Nursing education after COVID will rely more on technology and digital tools than ever. Simulation and online learning will be part and parcel of the curriculum for nursing students. It will also be more competency-based as the new AACNEssentials further integrate into nursing curriculums.
But what about the content of the curriculum?
Nursing education, according to Mary Dolansky, Ph.D., RN, FAAN, Sarah C. Hirsh Professor, Frances Payne Bolton School of Nursing and Director, QSEN Institute at the school, may include instruction on telehealth, an emphasis on systems thinking, stress on leadership, and a focus on innovation and design thinking.
Mary Dolansky, Ph.D., RN, FAAN, is a Sarah C. Hirsh Professor at the Frances Payne Bolton School of Nursing and Director, QSEN Institute at the school
A Look at Nursing Education After COVID
Understanding how to use telehealth in nursing is key, according to Dolansky. The Frances Payne Bolton School of Nursing at Case Western Reserve University, Cleveland, developed a series of four modules on telehealth so that all students received a basic foundation in telehealth nursing, including telehealth presence. It included teaching on using Zoom or the phone to assess and evaluate patients. She notes that interactive products that give students a feel for how such interactions occur and practice them can provide an excellent education.
Another aspect of post-COVID nursing education involves systems thinking, says Dolansky. This involves “really getting students to think beyond one-to-one patient care delivery and about populations. We need to create more curricula for nurses out in primary care sites and nurses out in the community, and that has not been a strong emphasis in schools of nursing. Instead, we focus mainly on acute care.”
More specifically, students should learn, for instance, how to use data registries to look at areas of patient need. One COVID example, notes Dolansky, would be to use registries to identify long-term COVID patients. Another could be to use a registry or database to discover what patients have followed up on their chronic disease since, during COVID, many patients stopped visiting healthcare providers.
In the post-COVID curriculum, developing leadership skills may become more critical. “What we observed in the COVID crisis,” says Dolansky, “was an opportunity for nurses to stand up and speak out more. We were the ones at the frontline and had the potential to be more innovative and responsive. Many great nurses did step up and speak up, but we need to ensure that every nurse can speak up for patients in future crises or even advocate for our patients now. Nurses can be the biggest advocates for patients.”
Every school of nursing probably has a leadership course, Dolansky notes. But ensuring that there are case studies from COVID as to how nurses did stand up and speak out and how that made a difference would be a fundamental curriculum change.
“We want to prepare our students that you will be a leader and you will be on TV talking about how you are innovating and adapting to the changing needs of the health of our population. And COVID was a great example for that.”
Post-COVID, nursing education needs to help students with innovation and design thinking, notes Dolansky. Over the past 10 years with QSEN, “what we’re trying to advocate is shifting the lens of a nurse from direct patient care delivery, which has been the focus of nursing, to shifting a little bit to systems thinking.”
Critical thinking, notes Dolansky, focuses on making decisions for an individual patient. Design thinking and innovation are more about “looking at the system in which we work and empowering the nurses to fix the systems. This is key to quality and safety, but it’s also key to the need for our nurses to contribute strongly to the health of the future population. They have to be at the table to respond to these crises. We need them to have the skill set of being a leader, standing up, being at the table and when they’re at the table, having ideas, being creative, and knowing how to test them. And having the technical skills to use the technology is probably where most of the solutions will be for the future.”
While revising the Essentials began before the pandemic, the experiences and learnings from the pandemic greatly impacted the work, notes a recent article in Academic Medicine. As a result, the Essentials includes population health competencies that specifically address disaster and pandemic response and will better prepare the next generation of nurses to respond safely in future events, the article says.
Now, a crosswalk has developed between QSEN competency statements and the 2021 AACN Essential Statements, notes Dolansky. However, she notes that the AACN is taking the QSEN foundation and moving it forward, stating to the public that “the nursing profession has these competencies that are providing safe quality care to the public.”Since 2012, the QSEN effort has been based on the Frances Payne Bolton School of Nursing.
“Own Their Competency”
In the culture of nursing education, students now need to be educated to “own their competency,” says Dolansky. “Students will see that competency development is part of their lifelong professional development.
Hospitals have dedicated tremendous resources to create an integrated clinical environment that results in better patient care and outcomes, reduces readmissions, and increases hospital utilization, in hopes of reducing the overall cost of health care.
Unfortunately, health IT projects either fall short of business and clinical goals or are completely abandoned at an astonishing rate. Studies vary, but failure-rate estimates range from 35% to 75%.
Overrun budgets and functionality problems are often cited as the primary culprits of doomed implementations. However, the failure to include direct-care clinical staff—including nurses—in the evaluation, implementation, and training of new technology should not be overlooked.
It’s easy to consider a new hardware or software solution and imagine its transformative potential. Health care trade shows brim with thousands of devices, enterprise systems, and software applications marketed as painless solutions for any clinical challenge facing a hospital or care unit. But a poorly implemented system that did not evaluate the impact to the clinical workflow can just as easily exacerbate inefficiencies and reduce the overall quality of patient care.
