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Med-e-Tel 2009 – Telenursing session April 2, 2009

Posted by peterjmurray in conference, Europe, health informatics.
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It’s Thursday afternoon, so it’s the Telenursing session. I am giving a talk as part of this, but am also blogging the rest of it. The first talk, on “Telehealth’s evolution and future in Canada” (Lois Scott; presentation given by Diane Castelli), started with a geographic overview of Canada, which covers a large area, but has relatively small population, with 90% concentrated in the south, within 200 miles of the border with the USA. Canada, as with many countries, has a shortage of healthcare workers in all disciplines; average age of nurses is 46. Patient safety is an increasingly important issue, and patients are playing a more active role in decisions about their healthcare. The first telehealth era, the 1940’s, was based around the use of telephone contact, most often to give advice/help in acute situations, but often with no protocols. The second era, the 1950s to 1970s, saw the emergence of social crisis lines, often staffed by lay volunteers, and with the emergence of formal protocols. The third era, the 1980s to early 90s, saw expansion of telemedicine services, with homecare monitoring, telepsychiatry, and development of web-based health information. The current (fourth) era, the mid 1990s to the present, saw the emergence of telephone triage, telecare services and support from electronic decision support systems. Currently, most of the Canadian provinces and territories are providing 24/7 telecare services for their populations; all are mostly telephone contact centre-based, for people across the spectrum from the well to those with severe illnesses. canada has found that public uptake levels have depending on marketing of services, and most opposition to services comes from health professionals, rather than from patients, while competencies and standards for telenursing need to be further defined.

Diane then gave her own talk, “The advancement of international telenursing”. She began by defining telenursing as ‘the practice of nursing over distance using telecommunications technology” (a 1997 definition from the USA). In the USA, there are examples of nurses providing telehealth for prisoners and for rural natives in remote clinics. She then discussed the ISfTeH telenursing working group.

Elenor Kaminsky, from Uppsala University, Sweden, spoke about “Detective or educator? – telenurses’ understanding of work”; this was based on work that has been published in the Journal of Advanced Nursing earlier this year. Telenursing is a first line of healthcare in Sweden, started in 2006 and using call centres with telenurses; there are 75-90 calls per working day per nurse, and provide an opportunity to influence public health. She described a qualitative study, based in phenomenography, to study variations in conceptions among the 12 telenurses interviewed in 2004-05. Five categories were work were identified [1] assess, refer and give advice to the caller; this was a form of detective work, with the nurse listening for clues; [2] support the caller, guiding them and maintaining contact; [3]  strengthening the caller, increasing their self-confidence; [4] teaching the caller, with an emphasis on what the telenurse thought the caller needed to be taught; and [5] facilitate the caller’s learning. All nurses in the study expressed category 1, while only proportions identified the other categories within their  work; category 5 was seen as a ‘highest level’, and nurses identifying this also identified all other 4 areas. This identifies different forms of work – in effect, different health services, possibly leading to variation in outcomes, depending on which nurse answers the call. The outcome space identified forms a telenursing roadmap. My talk came next.

Annica Ernesater, from Sweden, presented “Computerized decision support systems in telenursing: how is it perceived by telenurses?” She also mentioned the Swedish call centres mentioned by Elenor, and it is similar to NHS Direct in the UK; this uses a computerised decision support system (CDSS). Telenursing is seen as knowledge-intensive work, with the telenurses triaging callers’ needs and giving advice, including self-care advice. She described a study of nurses’ use of the CDSS, which showed that telenurses found the system to be supporting, inhibiting, and controlling – the system was found to simplify their work, but there could also be disagreement between the CDSS recommendations and the nurses’ previous professional experience, with the software being incomplete; this lead to frustration among the nurses. Searching the CDSS for information sometimes lead to nurses paying less attention to the callers as they searched the system for information, although it also meant more consistency in the information given to the patients. The CDSS cannot replace nurses’ knowledge and experience, and should be seen as complementary, not competitive to their own skills.

The final talk of the session, “It’s easier to talk to a woman – aspects of gender in Swedish telenursing”, was from Anna Hoglund, also at Uppsala University. 90% of the nurses staffing the Swedish call centres are female, and all are registered nurses who act as the first line of response to callers. About 50% of calls are for self-advice, while rest are for a mix of issues, including getting appointments. Most of the callers to the help line are women (60-80%). An interview-based study of Swedish telenurses in 2004-05 found 5 themes – [1] female subordination in the family, ie females in some families are not free to contact health services themselves, especially in cross-cultural encounters; [2] disrespect in dialogue with female nurses, ie from male callers who were not valuing the nurses’ experience; [3] distrust in fathers’ competence, ie mothers being better to describe the problems with children; the telenurses seemed to trust female callers more, especially in relation to child issues; [4] reluctant male callers, ie callers needing to be encouraged by their family members to call; and [5] woman-to-woman connection, ie ‘its easier to talk to a woman’, resulting from commonalities of experience. The study concludes that gender aspects in various forms in telenursing, and there is a risk of stereotyping dialogues depending on callers’ genders.

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