Using telenursing after discharge to counsel patients diagnosed with COVID-19

Nurses were at the forefront of the COVID-19 pandemic, an extraordinary situation not previously experienced or foreseen by the healthcare system. In addition to caring for patients with COVID-19, nurses assumed the roles of educating and counseling patients on discharge and postdischarge. This study defines and examines the counseling role of nurses practicing telenursing during the COVID-19 pandemic. Background Throughout its history, the nursing profession has become increasingly instrumental to improving health and advancing health services.1 As the healthcare industry has changed, the nursing profession has also evolved, with nurses taking on various roles in the care and treatment of individuals and contributing significantly to the development of the profession.2,3 In addition to providing care services to individuals, families, and the community, primarily working in hospitals, outpatient diagnosis and treatment centers, and home health organizations, nurses increasingly produce and disseminate information through their work in research and development, health education, and consultancy roles.1 Nurses in these roles act as collaborators, advocates, educators, investigators, decision-makers, career developers, communicators, coordinators, rehabilitators, and consultants.4 Through their education and experience, nurses possess the knowledge to achieve better health outcomes, not only by treating diseases but by improving the overall community.2 With this knowledge, nurses are well positioned for the counseling role and emerge as trainers, communicators, and coordinators.3 Nurses can counsel sick and healthy people of all ages, educating them about diseases by raising awareness, providing information about available resources for coping with diseases, encouraging the effective use of healthcare resources, increasing the quality of care, and sharing evidence-based scientific information with patients.2,3,5 Telenursing practices With advances in technology, nursing science continues to be influenced by telehealth practices.6 Nurses need to remain up to date on developing information technology and use it in practice to improve the quality of patient care.2 Using the latest technology, nurses can monitor individuals and families remotely in the environments where they live, giving them access to the information they need to provide the best care.7,8 The International Council of Nurses (ICN) reports that telenursing practices strengthen patient care. ICN defines telenursing as "remote communication between humans and/or computers using electronic or optical communications."9 Telenursing practices started in 1992 when the American Nurses Association (ANA) accepted nursing informatics as a specialty.10 After the US, the Netherlands (1994), Finland (1998), Brazil (1999), and Israel (2004) accepted nursing informatics as a specialization area, and telenursing applications, a subbranch of nursing informatics, became widespread. In 1998, an interdisciplinary work group developed the ANA Core Principles on Telehealth addressing nurse practices and competencies regarding the use of telehealth technologies in nursing.10 A panel was held in October 2018 to review and update the basic principles of telehealth. The ANA defined telenursing as a professional nursing practice that's a subdimension of telehealth, involving the integrated use of the telecommunication network and health technologies.10,11 Telecommunication tools used for the delivery, management, and coordination of nursing care and practices include telephone, mobile phone, SMS (short message service or texting), fax, email, internet, video surveillance, and interactive video.7,11,12 The ANA stated that practice and clinical guidelines in telenursing should, whenever possible, be based on empirical evidence and professional consensus among all relevant health disciplines and be developed in collaboration with government agencies.13 Telenursing can be applied in a variety of settings in countries with well-developed telehealth programs, such as the US, Canada, and New Zealand, including telephone triage systems, symptom management practices, call centers, emergency services, ambulatory care, hospital units, home care, insurance companies, and public health units.11,13 In this context, it has been used for counseling and distance education. In addition, telenursing applications contributed to areas such as nursing research and management. Telenursing programs also support the effective implementation