Executive Summary:
2000 U.S. Telenursing Role Study
Feb 2001
Loretta Schlachta-Fairchild RN, Ph.D.
Purpose
With the emergence of
telehealth and telemedicine, much initial focus has been upon the
role of physicians in the technology. The true definition of telemedicine,
with tele – meaning ‘distance’ and mederi –
meaning ‘healing’, is a global term that applies to
all members of the health care team. The ability of telemedicine
technology to provide monitoring, education, follow-up, remote data
collection, remote interventions, pain management, family support
and multidisciplinary care is a focus that is as of yet unperceived
in the general health care arena.
With nurses composing the largest group of health care providers
in the U.S., a study was undertaken to describe the scope of participation
of nurses in telemedicine. Telenursing is defined as “the
use of telemedicine technology to deliver nursing care and conduct
nursing practice” (Schlachta & Sparks, 1998). While Telenursing
encompasses telephone triage and advice nursing, the focus of the
2000 study was to identify the telenurses in the U.S. who were using
voice AND data/video in their nursing practice. Thus, the Telenursing
Role Study
excluded the population of telephone triage and advice nurses, and
focused on telenurses using telemedicine technologies.
The intent of the 2000 U.S. Telenursing Role Study was to examine the professional role and individual characteristics, work satisfaction, role stress, role ambiguity and role conflict of telenurses practicing in the United States. Using Role Theory as the theoretical framework, a national, descriptive study utilizing an online, web-based survey was undertaken. The focus was on examination of the telenursing role. The purposes of this research were to:
Methods
796 U.S. Telenurses (defined
as nurses using or working for programs/vendors using interactive
or store and forward video/data technology) were identified through
a three pronged, national identification process which included:
1) review of literature to identify telehealth programs, then identifying
the nurse(s) working for the program
2) contacting members from the American Telemedicine Association
and the Association of Telehealth Service Providers to refer telenurses
and
3) snowball sampling of known telenurses directing me to other known
telenurses.
213 of the 796 telenurses passed two screening questions which indicated they used video/data (live or store and forward) in their telenursing practice. Of the 213, 196 telenurses had complete responses that were used to calculate results of the Telenursing Role Study. Assuming an alpha level of .05 and a moderate effect size, and taking into account the most complex analysis intended for this study (Cohen, 1988; Kraemer & Thiemann, 1987), for a sample size of 196 telenurses, power was .97. These 196 telenurses represented 40 of the 50 states, including Alaska and Hawaii.
As a matter of interest, 38 of the 196 telenurses took the survey via the toll-free telephone number; the other 175 telenurses completed the survey online. The online survey proved to be an efficient and cost-effective method to collect, and then, analyze data. The average respondent took 22 minutes to complete the 152-question survey. Data was already in electronic format once the respondent submitted their answer. Data was then easily downloaded and imported into Excel for analysis using SPSS.
Three existing, validated survey tools were used to collect information and conduct comparisons and analysis: 1) The Department of Health and Human Services (DHHS), Division of Nursing, National Survey of Registered Nurses 2) the Stamps’ Index of Work Satisfaction, and 3) The Rizzo, House and Lirtzman Role Questionnaire. Cronbach’s Alpha Reliability for the Index of Work Satisfaction was .92; Cronbach’s Alpha Reliability for the Rizzo, House and Lirtzman Role Questionnaire was .92. Select professional and demographic questions from the DHHS National Nursing Survey were used for data collection and for comparison of Telenurses to the population of “regular” Registered Nurses in the U.S. in the analysis.
Findings
The typical Y2K (Year 2000) Telenurse is 46 years old, has worked 21 years in nursing and more than 6 months in her telenursing position. She has a one in three chance of being an advanced practice nurse, and has at least a baccalaureate degree, and likely a graduate degree as well. The typical Telenurse is white, female, married, and has children. She works full-time in telenursing and makes just over $49,000 per year. It is clear from past study of the roles and functions of U.S. nurses and telenurses, that the telenursing role is unique and emerging rapidly from the time of the Horton study in 1996. Horton identified 130 telenurses in 1996 in the U.S. In 2000, there were 796 telenurses identified, a 600% increase from 1996. This does not take into account the additional population of telenurses who were not identified by the three-phase process utilized for this study.
