The experiences of New Zealand nurses using teleconsultationJANE WRIGHT, RGON, MNURS, MICHELLE HONEY, RN, PHD, FCNA(NZ),

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.

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).

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)

Participant Clinical Title Years as a registered nurse

Time in specialty area (years)

Time using Teleconsultation (yrs)

Participant 1Clinical Nurse Manager 25 16 2.5

Participant 2Clinical Nurse Manager 31 15 3

Participant 3Staff Nurse 14 4 months 4 months

Participant 4Clinical Nurse Specialist 12 8 3

Participant 5Clinical Nurse Manager 22 15 8

Participant 6Clinical Nurse Specialist 15 8 3

Participant 7Clinical Nurse Specialist 30 4 2

Participant 8Clinical Nurse Specialist 19 3 3

Participant 9Nurse Manager 27 15 3

Participant Demographics

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.

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

Connectivity/RelationshipsCommunication

“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)

Connectivity/RelationshipsRapport 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)

Connectivity/RelationshipsCollaborative 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)

Connectivity/relationshipsEmpowerment

“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)

Connectivity/RelationshipsThe 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)

Connectivity/RelationshipsEtiquette

“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)

Sooner, better, more convenientAccessibility 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)

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)

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)

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)

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)

:

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)

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)

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)

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)

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)

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

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

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

Acknowledgements Participants

School of Medicine & Health Sciences, Auckland University

Canterbury District Health Board

Health Workforce NZ

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