Nursing and information and communication technology (ICT): A ...

G Model

NS-1808; No. of Pages 9 International Journal of Nursing Studies xxx (2011) xxx–xxx

Contents lists available at ScienceDirect

International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns

Nursing and information and communication technology (ICT): A discussion of trends and future directions Alison While *, Guy Dewsbury King’s College London, Florence Nightingale School of Nursing and Midwifery, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom

A R T I C L E I N F O

A B S T R A C T

Article history: Received 17 May 2010 Received in revised form 2 February 2011 Accepted 25 February 2011

This paper traces the development of information and communication (ICT) within health care and the emergence of telehealth as a key component of modern health care delivery as health care moves from the ‘face to face age’ to the ‘information age’. The paper examines the interface of ICT and nursing practice and highlights the limited evidence relating to the nursing contribution within telehealth particularly beyond data input and output analysis for other health care personnel. Additionally, the absence of research relating to the impact of ICT upon nurses and their working lives is identified. The paper concludes that nurses need to engage more fully with ICT so that they contribute to shaping the care system and emerge as leaders of the new care systems delivering future clinical activity. ß 2011 Elsevier Ltd. All rights reserved.

Keywords: Information and communication technology ICT Telehealth Telecare Telemonitoring Health portals

What is already known about this topic? ICT is increasingly part of health care delivery Nurses are using ICT in various ways What this paper adds This paper sets the context of future nursing practice within virtual and ICT delivered health care It describes the current state of knowledge regarding nursing and ICT It sets challenges for nursing to define its relationship with ICT

1. Changing context of health care By 2020 the older population will outnumber the younger population (United Nations, 2004) and this

* Corresponding author. E-mail address: [email protected] (A. While).

combined with the increasing prevalence of chronic illness (World Health Organization, 2003) is creating a heavy demand on the finite resources in terms of both money and personnel (Kinsella and He, 2009). The use of information and communication technology (ICT) is one of a range of potential solutions to this health care challenge. ICT encompasses a range of technologies which enable the exchange of data through the telephone or internet (Fig. 1). The United States (US) National Broadband Plan (FCC, 2010) has identified a key role for ICT in improving health and health care through enhancing care delivery and coordination, and engagement with patients. To this end there are Federal incentives to providers who adopt electronic health records (EHR) both inside and outside hospitals with the use of EHR expected both to reduce the costs of care and improve quality and safety (Bates, 2010). Indeed, the US Medicare (American Telemedicine Association, 2010) reimburses for telehealth services which include non-face-to-face services that can be conducted either through live video conferencing or via store and forward telecommunication services. The United Kingdom (UK) Government has published similar ambitions (Department of Health, 2008).

0020-7489/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2011.02.020

Please cite this article in press as: While, A., Dewsbury, G., Nursing and information and communication technology (ICT): A discussion of trends and future directions. Int. J. Nurs. Stud. (2011), doi:10.1016/j.ijnurstu.2011.02.020

G Model

NS-1808; No. of Pages 9 2

A. While, G. Dewsbury / International Journal of Nursing Studies xxx (2011) xxx–xxx

ICT systems

Applications

Telephone internet Satellite television Mobile ICT

Landline Computer-based Television-based Mobile devices

Frequently used terms across ICT system applications Telephone triage, telecare, telehealth, telemonitoring, telemedicine, health portals, mHealth, Apps, personal digital assistants (PDAs), Smartphone.

Fig. 1. ICT systems, applications and frequently used terms.

ICT has the potential to modify the way in which people use health services both by increasing access to information and providing other forms of support remotely. Expectations are changing with people wanting to determine their own health needs through advice on the internet or other technological interfaces and faster more person-centred services from health care providers including nurses. Indeed, we may be witnessing a move from the ‘‘face to face age of health care’’ to the ‘‘information age of health care’’. This discussion paper draws upon an extensive search of Pubmed and Medline for papers (n = 795) relating to ehealth, telehealth, telecare, mhealth and telenursing in addition to 63 books on health and technology to explore the developments relating to ICT in health care over time and the interface with nursing. Sources (n = 39 papers) were included where they added to the discussion; this was necessarily selective and it is acknowledged that a different search strategy may have yielded different sources such as those relating to nursing records. Forbes and While’s (2009) conceptual framework was used to categorise nursing activity reported across the material. The evidence of the contribution of nursing within ICT developments and the potential impact of ICT upon nurses’ working lives are foci for the discussion. 2. ICT and change over time Historically the patient and healthcare professional relationship was mediated through agencies such as hospitals and primary care services and person intensive relying on the face to face contact of health care professionals with patients. Fig. 2 illustrates changes over time with the replacement of wholly face to face contact by increasing use of ICT to deliver healthcare. However, the replacement of face to face contact by ICT has both potential advantages and disadvantages for health services which are set out in Fig. 3. As technology becomes increasingly ‘‘clever’’, there will be a shift of staff from direct face to face contact to increasing non-face to face contact with remote sensors carried on the patient transmitting clinical information to a centre which will act as a hub for appropriate interventions (Lewin et al., 2010). Mobile health technologies are not new, but in the coming years, new technologies will be developed yielding smaller and more discrete devices capable of large dataset monitoring (Technology Strategy Board, 2010; Fong et al., 2011).

