CHANG, CHI-PING MS, RN; LEE, TING-TING PhD, RN; CHOU, CHUN-CHEN MS, RN; MILLS, MARY ETTA ScD, RN
Diabetes is a disease characterized by insufficient insulin secretion. Based on changes in recent decades, prevalence is expected to double by 2025.1,2 Because of multiple complications associated with diabetes, diabetic patients’ age-adjusted mortality rate is twice that of those not afflicted.3 As a result, inpatient diabetes care and long-term care after discharge are significant financial burdens on the healthcare system.4,5
Diabetes care requires close long-term physiological monitoring to assist in the regulation of medication, diet, and exercise. By reducing the risks of complications and mortality, healthcare providers can improve patients’ quality of life.6 Nurses’ primary objective in caring for diabetic patients is to continually monitor their blood glucose levels and support them in long-term self-management.7,8 However, most health insurance policies limit patients’ hospital stays. As a result, the opportunity for providing appropriate and sufficient health education is severely curtailed. In addition, after patients are discharged, their blood glucose levels can be monitored only through regular monthly outpatient visits or through nurses’ home visits every 2 to 3 months. Consequently, a significant challenge remains to achieve the goal of monitoring patients’ daily blood glucose and diet while also providing integrated care and assistance in self-management.9,10
With the rapid advancement of information and communication technology (ICT), telecare has emerged as a means to incorporate ICT and long-term care practices that allow patients to receive health education and healthcare services at any time and without geographic restrictions. Telecare facilitates home care environments and allows patients to enjoy the same quality of care services as provided in hospitals.11 Appropriate use of telecare enables nurses to quickly obtain the overall health and lifestyle information of remotely located patients and provide timely care and treatment. Telecare allows nurses to have greater control in disease management and can improve job competency. Addressing imminent problems resulting from insufficient healthcare resources, telecare may prove to be a promising and cost-effective solution.9
Previous studies have shown that incorporating telecare into the care system improved the following: timeliness of disease management, accessibility to healthcare services, patients’ compliance with treatment plans, and a decrease in mortality.12,13 A 12-month study also showed that telecare reduced the frequency of rehospitalization and healthcare expenditures.14,15 These findings strongly suggest that telecare is an effective method for providing continuous, long-term diabetes care. To successfully implement ICT and improve nurse-patient interactions, the development of new information technology (IT) skills and remote communication skills is imperative.16
The effectiveness of technology use may be affected by several factors, including nurses’ demographics such as age or education17; the software and hardware in work environments, policy and regulations, and hospital staff18,19; patients’ disease characteristics and self-management abilities20; and integration of the healthcare system.20,21 The ability and capacity to adopt telecare in clinical practice may vary among nurses22,23; thus, understanding nurses’ experiences and expectations will help to enhance the relationship between nurses and patients, subsequently improving patients’ quality of life.24 Therefore, the purpose of this study was to identify nurses’ experiences with telecare for managing the health of diabetic patients. These results may serve as a reference for clinical practices and system design and development.
Setting and Sample
This study applied a qualitative methodology by using semistructured interview guidelines to conduct one-on-one in-depth interviews with community nurses who served as case managers. The research was conducted at two regional hospitals of the metropolitan area in Northern Taiwan. The telecare program for diabetes case management was implemented in these hospitals in 2007 and 2008, respectively, by certified diabetes case managers. Interviews were conducted between April 2011 and February 2012. Diabetes case managers used telecare technology to aid in patients’ disease management. The service content involved physiological monitoring, individualized drug consultation, diet and exercise education, and treatment referral. A device that patients or their families could use to upload blood pressure and glucose results was installed in the patients’ homes. Patients were instructed in the use of the monitoring equipment. Nurses received the data through a computer terminal at the hospital (Figure 1) and would make telephone calls to patients when abnormal data were detected. When patients made a return visit to the hospital, their physiological measurements could be displayed on the hospital information system using patients’ identification cards. The data were also available to physicians to refine treatment plans.
The study purpose, methodology, and research impact were explained to the case managers when study recruitment information was announced. Nine case managers joined this project for interviews. The study participants were all women, between 26 and 47 years old; two participants held an associate college degree and the remaining seven held bachelor of science degrees. Interviews were conducted during the daytime, and each interview took 40 to 60 minutes to complete. Study participants decided on the interview locations such as conference room or the nurses’ resting area, which allowed them to describe their personal experiences undisturbed.
Before participants were recruited, the research was approved by the institutional review board of the two study hospitals. Each interview was recorded with participant consent. Interviewees’ and organizational anonymity was guaranteed throughout the research process. Participants were allowed to withdraw from the study at any time during the interview.
