Nursing professionalsʼ experiences of the facilitators and barriers to the use of telehealth applications: - a systematic review of qualitative evidence

Review question/objective The objective of this review is to sythesize the best available evidence on nursing professionals experiences of facilitators and barriers to the use of online telehealth applications in nursing practice. Background Telehealth means the delivery of health care services and health-related information at a distance, using information and communication technology (ICT).1, 2 The first telehealth experiments were already conducted in the 1960's, but innovations started to win ground in the 1990's due to the development of new technologies.1, 3 At first, telehealth services meant mostly the use of videoconferencing systems. More recently, Internet applications and cellular phones have been taken in to use in communication between health care professionals and patients.4 Today, telehealth, telenursing, telemedicine and electronic communication are an essential component of patient care,5 and in future they may be increasingly used by nurses in their work.6 Telehealth provides opportunities for addressing social and geographical inequalities in health care.7 With increasing computer and Internet use8 more people have possibilities to communicate by telehealth applications such as videophones and videoconferencing systems or ordinary e-mail.9 It has been found that e-mail contact between health care professionals and patients can improve communication10, enhance patient-centred care11, facilitate patient education12, reduce costs and save working time.10, 13 However, it has been found that only a small proportion of nurses use telehealth applications although health services may be situated a long way from users.14 Some earlier studies point out that hospital-based health care is decreasing dramatically, while nursing at home is becoming more and more common.9, 15 These changes require new skills and attitudes among nursing personnel.16 Nurses need to be more flexible in their work17 and be open to new working methods.16 Integration of telehealth services in patient care is not always easy.18 There are many factors that may complicate the implementation of new applications. Nurses may feel that videophones should not replace actual visits to patients' homes in homecare.19 Staff members may also have insufficient knowledge about computers and difficulties in handling telehealth applications.20 While the benefits of electronic communication are recognized by both patients and personnel, concerns about confidentiality and security are also expressed.21 Staff education for the use of the new system has been a key component of the successful implementation of telehealth applications.19, 22 Nurses' perceptions of usefulness are also a main factor in the adoption of information technology in daily use. Nurses want to emphasize the advantages of applications in patient care.23, 24 However, Gagnon et al. reported that there is very limited evidence on effective interventions promoting the adoption of information technology applications by healthcare professionals.25 The use of telehealth applications has earlier been studied particularly from different patient groups' points of view. Cherofsky et al. performed a systematic review of the effectiveness of telehealth interventions in adult patients with congestive heart failure in a long-term home health care setting.26 They reported that the results of the review were equivocal. Only one study has demonstrated statistically significant results of telehealth applications' effects in reducing department visits and hospital readmissions. Also Inglis et al. have reported a review that focused on patients with heart failure.27 They analyzed randomized controlled trials of structured telephone support or telemonitoring compared to standard practice for patients with heart failure. The researchers concluded that structured telephone support and telemonitoring were effective in reducing the risk of all-cause mortality and chronic heart failure-related hospitalizations in this patient group. These interventions may improve quality of life and reduce costs. Bailey et al. have studied interactive computer-based interventions for sexual health promotion. The review concentrates on patients' point of view.28 According to the review, interactive computer-based interventions are effective tools for learning about sexual health, and they also show some positive effects on self-efficacy and sexual behaviour. McLean et al. have reviewed the effectiveness of telehealthcare for chronic obstructive pulmonary disease (COPD) compared with usual face-to-face care.29 According to the study, telehealthcare in COPD appears to have a possible impact on the quality of life of patients and the number of times patients attend the emergency department and the hospital. McLean et al. have earlier reported a review of the effectiveness of telehealthcare interventions in people with asthma.30 They summarised that telehealthcare interventions are unlikely to result in clinically relevant improvements in health outcomes in those with relatively mild asthma, but may have a role in those with more severe disease who are at high risk of hospital admission. Currell et al. found only little evidence of clinical benefits of using telecommunication technologies when they compared telemedicine with face-to-face patient care.31 In their review the