The increased adoption of ICT will impact on the way in which services are provided and herald a change in nursing allowing the nurse relationship with patients to move from the face-to-face encounters of traditional nursing to an increasingly virtual nursing experience outside the hospital setting. Thus nursing which involves direct contact face-to-face interaction will evolve to include remote assessment of health need, information giving, diagnostics, support and monitoring of the patient’s condition.

3. Nursing practice and ICT The adoption of ICT within clinical practice may bring substantial benefits through supplementing traditional nursing practice relating to assessment, health promotion, clinical interventions and service organisation (Fig. 4). Thus new technology may enable new services, for example, virtual health promotion sessions with one nurse working with a group of people simultaneously. Health portals will allow patients to store information as well as access information about their conditions in addition to receiving personalised health advice. Nurses will be able to conduct virtual visits over the internet and discuss a patient with other health and social care professionals through a secure connection in real time to enable better personalised care planning and care coordination. Mobile applications (mobile apps or portal devices) will increase in popularity and extend beyond the Apple Ipod and Iphone to other mobile devices enabling the download of appropriate applications to support people in managing

Fig. 2. ICT in healthcare delivery over time.


G Model

NS-1808; No. of Pages 9 A. While, G. Dewsbury / International Journal of Nursing Studies xxx (2011) xxx–xxx

Advantages One nurse can interact with patients remotely. One nurse can manage a larger caseload through remote monitoring. Improved information sharing. Reduced cross-infection and other patient ‘costs’. Less travel time and other health care costs.

Doctors and nurses can hold joint remote consultations with the patient and their family. Timely enhancements of patient self-care. Virtual titration of medication and virtual prescription changes. Efficient signposting to other services to maximize health resources.

3

Disadvantages Dehumanization of healthcare delivery. Reduction of “traditional” services may not be acceptable to all. Challenge of controlling virtual information. Formulaic approach may constrain practice and inhibit professional judgment. Significant investment will be needed to ensure all practitioners are “masters” of ICT. Patient expectations may be unattainable / unmet. Reinforcement of the “digital” divide. Compatibility issues across different ICT systems. Failure of ICT at any time will undermine healthcare system.

Fig. 3. Advantages and disadvantages of ICT in healthcare.

their own health needs relating to specific conditions including mental health concerns. Apps are still in their infancy but it is likely that they will become the easiest way for patients to receive health related information and remote monitoring. Thus if a patient’s clinical data fall outside the recommended range then the app will suggest contacting a health professional or set up a contact with a named person automatically. The incorporation of ICT into nursing practice and patient care pathways will bring about changes in nursing work not only regarding nurse-patient relationships but also in the context of practice with greater demands placed upon nurses’ ICT and remote communication skills. However, patients need not be the only beneficiaries of greater access to information because ICT provides the opportunity to increase nurses’ accessibility to evidence to inform practice in ways inconceivable a few years ago. 3.1. Health assessment The assessment process is a fundamental part of health mediation which ensures that health needs are identified early and appropriate interventions initiated. However, the evidence of the contribution of ICT to improvements in health assessment is limited both in its extent and its impact within the published literature, with examples of the use of various ICT applications being reported (Fig. 4). The UK’s national telephone advice service, NHS Direct, handled 5,180,000 calls in England in its first 3 years (1998–2001) but Munro et al. (2005) found that there was no change in overall demand for either emergency ambulance services or attendance at accident and emergency departments and there was no change in the usage of the four paediatric emergency departments in the study.

