Telehealth’s Impact On Traditional Nurses Essay

Telehealth’s Impact On Traditional Nurses Essay

Telehealth has emerged as an enhancement to health care, giving clients greater access to care
providers than ever before. It has benefited persons living in remote areas who cannot readily
access health services and it has helped clients who have chronic disease conditions that require
frequent monitoring, saving themselves and hospitals thousands of dollars. Nurses are an
important part of delivering telehealth, yet it is not currently being taught in many nursing
courses. The purpose of this project is to introduce telehealth into a pre-licensure nursing
program via a learning module and to assess the students’ understanding of the material before
and after the module has been presented. A two-tailed t test was given before and after the
module was presented with p <.05 which does not support the null hypothesis that there would
be no difference between the two tests, along with multiple regression analysis performed on
each independent variable compared to the dependent variable with the results being p > .05,Telehealth’s Impact On Traditional Nurses Essay


which upheld the null hypothesis that demographic variables would not influence the outcome of
either test. The learning module proved to be effective and could have further applications in
pre-licensure nursing programs.
Copyright © 2012 Dwayne F. More, MSN, RN
All Rights Reserved
I would like to acknowledge Dr. Susan Shea, PhD, RN for her guidance as my preceptor through
this process; without her assistance I would have had a much more difficult time completing this
project in a timely manner. I would also like to acknowledge Dr. Miles Shelton, EdD, President
of Galveston College, Galveston, Texas for allowing me to use the college as my test site and for
giving me access to all of the college resources I needed. I would like to recognize Dr. MaryAlice Hodge, PhD, RN, Gardner-Webb University for being my advisor and patiently answering
my myriads of questions throughout this process. Finally I would like to thank my partner, Mr.
James A. Elledge, Jr. for his wonderful support and understanding through this scholastic
endeavor. Telehealth’s Impact On Traditional Nurses Essay

Introduction to the problem
This capstone project emphasizes the importance of nursing students understanding
the use of telehealth. Telehealth is becoming an increasing venue for client care; the
American Telemedicine Association (2010) requests six mandates from the Obama
administration on public policy regarding telehealth, with one of those mandates being to
increase funding for telehealth projects. The use of telehealth has become an important
subject to the United States government as well. President Obama recognized the need
for Telehealth in his State of the Union Address (2011) “It’s about a firefighter who can
download the design of a burning building onto a handheld device; a student who can
take classes with a digital textbook; or a patient who can have face-to-face video chats
with her doctor.” The use of telehealth is becoming more widespread; at the University
of Texas Medical Branch, telehealth has been applied for many years and local home
health agencies are employing its use with greater frequency.
The importance of using telehealth
In the United States, five million clients are treated annually for Congestive Heart
Failure (CHF) (Thom, et al. (2006), with a direct cost of $29.6 billion to insurance
companies and $40 billion being paid out to Medicare beneficiaries. In addition there are
associated costs for increased medical doctor office visits and other health care
institutions, specifically hospitals. Due to rising costs, more effective methods for
treating the client at home need to be explored. The Federal Interagency Forum on AgeRelated statistics estimates the growth of the world’s elderly population grew to an
average of 795,000 per month in 2004, with estimates of that number increasing.Telehealth’s Impact On Traditional Nurses Essay
Hospital Compare (2010) indicated the national average for hospital readmission rates for
individuals with heart failure was 24.7%.
Congestive Heart Failure is only one of the disease processes in which telehealth has
had a significant impact. Other disease processes include Diabetes, Autism, and some
forms of mental health. According to the Health Resources and Services Administration
for Rural Health (no date), Telehealth is “ the use of electronic information and
telecommunications technologies to support long-distance clinical health care, patient and
professional health-related education, public health and health administration.
Technologies include videoconferencing, the internet, store-and-forward imaging,
streaming media, and terrestrial and wireless communications” (para 1).
Needs Assessment
Telehealth is rapidly becoming a viable form of client treatment to improve
outcomes and to reduce hospital readmission rates, yet a comprehensive literature review
revealed there are very few resources that discuss teaching the concepts of telehealth to
pre-licensure nursing students.
Significance of the problem
One of the goals for Healthy People 2020 from the Department of Health and
Human Services is to integrate more information technology in health care. To
accomplish this goal it will be necessary to instruct nurses about using informatics in
their client care, yet very few nursing programs are teaching the concept of informatics
with telehealth being a subset of the topic; therefore, nurses are graduating from nursing
schools without being informed about telehealth and its uses. Because teaching  Telehealth’s Impact On Traditional Nurses Essay
telehealth should begin in nursing school at the pre-licensure level, the sample for this
study will be nursing students at a community college; a review of the college’s required
courses for nursing revealed Informatics is not a required course, therefore telehealth is
not being taught.
