Connecting Rural Residents to the Nurse Practitioner via Two-Way Technology - Research Paper Example

Connecting Rural Residents to the Nurse Practitioner via Two-Way Technology: Implications for Clinical Practice A Prospectus Paper Shelly Kelly, RN,BSN Midwestern State University Chapter 1: Introduction 1.1 Overview of the Issues of Concern Internet and internet communication has grown out to be a powerful medium in healthcare in the present era. The internet acts as valid source of information for practitioners, caregivers and clients alike. More than 40% of the static information in the internet relates to health and healthcare (Nicholson, L., 1999). What is new about the role of the Internet in healthcare is the Internets transition from a communications avenue for researchers to a powerful medium of connection and communications for everyone. As a result, more people connect to the network and readily communicate using standardized and cost-effective tools. This connection creates an avenue for healthcare delivery, healthcare financing, and administration. All of these avenues are equally applicable to nursing care within the geographically isolated population. Indeed, these two-way communication systems dissolve and abolish the boundaries of space and time as well as the disadvantage of distance. 1.2. Author’s Involvement As the author, I am a nurse practitioner student researcher and have a stake in this research topic. My extended family members live in a rural West Texas community, and I have watched them struggle to access healthcare over the past several years. As a future family nurse practitioner, I hope to work in a clinic where I can serve the rural population. For these reasons, I am interested in seeing technology utilized by nurse practitioners in the rural clinic setting. 1.3. Background and Significance Internet is now a common tool of todays healthcare providers. Moreover, it is easily accessible, up-to-date, and a valuable information system for healthcare practice. Taylor-Seehafer has mentioned about studies that indicate that the nurse practitioners must master computers and the Internet to keep up with the needs of their patients and todays healthcare system (Taylor-Seehafer, Abel, Tyler, and Sonstein, 2004). From experience, we see through the Internet, communication has achieved a newer dimension by several available technologies that enable seamless audiovisual communications, the quality of which almost reach a virtual reality. The Internet is useful in multiple areas such as education, clinical decision making, and research. One such extended use may incorporate the Internet into the rural clinic practice. Two-way internet technology may extend care and provide information to the rural patient from the clinic without the need for travel. Today, more and more healthcare organizations are turning to Internet-enabled information technologies with different applications. Medical providers require significant information technology to capture, review, and disseminate administrative, financial, and clinical information. Harrison and Lee right points out that deployment of an internet-based two-way communication system in practice may be an avenue to control costs while improving care delivery and enhancing patient satisfaction (Harrison and Lee, 2006). The concept of the information-empowered patient is growing rapidly. In this new environment, where access to the Internet is not a problem, the advanced practice nurse should think about providing care through an internet-based model that consolidates their care delivery and information-sharing processes. This will not only provide cost-effective healthcare services, but may also reach across the continuum of care to all people inclusive of those who live in a remote area. However, moving from the old healthcare model to the new internet-based communication healthcare model will not be easy. This endeavor involves dismantling and reconstruction of the office-based care delivery that requires physical presence of both the patient and the nurse. The structures, tools, and processes that worked and proved valuable in the old environment will not be successful in this new model. Instead, new approaches are needed to meet the operational requirements of the new healthcare model that involves bidirectional communication in a virtual interface. The Internet is ideal for this purpose, but only if the design of each application supports the practice goals of the nurse practitioner. It is easy to think that the Internet is commodity-based and that its implementation is a no brainer." Clark argues, however, that this impression is dangerously far from the truth (Clark, 1998). The Internets value to healthcare providers lies in the contents that the applications offer. Well-designed and tested processes for developing content-based applications remain limited. The issues surrounding implementation are complex, and practitioners need a solid foundation for understanding them. This indicates the need for extra education for the nurse practitioners who would implement them if such a system were available for practice. If they master it, the use of this technology may improve healthcare delivery by nurse practitioners in the clinic setting. There are limitations to this proposal, such as, cost being a major deterrent, privacy issues, web design