become a household word. People, both healthcare professionals and the lay community, now have a general understanding of what telehealth is and how it can be provided. Telehealth, primarily videoconferencing, has been used to provide care to patients with COVID-19; connect these patients with family members; enable non-COVID-19 patients to receive care while avoiding exposure from travel to healthcare centers; and protect the healthcare workforce.

New Awareness of Telehealth Challenges
While the telehealth expansion has been met with overwhelming acceptance, it is not without limitations. Problems have occurred due to untrained health professionals implementing telehealth. Many facilities quickly adapted to telehealth by purchasing platforms and equipment without an awareness of what technologies would best fit their practice or patient population. Months after these expensive purchases, many are left with buyer’s remorse.

Unique cultural nuances and telehealth etiquette required for a virtual visit were not considered...Nurses were asked to begin delivering telehealth care without training. Anecdotal reports and interviews demonstrate that this quick deployment resulted in a lack of comfort with technology for both the nurse and the patient. Unique cultural nuances and telehealth etiquette required for a virtual visit were not considered, leaving some patients unhappy with the technology (Olsen, 2020; Sykes, 2020). Many nurses were unprepared to address sensitive issues via telehealth, such as a patient’s discomfort or concern about privacy. Thus, with increasing awareness of these challenges, it is now an appropriate time to step back and rethink best practices for telehealth related to the role of nursing, and nursing education.

Role of Nursing in Telehealth

Some roles have been long-term and others have occurred due to the COVID-19 pandemic. Nurses have assumed many roles within the telehealth arena. Some roles have been long-term and others have occurred due to the COVID-19 pandemic. Very few nurses have been trained for roles in telehealth as a part of their formal education; most have learned on the job and often were taught by vendors. These roles identified by authors from their experience in varying healthcare sites are presented in table 1, include: 1) program development and implementation, 2) direct patient and family contact, and 3) nurse to healthcare professional collaboration. Nurses may participate in several of these roles at the same time. For instance, a nurse might review the data delivered via the remote patient monitoring, then collaborate with the patient’s PCP, and finally have a videoconferencing session with the patient to coordinate care. 

Table 1. Nursing Roles in Telehealth

Telehealth Roles

Description

Potential Practice Setting

1. Program Development and Implementation

Telehealth Manager/ Director

Manages telehealth activities at site

Develops protocols, scheduling templates, consents; assist in technology selection; determine patient populations for telehealth

Manages the telehealth program, provides ongoing management and review outcomes with a goal of refining and expanding the program

  • Hospitals
  • Ambulatory Care Settings
  • Urgent Care Centers
  • FQHCs
  • Government Health Systems
  • Home Health Agencies
  • Jails
  • Behavioral Health Facilities
  • Long-Term Care Facilities
  • Schools

Telehealth Coordinator

Coordinates telehealth operations and delivery

Implements telehealth encounters in conjunction with standards, guidelines, policies, procedures

Orients/educates providers on telehealth program

Identifies/evaluates telehealth patients/candidate

Manages inventory and utilization of equipment

Assures program evaluation

2. Direct Patient/Family Contact

Educator/ Health Coach

Educates patients synchronously and asynchronously

Manages medication

Reviews test results and provide education

Reviews patient uploaded data

Coaches patient on behavioral changes

  • Ambulatory Care Facilities
  • Specialty Clinics
  • FQHCs
  • Government Health Systems
  • Skilled Nursing Facilities
  • Discharge Planning in Hospitals
  • Bedside Nursing

Triage

Consults with patients inquiring on need for emergency department visit

Consults with providers to determine appropriate transfer from facilities

  • Emergency Departments
  • Jails
  • Skilled Nursing Facilities
  • Military Field Settings
  • Behavioral Health Facilities

Discharge Planning/ Follow-up

Manage pre and post discharge of chronically ill patients and/or post-operative patients.