Equipment that doesn’t work properly or causes needless redundancies in daily tasks is enormously frustrating. The lack of sufficient training and vendor support increases the chances of mistakes or encourages direct-care staff to either work around a new solution or outright revolt at go-live.
A Shared Vision
Many of the doomsday scenarios associated with technology adoption and implementation can be mitigated with adequate planning, training, and collaboration. By listening to, engaging with, and educating front-line staff, hospitals can dramatically increase their chances of success with technology adoption.
For example, consider medical devices with alarm capabilities. Nursing staff are charged with the proper setting of the alarms and the prompt response when any of the devices send an alert. As the presence of alarm equipment continues to grow, nurses find their workflow and ability to engage with patients disrupted as they chase down hundreds of (often non-actionable) alarms. Without proper education and implementation of alarm devices, it’s all too easy to imagine clinical staff arbitrarily adjusting alarm settings—or even turning them off entirely.
Involving direct-care staff is critical to the success of any new technology. How will this new technology impact how nurses deliver patient care? What adjustments in workflow and practice need to be made—at go-live and beyond? Starting with these questions fosters buy-in from the staff who will be utilizing this equipment. If end-users are not involved in the selection, adoption, and implementation of a technology, then the likelihood that they will become owners of that product is significantly lower.
Environmental and Workflow Assessments
Hospitals each have their own unique characteristics, culture, and needs. Identifying and documenting those attributes are critical to any successful health IT implementation. To achieve measurable progress in health IT adoption requires that hospitals identify and support internal champions in all relevant departments.
For hospitals and health systems, especially those that are breaking ground on new technology integration, the first step is an assessment of needs and potential impact to workflow. The formidable task list that comes with any technology implementation requires the input and expertise of a project team, which ideally, should be comprised of leadership from myriad stakeholders, including IT networking, facilities, patient safety experts, educators, informatics nurses, laboratory staff, pharmacists, electrical engineers, biomedical engineers, quality improvement specialists, vendors, and direct-care clinical staff . This team will be responsible for every phase of deployment—evaluation, acquisition, rollout, implementation, and transition to live operations. They will determine the hospital’s objectives and integration goals, as well as vendor evaluations, business and clinical requirements, risk management concerns, patient safety goals, and costs.
The project team will also be charged with identifying the departments or units the integration will first impact. Big bang, enterprise integrations are not unprecedented, but a phased roll out in a single department or set of departments with the highest acuity, such as the surgical suite, allows more time and space for assessments, lessons learned, and best practices, which can be applied as the integration spreads to the rest of the enterprise.
One aspect of integration that is often overlooked is the value of clinical workflow, which can vary among hospitals and individual units. Workflow should not be minimized because it will largely define how data is collected, how it is displayed, and what is displayed. Hospitals should incorporate clinical workflow as quickly and as early as possible in the process.
Designating a nursing champion—or super-user—at the outset allows other nurses and direct-care clinical staff to receive information, training, and support during all phases of adoption. These super-users would be working closely with the interdisciplinary team assembled for the implementation project.
Health IT implementations can be expensive, complex, involve dozens of stakeholders, and are often up against aggressive deadlines. Technology can also be disruptive and bring new uncertainties to the entire organization. However, the quality of the relationship with the vendor supplying the solution can make a huge difference.
Any hospital or health system has business and clinical needs and cultures that make them different from other organizations. A partner with deep knowledge of the unique aspects of your organization not only will help you avoid common mistakes, but also keep you focused on detailed integration points and workflows.
A partner that knows your organization also helps other vendors get acclimated, provides guidance, and ensures everyone stays accountable. A positive and fruitful collaboration allows hospitals to establish benchmarks and ensure that configurations and interoperability are optimized and seamless.
An excellent vendor also acts as a consultant and educator, making hospital staff comfortable with new technology and uncovering strategies for optimizing workflow. The importance of evaluating the vendor as much as the product they are delivering cannot be stressed enough. Vendors that lack expertise, training capabilities and clear steps toward go-live and beyond are critical red flags.
Can the vendor explain their process? Can they share metrics? Do they offer continued training and support after the implementation is complete? Answers to these questions will give your project team keen insights into the potential challenges of a technology implementation.
If your vendor supplies references, ask their customers specifically about their specific challenges and the vendor resolved them. Setbacks are a natural part of any implementation, but the true difference maker is determining the level of support and collaboration provided to overcome it.
A team approach to health IT doesn’t guarantee that technology adoption and implementation will be a success—but it will significantly increase its chances of sustainability. Today’s nurses have neither the desire nor the option to be passive consumers of health care technology. The seamless integration of technology requires that direct-care clinical staff have influence in the design and testing of equipment and applications. Involving end-users in the early stages of system analysis and design specifications can lead to better adoption of new technology, as well as identifying how current technology can be adapted for greater user acceptance.