However, they noted a significant reduction in the calls to out-of-hours general practice which suggested some workload diversion away from general practice. Similarly North and Varkey’s (2008) review of telephone triage calls (27,979 symptom assessments for mainly female callers [71%] received by the Ask Mayo Clinic, US July 2006–June 2007) noted that 16% of callers (n = 4469) had intended to seek help from emergency services if they had not accessed the triage service suggesting some diversion of activity away from emergency services. However, an analysis of the large UK General Household Survey dataset (n = 20,421) has revealed a consistent socioeconomic bias regarding the use of telephone advice compared to accident and emergency services with those in lower socio-economic groups, older people, those with long term illnesses and from minority ethnic groups being less likely to use telephone services (Shah and Cook, 2008). This suggests that affluent households are more likely to benefit from the provision of telephone advice services emphasising the importance of adequate health facilities for less affluent households. Indeed, this socio-economic bias appears to extend to internet usage with Gracia and Herrero’s (2009) national survey of internet use and selfrated health among older people (n = 709) in Spain finding that internet users had better self-rated health than nonusers (p = 0.002), although with weighting for social class the significance of the results disappeared. In contrast the evidence relating to assessment in the form of chronic illness monitoring is more positive with consistent evidence of positive clinical outcomes, sometimes quite limited, consequent upon tele-monitoring especially in relation to advanced heart failure from a range of countries where small trials have been conducted (Antonicelli et al., 2008; Biddiss et al., 2009; Scherr et al.,


G Model


4

Assessment

Health promoon

Remote signposng including contact with health care professionals or other agencies Telephone triage Telemonitoring Internet self-assessment Portable mHealth Mobile apps for clinical monitoring Clinical Intervenon Remote consultaons (may include MDT) Remote traon of therapy including prescripons where needed Remote psychological therapies eg movaonal interviewing, CBT Remote carer support

Telephone, text, email intervenon / prompts Health portals delivering personalized health promoon Webcasts and podcasts intervenons

Service organisaon Electronic health records / electronic paent records (EHR/EPR) Care pathway management Care system governance (audits etc) Professional clinical networks (discussion boards etc.) e- CPD for professionals.

Fig. 4. ICT and potential applications to nursing practice.

2009; Maric et al., 2010). However, none of these trials properly accounted for the ‘non-key interventions’ which may also be important to patients in a number of ways including: promoting confidence in the quality of care; alleviating social isolation; and improving the relationship between health care providers and the patient. Currell et al.’s (2000) systematic review involving seven trials of telemedicine versus face to face care also questioned the benefits of telemedicine despite its acceptance by patients and particularly noted the absence of formal economic analysis and evidence of safety. Importantly all the available evidence relating to health assessment and the use of ICT fails to articulate the nursing contribution with any clarity. Indeed, nurses were reported as either delivering or were part of the delivered health care assessment but few details emerge relating to the nursing activity undertaken. 3.2. Health promotion Health promotion, which includes health education, health protection and preventative work, forms a key component of health care practice and will be increasingly important if global health demands are to be controlled through preventative action. All forms of ICT may augment the nursing contribution to health promotion by extending contact beyond traditional face to face practice, however, the literature to date only reports the use of the telephone and computer based interventions with studies of personalised e-health, podcasts and webcasts not yet published (see Fig. 4). Fry and Neff’s (2009) systematic review of limited contact interventions targeting weight loss, physical activity, and/or diet included 19 studies (1988–2008) with combined sample size of 15,655. Studies were included if a

periodic prompts were used as an intervention or a component of an intervention, a behavioural or biological outcome measure was used, and an ongoing health promotion behaviour was targeted. Eleven studies reported positive findings regarding the use of periodic prompts with benefits relating to diet, weight loss and exercise behaviours and nine studies showed enhanced effectiveness when prompts were frequent and personal contact with a counsellor (sometimes a nurse) was included. However, Fry and Neff identified the need for additional research on limited contact interventions targeting health behaviours such as weight loss, physical activity, and/or diet to test prompt types and frequencies, specific intervention components and prompt characteristics. Additionally data are needed regarding the short term and longer term effectiveness of limited contact health promotion interventions. The importance of access to the internet and email were highlighted by Bot et al. (2009) who carried out an emailbased health intervention for pregnant women (n = 14,154) in the Netherlands and found that only 8% of the pregnant women could be reached though the email intervention with the educational level of the women also affecting their active engagement in the process (p < 0.001). This digital divide has been noted by others in relation to internet access across both social-economic and age groups (An et al., 2007; Verdegem and Verhoest, 2009; Weaver et al., 2009) Additionally a US quasi-experiment (Pak et al., 2009) of online health information seeking for different aged participants (n = 50, 18–23 years; n = 50, 60–80 years) found differences in the seeking behaviours of participants from the different age groups. The older people reported using computers for less time (p = 0.002) and less often (p = 0.001) whereas the younger adults had greater spatial


G Model


visualisation and orientation abilities (p < 0.001) and a larger memory span (p = 0.001). Further, in the information search tasks the older adults performed worse than the younger adults (p =