participants were qualified health professionals and patients receiving care through telemedicine. Wade et al. conducted a systematic review of economic analyses of the clinical use of telehealth services.2 They concluded that delivery of health services by real-time video communication was cost-effective for home care, while not being cost-effective for local delivery of services between hospitals and primary care. Some systematic reviews on this subject will also be published in the future. There are some accepted protocols in Joanna Briggs Institute (JBI) and Cochrane databases. Collins et al. will review studies which concentrate on the effectiveness of web-based interventions in achieving weight loss and maintenance in overweight and obese adults.32 Yuginovich and Pearce will identify the best available evidence in relation to the experiences with assistive technology of consumers aged over 65 years living in community dwellings, their carers and health care professionals.33 Atherton et al. will assess the effects of health care professionals' communication with patients via e-mail. The review will consider both health care professionals' and patients' points of view.34 Tan and Lai have published a protocol for a systematic review to evaluate if the use of telemedicine technology aimed to provide education and support for the families of newborn infants receiving intensive care affects the length of hospital stay.35 We can state that online communication between nurses and patients has not really been studied from the nursing professionals' point of view. In this review telehealth means the delivery of health care services and health-related information at a distance, using information and communication technology (ICT). The study concentrates especially on online services which are examined from nurses' point of view. Inclusion criteria Types of participants This review will consider studies that include nursing professionals. For this systematic review, nursing professionals refer to all those members of nursing staff who participate in the immediate patients' care. Phenomena of interest This review will only consider studies that explore nursing professionals' experiences of facilitators and barriers (such as, but not limited to, behavioural issues, technology and infrastructure issues, workload issues, education and training issues, access to resources issues) to the use of online telehealth applications. This review will look at telehealth experiences from a wide range of clinical nursing environments such as acute care, special health care, primary health care, community nursing and home health care. For this systematic review, online telehealth refers to the delivery of health care services and health-related information at a distance, using information and communication technology applications. Types of studies This review will consider any interpretive studies that draw on the experiences of nurses using online telehealth applications. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of the MEDLINE and CINAHL databases will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched include: 1. ARTO 2. CINAHL 3. Cochrane Library 4. EMBASE 5. ERIC 6. LINDA 7. Medic 8. MEDLINE 9. Ohtanen 10. PubMed 11. PsycINFO 12. Web of Science The search for unpublished studies will include: Grey literature in the form of conference materials, documents on Internet pages of ministries, WHO, the European Union, health care organizations etc., that meet the inclusion criteria will be included. Reference lists and bibliographies of articles collected from those identified in the above process will also be searched for eligible studies. Limitations: The search will be limited to the years 1995-2012. The search is unlikely to identify studies using telenursing applications prior to 1995. Telenursing technology is still a new concept in many countries. Studies published in English and in Finnish will be included in the review. Initial keywords to be used in this review will be: Participants: Nursing professionals - nursing professional - nursing staff - nursing personnel - nurse - registered nurse - homecare nurse - community nurse - midwife - practical nurse - nurse specialist Interest: Use of online telehealth applications - telehealth - telenursing - telemedicine - telecare - eHealth - telecommunication - online communication - real-time communication - electronic communication - Internet - World Wide Web - web-based technology - information technology - communication technology - barrier - facilitator - qualitative method - qualitative design - qualitative data - descriptive design - interview study - thematic interview - open-ended questionnaire Context: Nursing practice - health care - hospital - clinical nursing - acute care - special health care - primary health care - outpatient clinic - maternity care - community nursing - home health care - hospice Assessment of methodological quality Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details on the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Where possible, qualitative research findings will be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation through assembling the findings (Level 1 findings) rated according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Conflicts of interest None Acknowledgements This study is partly funded by Satakunta Hospital District (EVO 81535) and the Finnish Cultural Foundation (Kaisu and Antti Ravani Foundation).