To ensure trustworthiness of the qualitative data, methods were applied to increase rigor by ensuring transferability, credibility, and auditability.25 Transferability of the findings was addressed by purposively recruiting case managers who had participated in current telecare projects. Credibility was enhanced by including numerous quotes from the participants’ verbal descriptions in the findings of this study. Data transcription and analysis were conducted concurrently, exploring the meanings of words, phrases, paragraphs, or an entire transcription document. Demonstrated auditability was achieved by discussing and comparing the content categorization and emerging themes with a nursing professor with related expertise to ensure the objectivity of data analysis.
Data Collection and Analysis
The researcher (first author) has been a community care nurse for more than than 20 years and is currently studying nursing informatics in a doctoral program. The researcher had taken qualitative courses and interviewed interested study groups, such as teenagers’ smoking cessation experience and nurses’ attitudes toward telecare use. In this study, the researcher interviewed all participants. The semistructured interview guidelines are as follows:
1. What is your experience with respect to telecare technology for diabetes management?
2. How does telecare influence your care and what is the effect on diabetic patients?
3. Do you have any concerns or suggestions, that is, software, hardware, user training, or service fees, with regard to telecare for diabetes management?
After the interview content was obtained from the study participants, audio recordings were transcribed within 24 hours. The content analysis method introduced by Miles and Huberman26 was adopted, and Atlas.ti 5.0 (Atlas.ti, Berlin, Germany) qualitative analysis software was used to facilitate data analysis and generalization. For data analysis and result interpretation purposes, further telephone calls were made under the informant’s consent if the meaning of the content needed to be clarified.
According to the interview results, study participants felt a greater sense of empowerment when using telecare services for the management of diabetic patients. The interviews also covered topics on the prerequisites of telecare in context with advances in IT. The emerging nursing telecare implementation issues and nurses’ perceptions and recommendations for future applications of the technology were also discussed. The following four major themes were identified from the findings: (1) improved case management, (2) setting appropriate expectations for care outcome, (3) acknowledging patients’ sense of losing privacy, and (4) disease prevention and interdisciplinary cooperation. These four themes are detailed in the interview results below.
Improved Case Management
The study participants agreed that IT technology and electronic medical equipment have advanced significantly over a short period. These devices have become more easily incorporated into healthcare service systems for diabetic patients, enabling the establishment of integrated healthcare services.
Wired data transmission mode in the past was not effective, because it required someone who knew how to use the computer for uploading data at home. Now, we use wireless general packet radio service (GPRS) and data can be transmitted automatically. In addition, the machine provides audio instructions that are helpful to patients with eyesight problems. For example, when patients hear “please draw blood,” they know it is time to take blood samples. The system also allows data collection for four people and is suitable for household diabetes management, because diabetes is often related to family eating habits. I think this entire machine system is worthwhile!
Telecare overcomes the constraints of time and geography and allows nurses to monitor patients’ blood glucose levels in a timely and accurate manner. On the basis of the data, nurses can provide prompt health education and intervention plans to prevent complications. The telecare system reduces work pressure and enables nurses to demonstrate their professional competency.
When I was transferred from inpatient care to this long-term care environment, I was worried about losing track of patients’ conditions. However, the instant access to data enables me to identify patients’ status and to perform care planning. For example, one of my diabetic patients had suffered a stroke. Before we used telecare devices, I had to use a telephone to keep track of him. Whenever I asked him about his blood pressure, he said he forgot. If I asked if he had measured his blood glucose, he replied yes, but he did not recall the digits either. With the implementation of the telecare system, these results are available on the computers, which help me to prevent him from suffering a second stroke.
Cumulative physiological measurements supported by telecare can assist in the understanding of a patient’s lifestyle and enable case managers to provide timely and necessary healthcare treatment and encourage patients’ self-management. The active coordination of disease management between healthcare providers and patients can gain the confidence of both parties and provide a sense of satisfaction.
The physiological data reflects patients’ lifestyles. For example, once I asked a patient (who was approximately 30 years old) if his blood glucose was higher before or after meals so we could diagnose the problem. Then the patient was shocked by finding such a high blood glucose level before eating. I told him: “High fasting plasma glucose levels before meals could be attributable to problems during the night.” He answered: “I work late and usually have night snacks.” After he changed his behavior of eating snacks late at night, he successfully lost 9 pounds and gradually regulated his blood glucose levels. He now works for an American business company. Weight loss has given him confidence, and I also feel great in caring for him.