of basic nursing practices, including assessment, patient education, decision support, and identifying potential problems to increase the quality of life even for individuals in remote locations.13 The most important advantages of telenursing are that individuals who live far from healthcare facilities can benefit from health services, and these applications are inexpensive and increase patient satisfaction.14 Telenursing also makes it easier to conduct follow-up visits with patients, get information to meet patients' healthcare needs, provide consultancy and support, and deliver fast and effective solutions.2 Telephone counseling programs are important in terms of early detection and control of symptoms in cases of acute or chronic illness, helping patients return to their daily activities and informing nurses' decisions to refer patients to a healthcare facility at the appropriate time.8,15 With planned, well-organized phone calls, patients can take responsibility for their own treatment and care to manage disease adverse reactions, participate in care and treatment decisions, and increase their adherence with care and treatment. Studies indicate that patients are highly satisfied with this practice.13,16 Telenursing practices during the COVID-19 pandemic Nursing is the largest healthcare profession in the world, with an estimated 3.8 million nurses in the US, approximately 255,000 in Turkey, and more than 20 million worldwide.17-19 One of the most reliable health professional groups, nurses also play a key role in developing public health practices for disease prevention, reducing the spread of misinformation in pandemic situations, and providing education about diseases.18,20 The COVID-19 pandemic spread rapidly across the globe, with the first cases reported from Wuhan, China, in December 2019. On March 11, 2020, the World Health Organization declared the situation a global pandemic and reported that this newly defined virus is rapidly transmitted from person to person through droplets and close contact.19,21,22 Nurses were on the front lines of the pandemic, caring for patients diagnosed with COVID-19. Nurses acted as educators and counselors and were closely involved in evaluating and monitoring patients both in the clinical field and in the community.7,18,19 The use of telehealth/nursing applications during the COVID-19 pandemic to follow up with patients after discharge improved access to health services and reduced gaps in patients' treatment and care, and nurses were instrumental in facilitating the use of this important tool.8,14,23 Using telehealth, nurses played an important role in maintaining public health by providing effective counseling services in the postdischarge period for patients diagnosed with COVID-19. Although there are studies in the literature showing that telenursing practices have positive results, the authors found no research regarding telenursing practice and the nursing consultancy role during the COVID-19 pandemic.12,15,24 Accordingly, this study was designed to contribute to the literature. Methods This study aimed to determine the counseling role of the nurse, performed after discharge of patients diagnosed with COVID-19 using telenursing practice. The descriptive and cross-sectional study was conducted in a state hospital affiliated with the Ministry of Health in Istanbul, Turkey, between June 20, 2020, and August 20, 2020. This study was approved by the Clinical Research Ethics Committee of Istanbul Health Sciences University of Suleiman the Magnificent Training and Research Hospital. The study population consisted of 1,047 patients with a diagnosis of COVID-19 who received inpatient treatment, and the sample consisted of 877 patients who voluntarily accepted the telenursing application and could be reached by phone. Inclusion criteria for the study were patients between the ages of 18 and 90 years who were hospitalized with COVID-19 and discharged within the scope of the home isolation order determined by the Turkish Ministry of Health and who volunteered to participate in the study.25 The primary clinic nurse gave discharge training to all patients on the day of discharge. After informing the researchers that the discharge training was complete, a voluntary consent form was obtained from the patients. The patients were called by the same nurse every day for 5 days following their discharge. The two nurses who served as consultants are competent in their field: they have a bachelor's degree, more than 15 years of professional experience, and have completed 40 hours of training