Telenursing Practice

Case study adapted from Telepractice Guideline (2020), College of Nurses of Ontario. Disclaimer: Case studies are fictional educational resources. Scenarios are made to be as realistic as possible, any resemblance to actual people or events is coincidental.

Jane is an RN in the community. Her employer is supportive of nurses providing care over the telephone to known patients. She performs a telephone follow-up with Ms. Martens, a patient she saw 2 days ago. Ms. Martens had a lumpectomy and axillary dissection for cancer of her left breast 5 days ago and is receiving home nursing care. She informs Jane of redness, tenderness and discharge from her left breast incision and asks for clarification on the skin care information that Jane provided last visit.

Jane has knowledge of skin healing in a surgical incision and knows the parameters for referral. She asks Ms. Martens about her symptoms. Ms. Martens describes them with great difficulty and contradicting information. Jane also pays attention to her patient’s auditory, verbal, and emotional cues. She sounds very nervous and informs Jane that, she has not performed her skin care and is having difficulty understanding the care instructions.

Jane determines that the surgical incision can only be assessed properly in a face-to-face encounter, to determine if further referral is required. Ms. Marten’s ability to assume the skin care, as initially planned, will also have to be re-assessed.

Jane informs Ms. Martens of her options. She agrees that Jane schedule a re-assessment visit with the evening nurse. Jane knows this will require a complete re-assignment and impact the workload on the evening shift. She schedules a meeting with her supervisor to discuss other forms of technology that would allow comprehensive virtual assessments and more efficient use of the program’s resources and better access to care.

Ms. Martens’ chart is not available, so Jane documents the phone call in the telephone log, as per employer policy. The log guides the documentation by including areas to record date / time of call, patient’s name/ telephone number, reason for call, assessment of signs and symptoms, specific protocol used to manage the call, support/education provided, required follow-up, and nurse’s signature/designation. Jane photocopies her documentation and follows the procedure to add the documentation to the patient’s chart.

Professional judgement and additional considerations (see Table 1) are required to determine if virtual care supports the delivery of evidence-informed and high-quality nursing care, that meets the needs and is in the best interest of the client.

Table 1: Reflecting on Duty to Care
This list of questions is not exhaustive and is meant to assist in the reflexion that should occur to determine the appropriateness of telenursing practice.

• Have you met all registration requirements?
• Are you following the standards of practice?
• Can you ensure quality of nursing practice and client safety?
• Do you have the required technical and clinical competencies for telenursing practice?
• Can you apply the nursing process through this platform?
• Are you obtaining informed consent?
• Is the client able to participate in this virtual application of care?
• Is the nursing process and your rationale for decision-making captured in your documentation?
• Can you arrange for continuity of care (availability of imaging, laboratory, and pharmaceutical services, acceptance of virtual prescriptions/orders, and health care instructions)?

In this case, does this mean of providing care allow to meet the requirements of the duty to care?

	This is a telephone follow-up, so a duty to care has been established.
	Jane is respectful of the principles of Telenursing practice: she applies strategies to reduce the risk of missing information.
	Jane ensures that the decision being made is in the client’s best interest.
	The application of the nursing process is altered since this platform does not allow for a comprehensive assessment of the current situation.

The form of technology used for telenursing practice must correspond to the level of care required and meet clients’ needs. Therefore, it is important to reflect on what is appropriate technology for telenursing practice. (see Table 2).

Table 2: Reflecting on Technology
This list of questions is not exhaustive and is meant to assist in the reflexion that should occur to determine the appropriateness of telenursing practice.

• Does the technology allow to meet the client’ needs?
• Is the connection / data transmission reliable?
• Do you have a dedicated computer or phone line?
• Do you have measures in place to reduce the risk for breaches of privacy and confidentiality (e.g., cybersecurity, encryption of data)?
• Is the technology accessible and easy to use for the clients?

In this case do we have the appropriate technology?

	Providing care over the telephone is an established part of the community program and allows better access to care.
	Other technology is needed to allow virtual assessment of surgical incisions.

Telenursing practice must be supported in all settings to ensure safe and appropriate provision of telenursing care. Policies clearly articulating the form(s) of telenursing care that can be provided (e.g., telephone consultation, videoconferencing, tele robotics) and how telenursing care should be conducted allows providers and clients to connect in a safe way. This ensures nursing practice expectations are met.

The nurse must consider the type of support that is required and available, to provide optimal telenursing care (see Table 3) and adhere to relevant legislation and policies.

Table 3: Reflecting on Support
This list of questions is not exhaustive and is meant to assist in the reflexion that should occur to determine the appropriateness of telenursing practice.

• Are policies and processes in place to guide your telenursing practice? re: client identification/ verification of location, informed consent, privacy and confidentiality, protection of personal health information, management of downtimes / failure of technology, and documentation.
• Does your workspace allow you to maintaining client privacy and confidentiality?
• Who is the custodian of the client record?
• Is collaboration/consultation with other health care providers possible?
• Do you have access to decision-making tools to support the delivery of telenursing care consistently and according to best practices?

In this case do we have the appropriate support?

	Employer is supportive of care over the phone.
	Adopted parameters for referral guide continuity of care.
	Adequate documentation tools are in place and documentation is supported by employer policy.
	Jane will advocate for technology to support safe and quality care.