  • Hospitals
  • Insurance Companies
  • Government Health Systems

Telepresenter

Prepares patient for telehealth visit (connection, security, room set up, expectations). Uses telephone, videoconferencing, or other web-based technologies

Enrolls/manages patients, verify provider orders and patient consent, assists patient with participation

  • Ambulatory Care Settings
  • FQHCs
  • Government Health Systems
  • Jails
  • Long-Term Care Facilities
  • Schools

Bedside Nursing/ ICU Nurse

Facilitates rounds with isolated patients

Facilitates family contact with isolated patients

Facilitates virtual visits with specialists from bedside

  • Hospitals

Remote Patient Monitoring

Tracks patient’s condition at a distance

Assesses biometric data sent through wearables and home monitoring devices (i.e., blood glucose)

Conducts virtual visits with patient/informal caregiver

Manages algorithms to predict care

  • Specialty Practices
  • Hospice/Palliative Care Settings
  • Hospitals
  • Home Health Services

3. Nurse to Healthcare Professional Collaboration

Patient Navigator/ Care Coordinator

Connects interprofessional team and patient virtually to navigate care

Arranges visits via telephone, synchronous or asynchronously

  • Specialty settings (e.g., oncology)
  • FQHCs
  • Free clinics and/or small hospitals

Nurse Consultant

Connects a provider at a point of care to a colleague in another location

Arranges virtual consults with nurse exert and bedside nurse

  • Hospitals
  • FQHCs
  • Free clinics/small hospitals
  • Jails

Care Transition Coordination

Coordinates delivery of care within practice setting and across healthcare settings through technology

Coordinates collaboration/connection between providers/settings

  • Insurance Companies
  • Hospitals
  • Home Health Agencies

Case Management

Arranges virtual access for all the activities that would be done in person (e.g., intake, scheduling, documentation, payment)

Collaboration and connection between providers and settings

  • Insurance Companies
  • Hospitals
  • Home Health Agencies

Tele-ICU

Provides clinical knowledge to nurses covering current and expanded critical care units using technology, virtual rounding, and increased collaboration

  • Hospitals
  • FQHCs
  • Critical Access Hospitals
  • ICU to bedside nurses

Telemetry

Manages remote patient telemetry monitoring

  • Hospitals
  • FQHCs
  • Critical Access Hospitals
  • ICU to bedside nurses

Source: Author created table (Chike-Harris, 2020)

Sites Requiring a Telehealth Nurse

As telehealth has expanded, so has the role of the telehealth nurse. Telehealth nursing spans sites such as primary care, acute care, chronic care, follow-up, palliative, and end of life care. Nurses practice the delivery of telehealth for preventive care, health maintenance, and coordination throughout the continuum of care (AAACN, 2018). Below is a synopsis of some practice areas where nurses deliver care through telehealth technologies.

Ambulatory Care
These strategies have included an emphasis on the ambulatory role for nurses...Over the past few decades, there has been a greater emphasis on caring for patients at home or within the community as opposed to the hospital setting. As a result, strategies have been implemented to support care for patients within the community. These strategies have included an emphasis on the ambulatory role for nurses, in addition to the traditional hospital-based care role. The Health and Human Services Administration (HRSA) has provided grant funding to undergraduate nursing education programs to develop more training for the registered nurse in ambulatory care (HRSA, 2018). Nurses now take a more active role in ambulatory settings, such as primary care and specialty offices, schools, jails, FQHCs, and home health. This effort has been increased to keep more patients out of hospital settings; increase their ability to remain in the community; and optimize their health status. As such, the role of telehealth for nurses in the ambulatory setting is increasing with a greater focus on the utilization of technologies.

In response to a growing vision for nurses to become more involved in telehealth, the AAACN developed and published the first set of standards for the practice of telehealth nursing. Since this first writing, 16 standards have been refined through a series of six editions; the most recent update occurred in 2018 (AAACN, 2018). Both the AAACN and the ANA (2019) recognize the professional nurse as the appropriate provider of telehealth nursing services (ANA, 2019).

Primary/Specialty Care Offices. Nurses use telehealth technologies for communication, counseling, coaching, providing education, and overseeing care management for patients in both primary...nurses have assumed a major role in providing telephone triage regarding COVID-19 and specialty care settings. They can track and manage chronic conditions for patients who suffer from illnesses such as heart disease and diabetes using remote patient monitoring. Such approaches by nurses are supported by major healthcare organizations and centers. For instance, the Center for Disease Control and Prevention (CDC) supports nurses addressing treatment for diabetes, tobacco cessation, and epilepsy through telehealth nursing to rural communities (CDC, 2019). With the recent pandemic, nurses have assumed a major role in providing telephone triage regarding COVID-19 (CDC, 2020; Military Health System Communication Office, 2020; TriageLogic, 2020).