issues, video telemedicine vs. internet telehealth, and barriers to use of internet communication systems by the proposed rural Texas population. Brown has nevertheless foreseen this and states that this is going to be an imperative since technology has invaded todays healthcare delivery system, and is here to stay. It is time for the nursing faculty to introduce Internet and related technologies by creatively facilitating them in the curriculum (Brown, G., 1999). Internet usage, installation of requisite software, and cost of computer hardware would be matters of immediate concern to the practitioner. Cost may be one of the most significant barriers in implementation of such a project for an advanced practice nurse. Community centres, schools, and other places in a remote community now have facilities for internet ability. Grants can help obtain coverage for the cost of equipment and installation fees. Moreover, Newhouse points to the recent Medicare policy of reimbursing the cost of telecommunication to the nurse practitioner, which is an important advancement in this wake to remove barriers to use the internet for practice for the nurses (Newhouse, R. P., 2005). Medicare does reimburse the patients for internet use in case of pregnant and nursing mothers. Appendix 2 of Medicare Part B document also allows internet reimbursement for nurse practitioners (Medicare Hand Book, Part B, Appendix 2). Chapter 2: Integrative Review of the Research Literature 2.1. Strategy of Literature Review For the purpose of the preliminary review of literature to support the rationale, need, and continuation of the project, the author conducted an exhaustive literature search. Electronic databases accessed for information included: CINHAL, Medline and Pubmed along with the Google Scholar internet search engine. The key words in the search included: rural, women, health promotion, nurse practitioner, computer, technology, education, internet, telemedicine, telenursing, telehealth, webcam, communication, access to care, Medicare reimbursement and improvement in practice. Inclusion criteria for each article reviewed were answers to the following questions: 1. Was the article a valid research article? 2. Did the article’s study include computer and internet based communication technology applied to nursing practice? 3. Was the article published within the past 10 years? 4. Did the article have some identification with a rural American population healthcare delivery? Each article must answer “yes” to all of these four questions. Based on these criteria, out of about 250 initial articles, only 25 fit the criteria described above. In this prospectus paper, this author intends to present only the overview of the article reviews that provides a strong supportive basis for the proposed project research paper. If allowed to continue, the final presentation will include an exhaustive review of literature and a conclusion derived from a critical point of view. 2.2. Review of Literature As highlighted in the introduction, the advent of the Internet has brought a wave of new terminology. U.S. Department of Health has defined Telehealth as the use of telecommunication technologies for healthcare. When applied in clinical care, it is known as telemedicine. By this definition, this can also be used in patient teaching and home health, distant learning of the professional education through computer and internet, administrative and program planning, and many other diverse aspects of healthcare delivery system that are developing and hitherto unknown (U.S. Department of Health and Human Services). As cited in Sorrell-Jones and coworkers work, this uses medical information exchanged from one site to another via electronic communication systems to improve the patients health status. The avenues of technology that can deliver this form of care include video conferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, patient education and professional education, and nursing call centres. The definition of Telehealth is delivery, management, and coordination of care and services provided through these technologies within the nursing practice domain. This could encompass all types of nursing care and services delivered across a distance (Sorrell-Jones, Tschirch, and Liong, 2006). This is, however, a broad term that includes telephone, fax, electronic mail, internet, internet-based video conferencing and other two way communication systems, video monitoring, and interactive video to remove time and distance barrier for the delivery of nursing care. Perednia, & Allan’s study, as cited in Laflamme, Wilcox, Sullivan, Schadow, Lindbergh, & Warvel, et al., 2005, conceptualizes specifically the nurse who is often an advanced practice nurse providing healthcare through a two-way communication with the clients at rural areas through a distance. Depending on the specialty of practice of the advance practice nurse, the term may change to telepsychiatry where the provider uses two-way audio and video transmission to provide mental health services. In this regard, interactive video conferencing uses monitor and a dedicated telephone line to provide internet service. In this system, images and voice transmission occur bilaterally between the nurse and the patient at a geographically distant site. The need of the hour is to leverage information technology to improve