The use of telehealth became a global necessity during the COVID-19 pandemic, and although many medical settings have since resumed in-person services, telehealth is now firmly situated as a mainstay across most areas of health care. Although its overall benefits in terms of access, convenience, and cost are undeniable, recent study findings point to an overlooked downside of the growing reliance on telehealth: an increased burden on nurses.
Even before the COVID-19 pandemic, the use of telehealth led to an approximately 2-fold increase in the number of activities nurses perform, according to a study published in the Western Journal of Nursing Research by researchers from the University of Missouri Sinclair School of Nursing. Among patients with type 2 diabetes and hypertension who were receiving care in a primary care setting, the researchers compared the amount of work required for nurses facilitating patients using an in-home telehealth monitoring system vs those receiving usual care.
The results showed that nearly twice as many nursing activities were completed for the in-home telehealth monitoring group compared with the usual care group (14.1±8.8 vs 7.3±4.5). In addition, a greater amount of communications — mostly initiated by the nurses — occurred in the in-home monitoring vs usual care group during the 12-week study (4.6±2.4 vs 2.6 ±1.3).
To further explore the impact of telehealth on nurses as well as potential solutions to related challenges, we interviewed lead author Chelsea Howland, MSN, RN, a PhD candidate at Sinclair School of Nursing at the University of Missouri in Columbia; and Erin Fecske, DNP, APRN, CNRN, CPNP-PC, FAES, an epilepsy nurse practitioner in the Comprehensive Epilepsy Center at Children’s Mercy Hospital Kansas City.
What are the implications of your findings and what have you observed in practice regarding the effects of the surge in telehealth on nurses?
Ms Howland: Our findings are unique in that they describe the nursing activities and communication processes that nurses undertake when implementing a home-based telehealth monitoring system. It is important to understand how these new nursing activities and communication processes affect the nurses’ workload and workflow.
Their workload consists of the time nurses spend on patient care, workplace activities, and professional development. Integrating telehealth into practice has the potential to change the amount or type of time nurses spend providing patient care and presents new requirements for training and education to use new technologies and optimize patient care.
Workflow is used to describe the groups of tasks nurses perform to complete an outcome. Integrating a home-based telehealth monitoring system presents changes to the nurses’ previous workflow in that there are new process requirements to review data, tasks to be completed, and communication pathways to follow up on. Understanding nurses’ workflow with telehealth can help to refine tasks, increase efficiency, and decrease workload.
While this study described the nursing activities and communications process with an in-home telehealth monitoring system, additional research is needed to quantify the time spent performing nursing activities with telehealth systems to better understand what an appropriate caseload is for a nurse to provide high-quality patient care. Given the rapid uptake in telehealth during the COVID-19 pandemic, the study findings provide evidence of changes in nurses’ workload and workflow when a home-based telehealth monitoring system is integrated into a primary care clinic setting.
Not all telehealth services and time requirements are the same, as noted by Dr Feske.
Dr Fecske: There is a broad spectrum of what telehealth looks like in health care. For this purpose, I’m referring to telehealth as virtual visits via a secure platform with video/audio use but without any ancillary devices or facilitated examination. In the virtual visit platform, a nurse’s role may vary based on the institution and clinic. In our setting, our nurses continue to perform the patient intake. This includes updating the medication reconciliation, getting an updated weight if the family has one, as well as updating any pertinent medical information.
The biggest increase in responsibilities is not in the actual intake for a clinic patient, but rather the additional technology troubleshooting that the nurses are now performing with the families. In addition to becoming experts in epilepsy nursing, I’ve watched as the nursing staff has also worked to become experts in IT. Not only does that add more pressure and responsibility, but the nurses also feel a burden to resolve issues quickly so that the provider is still able to see the patient and [does not] have to reschedule. So, nurses are learning a new task under significant time pressure.
Currently, there is significant attention paid to spacing in our clinic. Although the same number of providers may have clinic scheduled as pre-COVID-19, some of those clinics are in person and some are virtual. This means that the nursing staff must be divided between 2 different locations effectively. The other side of this is that trying to find appropriate spacing for the nurses working virtual visits means they often end up working alone in a spare clinic room. This creates a sense of isolation from their colleagues.
What is needed from employers and institutions to help foster more balance in nurses’ workload as the use of telehealth continues to expand?
Ms Howland: Employers and institutions will need to develop new policies and procedures around the implementation of telehealth systems, taking a collaborative interdisciplinary approach. Additionally, it is integral that nurses receive education and training to optimize their ability to analyze and interpret patient information.
It is also important for employers and institutions to evaluate how workload and workflow are affected to implement evidence-based practices that are supportive of both nurses and patients.
Dr Fecske: Getting appropriate help from IT is essential. Organizations shouldn’t be relying on nurses to help troubleshoot IT issues. While nurses have learned a lot about telemedicine technology, they have other clinical responsibilities and should be able to focus on those.
Ideally, test appointments should be available. By this I mean that families should have a time and location in which they can test the software that will be used, troubleshoot issues, and get comfortable with the platform. While not all families may have the ability to take advantage of this, creating this option may lighten some of nurses’ time burden when trying to solve problems quickly.
Institutions need to allow for additional time to transition between in-person and telemedicine visits as well as understand that these tasks require slightly different skill sets and very different equipment. We cannot look at just the number of patients being seen, and we need to take into consideration the locations of these patients and allow for extra time when needed to transition.
Telemedicine training and support represent additional needs. Many providers received telemedicine training with our credentialing. We were trained on how to use the software and how to respond to the camera, and there have been numerous CEU offerings since the pandemic began to help support creative uses and assessments. I don’t know that the same can be said for nursing education and support, and I would love to see nurses receive focused telemedicine training.
What are some relevant recommendations for nurses?
Ms Howland: For nurses, I recommend actively engaging and participating with interdisciplinary teams to develop policies and procedures to effectively integrate telehealth with their existing workload and workflow. Nurses have an important role in telehealth, so it is integral that nurses recognize the importance of their role in terms of analyzing and identifying pertinent data, communicating with primary care providers, and implementing changes in patient care, including communicating with patients to follow-up on changes to the plan of care.
Dr Fecske: Make sure that there is dedicated space with appropriate equipment for telemedicine so that nurses aren’t struggling with those essentials every day.
Create space and breaks for collaboration and time with colleagues. If you can’t physically be together, create a virtual space to ensure that communication continues as it would when sharing an office. Advocate for IT support and telemedicine training.
So much of clinic nursing is done by phone. I would love to see nursing leverage the new telemedicine models and see how that can evolve the clinic nursing practice. If you [have] a family that is new to epilepsy and [they] call the nurse because [their] child is actively seizing or because [they] have a concern, wouldn’t it be amazing if the nurse could start a video chat and see what [the parents/caregiver] is seeing?
Chelsea Howland, MSN, RN, is a PhD candidate at the Sinclair School of Nursing at the University of Missouri in Columbia. Erin Fecske, DNP, APRN, CNRN, CPNP-PC, FAES, is an epilepsy nurse practitioner in the Comprehensive Epilepsy Center at Children’s Mercy Hospital Kansas City. Dr Fecske notes that she is commenting solely from her perspective as a provider and not based on a consensus of nursing staff at her facility.
Howland C, Despins L, Sindt J, Wakefield B, Mehr DR. Primary care clinic nurse activities with a telehealth monitoring system. West J Nurs Res. 2020;43(1):5-12. doi:10.1177/0193945920923082