Schools. Telehealth technologies complement the care that onsite school nurses can provide. School nurses use technology to connect with community providers not available within the school, such as PCPs, social workers, and speech and language pathologists. Technology includes, but is not limited to, Bluetooth stethoscopes, otoscopes, spirometry, oximetry, and glucometer machines. Technology is leveraged in these settings to broaden the reach of healthcare services to underserved individuals attending school (Love et al., 2019).

Jails. Nurses have been telehealth providers in correctional settings for years. The United States (U.S.) has a large correctional population who have acute and chronic diseases that require Nurses have been telehealth providers in correctional settings for years. diagnoses and management throughout incarceration. In this setting, the correctional telehealth nurse serves as the telepresenter, facilitating comprehensive care through technologies for inmates. Visits are conducted both asynchronously (store and forward) and synchronously (real time) using secure platforms and peripherals (e.g., Bluetooth stethoscope, high definition camera). An example of store and forward is sending x-rays via technology to be reviewed; the x-ray is stored and then forwarded to be reviewed. Nurses also provide teletriage in this setting; this allows more appropriate decision-making regarding necessary transportation (Young & Badowksi, 2017).

Federally Qualified Health Centers. FQHC providers were early adopters of telehealth. Technologies expanded access to quality healthcare services in sparsely populated, high need areas. Since Nurses serve as the telehealth leaders and champions in most FQHCsCOVID-19, 98% of these FQHCs now use telehealth services to reach their patients (National Association of Community Health Centers, 2020). Nurses serve as the telehealth leaders and champions in most FQHCs. The nurse is not only responsible for the delivery of nursing care through telehealth, but also the development of telehealth protocols related to reimbursement, training, and safe patient connections (National Association of Community Health Centers, 2020).

Military/Field Medicine. In 2016, the Military Health System added telehealth as a means to provide healthcare services to the nation’s military members and their families. Primary, specialty, and behavioral services were delivered by telehealth (Wicklund, 2016). The Department of Veterans Affairs developed numerous telehealth programs to provide comprehensive care for the veteran population.

Telehealth has eliminated the difficult time that veterans who live in rural areas have had with access to specialty servicesTelehealth has eliminated the difficult time that veterans who live in rural areas have had with access to specialty services (Barthelemy, 2018). Military nurses have also deployed telehealth during disasters such as Hurricane Maria in Puerto Rico in 2017. Nurses helped to provide synchronous critical care to the victims from various command centers such as the Naval ship, Comfort (Barthelemy, 2018). In 2018, nurses on the Navy hospital ship Mercy transmitted for the first time a telemedicine broadcast to the specialists at the Navy Medical Center in San Diego (Barthelemy, 2018).

Home Health. Nurses have been managing remote patient monitoring (RPM) dashboards for home health agencies and chronic care management clinics for many years. Home health nurses are now reimbursed for virtual visits.They track biometric data that are submitted both synchronously and asynchronously. Based on this data, the nurse utilizes critical assessment and communication skills to provide feedback and education, with the goal of keeping patients in their homes. As a result of the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) expanded telehealth coverage to include face-to-face telehealth visits. Home health nurses are now reimbursed for virtual visits. At the time of this writing, staff training and assessment visits can also be conducted through video visits (CMS, 2020a).

Hospice/Palliative Care. Telehealth is showing great potential and value for patients receiving palliative care. The telepalliative care nurse can monitor patients through RPM, which allows for The nurse can monitor the patient in real time for functional decline. continuous tracking of symptoms and improved care management. The nurse can monitor the patient in real time for functional decline. This supports early intervention to help the patient to return to a level of comfort as soon as possible. Real-time monitoring alerts telepalliative care nurses about impending death; this early notice can better assure their presence during the time of death (Head, Schapmire, Zheng, 2017).

Non-Ambulatory Care
We do not often think of telehealth at the bedside.Hospital. We do not often think of telehealth at the bedside. In fact, over half of all U.S. hospitals now use some form of telehealth (American Hospital Association [AHA], 2019). Nurses facilitate consultation with specialists at the bedside. Bedside nurses use tablets and smart phones to connect patients to family members to improve the patient experience. Telehealth nurses care for patients in intensive care and telemetry units from distant command centers where they can consult with providers and provide management and direction as needed. In the hospital setting, the telehealth nurse coordinates discharge management and care coordination via technologies. As the “hospitals without walls” initiative is expanded, nurses play a key role in deploying telehealth services. In this situation, care is provided virtually from the hospital to outlying critical access areas, pop-up clinics, and homes (CMS, 2020b).