quality and efficacy of healthcare delivery. When considering this technology, access to computer by rural population continues to be a prominent question. A recent study by Bullock (2004) reported that in the rural West Texas town of Littlefield “…284 (75.3%) of the respondents reported they had access to a computer.” In comparison, the U.S. Census Bureau reports that in 2003, 70 million American households, or 62 percent, had one or more computers, up from 56 percent in 2001 (Cheeseman-Day, Janus and Davis, 2005). The issue of limited computer access is therefore rapidly fading out with increasing availability of computers and internet access in the rural population (Wickham & Stewart’s study, cited in Kennedy, A., 2005). Another concern may be the cultural acceptability of such unconventional healthcare. Rohland and colleagues investigate the barriers to this and suggest that unfamiliarity with the technology or system, confidentiality issues, impersonal approach to healthcare, and lack of knowledge may act as a barrier to participate (Rohland, Saleh, Rohrer, & Romitti, 2000), whereas Chaffin and Maddux argue that this can also be a problematic medium for those who have difficulty with hearing or vision. The user-friendly appearance of the WebPages is very relevant and significant, since WebPages are important tools for the nurse to deliver health education (Chaffin & Maddux, 2007). Users must be educated to use Internet communications in an effective manner. Bohnenkamp and coworkers have analysed the reasons for potential failure of such an effective medium due to lack of training, nervousness to use a new technology, difficulty communicating through a audiovisual system, and a possible experience of emotional distance between the patients and the nurses (Bohnenkamp, McDonald, Lopez, Krupinski, & Blackett, 2004). Furthermore, nursing care is not just giving medications, it involves care of the whole person through a holistic model where every interaction serves as a cue to care. While communicating online, the nurse may face problems reading body language, ascertaining voice fluctuation, and inferring the meaning of the written word through a computer screen. Moreover, the therapeutic touch, which is an important nursing intervention, would be missing. In order to circumvent these issues, an initial face-to-face consultation before beginning the online relationship would be essential. Mattson and coworkers raise yet another concern of internet communication with a nurse practitioner which is privacy and confidentiality. One particular article documents attempts made to intervene and protect patient confidentiality and identity with utmost privacy protocols in internet communications (Mattson, Shearer, & Long, 2002). As noted previously, the current perceived barrier by advanced practice nurses for use of such telecommunication is cost. Newhouse has already pointed out that this reluctance due to cost is no longer valid since they can now bill Medicare for such costs for the use of such service (Newhouse, R. P., 2005). Video teleconferencing or VTC has been in use for quite some time, and literature provides evidence of its use in a wide array of healthcare settings. Laflamme et al. has reviewed researches that have studied the use of VTC and has recommended its remote use in nursing home residential care in the given scenario of paucity of clinicians and nurses there (Laflamme et al., 2005). Wound care nursing through VTC in such settings has yielded positive and encouraging results. When time and distance make availability of the nurse an impossibility, VTC has been found to be sufficient to make a diagnosis and prescription. It has also been recommended that nurse practitioners can use it during office hours or as an as needed program when any issues arise. Armer reports the use of VTC in professional development of a nurse practitioner in rural locations through internet based mentoring programs. VTC and internet consultation can also be used for online collaborative practice with an off-site practitioner that otherwise would have been more time consuming and cumbersome, and in these situations, the nurse can provide more confident management (Armer, J. M., 2003). Faulkner & McCelland report internet based VTC broadcast of a live video on menopause to female patients in 11 rural sites and positive feedbacks from 92% of the participants. Technical difficulty is always a problem, but the conclusion to provide such education through VTS in future indicates the benefits of such systems (Faulkner, K., & McClelland, L., 2002). There could be many more applications validated by different studies, such as home care in postoperative patients discharged to home and telenursing homecare virtual visits. Apart from significantly better patient satisfaction, Hart and Schmidt mentions, this could reduce the duration of hospital stay of colostomy patients (Hart, A.C., & Schmidt, K., 2003). Advanced practice nurses can extend a remote practice to these recent postoperative patients (Bohnenkamp, S. K., McDonald, P., Lopez, A. M., Krupinski, E., & Blackett, A., 2004). Although no specific research is available, webcam is an excellent development in technology that is being extensively used in internet-based communications through simple to execute programs, and it has a potential to be used in internet-based two-way