INTRODUCTION:

Tele-nursing refers to the use of telecommunication and information technology for providing nursing services in health care whenever a large physical distance exists between patient and nurse. The physical separation from patient may make it more difficult to establish a therapeutic relationship and require nurses to develop enhanced communication skills as well as technological competency. Tele nursing is not new, in some setting nurses have provided health information and nursing advices over the telephone for decades. Special licensure and certificate are not required but systems need to be in place to ensure the delivery of safe practice and quality of care¹.

Applications of Telenursing:

It Helps patients and families to be active participants in care, particularly in the self-management of chronic illness. Patients can contact on-call nurses any time and arrange for a video consultation to address any problems; for example, how to change a dressing, home monitoring of physiologic parameters, such as blood pressure, respiratory peak flow, and weight, via the Internet/Phone. It Enables nurses to provide accurate and timely information and support online. Continuity of care is enhanced by encouraging frequent contacts between health care providers, individual patients and their families. More timely information to patients and families reduces the use of expensive health care services (physician's office, emergency units, hospitals and nursing homes). Tele-nursing can reduce the requirement for, or the length of hospital stays. Adults with chronic conditions who need frequent monitoring, assessment, and maintenance but do not meet home care criteria or have no money to pay for services can benefit from technology. The result is a decrease in total health care costs and increased access to health care with more appropriate use of resources².

Issue in Tele Nursing in India:

Advantages of Telenursing:

Tele nursing provides an invaluable, immediate and constant link to information and support resources. It enables closer monitoring so that potential problems can be identified and intervention initiated before these escalates into crisis for patients and families. Tele nursing also provides education to the patients, families and in home care givers in early recognition of signs and symptoms that might necessitate further evaluation and intervention. Through Tele nursing, unnecessary visits to the physician can be precluded. Tele nursing reduces the number of visits to hospital emergency visits. It also reduces the number of in-patient admissions or re-admissions. Tele nursing also delays the need for transfer to an extended care facility. A common application of Tele nursing is also used by call centres operated by the managed care organizations, which are staffed by registered nurses who act as case managers or perform patient triage, information and counseling as a means of regulating patient access².

Tele nursing enables the effective management of the behavioral health conditions. With the advancement in Tele nursing, the self esteem and self confidence of patients, families and in –home care providers can be improved. In addition to the management of illness, it is anticipated that the goal of societal wellness and the prevention of illness is so far as possible may be ultimately realizable by utilizing Tele health technologies. Tele nursing also expands the opportunities for teaching patients to effectively self manage their medical conditions and regimens. The ability of the nurse to provide teaching to a patient is central in home settings. The evolution of Tele nursing, communication with the patients who have chronic conditions or debilitating illnesses can be maintained¹.

With the help of Tele nursing, the health care services are provided to the patients that are uninterrupted by time, distance and setting. Limited resources can benefit a large population spread over a broad geographical region. Tele-nursing helps patients and families to be active participants in care, particularly in the self-management of chronic illness. Tele-nursing can reduce the requirement for, or the length of, hospital stays, Nurses engaged in tele-nursing practice continue to assess, plan, intervene and evaluate the outcomes of nursing care, but they do so using technologies such as internet, computers, telephones digital assessment tools and tele-monitoring equipments².

Disadvantages of Telenursing:

Health care providers also feel that they will lose the patient/ health care provider personal relationship if they utilize e-care and e-monitoring and that there will be a lack of hands on client care and lack of certain physical assessment parameters. Health care providers feel that they will have to learn a new technology and that caring for patients this way means that they will have to continuously look at patient data. Health care providers will have more time to review web data with the patient's chart available and potentially can communicate more efficiently by posting secure messages to the patient's individual secure "virtual care room" along with links to information sources. The first comment of health care providers is that e-care and e-monitoring will consume more of their time. some clients are concerned with confidentiality, they are uncertain if their rights will be violated. Some patients may feel violated because they are not sure who has access and/or viewing their information³.

This is more time efficient than a 5-10 minute office visit where the provider often feels rushed is interrupted by other calls or staff, and where the provider might forget to tell the patient important information. The patient might also either forget what the doctor told them or is afraid to ask their provider during a rushed office visit. With e-health care both patient and provider communication can potentially improve. E-health care has the potential to actually improve the quality of health care delivery. The problem of inadequate physical assessment will be obviated or greatly reduced when audio and video are more readily available³.

Ethical Dilemmas in Telenursing:

There are different kinds of ethical dilemmas that nurses encounter in their daily practice. Likewise, increasing ethical dilemmas have been shown to create stress reactions among healthcare personnel. Moral distress can be defined as negative stress symptoms that occur due to a situation where the healthcare provider has identified an ethical dilemma and assumes she knows the right thing to do, but institutional constraints hinders him/her from pursuing the desired course of action¹.