Nursing Homes. Prior to the COVID-19 pandemic, there were very few nursing homes using telehealth. With the significant outbreak of COVID-19 in the nursing home setting, nurses now use telehealth technologies to connect residents with providers and specialists. Research has shown that 70% of the transfers that occur from a nursing home are unnecessary (Lemoyne, 2019). Telehealth consultation has decreased these transfers.

While this type of communication is generally thought of as social, in this situation it is telehealthNurses are key to facilitating these visits. Another important role that nurses have played during the pandemic is establishing the critical connection between residents and their families through technologies such as FaceTime and Zoom. While this type of communication is generally thought of as social, in this situation it is telehealth (Gustin, Kott, & Rutledge, 2019).

Emergency Departments (ED). Telehealth triage nursing has been implemented in the emergency departments of large organizations such as the Mayo Clinic and MedStar The telehealth triage nurse has proven to be cost effective, safe, and appropriate triage modality...Health (AHA, 2018). Nurses responsible for telehealth triage are often the first or second line of access for the patient. The telehealth triage nurse is uniquely prepared with the critical thinking, virtual assessment, and virtual communication skills necessary to determine access prioritization. Telehealth triage nurses facilitate transitions of care ranging from calling 911 for emergent residential issues to connecting patients with social workers. The telehealth triage nurse has proven to be cost-effective, safe, and an appropriate triage modality for populations who seek emergency services. Research has shown that this type of care results in 50% less patients requiring an emergency room visit (Lee et al., 2017). However, to date, the use of telehealth nurse triaging has remained low (IntellaTriage, 2019).

Telehealth Education

The American Telemedicine Association (ATA, 2020) projects that more than half of all healthcare services will be delivered virtually by 2030. Patients have become consumers of telehealth and now expect to continue care through telehealth (Abrams & Kobra, 2018). A recent survey reported that 25% of consumers would switch providers to have access to telehealth (Tatar, 2020). Given the value and trends of telehealth nursing, it is essential that educational settings prepare future nurses for telehealth.

Patients have become consumers of telehealth and now expect to continue care through telehealth To optimize their potential roles, it is imperative that nurses and nursing students understand all phases of telehealth delivery as well as possess skills in telehealth etiquette or webside manner, technology use, and the provision of nursing via telehealth technology. This understanding should be provided through specific telehealth education that can best be imbedded into nursing curricula through didactic encounters, simulation activities, projects, and clinical experiences (Rutledge et al., 2017). Without proper training, many of the nuances that impact the patient/provider satisfaction, effectiveness, efficiency, cost, and security of telehealth delivery are often not addressed (Gustin et al., 2019).

The Four P’s of Telehealth in Education and Practice

The Four P’s of Telehealth serves as an ideal framework to provide appropriate, comprehensive training in telehealth. This framework addresses all facets of telehealth, from the conceptualization of the idea to the evaluation of outcomes. The Four P’s include: 1) planning, 2) preparing, 3) providing, and 4) performance evaluation (Rutledge et al., 2020). The nurse has a vital role to play in each of these areas. For a summary of the Four P’s, see Table 2.

Table 2. The Four P’s of Telehealth Framework to provide Telehealth Education in Nursing

Phases of Telehealth Education: The 4 P’s of Telehealth

Educational Content

Planning

Selecting a telehealth delivery program

  • Telehealth roles for nurses
  • Identification of appropriate patients, settings, and care for telehealth
  • HIPAA, secure telehealth platforms, consent
  • Legal and regulatory issues
  • Benefits and barriers to telehealth
  • Telehealth technology and models of delivery

Preparing

Establishing the telehealth program

  • Protocol development
  • Patient engagement in telehealth
  • Consent process
  • Telehealth delivery requirements/setting
  • Telehealth etiquette
  • Telehealth technology

Providing

Providing nursing care through telehealth

  • Setting the stage for telehealth use
  • Conducting nursing through telehealth
    • Patient Education/Coaching
    • Patient Monitoring
    • Motivational Interviewing
    • Care Coordination/Case Management
    • Triage
  • Wrap up/follow-up for a telehealth encounter

Performance Evaluation

Evaluating the effectiveness of the telehealth program

  • Assessment of telehealth variables (e.g., cost, patient outcomes, impact on patient/provider)
  • Tools for data collection
  • Utilization of data

(Rutledge et al., 2020)

Planning Phase
Nurses are positioned to serve as champions or advocates for telehealth within their organizations regardless of location. To be effective, it is imperative that nurses understand their roles within the telehealth arena, as well as understand requirements that must be met to implement a telehealth program. It is only through this knowledge that nurses will be able to advocate for a telehealth program.