Telenursing is causing change in titles and work locations of nurses. In addition, the telenursing role demands multitasking abilities, business and technical skills. The business skills demanded of telenurses are beyond the typical administrative skills in a head nurse or nurse manager position. Business skills require proposal preparation, budgetary preparation and justification, knowledge of business structure, joint ventures and partnerships, marketing and public relations and a host of other business-specific skills.
While telenurses are still based predominantly in hospitals, the percentage of telenurses (23.5%) in hospitals compared to regular nurses (60%) in hospitals is less than half. Therefore, a conclusion is that the numbers and varieties of practice settings of telenurses are expanding from the traditional hospital setting. Entrepreneurial aspects of the role are evident as nurses are working in nine newly identified nursing settings such as owners and shareholders, for web portals and telemedicine equipment vendors. The emerging professional role of telenurses may demand a new or enhanced curriculum at the graduate or post-baccalaureate level to prepare nurses for this new role.
Telenurses have
moderate work satisfaction, aligned with other populations of nurses.
Work satisfaction of telenurses is negatively associated with role
stress, role ambiguity and role
conflict, such that lower work satisfaction is associated with higher
role stress, role ambiguity and role conflict. The factors most
important to telenurses’ work satisfaction are respectively,autonomy,
interaction, professional status, task requirements, pay and organizational
policies.
In the Telenursing Role Study, the majority of telenurses (73.6%)
reported that they were
comfortable with their level of technical competence related to
use of telemedicine technology.
As was also reported, 83% of telenurses had been in their telenursing
roles for > 6 months.
Logically, level of competence is expected since even those who
are in a new role should have a
level of comfort by the time they have been in the role for more
than 6 months. What is of
concern is that when the responses to the two open-ended questions
regarding preparation of
telenurses for their telenursing role, and strategies for patient
safety in the use of telemedicine
technologies are examined, there is a wide range in the reported
strategies. A brief review of
the descriptive responses to the open-ended questions reveals that
there is a lack of
standardization in the telenursing role preparation process, as
well as the patient care process for
telehealth-delivered care. Preparation for the role of telenursing
was reported as ranging from
“none” to “6 months of precepting with a mentor
and competency checklist”, with a variety of
strategies in between such as vendor training, on-site visits for
training, technical training, and
structured orientation programs ranging from one day to 3 weeks.
Telenurses practice in over 29
different healthcare and healthcare-related settings. It is apparent
that in the range of answers
provided, there is a large disparity in strategies for preparation
for the telenursing role and a
resultant need for agreement upon a common strategy for all nurses
involved in the telenursing
role, regardless of subspecialty.
In parallel, the need for patient safety strategies related to informed
consent, telemedicine equipment safety, infection control, electrical
safety standards, and thorough knowledge and
training in use of telehealth devices and equipment is evident.
There are a large range of patient
safety strategies reported from “none” to detailed patient
consent and training methodologies.
Again, there are no set standards as of yet.
The role of telenursing is rapidly emerging, as has been documented
by the current study. A minimum of a 600 % increase since 1996 in
the population of telenurses has been revealed by the current study.
Telenurses cross all boundaries of specialties, with particular
emphasis on advanced practice nurses. Telenurses practice in nine
newly identified practice settings, and have a host of new titles.
With the rapid evolution of digital technologies, digital Internet
service via cable TV companies, wireless email via cell phone, and
other leading edge, advanced technologies, the role of telenursing
is only expected to grow more rapidly. A recommendation is for nursing
leaders of professional nursing organizations to collaborate in
response to the challenge of emerging technologies. Leaders should
join forces to proactively promote, support and guide the emerging
telenursing role.
Summary
The Telenursing Role Study serves as a baseline for nursing practice for the emerging role of telenursing. The role of telenurses has been benchmarked by this study. Future growth and maturity of the telenursing role can be measured against the findings of this study. The growth of the role of telenursing is inevitable in the technological society in which we live.