In this case if we use the framework to determine if telenursing is appropriate, it points to not being able to fulfill the duty to care appropriately, not having the appropriate technology for assessment, although there is evidence of appropriate support. Therefore, telenursing practice is NOT an appropriate mean to provide care to Ms. Marten, therefore a face-to-face visit is scheduled.

Disclaimer – Case studies are fictional educational resources. Scenarios are made to be as realistic as possible, any resemblance to actual people or events is coincidental.

Marco is an NP in a rural distant community hospital. He has identified the need to add a telehealth component to his practice. Many clients in his patient population suffer from complex cardiac conditions. He will set-up consultations with a cardiologist from another city. To prepare for this, and ensure compliance to applicable requirements, he seeks information on his professional, ethical, and legal responsibilities related to telenursing practice. He participates in a webinar, reviews NANB resources on telenursing practice and completes training on the use of the video technology and the electronic stethoscope.

Marco plans this virtual care component as follows:

• He will request video consultations (state of the art dedicated system) with Dr. Roth, the cardiologist, for clients that are not responding to treatment.
• Patients will receive information on the telehealth process the week prior to the consultation. He will review the information with the clients to ensure they understand how the consultation will proceed in a private room, how personal health information will be handled, and the risks involved. The consent form for the telehealth session will be signed prior to the encounter.
• Marco will operate an electronic stethoscope to allow Dr. Roth to complete a comprehensive cardiac assessment. He will complete a physical exam and share the information with Dr. Roth.
• Dr. Roth will advise the client on their treatment options and follow with a written summary of the recommendations for inclusion in the client’s health record.
• Marco will confirm that the client understands the treatment options and obtain consent for the recommended treatment.  He will follow up on the treatment plan. Marco will document his decisions and actions in the patient’s health record.
• Privacy and confidentiality will be respected in the same manner as in a face-to-face consultation.

Employer policies will address and support: the consultation process, choice of technology, technology failure, informed consent process, privacy & confidentiality, documentation, ownership of client records, appropriate video/telephone behaviors, liability protection, process for ordering pharmacological, non-pharmacological and diagnostic tests.

Professional judgement and additional considerations (see Table 1) are required to determine if virtual care supports the delivery of evidence-informed and high-quality nursing care, that meets the needs and is in the best interest of the client.

Table 1: Reflecting on Duty to Care
This list of questions is not exhaustive and is meant to assist in the reflexion that should occur to determine the appropriateness of telenursing practice.

• Have you met all registration requirements?
• Are you following the standards of practice?
• Can you ensure quality of nursing practice and client safety?
• Do you have the required technical and clinical competencies for telenursing practice?
• Can you apply the nursing process through this platform?
• Are you obtaining informed consent?
• Is the client able to participate in this virtual application of care?
• Is the nursing process and your rationale for decision-making captured in your documentation?
• Can you arrange for continuity of care (availability of imaging, laboratory, and pharmaceutical services, acceptance of virtual prescriptions/orders, and health care instructions)?

In this case, this mean of providing care allows to meet the requirements of the duty to care.

	Marco is well informed and ensures that he can comply with legal and regulatory requirements of telenursing and ensure professional accountability in relation to his standards of practice.
	He completed training to ensure he has the competency to use the technology.
	He obtains informed consent for this platform.
	There is an established process to ensure the continuity of care and has access to the resources that are required to care.

The form of technology used for telenursing practice must correspond to the level of care required and meet clients’ needs. Therefore, it is important to reflect on what is appropriate technology for telenursing practice. (see Table 2).

Table 2: Reflecting on Technology
This list of questions is not exhaustive and is meant to assist in the reflexion that should occur to determine the appropriateness of telenursing practice.

Does the technology allow to meet the client’ needs?
Is the connection / data transmission reliable?
Do you have a dedicated computer or phone line?
Do you have measures in place to reduce the risk for breaches of privacy and confidentiality (e.g., cybersecurity, encryption of data)?
Is the technology accessible and easy to use for the clients?

In this case do we have the appropriate technology?

	Marco will be using an electronic stethoscope to allow a comprehensive cardiac assessment by the cardiologist.
	They will be using a dedicated state of the art videoconferencing system.

Telenursing practice must be supported in all settings to ensure safe and appropriate provision of telenursing care.  Policies clearly articulating the form(s) of telenursing care that can be provided (e.g., telephone consultation, videoconferencing, tele robotics) and how telenursing care should be conducted allows providers and clients to connect in a safe way.  This ensures nursing practice expectations are met.

The nurse must consider the type of support that is required and available, to provide optimal telenursing care (see Table 3) and adhere to relevant legislation and policies.

Table 3: Reflecting on Support
This list of questions is not exhaustive and is meant to assist in the reflexion that should occur to determine the appropriateness of telenursing practice.

• Are policies and processes in place to guide your telenursing practice? re: client identification/ verification of location, informed consent, privacy and confidentiality, protection of personal health information, management of downtimes / failure of technology, and documentation.
• Does your workspace allow you to maintaining client privacy and confidentiality?
• Who is the custodian of the client record?
• Is collaboration/consultation with other health care providers possible?
• Do you have access to decision-making tools to support the delivery of telenursing care consistently and according to best practices?

In this case do we have the appropriate support?

	Privacy and confidentiality will be respected with the private space.
	Employer policies to address and support this practice are in place.

In this case, if we use the framework to determine if telenursing is appropriate, it points to being able to fulfill the duty to care appropriately, to having the appropriate technology and evidence of appropriate support. Therefore, telenursing practice is an appropriate mean to provide care for this patient population.