The purpose of the project is to introduce the concepts of telehealth to pre-licensure
nursing students, to discuss how to use telehealth, analyze situations where telehealth will
be of value, and contrast the advantages versus the disadvantages of using telehealth by
using a learning module. The purpose also includes evaluating the effectiveness of the
learning module.
Research Question
Is the use of a learning module effective in teaching pre-licensure nursing students
about telehealth?
Key concepts of telehealth
Telehealth is “the use of electronic information and telecommunications technologies
to support long-distance clinical health care, patient and professional health-related
education and training, public health and health administration” as stated by Bedi and
Murthy (2003). Telehealth is a process of telemedicine, which according to Bedi and
Murthy (2003) is defined by the World Health Organization:
The delivery of healthcare services, where distance is a critical factor,
by all healthcare professionals using information and communication technologies for the exchange of valid information
for diagnosis, treatment and prevention of disease and injuries,
research and evaluation, and for the continuing education of healthcare
providers, all in the interests of advancing the health of individuals
and their communities. ( p. 11)
Bedi and Murphy (2003) also clarify other concepts as well; they indicate telehealth
systems use different processes to send information to a client’s Electronic Medical
Record (EMR). Some systems use a “store and forward” method, which allows data to
be captured and sent to a healthcare provider at set intervals or upon demand. Other
systems use real-time transmissions of information which makes data available to a
healthcare provider as soon as the data is captured. This data may be x-rays, laboratory
results, Magnetic Resonance Imaging (MRI) or Computerized Axial Tomography (CAT)
scans. Because of the real-time applications, telemonitoring or teleconsultation can be
accomplished as well, with the client in one location and the healthcare provider in
another.Telehealth’s Impact On Traditional Nurses Essay
Theoretical Framework
Kolbs Experiential Learning Theory
In the area of constructing teaching modules on telehealth, the students’ learning
styles have to be considered. The learning module is best suited for D. A. Kolb’s (1984)
Experiential Learning Theory. The concepts that apply to this learning module are:
Abstract Conceptualization (AE): The individuals who score high in this area use an
analytical approach to learning, relying on logical thinking and rational evaluation.
These learners tend to be oriented towards things and symbols and less toward people.
They do best in authority-directed, impersonal learning situations that emphasize theory
and systematic analysis. They don’t care for unstructured learning forms that allow
students to “discover” things, like exercises and simulations. Because the learning
module is a passive experience, the student has time to reflect on the information learned,
especially if the student recorded the audio portion of the module or took notes.
Reflective Observation (RO): The students who score high on this category use a
tentative, impartial, and reflective approach to learning. They rely on careful observation
in making judgments, and prefer lectures that permit them to take the role of impartial
observer. This again is a suitable approach to the learning module. Based on what they
have heard, the student can draw inferences about telehealth, such as when would it be
best used, and to whom telehealth would be most beneficial.
Kolb also states that some people use several learning styles in combination. This
module would be suited for the Assimulator, a combination of the AC and RO. These
people score high in the AC and RO areas. They can understand and create theories.
They excel in inductive reasoning and synthesizing various ideas and observations into an
integrated whole. They are less interested in people and are more concerned with
abstract concepts. A theory for them must fit the facts or they will discard it or reexamine the facts. This combination would be suitable, because the use of telehealth
requires a set of facts before it is placed into use and while it is being used. The student
would have to draw appropriate conclusions and actions for clients who are using
telehealth.Telehealth’s Impact On Traditional Nurses Essay
Conceptual-Theoretical-Empirical Diagram
Conceptual Model: D.A. Kolb’s Experiential Learning Theory
Concepts Studied: Students’ learning styles
Middle Range Theory Concepts
Abstract Conceptualization Reflective Observation
uses an analytical approach to learning uses a tentative, impartial, and
and relies on logical thinking and rational evaluation. reflective approach to learning
Relies on careful observation in
making judgments and prefers
Assimilator, a combination of the AC and RO
Can understand and create theories. They excel in inductive reasoning and synthesizing
various ideas and observations into an integrated whole.