Although telenursing brings great advantages for both patients and personnel in the form of, for example, resource and time allocation and improved patient access, it might also entail ethical difficulties. Kaplan and Litewka have identified privacy, security, confidentiality and autonomy as ethically troubling areas in telemedicine in general, of which telenursing is one branch. We argue that autonomy, integrity, prioritising, information and documentation are ethical aspects that can be particularly challenging in telenursing. These ethical aspects are-

Autonomy versus beneficence:

Within telenursing it is not unusual that the caller is not the actual patient, but a close relative. It may be a parent calling on behalf of a sick child or a wife calling for her husband. The ethical dilemma telenurses can experience in the latter situation is a conflict between the patient’s autonomy and the relative’s, as well as the nurse’s, ambition to do help the patient. Hence, the principles of autonomy and beneficence are in conflict. The nurse always strives to speak to the patient herself, but when that is not possible she has to walk a fine line between help and respect⁴.

Integrity and documentation:

One aspect several telenurses experience as ethically troubling is that the encounter over the phone is “faceless” which makes it difficult for the nurse to “read” the patient through body language and face expressions. This means that decisions must be based only on the verbal information the caller chooses to reveal. Further, the nurse can never be fully sure of the caller’s identity, in spite of the fact that the caller gives a name and a social security number. This raises the ethical question of how to ensure the caller’s integrity within telenursing⁴.

One way to handle this dilemma is by being restrictive about information on previous illness and calls. Furthermore, a telenurse should be cautious when sensitive information is to be documented, for example, when calls concern psychiatric illness or gynaecology. On such occasions, a telenurse may just note ‘referral’ in the record, which is a correct but not very informative notation⁴.

Priority setting and the healthcare organization:

As a telenurse can be described as being both a healthcare adviser and a “gate-keeper”, priority setting is part of the day-to-day work in telenursing. So priorities should be made according to a platform consisting of three ethical principles, namely the principles of human dignity, need and solidarity, as well as cost-efficiency⁴.

Responsibility and information:

Ethical dilemmas in telenursing can also occur due to the nurse’s obligation to inform the patient and at the same time avoid giving too much information that might overwhelm the patient and make him/her deny the symptoms. Here, the ethical demand of presenting honest information to the patient might clash with the principle of non-maleficence. An example of a situation that may create this dilemma is when a patient calls in for what s/he believes is a small problem, needing only some advice on self-care, while the nurse apprehends that the symptoms described are signs of a serious illness. The telenurse feels that she cannot confrom the caller with the truth too abruptly, but sshe must at the same time try to make the caller realise the severity and urgency of the symptoms⁴.

Future of Tele Nursing in India:

Emerging new wireless technologies have introduced new options in Tele-health, which includes nanotechnology and artificial intelligence. Tele-nursing is achieving a large rate of growth in many countries. For the full growth of Tele nursing all over the world requires efforts. However it needs a careful management in Indian scenario, the staff shortage in the hospitals across the country will require dedicated staff exclusively to be available to patients for attending to the phone calls which may be a big challenge in terms of manpower planning. Training of nurses deployed for telenursing is also necessary. There is a need to develop protocols and standards for communication for telenurses, to decrease the ambiguity in nursing responsibilities. These protocols should be reviewed by the nurses and medical staff and should be approved for the practice. These protocols should be used as guideline only, nurses must avoid over reliance on these protocols. Documentation increases the efficiency and decreases the liability. It supports the systematic assessment and standardization of the nursing practice. Nurse would require training in documentation of services provided to the patients through telenursing. The correct Documentation serves as data base for program analysis and quality initiatives of the patient care. Tele health nurses needs to demonstrate the competency in clinical knowledge, critical thinking, interpersonal and technical skills to provide care that is evidence- based, safe, effective, patient centered, timely efficient and equitable. It is expected that the health care planners may pay attention to these challenges, and telenursing can become a possibility in india as the health care resources are deficient as compared to the load of patients on the health care system⁵.

REFERENCES:

1. Loretta Schlanchta-Fairchild,Victoria Elfrink, Andrea Deikman; Patient Safety, Telenursing, and Telehealth. Accesed from https://www.ncbi.nlm.nih.gov/books/NBK2687/

2. https://en.wikipedia.org/wiki/Telenursing

3. Mary Ann Lavin, ScD, APRN, ANP-BC, FNI, FAAN. Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings. Available from http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-20-2015/No2-May-2015/Articles-Previous-Topics/Technology-Safety-and-Professional-Care-Documentation.html

4. Carol Rutenberg, Kathleen Oberle. Ethics in Telehealth Nursing Practice. Home health care management and practice. Feb 21, 2018.

5. Saroj Kanta Mishra, Lily Kapoor, Indra Pratap Singh. Telemedicine in India: Current Scenario and the Future. Available from https://pdfs.semanticscholar.org/1503/f3ca6457d6e8e566b514d600c08a02b170c5.pdf

Received on 20.06.2019 Modified on 10.07.2019

Asian J. Nursing Education and Research. 2019; 9(4):573-576.

DOI: 10.5958/2349-2996.2019.00125.3