Setting Appropriate Expectations for Care Outcome
Participants believe that to apply technology in case management to facilitate effective healthcare services, adequate preparation is necessary. First, the interview content indicated that remote health management requires nurses to try the telecare device to understand the situations that patients could be faced with. Nurses should be aware of potential problems so that they can assist with patients’ usage difficulties.
Before providing the telecare equipment to patients, we usually bring it home to test it for a while. For example, transmission problems could be caused by weak wireless signals in certain locations. If this happened, I would then ask my patients to move the machine. Besides, after taking a blood glucose test, you need to press a button so that the test paper can pop out, and these are just some simple tips. We had tried another machine before, but it turned out that users could receive electric shocks. How could we provide that kind of device to patients? We finally abandoned that one.
Telecare services may not create the outcome that nurses expect. Therefore, nurses should evaluate the characteristics of their patients before implementing this healthcare model. Telecare may reach its maximum use outcome only when patients are aware of the significance of disease control and are positive and willing to take initiative. Without these prerequisites, nurses could be disappointed when patients’ responses do not meet their expectations and might think that patients are not be appropriate for this kind of care service.
It takes time to find a suitable patient. They need to be willing and able to understand their condition, and should have strong autonomy and motivation. For example, one of my patients did not really care about his blood glucose levels, although he agreed to use the machine. Even though he did not admit dislike of the telecare system, whenever I called him to warn him about high blood glucose levels and asked what he had been eating, he answered me with disinterest. His tone showed a lack of concern, and this poor cooperation did not bring the telecare function into full play. Therefore, it is important to select the right patients before implementing telecare.
Acknowledging Patients’ Sense of Losing Privacy
The implementation of telecare services creates a novel type of nurse-patient relationship. The participants in this study stated that patients may complain about being monitored. Hence, it is necessary for nurses to respect patients’ feelings and adopt effective communication skills and various strategies to facilitate remote healthcare. If the patient decides to discontinue using this service, his/her decision should be respected.
A patient told me that he felt stressed from continually having his blood glucose levels monitored by the case manager. I told him: “I truly care about you and would like to help you. I am not keeping you under surveillance. However, whenever I find any abnormality, I will give you a call. For example, I take into account your previous blood glucose records. If your data remain around 200, it’s okay. However, if I find any changes, such as a decreasing or increasing value, I will call you.” I usually told my patients in advance that I would be calling them once a week. Nevertheless, if a patient insisted that they wanted to quit the telecare services, I respected their decision and took back the device.
The study participants explained that some patients thought people with diabetes were stigmatized. Although the technology brings convenience, it also increases the sense of losing privacy. Nurses should be sensitive to this issue when using telecare services.
Some patients feel shame because they have diabetes. They thought having diabetes meant that they ate a lot. Some obese patients felt bad because they were worried that others would blame their diabetes on obesity. Some male patients believed diabetes was associated with sexual dysfunction (a theory of traditional Chinese medicine). Although these patients would like to try this service, they did not want the results to be disclosed to others, even their families. Since our telecare machine provides audio instructions, there have been times when we have to turn the sound off due to the patient’s request so others cannot hear the test result.
Disease Prevention and Interdisciplinary Cooperation
The participants in this study indicated that there could be a more appropriate model in the future for applying remote healthcare in diabetes case management. The optimal time for implementing this technology is at the disease diagnosis phase before complications occur. The application of telecare at this stage focuses on altering lifestyle behavior, strengthening disease self-management, and effectively preventing diabetic complications.
A patient initially had an HbA1c of 11, and that figure dropped to 7.3 after 2 to 3 months of telecare intervention. He had diabetic retinopathy. Although his blood glucose had been well controlled after the intervention, the intervention was too late to prevent blindness. The patient’s wife appreciated our help. Although the patient had lost his sight, with proper disease management, other complications did not occur early. Therefore, rather than providing treatment during the later stages of disease progress, we should adopt telecare during the early stages.
Nurses working on the frontline could use telecare for disease self-management to assist in the detection of diabetes and provide intervention at an early stage. Nevertheless, the general population thinks that telecare is unnecessary and believes in the traditional care model—to visit physicians and take medications.19 It would be helpful if physicians could use their professional status to persuade and promote the use of telecare for diabetes management. Cooperation within the medical team may more effectively encourage patients to self-manage their disease.
Once we went to a factory to perform diabetes outreach for the employees and found approximately 20 people who had high blood glucose, blood cholesterol, and blood pressure. We provided them with telecare machines and encouraged them for home use. Guess how many of them used it? Only two. The others thought they did not need the machine as long as they visited their doctors and took medication. The nurses’ words do not weigh the same as compared to physicians’ opinions. We really hope that one day we will hear physicians telling patients, “Your blood glucose is poorly controlled, and we have a service (telecare) and that will be good for your disease control.”