Recent studies by the American Hospital Association on the use of telehealth nursing services have shown that 76% of patients prioritize access to care over the need for human interactions with their health care providers and 70% of patients are comfortable communicating with their health care providers via text, e-mail, or video, in lieu of seeing them in person. This trend toward remote and immediate access is becoming more prevalent in the industry and telehealth nursing positions are becoming more well-known and necessary in the care continuum.
Telehealth nursing assists the health care industry in many ways. According to the American Telemedicine Association, it contributes to reducing health care costs by decreasing hospital admissions and emergency department visits, assisting with managing chronic illnesses, and impacting the nursing shortage by improving nurse utilization.
Telehealth nursing is unique in that it can be practiced almost anywhere from clinics to offices, hospitals to call centers, and even nurses’ homes. It is vital in enabling health care providers to connect with patients across vast distances. These nurses aim to deliver and continuously improve patient access and adherence programs to ensure patients receive the best possible care at every stage of their therapeutic journey.
Below are a few additional facts that you may not have known about telehealth nursing:
RNs have meaningful contact with patients because they do not have other patients to be seen or distractions from others coming in room, etc.; 1:1 uninterrupted time with patients.
They get to build relationships with patients over the course of the entire disease process.
Expertise extends deeper in the field because telehealth nurses have the opportunity to interact with other components beyond the patient including the provider, pharmacy, payer, and others.
Telehealth nurses have the opportunity to learn about rare diseases and state-of-the art therapies in medicine.
Even though the location is not within a hospital, telehealth nurses are still supporting and educating patients in a very designed and specific approach with very clear outcomes.
Telehealth nurses get input and exposure to the business side and operations, growing their acumen in other areas.
Being in telehealth expands one’s expertise because they work with a broader audience of patients and are forced to learn how to communicate with patients over the phone vs. side-by-side or in-person.
Various health systems are adopting telehealth practices because it provides convenient access for patients and focuses on increasing access and patient satisfaction. Telehealth nursing offers the potential to improve efficiency and convenience in our health care system as new delivery and payment models evolve.
I have been telehealth nursing for over six years and I truly believe nurses have an impact on patients and their caregivers. When a patient is first diagnosed with a chronic illness or terminal disease, sometimes our team is their first call. Our team works with purpose by listening to patients and educating them about what to expect throughout their therapeutic journey and providing counsel on properly taking medicine. As a Senior Nurse Manager at Lash Group, a part of AmerisourceBergen, I support the managers and nurses through compassionate communication, empowerment, and working together to ensure patient adherence.
Working in telehealth is exciting because each call is different and you never know what type of situation, question, or comment you will be presented. The utilization of your listening, critical thinking, and assessment skills are critical when it comes to supporting the patient. As a telehealth nurse, your eyes become your ears and you are an expert at identifying even the subtle changes in a patient’s voice. Building rapport is also key. Once trust is established, the patient and the nurse are able to work through barriers together, whether it’s navigating through benefits, obtaining education, or supporting the patient through medication adherence.
Telehealth nurses have a positive impact on the lives of patients every day. For example, one time a patient called in to our program and was adamant about speaking to a manager. She stated she was newly diagnosed, had a lot of questions, and described that if it was not for her nurse, she would have never started on her medication. The nurse thoroughly explained the benefits, answered her questions, and walked her through the prescribing information. She was extremely thankful for the support that she received.
According to sources at the American Telemedicine Association, industry experts estimate that 50% of health care services will be provided by telehealth within the next five years, and the need for these nurses and health care professionals is going to continue to rise. Providing support and guidance to patients is the main role of nurses and telehealth has shown it can improve patients’ access to care and as a result, contribute to successful health care outcomes.
In recent years much research has been done outlining the health care disparities that exist between minority populations and the Caucasian majority. Now it’s time to do something about those inequalities by testing solutions and putting interventions in place.
This is the thinking behind a nationwide program funded by the federal Agency for Healthcare Research and Quality (AHRQ). The agency has awarded five-year grants to nine Excellence Centers To Eliminate Ethnic/Racial Disparities (EXCEED):
• Morehouse School of Medicine (Atlanta)
• University of Pittsburgh
• Mount Sinai School of Medicine (New York, N.Y.)
• University of North Carolina (Chapel Hill)
• University of California, San Francisco
• Baylor College of Medicine (Houston)
• University of California, Los Angeles
• Medical University of South Carolina (Charleston)
• University of Colorado Health Sciences Center (Denver)
“A lot of the research on disparities had been effective in identifying [problem areas] but less effective and less advanced in understanding why they existed and what could be done about them,” says Daniel Stryer, MD, who was AHRQ’s senior medical officer when the EXCEED program was launched some four years ago. “EXCEED was designed to take research on disparities to the next level, to build on the work that had been done, documenting a lot of disparities, trying to understand why they exist and what can be done [to eliminate] them.”