on communication and 4 hours of training on the COVID-19 disease process. Nurses followed up with patients by mobile phone (audio and WhatsApp video) to determine their needs regarding COVID-19 care and treatment and to provide patients with the necessary information to meet those needs. The duration of this nurse consulting service was between 15 and 30 minutes, and the average number of patients per day was 40. Data collection and analysis Researchers used a semistructured form consisting of 17 questions to collect data through telephone interviews conducted during a 5-day period and recorded the answers in a computer spreadsheet program. The first part of the form (only the questions asked on the first day) includes sociodemographic characteristics, such as the patients' age and sex. The second part of the form includes patients' symptom status, such as cough, weakness, and respiratory distress. The last part notes the subject areas in which the patients want to receive counseling and whether they're satisfied with the telenursing application (yes or no). Patients indicated their level of satisfaction from 1 (not satisfied) to 5 (very satisfied). Researchers analyzed the data using the IBM SPSS Statistics 21 program and made descriptive (frequency, percentage, minimum-maximum-mean and standard deviation) analyses. Results The distribution of the age and sex of patients in the study sample (n = 877) is presented in Table 1. Researchers determined that 54.02% were male and 45.98% were female between the ages of 18 and 90; most patients (36.37%, n = 319) were in the 41-60 age group; and the mean age was 52±3.02 (see Table 1). Table 2 shows the distribution of the patients in the study sample according to their marital and educational status. Of the patients participating in the study, 87.91% were married and 60.32% were high school graduates (see Table 2); 12.09% of the patients lived alone, 62% lived with their spouses, and 25.91% lived with their spouses and children. Table 1: - Participant demographics (n = 877) There were more men than women in the sample, and the largest age group was individuals age 41 to 60 years (bold). Age 18-40 41-60 61-80 81-90 Sex n % n % n % n % n % Female 106 12.09 126 14.37 149 16.99 23 2.62 404 45.98 Male 130 14.82 193 22.01 126 14.37 24 2.74 473 54.02 Total 236 26.91 319 36.37 275 31.36 47 5.36 877 100.00 Table 2: - Distribution of patients by marital status and educational status (n = 877) Most participants were married and had a high-school education level (bold). Marital status n % Single 106 12.09 Married 771 87.91 Total 877 100.00 Education status n % Primary education 194 22.12 High school 529 60.32 University 154 17.56 Total 877 100.00 Table 3 presents the distribution of symptoms of patients diagnosed with COVID-19 in the research sample according to telemonitoring periods. Table 3 includes the COVID-19 symptoms detected by telephone follow-up for 5 days following the discharge of the patients. The patients were followed up for fever, cough, respiratory distress, weakness, and any other symptoms. Nurses contacted 68.64% of the patients via a voice phone call, and they conducted video counseling with 31.35% of the patients. Table 3: - Distribution of symptoms of patients diagnosed with COVID-19 by telemonitoring periods (n = 877) The highest number of participants reporting each symptom on a given day is listed in bold (fever, Day 1; cough, Day 1; respiratory distress, Day 2; weakness, Days 1 and 2). Day distribution Symptoms Day 1 Day 2 Day 3 Day 4 Day 5 Total n % n % n % n % n % % Fever Yes 16 1.82 12 1.37 7 0.8 3 0.34 2 0.23 0.91 No 783 89.29 769 87.68 782 89.17 800 91.22 789 89.96 89.47 Couldn't be reached 78 8.89 96 10.95 88 10.03 74 8.44 86 9.81 9.62 Total 877 100 877 100 877 100 877 100 877 100 100 Cough Yes 109 12.43 97 11.06 66 7.53 50 5.7 31 3.53 8.05 No 675 76.97 693 79.02 713 81.3 736 83.92 738 84.15 81.07 Couldn't be reached 93 10.6 87 9.92 98 11.17 91 10.38 108 12.32 10.88 Total 877 100 877 100 877 100 877 100 877 100 100 Respiratory distress Yes 40 4.56 41 4.68 27 3.08 18 2.05 7 0.8 3.03 No 757 86.32 736 83.92 765 87.23 789 89.97 760 86.66 86.82 Couldn't be reached 80 9.12 100 11.4 85 9.69 70 7.98 110 12.54 10.15 Total 877 100 877 100 877 100 877 100 877 100 100 Weakness Yes 48 5.47 48 5.47 34 3.88 22 2.51 15 1.71 3.81 No 748 85.29 730 83.24 755 86.09 777 88.6 768 87.57 86.16 Couldn't be reached 81 9.24 99 11.29 88 10.03 78 8.89 94 10.72 10.03 Total 877 100 877 100 877 100 877 100 877 100 100 Total Yes 213 198 134 93 55 693 No 2,963 2,928 3,015 3,102 3,055 15,063 