...nurses must understand the benefits of and barriers to telehealth.Much of the educational content required for the planning phase can be provided through didactic lectures (synchronous or asynchronous). First and foremost, nurses must understand the benefits of and barriers to telehealth. This knowledge will allow them to advocate for telehealth implementation and prepare strategies to remove barriers. They must understand when telehealth should be used and when it should not. This includes understanding characteristics of the patient population that allow for successful telehealth encounters versus those that compromise the encounter. Things to consider may include patient ability to use technology, mental capacity, or visual and auditory acuity.

Certain settings limit the use of telehealth. For instance, rural areas are impacted from limited access to broadband high speed internet connections, patients with no technology, or technology without audio or video capability. Telehealth may also have limited use in addressing certain healthcare issues, such as patients with vision or hearing loss.

Didactic programs should be able to address the varying telehealth delivery models that may be available. Potential models include remote patient monitoring; videoconferencing (used for patient education, coaching, case management, consultation); store and forward (patient tests, notes, and records); and mHealth (smart phones and tablets with and without peripherals). Nurses must have knowledge of the telehealth technology that can be used for each approach. They must know which telehealth platforms are considered secure within their settings. For example, all Zoom platforms are not HIPAA secure, and FaceTime is not considered secure in most facilities.

Nurses must be aware of legal and regulatory issues, including security and licensing issues, especially because states vary in rules and regulations. Visits, for example, cannot occur across state lines unless both the nurse and provider are licensed in the state where the patient is located (Dizon, 2018). If the patient and nurse are in different states, the nurse must adhere to the Board of Nursing guidelines for each state. The telehealth nurse must also be trained in the proper delegation of non-RN tasks to unlicensed staff and Licensed Practical Nurses. The need for telehealth consents varies between states. It is the nurse’s responsibility to provide lawful, evidence-based, high quality personalized care grounded in the Code of Ethics for Nurses (ANA, 2019).

Preparing Phase
Once there is agreement on the site plan for telehealth delivery, it is time to prepare for implementation. This includes developing needed protocols; acquiring and setting up equipment; establishing a setting for telehealth delivery; and skills training for relevant staff and providers. A combination of didactic content, simulation, and projects can be used to prepare nurses for this phase of telehealth.

Nursing students may engage in projects that require them to develop protocols. Nursing students may engage in projects that require them to develop protocols. Specific protocols should address topics such as handling emergencies identified through telehealth; addressing technology difficulties; preparing the setting for a telehealth visit; scheduling and consenting patients; and preparing the patient for the visit. Nurses must also prepare for the unique interpersonal skill set, “telehealth etiquette” that is required for the visit. In addition, they must understand how to use the telehealth equipment and how to provide nursing care via telehealth.

There are resources available to help nurses develop appropriate skills. Videos can demonstrate proper and improper telehealth etiquette (Bear in Mind Stratgies, 2020). Simulations may be used to teach and evaluate nursing students’ telehealth etiquette, and their ability to utilize appropriate technology and provide nursing care during an encounter. For example, students may improve their comfort and proficiency level by participating in common simulated clinical encounters with telehealth equipment utilized in the delivery of care. This type of simulation provides practice in using the equipment with patient actors. Didactic content is helpful to address topics such as motivational interviewing, providing patient education, and coaching that is delivered via telehealth for varying learning styles. It is important for students to acquire these skills before they become involved in clinical rotations that utilize telehealth to provide care.

Providing Phase
The providing phase occurs when nurses deliver nursing care in the clinical arena utilizing technology. The different nursing roles that may occur in the providing phase can be found in Table 1. Nursing students should be expected to set the stage, or prepare patients for the use of telehealth. This includes helping patients know what will occur; their specific role in the process; and the expected outcomes.

The providing phase occurs when nurses deliver nursing care in the clinical arena utilizing technology. During the providing phase, nurses should be able to demonstrate educational, coaching, and motivational interviewing techniques appropriate for telehealth encounters. They should be able to deploy, troubleshoot, and educate patients about the use of remote patient monitoring equipment. They need to track, assess, and manage a patient’s health status from the RPM provider’s dashboard. Many of these skills will be evident as nursing students work with mentors and faculty within clinical situations, affording them opportunities to practice and learn.