Each center is working on between four and nine projects, according to Stryer, now the director of AHRQ’s Center for Quality Improvement and Patient Safety. “The centers were also set up to develop greater capacity to study minority health issues,” he adds, “and to train minority researchers as well as others who are interested in racial and ethnic disparities.”
AHRQ is supporting the projects in partnership with several other Department of Health and Human Services agencies, including the National Center on Minority Health and Health Disparities. Stryer says AHRQ hopes the lessons learned through EXCEED’s research, including practical tools and strategies to eliminate disparities, will be generalized beyond the communities studied so they can be used nationwide.
EXCEED aims to foster efforts to augment the research skills and abilities of ethnically diverse researchers and institutions. Building relationships with communities and local organizations and working with community health centers and other health care groups serving ethnically diverse populations is also part of the EXCEED strategy.
Multidisciplinary teams are doing the research, with nurses playing major roles. “Nurses can often overcome cultural barriers and help reduce those barriers,” Stryer says.
At Morehouse School of Medicine, a historically black institution, EXCEED’s theme is “Access and Quality of Care for Vulnerable Black Populations.” The research seeks to identify and examine effective interventions for chronically ill African-American adults and low-income children who receive care from community providers in inner city and rural areas.
The principal investigator, Robert M. Mayberry, MPH, PhD, a professor and director of the Program for Healthcare Effectiveness Research at the school’s Clinical Research Center (CRC), has nurses working in key EXCEED roles. Nurses of color, he says, add a level of sensitivity, understanding and deep insight, which comes from having a similar cultural perspective to that of the project participants.
“Typically persons from the same cultural, historical and social environment relate, can translate, can understand and can be more supportive than someone who is coming from outside of that environment,” explains Mayberry, who is African American. “That becomes the key reason why the minority nurse becomes so critical in these types of interventions.”
Patricia Jackson, RN, an African-American clinical research nurse at the CRC, works on the “Telehealth Heart Failure Project to Improve Access and Adherence” study. This EXCEED project delivers intensive education and risk factor modification via a computer-based telemonitoring system. The project focuses on high-risk patients with a primary diagnosis of congestive heart failure. They have been randomized into two groups–an intervention group and a “usual care” group.
So far 106 patients have been enrolled for a three-month monitoring period. Mayberry hopes to increase enrollment to 240. Every patient in the study has an in-person quality of life assessment done one-on-one with Jackson at baseline or enrollment in the study, and then at 30 days, 90 days, six months and a year via telephone.
“Usual care” patients continue to go to their physicians and follow their care plans. If problems arise they can beep Jackson 24 hours a day. She also verifies hospitalization and clinic visits by reviewing hospital discharge or other health services records.
The intervention group patients receive telemonitoring equipment, which includes a setup for a stethoscope and a scale. On her initial visits, Jackson teaches patients how to use the equipment. “It is a like a little computer in their home with a camcorder on top, where I can see them and they can see me,” she says. “I can take their vital signs, blood pressure and weight. I listen to their heart sounds and their lung sounds.”
The protocol seeks to reduce emergency room, clinic or hospital visits, Jackson explains. “With this we are able to detect and correct clinical deterioration and complications quicker, so their hospitalizations and ER visits are kept to a minimum.”
Her job requires travel to patients’ homes, hospitals and clinics. Oftentimes, she says, elderly people in the rural areas don’t get appropriate care. Some may live 45 minutes to an hour from the hospital or in small country towns that don’t have health care facilities. “By doing this you are teaching them to be more compliant and to take care of themselves,” Jackson says.
Filling Unmet Needs
Another EXCEED project at Morehouse where an African-American nurse is playing a key role is “Translating Prevention Research into Primary Practice.” This demonstration project aims to improve and increase the delivery of preventive care services within the medical school’s physician practice plan, Morehouse Medical Associates, Inc. (MMA).
The project includes a randomized controlled trial comparing two ways of delivering preventive services to predominately African-American, low-income, inner city patients from Atlanta served by MMA. There are 240 patients in the study, split into a nurse-mediated group and a traditional physician reminder group.
Adult outpatients, 18 years of age and older, are eligible for the study and are recruited during regular office visits. The participants are seeing physicians for a range of conditions, from urinary tract infections to hypertension and diabetes. Linda Franklin-Sanders, RN, BSN, a research nurse at MMA, works with every project patient. At enrollment she takes a preventive history based on recommendations of the US Preventive Services Task Force, which enables her to identify unmet preventive care needs.
For the physician reminder group, Franklin-Sanders places reminder information in patients’ medical records for physician review. “[After the initial assessment] I talk with the physician and inform him or her of any other things that may have come up in my interview that the physician would need to know,” she says.
For the people in the nurse-mediated group, Franklin-Sanders initiates procedures for taking care of unmet needs, including making appointments for services ranging from mammograms and colon cancer screening to flu shots. “The patients are very receptive,” she reports. “They are open to your suggestions and they will call you if they need something. They like the nurse-mediated role and they seem to think it is something that should stay. Even though we have nurses here in the clinic, to have personal one-on-one [care is appreciated]. Everyone likes to be shown a little extra attention.”