Empirical Research
Learning Module

The use of a pre-test evaluated the nursing students’ knowledge of Telehealth. The
learning module establishes the rules for using telehealth; this allows the student who
uses abstract conceptualization to begin to logically think of instances where telehealth
might be useful. The student who uses reflective observation will begin to mentally
compare what he or she knows about nursing care and how telehealth can augment,
replace, or not replace traditional forms of client treatment. The student who uses
assimilation may begin to reflect on what he or she has learned about telehealth and how
the processes might be improved or how it might be used in combination with in-hospital

Chapter II
Review of Literature
Purpose of Literature Review
The purpose of the literature review is to explore existing literature that discusses
why telehealth is useful; the review is also used to explore the number of studies that
examine specific telehealth devices or services, discusses student learning styles, and to
explore literature that exists that discusses instruction to nurses or nursing students about
the use of telehealth.
Sampling Strategies
Two hundred articles were reviewed based on several criteria:
1) Article discussed the use of telehealth
2) Article was no more than six years of age (unless no other resource found)
3) Article was written in English
4) Article gave a control and an experimental group
5) Article discussed teaching telehealth to nursing students
6) Article discussed cost of telehealth as opposed to hospitalization for the CHF
7) Article discussed learning styles of students
8) Article discussed re-admission rates for clients after a CHF exacerbation episode
Of the articles reviewed one hundred and seventy-seven were eliminated because they did
not meet the stated criteria.
Keywords or terms: Re-admission rates, cost, telehealth, informatics, telehealth devices,
nursing student’s attitudes toward technology, student learning styles, student
demographics, and nursing curricula
Background and Significance
Readmission Rates
The causes of client readmission rates are varied, from the existence of co-morbidities
that influence CHF for example to inadequate follow-up care. Delgado-Passler and
McCaffrey (2006) state readmission rates occur in 20-50% of clients with CHF between
14 days and 6 months after hospital discharge and 16-25% of those relate to repeat
episodes of heart failure exacerbations. Anderson, Tyler, Helms, Hanson, and Sparbel
(2005) found factors influencing readmission rates included being discharged early from
the hospital in an unstable condition, which resulted in 33-40% readmission rates because
of poly-pharmacy, poor nutrition, and socio-economic status.
Cost Telehealth’s Impact On Traditional Nurses Essay
Cost is a factor when clients are hospitalized. The actual cost of hospitalizations to
the CHF client is illustrated by research performed by Neumann, et al. (2009). CHF is
cited as one of the most cost-intensive chronic diseases, being responsible for one to two
percent of direct health cost in Western industrialized nations and in Germany. In
persons 50 years old or greater, CHF becomes a more frequent primary reason for
admissions/re-admissions. The cost to the German public health system was 2.9 billion
euros ($3.74 billion). These data were cited as a means of predicting future costs; of this
amount, 1.3 billion euros ($1.67 billion) went for hospitalizations. Based on this
information, the cost in the United States was estimated to be double that of Germany.
When clients present with CHF, many have other co-morbidities. When this occurs,
the cost for hospitalizations increases. Chatre, Weioner, Jayadevappa, & Johnson (2006)
examined hospitalization costs in clients with both Alzheimer’s disease and CHF. The
study involved 904 elderly clients who were sub-divided into four groups: Alzheimer’s
disease (AD) and CHF (n=240), AD only (n=664), CHF only (n=712), and no-AD and
no-CHF (n=2904). Inpatient care accounted for 78% of the total cost for the AD + CHF
group, 75% for the AD only group, 82% for the CHF only group, and 74% for the nonCHF, non-AD group. The average length of hospital stay was greatest with the AD +
CHF group.
Telehealth has shown promise in reducing costs associated with re-hospitalizations as
illustrated by Jerant, Azari, Martinez, and Nesbitt, (2003) “Three post-hospitalization
nursing care models for reducing readmission charges were examined during 180 days of
follow-up care”( pg 2). The three modalities studied were: 1) video-based home care; 2)
telephone calls; and 3) usual care which includes home care visits. The study found CHF
related readmission charges were $44,470 at the trial mean cost in the usual care group,
$5,850 trial mean for the telecare group, and $7,320 trial mean for the telephone group.
These results were 86% to 84% lower in the telenursing groups compared to usual care.
Both groups had a significantly lower number of visits to the Emergency Department
(p=0.0342) and incurred fewer costs (p = 0.0487).
Telehealth Systems
There is evidence to support the value of telehealth in the area of client monitoring for
certain disease processes through the use of different devices, and several studies have
been done using various telehealth delivery systems; which devices to use often depend Telehealth’s Impact On Traditional Nurses Essay
on client preference and the client’s specific need.