communication, and the nurse practitioners can literally reach the patients home on a one to one basis, and they should learn the application. Internet consultation, however, uses a different technology for e-health consultation than VTC. These are also media of two-way communications without usually any visual communications, and they depend on e-mail, chat rooms, online focus groups or web based interaction software such as WebCT. Chaffin & Maddux examines their potential and states these can provide education, answer questions, and can provide support by connecting the patient to the provider. These programs have provision to add a visual element to it, if webcam is added to these. The remote users abilities and physical limitations must be considered, and accommodations must be made for age-group oriented adjustments for site, hearing, and dexterity. The nurse practitioner while contemplating communication with older people, must consider these factors (Chaffin, A. J., & Maddux, C. D., 2007). Kennedy examined a project of use of WebCT to bring a group of people at distance, together is possible, and this can be used as a dynamic internet-based interface for interactive discussions. This can also anonymize the user, and it can provide a non-threatening medium to participate and interact. This can provide a cheap and secure system of communication in multiple ways. The user does not need to use any software to run the program, and the nurse practitioner can use it to offer education to patients (Kennedy, A. J., 2005). The 2006 Chester & Glass review provides evidence for the usefulness of such system in online counseling for those living in geographically remote areas (Robson & Robson’s study as cited in Chester, A., & Glass, C. A., 2006). Practitioners are not unanimous about the effectiveness of such program, but they opined about the necessity of nurses awareness about the patients cultural backgrounds, environment of the session, presence of influential family members, and legal jurisdiction before implementation of such programs since they affect the quality of counseling (Shapiro & Schulman’s study as cited in Chester, A., & Glass, C. A., 2006). There is a need for legislation about practice in internet, and the nurse practitioner must be aware and give consideration to these factors when contemplating online consultation to a remote geographic area. Recently, Sullivan, Weinert, & Cudney examined the evidence that chronic illness management in rural areas may be accomplished through internet communication systems, specifically in womens health self-management areas (Sullivan, T., Weinert, C., & Cudney, S., 2003). Oriet, Cudney, & Weinert study provided evidence that through this Health Chat program a Women’s Health nurse practitioners facilitated discussions on questions posed by women, and most of the participants provided positive feedback (Oriet, P., Cudney, S., & Weinert, S. L., 2007). Internet based care delivery has been applied in the domestic violence shelters. Mattson and coworkers’ relevant study has shown that internet based focus groups in DVS via telehealth has been successful, although privacy was the main negative issue identified by the participants since possible violation of it through internet communication may also violate their safety by their violent partners (Mattson, S., Shearer, N., & Long, C., 2002). Tschirch and colleagues implemented a project through The Texas Tele-Mental Health Network used the service of nurse practitioners through internet-enabled communication to provide psychiatric assessment, diagnosis, and treatment, including psychopharmacological agents, to women living in the Women’s Shelter of East Texas through a telehealth network. In this collaborative project, the outcomes were very much acceptable from the perspectives of telemental health program (Tschirch, P., Walker, G., & Calvacca, L. T., 2006). Finally Tachakra reports that teleconsulation and teleradiology through remote-internet enabled PDA systems have been successful to treat and manage injuries and trauma (Tachakra, S., 2006). Chapter Three: Identification and Feasibility of the Project 3.1. Purpose It is possible to have video teleconferencing without internet access, and it is possible to conduct internet consultation without video capabilities. Both of these avenues have been shown to be valuable to the nurse practitioner in her practice with rural women. It is this author’s belief that future education and management of chronic illness for the rural woman will be facilitated in the patient’s home. Bagshaw and Neill commented that the internet and video capabilities each hold tremendous value in their own respects in paving the way for the nurse practitioner to be effective in these treatment and educational arenas despite the miles and time that separate the rural woman and the NP (Bagshaw, BA. and Neill, KM., 2000). 