Each time a study participant returns for care, Franklin-Sanders updates the patient’s preventive needs and repeats the process of either providing the services directly or placing a physician reminder in the patient’s record. The medical records of all subjects are reviewed–at baseline, one year and two years–to identify how frequently preventive services are documented and to record demographic information and diagnoses.
It is challenging to work with patients with serious illnesses, says Franklin-Sanders. “They really need education and counseling to get them to see what it is they need to do [to manage] their condition and stay healthy. But [when you succeed, it is] very rewarding,” she adds.
At Mount Sinai School of Medicine in New York, the EXCEED theme is “Improving the Delivery of Effective Care to Minorities.” Projects assess the reasons for minority patients’ underuse of effective interventions for managing premature birth, breast cancer, stroke and hypertension. The study also evaluates ways to eliminate underuse.
AHRQ Offers Resources for Nurses The Agency for Healthcare Research and Quality (AHRQ)–originally known as the Agency for Health Care Policy and Research (AHCPR) when it was created in December 1989–is a Public Health Service agency in the Department of Health and Human Services (HHS). Reporting to the HHS Secretary, the agency was re-authorized as AHRQ in December 1999. Its sister agencies include the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Centers for Medicare & Medicaid Services (CMS) and the Health Resources and Services Administration (HRSA). With a $269.9 million budget–nearly 80% of which is awarded as grants and contracts to researchers at universities and other research institutions across the country–AHRQ provides evidence-based information on health care outcomes and health care quality, as well as cost, use and access. The agency has a Nursing Research arm that grants awards to nurses involved in heading up research projects. It also sponsors workshops and conferences. To learn more about AHRQ, visit www.ahrq.gov/ or contact the agency at 540 Gaither Road, Rockville, MD 20850, (301) 427-1364, [email protected].
The EXCEED researchers work in conjunction with Mount Sinai’s Center of Excellence in Partnerships for Community Outreach, Research on Health Disparities, and Training (EXPORT), which is funded by the National Center on Minority Health and Health Disparities. “There are known ethnic and racial disparities in health and in health care, and there are also known medical interventions that we know have been proven effective,” says Nina Bickell, MD, MPH, co-director of EXPORT.
Past research has shown there is a greater underuse of health care services in minority communities. “Our goal is to actually figure out what the causes of the under-use are and target specific strategies to those causes to reduce them,” Bickell explains. “[We hope to] reduce the disparity in underuse and thereby reduce subsequent poor health consequences of not getting treatment that has been proven effective. That is actually something we can work to effect a change in.”
Wanda Garcia, RN, BSN, is the nurse in Mount Sinai’s study “Improving Hypertension Control in East and Central Harlem.” East Harlem, often known as Spanish Harlem, has historically had a predominately Puerto Rican population, although there has been a recent large influx of Mexicans and Central Americans; Central Harlem has historically been an African-American community. Garcia works with six area health providers.
The study–a randomized controlled trial–is targeting problems that cause hypertensive patients to have poor control of their blood pressure. The research seeks to identify specific patient, provider and system problems, and then develop customized interventions to address them.
There are three participant groups in the study: usual care, blood pressure self-monitoring and nurse management. Patients who get usual care receive treatment from their regular clinicians. The research team provides blood pressure monitors to patients in the self-monitoring group.
Patients under Garcia’s care receive a blood pressure monitor and meet with her over the course of nine months. She makes initial home visits and teaches patient how to use the monitor. For the first two weeks of the study, patients in her group check in with her four times daily.
Garcia is directly involved in intervention. “I need to determine what I must do to get their blood pressure under control,” she says. “So, for example, if I see a patient for the first time and the blood pressure is not under control, I need to find out why. Is it non-compliance? Is it insurance issues or medication that needs to be titrated? Depending on the problem, then I have to intervene. Sometimes I have to contact the doctor.” If there are financial issues, Garcia helps connect the patient with a social worker or assistance program.
Over the nine months, Garcia has scheduled patient call dates. “In every follow-up phone call,” she says, “I discuss diet and exercise and lifestyle changes we are hoping they can institute to [make them] feel like they are more in control of the disease–as opposed to the disease being in control of them.”
Eventually the study will assess differences in blood pressure changes among the three study arms. It will also outline differences in quality of life, patient satisfaction, costs and cost-effectiveness.
As a bilingual Hispanic nurse, Garcia can easily communicate with patients who do not speak English. “Also, I know the culture because I am part of the culture,” she adds. “They feel they can relate to me. They can be more open and more willing to disclose the issues they are going through. In that way, I am better able to help them.”
Often Garcia has to factor in socioeconomic and lifestyle issues, such as poverty, smoking, drug abuse, alcohol and diet. “You go into the neighborhood and you are going to find all the fast food chains,” she notes. “All their lives they have been eating this type of food that they can financially afford. These things are all part of their lives. They have had a very rough life socially and financially.”