The participants in this study indicated that telecare could improve healthy behavior. Once a patient has established a healthy lifestyle, switching back to the traditional regular hospital visits is sufficient for disease management. Patients will no longer require long-term use of the telecare machine, and the machine could then be made available to the next patient, which could help efficient resource use and reduce healthcare costs.
Implementing telecare at the right time helps stabilize patients’ conditions. Actually, the implementation of telecare provides the best learning opportunity, in which patients and their families learn to handle specific symptom management. After monitoring for a few months, we observed that patients had learned how to solve some of their health problems and they knew when to call us for help. Once a patient has learned how to manage their condition, we can take back their telecare machine and make it available for others.
It is anticipated that the advancements in telecare technology may assist in addressing several problems such as shortage of healthcare providers, diabetes prevalence rates, healthcare costs, and providing high-quality care to patients with either type I or type II diabetes.10,12 In addition, telecare makes it possible for nurses to remotely monitor their patients’ conditions and provide timely evidence-based recommendations to support patients’ self-care.27 The participants in this study stated that timely message transmission and nursing interventions gave a sense of empowerment with the application of this technology. Therefore, with appropriate use of rapidly advancing IT, nurses and patients can both enjoy a better care process.
In recent years, there has been a significant amount of attention focused on the improvement of care quality and patient safety through the implementation of IT. As nurses account for the largest proportion of healthcare manpower, their IT skills are now regarded as critical to professional competency and a key to successful promotion of IT use.28 In this study, nurses tried the telecare machines in advance so they could share their experiences with the patients. Despite rapidly expanding technologies, the limited experience of most patients and their families in using IT equipment often hinders the promotion of telecare services.20 As a result, basic problem-solving skills for device use will become another required competency of the telecare nurse.
Remote technology has changed nurse-patient interactions and facilitates timely transmission of relevant data. It requires nurses to show concern, listen to patients, and communicate effectively to perform care through telecare16 because no one likes to be patronized for being different from other people because of an illness.29,30 Nurses need to acknowledge the new nurse-patient relationship and remain vigilant with regard to the patient’s right to privacy. Care cannot become a burden to the patient, as this would reduce the effectiveness of telecare services.30,31
As nurses become more conversant with remote technology and experience the related benefits, they must also become aware of the pitfalls. Telecare is an integration of interdisciplinary fields such as medicine and information science. The provider must try to maintain the confidentiality of any protected health information.32 Nursing in diabetes care is a profession that relies on patients’ trust33; thus, telecare use must carefully consider the software and hardware design not to reveal patient data to others by either video or audio use.34 Serving in the frontline of a medical team, nurses need to be empathic and sensitive to their patients to prevent breach of patient confidentiality in telecare practices.
In this telecare program for diabetes care, nurses recognized the value of assisting diabetes management. Nevertheless, nurses believe that physicians are the key to influencing patients’ decision to use telecare. The attitude of physicians is a crucial factor18 in the promotion of telecare services. Nurses have indicated that there exists insufficient integration and cooperation among healthcare team members to fully elaborate on the use of the program. Remote nursing care has the potential for growth in the future16; however, from the team care perspective, reaching a consensus on patient care philosophy and establishing care protocols19 still requires interdisciplinary cooperation in the current healthcare system.
Self-management is the core of effective diabetes care.7,8 Diabetes self-management behavior can be influenced by personal belief and values; however, patients’ lack of knowledge, skills, and motivation is the greatest challenge in successfully altering patient behavior with respect to disease control.35 This study indicated that the most effective time to implement telecare is during the early phase of the disease, in which information and timely health education are the most effective disease self-management methods.27,36 To maximize disease control, telecare requires early disease diagnosis, early intervention, and patients’ motivation and willingness to put effort into long-term disease control.37
Because only nine participants provided user experiences, the results of this study should be interpreted with this consideration. Similarly, applicability to a wider population is limited. The results from the interviews show that diabetes case managers were impressed by the rapid advancement in remote healthcare equipment, and they experienced a sense of empowerment in caring for diabetic patients with instantly available physiological data. Nurses must become familiar with the device use in advance and be aware of potential problems that may occur during the administration of the services. In addition, as IT progresses, nurses must be cautious with confidentiality issues and potential negative feelings resulting from the changing nurse-patient relationship. Furthermore, patients’ motivation for self-management, early intervention of telecare services, and a consensus among members of the healthcare team will assist in promoting the effectiveness of telecare services.
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