Health Buddy® system is an in-home communication device that allows interaction
between the client and the health care provider. LaFramboise, Todero, Zimmerman, &
Agrawal, (2003) conducted a random study using this system involving ninety people
divided into four groups over two months. The first group (n=26) received telephone
management only; the second group (n=23) received five home visits by a research nurse;
the third group (n=21) received assessment and education through the Health Buddy®
system; and the fourth group (n=20) received a combination of five home visits plus the
use of the Health Buddy® system. The specific areas of interest were: self-efficacy,
functional status, depression, and health-related quality of life. The results evaluated
each area. Self-care efficacy was evaluated using a Scheffe’s test which found a
significant difference between the four groups with the results of a p value of 0.05,
indicating the telephone only group demonstrated a decreased confidence in carrying out
their self-care needs. The functional test group had a p value of 0.005 with no
significance between the groups. With all groups together, a six minute walk test was
measured at the base line measurement and two months. Fifty- two point two percent of
those participating improved their walking distance by ten percent, and 44.8% improved
their walking distance by 20%. The depression scale showed 29% of the participants
having depression at the beginning of the study, and this improved over time with a p
value of 0.054, approaching statistical significance. LaFramboise et al. (2003) indicate Telehealth’s Impact On Traditional Nurses Essay
that the Health Buddy® system did not appear to have any significant advantage over any
other approach; however, the use of the Health Buddy® system can be used in place of
another delivery system or in conjunction with another system resulting in possible
decreased cost. Other systems such as Phillips Command Station® and mymedic®
operate essentially as does the Health Buddy® system.
Some clients need face to face monitoring in order for the physician to examine body
language, facial expressions and other assessment items that can only be seen. Some
teleheatlh systems like ValueOptions® services utilizing high-definition video
conferencing units and IP-based networking enabled the delivery of tele-psychiatry.
Value Options ® website (no date) states, “Shortly after implementation, The David
Lawrence Center received dramatic evidence of the solution’s effectiveness. During a
virtual consultation, the attending physician was able to pick up both verbal and nonverbal cues of a patient at risk of a harmful breakdown. The physician was able to
immediately affect an intervention through the proper channels and have the client
admitted to a hospital for treatment, a potentially life-saving event” (Value Options, p. 1).
“The anecdotal evidence of success is supported by the study findings: for a 14-week
period from June 28 to October 1, 2010, the service had a 62 percent increase of care
delivery to clients over the same period the previous year. That equates to an increase
from serving 95 clients and providing 645 services during the June to October timeframe
in 2009, to 157 clients served and 1,223 services provided during the same period in
2010.” (Value Options p. 2).
Telehealth360® as stated by the website Healthcare Interactive (no date) is an
Interactive Voice Response (IVR) model that works in real time and unlike the
previously stated telehealth systems, does not require any installation of equipment in the
client’s home. As soon as clients enter data via their home or cell phone, the data is


immediately available to the medical professional giving access to the client medical
record through the system. The system is designed to call clients at pre-selected times,
asking clients specific questions about their health status and obtaining several
physiological and vital signs in alpha numerical values. Depending on the clients’
responses, follow-up telephone calls or additional in-home visits can be made, and the
clients’ physician can be immediately notified of any significant changes in the clients’Telehealth’s Impact On Traditional Nurses Essay
Nursing Students’ Attitudes
“The recent information technology revolution in healthcare has created demand for
nurses with sound knowledge of Nursing Informatics (NI); however, many undergraduate
nursing schools across North America do not offer sufficient informatics education”
(Pilarski, 2011 p. 1) indicates. Maag, (2006) stated, “Nursing students’ predispositions
toward technology may be a factor affecting their use of technology in educational and
clinical settings” (p. 112). Pilarski, (2011) continues to attest a national survey was
conducted to collect attitudinal measures toward technology and data on technology
instruction. This was accomplished in order to assist educators with developing
informatics technology in their respective curricula. The outcomes indicate the students
had an overall positive attitude toward technology; however the students reported formal
education in the use of technology applications was low. This shortcoming should be
addressed through enhancement of nursing core curriculum. McNeil, et al. (2005) found
that half of the undergraduate programs were teaching informatics in some form such as
word processing and informatics literacy skills; however, teaching the use of information
system data standards, the Nursing Information and Data Set Evaluation Center criteria,
the unified medical language system (UMLS), and the nurse’s role in the life cycle of an
information system was lacking. Almost 50% of the students felt faculty was “novices”
and “advanced beginners” in teaching and using NI applications. Participants reported no
future plans to offer NI training in their region.