At the Medical University of South Carolina, “Understanding and Eliminating Health Disparities in Blacks” is the EXCEED theme. The research is examining strategies to address inequalities in health status between African Americans and whites, including those in rural areas, with specific clinical conditions that include HIV disease, cardiovascular disease and cancer.
Winnie Hennessy, RN, MSN, PhD(c), is a nurse specialist for palliative and supportive care working on “An Exploration of Racial Differences in End-of-Life Care Preferences Among Cancer and Congestive Heart Failure Patients.” One part of the study–the Team Planning and Care Education project–focuses on improving communication between patient and clinician and on respecting patients’ preferences in care planning. The project also explores and describes racial differences in needs, preferences and impact of the intervention.
“In the world of advanced illness, cultural perspective drives how family and patients will incorporate illness into their lives and how they will incorporate treatment,” Hennessy says. “These treatments need to fit what their vision is of health, getting well, sickness and how to overcome it–or in this case, where sickness cannot be overcome, [how to deal with that]. And if we don’t understand that or at least be sensitive to it, we as health care providers will not be able to help these people manage their illness, their dying and ultimately their death.”
In an ambulatory care, hospital-based oncology clinic, researchers are testing two interventions: a structured clinical needs assessment (CNA) form versus nurse counselor follow-up via telephone.
The CNA helps legitimize the discussion of psychosocial issues related to end-of-life care, Hennessy explains. It is a self-administered paper form, facilitated by the clinic nurse prior to the physician visit. This will then cue the physician to patient concerns. The nurse counseling calls allow time for problem solving, planning and referrals. Researchers are also in the early stages of developing a project to help cardiologists and physicians with their awareness of palliative care in congestive heart failure patients.
Overall, the nature of EXCEED projects shows the critical role nurses can play in improving the quality of care for patients in general, and the impact nurses of color can have on improving the quality of care for minority patients, says Robert Mayberry from Morehouse School of Medicine
“It is realization that is empirically based,” he emphasizes. “I think it is the wave of the future. As our health care delivery system continues to evolve, I think we will see more acts of participation [by] the nurse professional in these types of research activities and as part of the total quality improvement team.”
What do astronauts on the International Space Station have in common with Alaska Natives on Little Diomede Island, just 2.5 miles from Russia in the Bering Strait? Not much, other than they both receive health care services via telehealth technology (also known as telemedicine).
Just as it’s impractical to send doctors and nurses out into the solar system every time an astronaut is ailing, so is the idea of patients who live on this remote, isolated island traveling many miles by air, sea or snow to see health care providers for every earache or other medical complaint. But that’s what most Diomede villagers had to do in order to receive full-scope medical care before the advent of telehealth programs.
Telemedicine, according to the Telemedicine Research Center, is the transfer of electronic medical data from one location to another. Today, a growing number of nurses and nurse practitioners are tapping into developing technology–such as computer monitoring and satellite transmission–to provide long-distance nursing to medically underserved minority populations whose geographical isolation restricts their access to medical treatment and preventive care.
Telehealth got its start as a byproduct of the Space Age. The National Aeronautics and Space Administration (NASA) needed to monitor astronauts’ physical and physiological parameters during flight. It created sensors that sent data back to Earth through microwave signals. At flight headquarters, doctors were able to track the astronauts’ pulse rates, blood pressure and other critical indicators.
Eventually, NASA recognized the potential to apply this same approach to help residents of rural communities where health care access was extremely limited. Its first endeavor was the Space Technology Applied to Rural Papago Advanced Health Care project (STARPAHC), which focused on bringing medical care to the Papago Indian Reservation in Arizona. The project, which lasted from 1972 to 1975, revealed the huge promise of this nontraditional health services delivery system.
However, STARPAHC still relied on the expensive microwave technology, which made widespread application cost-prohibitive. For the next 20 years, proponents of telemedicine pushed to advance the technology into more practical and affordable solutions. Meanwhile, the computer and telecommunications industries were also undergoing significant advancements. These innovations helped refocus attention on the possibilities of telehealth, and by 1990 four programs were underway.
Technology Catches Up
Even though the technology had made great strides, telehealth programs in the 1990s were still bound by technical limitations. Often, patients’ cases were conducted through telephone conferences and choppy videoconferencing. For example, if nurses on cruise ships needed to confer with a specialist, they made ship-to-shore calls to get step-by-step consultations.
But today, in the 21st century, improved technology is finally allowing this revolutionary concept to catch up to its full potential. The Internet, DSL, broadband and satellite transmissions have elevated telehealth to a competitive level.
“Five years ago, nurses had to be in sync with [other health care providers] on the telephone. We didn’t have the computer technology that allowed telehealth to happen in a secured fashion,” says Debbie Carr, RN, a telehealth coordinator for the Alaska Federal Health Care Access Network (AFHCAN) in Anchorage.