3.2. Conceptual / Theoretical Framework It is known that the Internet can create another dimension where the nurses in the community can address the challenging health issues of the population they serve. Will the Nurse Practitioner be able to access clients located in a rural clinic and be able to communicate with them with the help of this technological advance? Can two-way communication in the virtual meeting place of the Internet obviate the need of a physical presence of the nurse practitioner in the remote rural clinic or of the long travel of the established rural clients to the office of the practitioner? Can use of such technology make both the parties feel satisfied about the virtual meeting where concerns can be addressed, questions may be answered, healthcare can be delivered, and information may be shared? Even if it does that, will it be effective in terms of outcome? These are pertinent questions, and fortunately research and literature provide a lot of evidence, although they do not cease to find out the barriers against implementation of such a care method. In this prospectus paper, this author proposes a review of current literature to examine the use of such technology in practice, and to answer the questions raised previously. The ultimate benefit could be seen in an article written and published in the journal Advanced for Nurse Practitioners. This medium would allow all nurse practitioners to gain knowledge and insight into the utilization of VTC and internet communication within the scope of their practice. There is not currently a nursing model that focuses specifically on the impact/implementation of computer technology in advanced practice nursing. After careful review and identification of themes and trends in the above research, this author proposes the possible construction of a nursing model that can be used as a guide when conducting future research on the relationships between technology, the rural population and the nurse practitioner. Based on current research, this nursing model may become a future framework for internet based communication in advanced practice nursing. This model would aim to solve the problems of remote patients, could incorporate appropriate training for the nurses and patients for such usage, would incorporate more modern software customise for such purpose, could validate the model through further research based on outcome, and could provide guidelines for internet-based telecommunication and nursing practice (Copeland, M., 2002). This model may work under the theoretical framework suggested by Grant, named the “Umbrella perspective on Communication Technology.” Although the details of this theoretical framework is outside the scope of this prospectus, in brief, the whole system can be compared with an umbrella, where bottom level of the umbrella consists of the technology, the next level, the organizational infrastructure; the top level including political, economic, and media systems, as well as other groups of individuals or organizations serving a common set of functions in society, such as healthcare authorities. Finally, the “handle” for the umbrella is the individual user, implying that the relationship between the user and a technology must be examined in order to get a “handle” on the technology. “The basic premise of the umbrella perspective is that all five areas of the umbrella must be examined in order to understand a technology” (Grant, AE., Unknown). 3.3 Rationale for Implementing the Project This author has evidence that the Internet has become a very valuable and powerful tool for connecting all the players in the healthcare industry. It has already shown great promise in providing new ways to improve communications, increase professional collaboration, and leverage intellectual capital through enhanced information sharing. This author therefore proposes a project that would investigate the feasibility of such internet-incorporated two-way communication system. This system could be used as a medium between the nurse practitioner and the remote rural patients who have sparse access to medical care and healthcare information, whereby high-quality clinical outcomes and timely interventions at a cost-effective rate are possible. To examine the pros and cons of such a proposal, a wide, in-depth, and critical literature review is necessary, and this author seeks permission for continuing the literature review on this project proposal. Prior research dated 1997 highlighted the implications of Information Technology in nursing practice, and it predicted that one day nurses will access information and manipulate the Internet within the information-rich environment to benefit patient care. In this proposed project, the case of Texas patients is just an example to show the increasingly important role played by the Internet and the World Wide Web. Many innovative approaches to this end have incorporated inquiry and internet-based information processing in nursing curriculum. It is evident that communication systems based on the internet will have important and increasingly prominent role within nursing practice. A review of literature, therefore, is of utmost importance and the need of the hour to find out current evidence for such a project which is very relevant to the area of this authors practice (McKenna, LG. and Ribbons, RM., 1997). Reference List Armer, J. M. (2003). A case study of the use of telemedicine by advanced practice nurses in rural Missouri [Electronic version]. The Journal of Continuing Education in Nursing, 34(5), 226-233. Bagshaw, BA. and Neill, KM., (2000). Nurse practitioners and the Internet. Clinical Excellence for Nurse Practitioners; 4(4): 245-9. Bohnenkamp, S. K., McDonald, P., Lopez, A. M., Krupinski, E., & Blackett, A. (2004). 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