ANSWERING HEALTHCARE questions over the phone is not a new concept. Dating back to the 1970s, office nurses have communicated via telephone to discuss various healthcare issues with patients, including lab results, medication refill needs, and advice on how to manage minor illnesses at home. Labor and delivery nurses often receive phone calls from expectant mothers about possible labor symptoms and fetal well-being. Similarly, ED nurses field calls about illnesses and injuries.1,2
According to the American Telehealth Association, telehealth nursing is a tool for delivering nursing care remotely to improve efficiency and patient access to healthcare.2 A telehealth call or inquiry is more than just a phone call, however, and the nurses who respond to these calls are participating in the healthcare continuum. The purpose of this article is to increase awareness regarding telehealth nursing by defining the service and its role in healthcare, as well as describing the necessary skills and competencies required of telehealth nurses.
Over the last 2 decades, the function of telehealth nursing has expanded, recently blossoming into an extension of some healthcare providers' offices, hospitals, and health plans. These include services not related to specific entities, such as independent nursing practices, corporations where multiple telehealth nurses work in a single location, or nurses working remotely from their homes.1 There are regional, statewide, and hospital contact centers.3
In some settings, telehealth nurses are accessible 24 hours a day, 7 days a week by phone for inquiries regarding symptoms and evidence-based guidelines. These healthcare professionals have a broad range of responsibilities, from calming the nerves of new parents to assisting with ambulance dispatch in life-threatening situations.4
A 2014 article on the benefits of telehealth nursing identified that nurses can assist with patient retention, decrease on-call hours for healthcare providers, and offer versatility for use during any time interval, including around-the-clock, weekend, or afterhours care.5 Telehealth nurses' versatility includes the ability to guide patients to ED visits, clarify appropriate treatment options, educate about self-care at home, and assist with appointment scheduling.6-11
Another study identified telehealth nursing as not only appropriate, but also beneficial both to the person calling and to the healthcare system in terms of cost savings and referrals.12 For example, by calling for nurse assistance, a patient with a minor health issue may avoid the expense of an unnecessary ED visit. Likewise, for parents trying to decide if a sick child's symptoms necessitate a nighttime trip to the ED, a phone call with a telehealth nurse can be beneficial for both the family and the healthcare facility. A 2015 study of parents receiving advice over the telephone attested to the support, encouragement, and confidence telehealth nurses instilled in parents caring for sick children at home.13
Training and credentialing
As telehealth nursing has grown in popularity over the years, its efficiency and has been recognized by the American Academy of Ambulatory Care Nursing (AAACN), which encourages telehealth nurses to become certified in ambulatory nursing through the American Nurses Credentialing Center.1,14,15 The AAACN no longer offers a specific certification for telehealth nursing, but has designated the practice a special interest group within ambulatory care.15
The AAACN has established competencies and practice standards for telehealth nursing and ambulatory care nursing, which cover:15-17
- professional experience
- interpersonal skills
- technical knowledge
- continuing education
- resource management
- practice and administrative issues.
Online training and education for telehealth nursing is available through the AAACN and many other organizations.
Most organizations with a telehealth nursing program require nurses to have 3 to 5 years of clinical experience, but this can vary. New telehealth nurses will undergo training before taking on real-world patient calls, but specific training protocols also vary by organization.
The AAACN has developed a guide to ensure continuity in the training of new hires. During their training, nurses learn concepts and descriptions to conduct assessments, analyze, and plan using proper decision support tools. These tools encompass algorithms and protocols that provide specifics to direct the telehealth nurse, as well as evidence-based guidelines for a basic outline of the encounter and an appropriate disposition for the symptoms described by the caller.17
Evaluation documentation for training serves a vital role in the nurse's ability to process calls appropriately, use clinical decision support tools, follow organizational policies and protocols, and perform with the technology provided. Training incorporates the use of preceptors to guide new telehealth nurses, and call processing to apply nursing processes to the clinical calls through assessment, plan implementation evaluation, and documentation.18
In a 2010 study, orientation training with simulated calls seemed suboptimal when compared with recordings of real patient triage calls.3 Because simulated encounters are more structured than those in clinical settings, comprehensive training is required to become proficient in the role. Simulation can help nurses learn how to interact with callers to prevent under- or overtriaging through the use of selected scenarios in which a tester makes simulated calls based on specific situations, signs and symptoms, and expected outcomes.