“Huge technical advances are driving the growth of telehealth,” agrees Gerri Lamb, PhD, RN, FAAN, associate professor and associate dean of clinical and community services at the University of Arizona School of Nursing in Tucson, and associate director of nursing for the Arizona Telemedicine Program (ATP).
“We’re doing things now that weren’t possible five years ago. We can do so much more than we even imagined.”
Indeed, tiny cameras now allow nurses to take images of a patient’s eardrum and load them onto a server from which a physician hundreds or thousands of miles away pulls them up on a computer for evaluation and instructions. Other recent developments in telehealth services include computer monitoring of blood pressures, pulses, blood sugar levels, and even long-distance wound care. The field is constantly being redefined as the equipment’s capabilities evolve.
“There are forms with pop-up templates that cue nurses for information they need to provide for an assessment,” says Penny Vasileff, RN, another telehealth coordinator for AFHCAN. “It’s new technology, but nurses already do a lot with technology.”
Although the technology is impressive, the biggest impact of telehealth is its ability to help reduce minority health disparities by increasing medically underserved populations’ access to health care services. According to the Telehealth Improvement Act of 2004, 36 million people in the United States lack direct access to physicians. Alaskan Native villages are excellent examples. These small communities can’t support a full-scale hospital on their own, so community health aides (CHAs) often provide the basic treatments. For more serious conditions, patients must travel to a larger facility, but 75% of Alaska Native communities aren’t connected to a hospital by roads.
“It’s expensive to come to Anchorage, particularly if you have to accompany children or elderly patients,” says Vasileff. “It can cost thousands of dollars just to come in for an earache. The alternative used to be no care. Telehealth makes it possible to get quality care to remote villages.”
AFHCAN, which is managed by the Alaska Native Tribal Health Consortium, has developed a statewide telehealth program–utilizing sophisticated hardware and software, 42 connected servers and a satellite-based IP network–to give CHAs and regional hospitals greater access to specialists. Since 1998, the program has been implemented in 248 sites throughout Alaska.
“There was such limited access before telehealth, with 12- to 15-month backlogs to see doctors in Anchorage,” explains Stewart Ferguson, PhD, director of AFHCAN. “Now, patients stay in their villages but can be seen by specialists. There’s been a 10 to 12 percent increase in patient volume because of telehealth. Doctors have reduced backlogs so much that there are now open spots at specialty clinics.”
Such successes are not restricted to Alaska. Similar programs are popping up around the country. In underserved communities ranging from Indian reservations and inner-city neighborhoods to rural prisons, telehealth enables nurses to extend their practice and eliminate barriers that have traditionally limited these vulnerable populations’ access to quality health care services.
“A characteristic of a lot of minority communities is that the patient population is low-income, which can prohibit access,” says Carr. “In urban areas, patients may have trouble getting to providers–maybe they have to take a bus and travel a long time. But with telehealth, the case is created in the patients’ locations and then sent to remote providers, who issue orders to either stay home or come in for extended care.”
Another population benefiting from telehealth nursing is the incarcerated. Not all prisons are located near hospitals, nor do they have full medical staff. Through technology, prison nurses can treat patients more effectively without having to transport them outside the guarded walls. The Arizona Telemedicine Program estimates it has saved more than $1 million in transportation costs because more than 80% of specialty medical consultations are conducted by off-site specialists.
An Extra Set of Eyes
In most of these environments, nurses create telehealth cases by inputting patients’ vital signs and other assessment observations into the computer. Then an off-site physician or specialist obtains the data from a server for evaluation. But health care providers aren’t the only ones who are sitting down at computers to help bridge distance gaps. In some cases, patients themselves are actively involved in the telehealth process.
For more than a decade, home health care has experienced consistent growth as more people are discharged from inpatient care still requiring nursing attention. Initially, nurses were assigned a group of patients for whom they had to make routine home visits. Logistics placed limitations on how many of these patients they could see per day, as well as how much time they could devote to each patient. With telehealth technology, many of those limitations are erased.
Once patients are set up with the telehealth monitoring equipment in their homes, they input readings on a regular basis. The data are stored until nurses remotely pull up the information. Clinicians can see a more complete picture of patients’ vital signs for extended periods, enabling them to make better assessments and treatment decisions. Another benefit is that home health nurses can oversee more patients per day in addition to making traditional on-site visits.
Anecdotal research also suggests that telehealth helps increase patient compliance. The electronic charting is a visible demonstration of how treatment is progressing. “Telehealth has been tremendously useful for patient education,” notes Lamb.
Even though health care providers and patients in many parts of the country are embracing telehealth, there are still a few obstacles preventing it from being fully put into practice on a national basis. A statement released by the Commerce Department in April reported that while approximately $380 million will be spent on telehealth this year, “that is a fraction of the estimated $80 billion that will be spent on all health care technology.” The report went on to quote Under Secretary of Commerce Phillip J. Bond as saying, “There is a lag in the application of [telehealth] technology in the real world.”