Couldn't be reached 678 682 681 677 680 3,398 When researchers examined the patients' symptoms according to the follow-up periods, the symptom reported by the highest number of patients on Day 1 was a cough (n = 109; 12.43%); that rate increased on subsequent days. The highest number of patients reported fatigue on Days 1 and 2 (n = 48; 5.47%), fever on Day 1 (n = 16; 1.82%), and shortness of breath on the Day 2 (n = 41; 4.68%). In general, researchers found that the symptoms decreased from the first day to the fifth day and cough was the most common symptom (see Table 3). Table 4 presents the distribution of other symptoms identified by telephone follow-up for 5 days following the discharge of patients with a diagnosis of COVID-19 in the research sample, according to telemonitoring periods. When researchers examined other symptoms experienced by study participants, they found that 72 patients (8.20%) experienced different symptoms; most of them (4.22%) had pain and 1.14% had nausea and diarrhea (see Table 4). Table 4: - Distribution of other symptoms experienced by patients diagnosed with COVID-19 by telemonitoring periods (n = 877) Day distribution Symptoms Day 1 Day 2 Day 3 Day 4 Day 5 Total number of patients n % n % n % n % n % n % Pain 29 3.31 32 3.65 33 3.76 32 3.65 32 3.65 37 4.22 Nausea 9 1.03 4 0.46 8 0.91 4 0.46 4 0.46 10 1.14 Diarrhea 10 1.14 9 1.03 10 1.14 9 1.03 9 1.03 10 1.14 Loss of appetite 7 0.80 8 0.91 7 0.80 8 0.91 8 0.91 8 0.91 Dizziness 2 0.23 2 0.23 2 0.23 2 0.23 2 0.23 3 0.34 Foot problems 2 0.23 1 0.11 2 0.23 1 0.11 1 0.11 2 0.23 Mouth ulcers 1 0.11 1 0.11 1 0.11 1 0.11 1 0.11 1 0.11 Inability to smell and taste 1 0.11 1 0.11 1 0.11 1 0.11 1 0.11 1 0.11 Total 61 6.96 58 6.61 64 7.30 58 6.61 58 6.61 72 8.20 The reporting status and result distribution of the COVID-19 test results performed on the fifth day after discharge of the patients in the study sample are presented in Table 5. On the fifth day after discharge, the COVID-19 filiation teams, assigned by the Ministry of Health of Turkey, went to the patients' homes to obtain test results. Investigators analyzed the reporting status and distribution of the COVID-19 test results and found that 95.43% of the patients knew the test results; 65.56% of those patients were negative; and 4.57% of them didn't report the results (see Table 5). Investigators also learned that 73.76% of the patients complied with the isolation precautions at home. Table 5: - Reporting status and distribution of COVID-19 test results performed on the fifth day after patient discharge (n = 877) Test result reported? n % Test result distribution n % Yes 837 95.43 Negative 575 65.56 Positive 262 29.87 No 40 4.57 No test results 13 1.48 Not tested 3 0.34 Insufficient sample 3 0.34 Unknown 21 2.39 Total 877 100 Total 877 100 The general conditions of the patients in the study sample and their relatives regarding the COVID-19 process are presented in Table 6. Among those living with patients in home isolation, 25.54% experienced symptoms; 53.48% contacted their family physician; 4.56% were sent to the hospital for an examination due to their complaints, establishing a control appointment; and 3.53% were readmitted to the hospital for treatment following the examination (see Table 6). It was determined that 0.28% (n = 3) of the patients in the research population (N = 1,047) had died and weren't included in the research sample because they didn't receive telenursing consulting services. Table 6: - General situation of patients and their relatives pertaining to COVID-19 (n = 877) Yes No General situation n % n % A relative is experiencing any symptom(s) 224 25.54 653 74.46 Communication with the family physician 469 53.48 408 46.52 Referred to the hospital for a control appointment 40 4.56 837 95.44 Readmission to the hospital 31 3.53 846 96.47 When researchers analyzed the information given to patients during counseling services, they identified the following themes: nutrition and physical activity-exercise practices (82%), issues to be considered during home isolation (62%), and issues related to the treatment process, such as medication (22%). Patient satisfaction with the telephone counseling service after discharge was 98.62%. Study participants rated their satisfaction level with the telenursing service as 4.95 (out of 5 points), and 96% of the patients answered "yes" to the statement, "It is much easier to access health services with telenursing application." Discussion Changes in healthcare have highlighted the necessity of telenursing services, and this practice continues to become