The 2010 study identified 11 case scenarios for adult and pediatric patients, including common healthcare problems such as mild fever, minor head injury, viral infection, and earache. Reviewers assessed the outcome of the encounter and whether nurses acted appropriately in response to the signs and symptoms presented. Assembling call scenarios that could encompass all possible symptoms and inquiries proved challenging, however, and some scenarios were rejected due to lack of consensus. These simulations still aided in ensuring quality in the calls being conducted, but more research should be conducted to ensure consistency with quality audits on recorded calls and records.3
The telehealth nursing process evolves as nurses interact with patients over the phone to identify and prioritize their health needs through questioning, information interpretation, symptom review, and skillful assessment of the urgency and level of care necessary to safely and effectively meet the caller's needs.1,19,20 In a landmark 1998 study, Dundas and Casler emphasized the need for effective communication between nurses and callers, and this continues to be an ongoing issue.21 Caller satisfaction typically increases when patients believe the nurse correctly comprehended their issues, expressed empathy, and provided them with a sense that their needs were met.13
To ensure continuity and quality, clinical decision support software (CDSS) has been developed for telehealth nursing. CDSS provides evidence-based guidelines for nurses during a patient call for safety, proficiency, and continuity. It is a tool nurses can use to navigate a call.22 Adjustments to CDSS assist nurses in leading an assessment rather than simply reading protocols and algorithms, which can vary based on organizational needs. It also allows them to make the appropriate clinical decisions through an algorithm for the symptoms being described.
For assessment in telephone triage, an intake list should incorporate the SCHOLAR problem history:23
- O-onset and duration
- A-aggravating or associated factors
- R-relieving factors.
The use of the SCHOLAR algorithm can expedite the triage process by helping nurses select appropriate guidelines.
Honing communication skills
Telehealth nurses must be critical thinkers and know when and how to probe for accurate descriptions of rashes, cuts, bruises, or any other signs and symptoms reported by a caller.24 Being a good listener is essential. Hearing a description and visualizing what is being communicated over the phone helps nurses perform an accurate assessment. Being a visual learner does not necessarily exempt a nurse from being compatible with the virtual world of telehealth nursing, however; in fact, this may enhance a nurse's ability to put together clear descriptions.24
The Process of Telephone Nursing Model describes the interaction between the nurse and the caller during the flow of a call.19 While observing telephone interactions between nurses and patient callers, Nagel and Penner also created a Conceptual Model for Telehealth Nursing Practice.24 This model noted that, while nurses may not be able to see the callers physically, a mental image of the patient and situation can be constructed in the nurse's mind through communication and assessment.24
Honing communication skills is essential for telehealth nurses. While assessing and constructing a mental image from the caller's description, the nurse can quickly develop a rapport with the caller. Using clinical knowledge, technical skills, listening skills, and computer-generated guidelines, the nurse can then form a final clinical decision and prioritize care.
Nurses working in telehealth nursing are in both a passive and an active position.22 The passive position involves choosing guidelines identified by definition based on the caller's stated symptom(s). The active position involves performing overrides and using his or her own judgment based on how a caller sounds. This allows the nurse to use clinical knowledge to ensure that patients who sound sicker than they are stating, have complicated health issues, cannot remember specifics, or have unusual symptoms can be examined sooner or referred to a higher level of care than the guidelines may suggest.
What the future holds
The digital age has opened the door to major sources of investment in healthcare. These investments are viewed as cost savings for the future. Technology such as robotics, computers, web portals, the Cloud, smartphones, and other technologic infrastructures has helped to shorten hospital stays, monitor chronic health problems, and link patients to providers. These allow for healthcare interventions without the need for patients to leave the comfort of their home and aid in a preventive capacity in rural areas.Alvandi expounded on the convenience of telehealth, as well as its ability to reduce travel, enhance scarce resources, and improve patient outcomes.25 As of 2017, it was estimated that 65% of healthcare interactions would be through mobile devices.26
Since the implementation of the Patient Protection and Affordable Care Act, continuity of care through patient-centered medical homes has been enhanced by supplying patients with telehealth nursing to call at their convenience, offering risk reduction and cost savings to providers and healthcare organizations and meeting the accessible care standards set by the National Committee for Quality Assurance.27,28
Telehealth offers more than just a phone call; it is a resource for both patients and their families. With training, experienced nurses can take on telehealth roles confidently to provide safe and quality care to individuals through a variety of technologies.