Because informatics (telehealth) is being recognized as a viable tool in managing
various disease processes, several universities are trying to integrate teaching about the
subject in their curriculum. Gallagher-Lepak, Scheibel, and Campbell-Gibson, (2009),
conducted staff training sessions at The University of Wisconsin to develop telehealth
courses for Theoretical Foundations of Nursing, Community Health Nursing, Nursing
Management, and Leadership, and Research. The faculty (n=26) were trained in new
technology and on how telehealth content was added into the nursing curriculum. The
five nursing degree granting institutions of the University of Wisconsin provided training
to faculty on informatics and telehealth. The faculty was given a pre and post-training
survey, Informatics and Computer Self-Assessment, to evaluate their knowledge before
and after training. The survey is built on a one to five scale, with one being no
knowledge and five being high knowledge. The scale consisted of 45 questions. The
results indicated faculty scored 2.5 (52.02 %) on informatics skills at the beginning of the
training, and scored a 3.22 (63.55%) after training. In the area of use of informatics
knowledge the faculty initially scored 2.38 (48.04%), but after the training they scored
3.22 (63.55%). The students who took the courses after the faculty were trained in
teaching telehealth and informatics indicated they understood how the role of telehealth
will help treat clients. Most, however, expressed concern the client still needed human,
one-on-one interaction with nurses and telehealth should not be used exclusively; they
were more favorable to the idea of combining telehealth with human interaction with the
client.Telehealth’s Impact On Traditional Nurses Essay
Because computerized learning is becoming more prevalent in schools, investigating
students’ attitudes toward technology is important. Johnson, Lillis, and Hall, (2010)
conducted a study to discover how Irish nursing students viewed technological supports
in the clinical laboratory setting at the University of Limerick, Scotland in the
Department of Nursing and Midwifery. The study indicates undergraduates of a
Bachelors of Science nursing program were instructed on components of Microbiology
Immunology and Infection Control. The theory component was taught on-line in a series
of learning modules. The laboratory component was taught via students video-recording
a specific skill. Before demonstrating the skill the students were required to study the
specific skill through the Digital Nursing Archive (DNA), the Skills Laboratory instructor
would in turn demonstrate the skill. Students were then randomly selected to perform the
skill correctly and videotape their performance. The video recording was later reviewed
and critiqued by faculty. In relationship to the students’ view of technology, some of the
comments by the students were quoted as: “found that this experience did enhance my
learning. It provided us a chance to re-visit our skills demonstration and learn from our
mistakes.” “…doing it practically and being video recorded it enhanced our ability to do
the procedure and by being video recorded we can critique ourselves.” All students
strongly agreed using the Digital Nursing Archive enhanced their learning. The other
modes of technology discussed were using a system called Moodle which was a content
management system that encompassed the laboratory sessions; the content was in the
form of power points, video clips, and PDF format lectures. A Likert-type questionnaire
was used to analyze the satisfaction with using technology in teaching the skill module.
Forty-four responded with a 4.5 agreement on the five point scale, with five being greatly
satisfied. The students expressed satisfaction with this type of learning as well. The
negative aspects cited were minor difficulties with accessing material, and general
uncomfortableness of being video recorded.
Fydryszewski, Scanlan, Guiles, Tucker (2010) examined outcomes and students’
perception of course quality of an undergraduate phlebotomy program that used either
classroom delivery or a web-based course. The student learning outcomes were
measured by final exam performance and perceptions of course quality. Seven principles
that were mentioned for good practice are: 1) encourages contact between students and
instructor; 2) develops reciprocity and cooperation among students; 3) uses active
learning techniques; 4) gives prompt feedback; 5) emphasizes time on task; 6)
communicates high expectations, and 7) respects diverse talents and ways of learning.
Students had the option to enroll in either the traditional course or the web-based course.Telehealth’s Impact On Traditional Nurses Essay
Of the 62 students enrolled, 33 enrolled in the live program and 29 in the web-based
program. The final study sample was 30, with 19 in the live program and 11 in the webbased program. Two tests were administered, covering part one and part two of the
course. The scores for the part one test from the live classroom mean was 88.79, with the
web-based mean being 87.27. For the part two test, the live classroom mean was 85.32
with the web-based group scoring 87.09. Therefore, there was no real significant
difference in cognitive outcomes between the two methods of course delivery. In the
area of student satisfaction, the students’ with live instruction rated contact with the
instructor higher than those in the web-based course. The overall satisfaction with the
courses was not significantly different the study noted Telehealth’s Impact On Traditional Nurses Essay