more widespread. It's proving to be an effective tool to help countries overcome geographic barriers and provide healthcare to remote populations. The COVID-19 pandemic required the use of new technology and practices such as telenursing to manage the treatment and follow-up care of patients, which played an important role in facilitating individual and integrated patient care and monitoring of their medical conditions. Nurses performing counseling and health services by phone also contributed to the continuity of patient care and solutions for individual health problems. As stated in the literature, telephone counseling can be beneficial in the monitoring and treatment of many diseases and it was effectively used in many countries during the pandemic.26-30 Healthcare practitioners need to regularly follow up with patients who've been diagnosed with COVID-19, even after treatment, regarding medication adherence and adverse reactions, diet, mental and psychological health, adherence with standards of care, and healthcare outcomes through telenursing.7 In this study, the rates of rehospitalization and additional treatment of patients were found to be low. Studies in the literature support this finding, reporting that telemedicine applications contribute to the decrease in the rate of readmissions to the hospital after discharge.31 In addition, this suggests that the rate of adherence with the treatment plan following discharge was high among patients in the study. Nurse counseling topics presented to the patients who were interviewed support our findings in the literature.7,32,33 Moreover, this study found that telenursing allows most patients to access health services much more easily, which is consistent with other studies reported in the literature.13,32 The quality and adequacy of health services can be measured according to the opinions and satisfaction of patients and their families. Patient satisfaction is the most important indicator of the quality of care.34 This study found that providing nurse consultation service by phone provided a high level of patient satisfaction. Patients were followed safely in isolation, reacted positively to the counseling service provided by the nurses, and were satisfied with this service. The results of this study support the findings of other studies that have determined that the satisfaction levels of patients and their families with nursing and hospital services increase in telehealth interventions after discharge.5,13 Limitations/recommendations for future research This study is limited to patients who were diagnosed with COVID-19 in a public hospital in Istanbul, Turkey, and were hospitalized and discharged. These results may not be the same in other patient populations or geographic locations. Therefore, it's recommended that additional research be conducted with other populations and study samples. Implications for nurse leaders It's suggested that telenursing counseling practices not only be used in disaster situations but also in different nursing specialties, with the support of legislators to protect the rights of nurses and patients. Nurse leaders should define the obstacles to telenursing practice, develop strategies for nurses to gain the competencies required by telenursing, and be aware of the legal and ethical problems that may arise in telenursing practices. They should form telenursing teams or strengthen existing teams through increased awareness and education. Patient discharge training should include an explanation of the concepts of telenursing. It's recommended that more nursing studies be conducted on the benefits of telenursing practices and counseling services in various fields. Leading the way Studies have indicated that telenursing services, especially during the COVID-19 pandemic, can facilitate public health protection and development strategies, increase patient satisfaction, and reduce the burden on healthcare systems by minimizing the increase in patient demand for hospitals. In addition, reduced readmission and hospitalization rates for patients who participate in telenursing services prevented an increase in nurse workload, which improved safety for both nurses and patients by reducing their exposure to patients who were contagious. Nurse leaders have a key role in the creation of procedures related to nursing practices as well as in the assignment of telenursing teams. Therefore, nurse managers' awareness about telenursing counseling services is vital. It's also important to develop strategies for establishing and strengthening telenursing teams.