For More Information American Telemedicine Association
(includes a Telenursing Special Interest Group)
www.atmeda.org Telemedicine Research Center
http://telehealth.hrsa.gov Office for the Advancement of Telehealth
http://telehealth.hrsa.gov Association of Telehealth Service Providers
www.atsp.org Center for Telemedicine Law
Until recently, telehealth projects were beta-type programs usually tied to universities. When the grants ran out, the programs struggled to secure new funding. Many telehealth programs are just now trying to transition from research applications to full-scale businesses. “Telehealth is in its infancy in terms of market potential,” says AFHCAN’s Ferguson. “But there are private companies doing project development, so it’s definitely a growing industry.”
Telehealth proponents say the next step is getting insurers on board, including Medicare and Medicaid. Currently, reimbursement coverage for telehealth services is uneven. The 1997 Telemedicine Report to Congress notes that Arkansas, California, Georgia, Montana, New Mexico, North Dakota, South Dakota, Utah, Virginia and West Virginia reimburse some telemedicine services through Medicaid. According to The Washington Times,Louisiana and Texas recently passed laws prohibiting insurers from discriminating between traditional and telehealth services.
What’s preventing full-scale reimbursement is determining who should be covered. Telehealth has two distinct participants: The nurse on-site inputting patient information and the physician off-site assessing the information, making a diagnosis and creating a care plan the nurse or CHA will carry out. Insurers haven’t decided how to divvy up the reimbursement payments.
Congress got involved this year by introducing the Telehealth Improvement Act of 2004 (S. 2325) on April 21. This bill, proposed by Democratic Vice Presidential candidate Sen. John Edwards, defines the need for expanded telehealth provisions and calls for further coverage under Medicare, including reimbursement for services provided in skilled nursing and assisted-living facilities and in county or community health clinics. The legislation is currently in committee.
Supporters assert that telehealth programs will save costs in the long run by addressing medical conditions earlier, when they are more easily treatable. “I think acceptance [by insurers] and reimbursement will grow, but there needs to be research that demonstrates the cost savings,” suggests Lamb.
Initial research seems to support telehealth’s cost-effectiveness. When telemonitoring was used to track patients with chronic heart failure (CHF), researchers documented substantial savings. They estimated a potential $4.2 billion, or 52.5%, savings per year per CHF patient from reduced hospital stays and annual labor costs and benefits budgeted at two nurses per patient.
Licensure of telehealth nurses is another issue demanding attention, because there are questions as to what regulatory body retains disciplinary rights. In the acute care setting, nurses adhere to the parameters set forth by their state’s Nurse Practice Act, which is overseen by the state Board of Nursing. But in cyberspace, there aren’t distinctions noting where one state’s boundaries end and another’s begin.
According to the Center for Telemedicine Law, nearly half of the state medical boards in the U.S. currently permit out-of-state doctors to practice or consult via telemedicine technology in those states’ jurisdictions, as long as the physicians have a current license in their home state. A separate program allows RNs to earn licensing credentials to provide health care online in any of 17 states.
Some analysts recommend that states adopt a telehealth licensing system that would be similar to policies currently in place at the Department of Veterans Affairs and the Indian Health Service. These federal agencies allow RNs with a valid nursing license issued anywhere in the U.S. to come work in their facilities. For example, a licensed RN from Arizona who gets a job with a VA hospital in Maryland doesn’t need to apply for a Maryland license; his or her Arizona credential is sufficient. Proponents of this type of regulatory system say the streamlined approach would remove obstacles that are preventing the expansion of telehealth services.
Is Telenursing in Your Future?
Telehealth is an arena whose potential has yet to be fully explored, and that includes the contributions nurses can make to the field. “Involving nurses is one of the most powerful things telehealth is doing right now,” comments Ferguson. “You need to be able to communicate in order to spread health care to remote and underserved areas, and that’s where minority [telehealth] nurses would be important.”
The importance of culturally competent care is not downplayed in telehealth. In fact, some practitioners say it becomes even more critical. Some minority health consumers are distrustful of the majority health care system, so when technology and the digital divide are added into the picture, it can create even more barriers. Minority nurses can play a crucial role in explaining how telehealth technology works in culturally and linguistically appropriate terms.
What does it take to become a telehealth nurse? From the clinical point of view, telenursing utilizes the same skills and competencies as traditional bedside nursing. The biggest difference? More time on the computer. “Nurses still need strong assessment skills to evaluate clinical situations,” Lamb explains. “It’s just that technology adds another piece.”
“You have to have previous clinical experience,” adds Carr, “and it helps to have a background in computers, servers and routers. Liking technology and not being afraid of it is important.”
Telehealth nurses also have opportunities to move into administrative roles. For example, they can become telehealth coordinators, who oversee other practitioners, lead training sessions, maintain medical data and schedules, and keep communication flowing between remote sites and participating physicians. As telemedicine technology continues to evolve and become accepted as an important tool for leveling the health care playing field, “there are huge opportunities for nurses to get involved at all levels,” says Lamb.