Finally, once telehealth visits are completed, nurses must be able to finalize the encounter. This process includes documentation, follow-up with the patient/family, consultation with providers, and care coordination.

Performance Evaluation Phase
Nursing students must understand why evaluation is important... During the performance evaluation phase, providers evaluate the telehealth program for its impact on the patient and provider in areas such as access to care, experience, effectiveness, cost, and outcomes. Nursing students must understand why evaluation is important and how to incorporate this into their telehealth encounters. A specific focus on evaluation techniques and tools should be included within the didactic content within the curriculum. Students can demonstrate their understanding of the evaluation process by developing an evaluation plan for a telehealth program of their choosing.

Conclusion

Formalized telehealth nursing education designed to be scaffolded throughout nursing curricula and practice is very limited. At this time, telehealth nursing is viewed as a delivery method of clinical care and is not recognized as a nursing specialty or subspecialty by nursing organizations such as the American Association of Critical-Care Nurses or AAACN (ATA 2019). Although certification is not available at this time, it is imperative that nurses receive telehealth education and training to develop requisite knowledge, skills and attitudes (KSAs) prior to executing telehealth activities (Van Houwelingen et al., 2016) Nurses who deliver care using telehealth technologies should be well grounded in general nursing knowledge, theory, and practice competencies and have clinical experience in addition to basic technology skills (Nagel & Penner, 2016).

...the role of the nurse in telehealth will continue to expand.As the U.S. healthcare environment continues to evolve, the role of the nurse in telehealth will continue to expand. Due to COVID-19, it has become clear that the nursing profession must embrace telehealth as a central focus. Now is the time for nursing education programs to incorporate telehealth competencies and prepare graduates to assume this promising and growing role in quality patient care.

Authors

Carolyn M. Rutledge, PhD, RN, FNP-BC
Email: crutledg@odu.edu

Carolyn Rutledge is Professor and Associate Chair of the School of Nursing at Old Dominion University (ODU). She is the director of the online Doctor of Nursing Practice (DNP) program at ODU, which ranks 15th in the nation. Dr. Rutledge is also a Professor of Family Medicine at Eastern Virginia Medical School where she has maintained an active clinical practice for the past 32 years and served in a faculty role for the medical school, family practice residency, and faculty development. Dr. Rutledge has published over 60 articles and served as an investigator on 32 successful grant applications totaling over $21 million with a primary focus on utilizing new models of care such as telehealth to provide care to rural and underserved populations. Since 2010, Dr. Rutledge has focused on improving the way healthcare is delivered in remote areas using telehealth to enhance patient care and communication. She was the lead in developing the NONPF position paper on educating Nurse Practitioners in telehealth. She is a national consultant in the area of telehealth education and has a book, “Telehealth Essentials for Advanced Practice Nursing”. She currently serves as the Academic Director of the Center for Telehealth Innovation, Education, and Research (C-TIER) at ODU. In 2014, Dr. Rutledge received the SCHEV Outstanding Faculty Award, the highest honor provided to faculty in Virginia.

Tina Gustin, DNP, RN, CNS
Email: Tgustin@odu.edu

Tina Gustin has over 35-years of advanced practice nursing experience. She is an Associate Professor at Old Dominion University (ODU) School of Nursing where she teaches in the Doctor of Nursing Practice Program. She is Director of the school’s Center for Telehealth Innovation, Education, and Research (C-TIER). The center serves as a telehealth learning hub and research center for the state and East Coast Region of the US. She is the clinical manager for the Pediatric Telehealth program at Children’s Hospital of the King’s Daughters in Norfolk Virginia. Dr. Gustin was responsible for the development of this new program and assuring clinical competence of the telehealth providers. She is the PI and Co-PI for several HRSA grants totaling over 6 million dollars to reach rural and underserved populations though telehealth and interprofessional collaboration. Dr. Gustin has extensively published and presented on both interprofessional team-based care and preparing providers for telehealth both nationally and internationally. She served on the ANA task force for technology and was elected to the Center for Telehealth and eHealth Law (CTeL) Advisory Board. She currently chairs the Telehealth Education Taskforce for CTeL. She has assisted several nursing and medical schools in the development of a telehealth curriculum.

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© 2021 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2021


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