Applying nursing skills to telehealth

Telehealth has been around for just about as long as the telephone. It’s said that its inventor, Alexander Graham Bell himself, once called a doctor for advice after injuring himself with battery acid. Most 911 calls involve health advice given by the operator, even if it’s just to keep calm and check vital signs. With this in mind, once internet-based communications platforms like Skype and Zoom entered into common use, it was only a matter of time until they began to be used to deliver health services.

What started out as a series of bespoke arrangements between doctors and patients with unusual needs, however, became mainstream medical practice almost overnight as a result of the COVID-19 pandemic. As with all such sudden changes, it experienced a few teething problems. Many people using it had to figure it out as they went along. Over time, however, clear principles and protocols emerged. Today, nurses have a much more standardized and consistent approach to delivering traditional models of care through this framework. This article provides an overview of how that works.

Why use telehealth?

In some situations, telehealth is simply a convenience —a way for people with busy lives to ensure they still get the check-ups they need and stay on top of any chronic illnesses. For nurses, it can make it much easier to keep up with a heavy caseload because no time is wasted on commuting. In other situations, however, it’s really the only practical way to provide an adequate service without requiring patients to completely change their lives.

It’s ideal for use in rural areas where coverage is sparse, including Alaska, where the nearest doctor is sometimes hundreds of miles away. It’s much more practical for severely disabled people who struggle to leave their homes and for immunosuppressed people who would be at risk if they did so. In addition to this, it has enabled some nurses who have ceased to be able to work in traditional settings due to disability or illnesses such as COVID-19 to continue using their skills and helping patients.

Patient suitability

At this stage, it’s important to note that not every patient can be properly cared for using telehealth, so the first thing nurses need to be able to do is assess patient suitability. Even if only part of a patient population can be supported in this way, it still has a positive effect on the population at large because it means that more time and resources are available for those who need in-person care.

With older patients and those with progressive illnesses, suitability assessments may need to be repeated at regular intervals, with nurses paying careful attention in the meantime to possible signs of decline. At the most basic level, you will need to check whether or not the patient needs physical support and, if that’s the case, whether or not there is a sufficiently competent caregiver present to administer it. You will also need to establish how confidently the patient can use the necessary technology, providing support as required, and how well they will be able to communicate their symptoms and concerns.

Special considerations

Telehealth consultations require a special approach distinct from other forms of nurse-patient interaction, and it’s important that you understand this if you’re going to be carrying them out. It begins with ensuring that the connection is good and that the patient can see and hear you clearly (or just hear you if you are limited to telephone calling, which some older people still strongly prefer). You should provide a callback number at the start in case you lose the connection, and assure the patient that it’s okay to use it right away in that event. Talk through what the consultation is going to involve and how it will work. Establish that the patient understands the process, has sufficient privacy, and is able to consent to your interactions.

Make adjustments if necessary. For instance, patients in the early stages of dementia may be able to manage if they are given simple interfaces to use, while patients with visual impairments may need any written materials to be supplied in large fonts. Finally, ensure you are able to conduct sessions and maintain adequate patient records without any risk of compromising confidentiality.

Active listening in a remote context

The way you communicate in a telehealth conversation is obviously different from how you do so face-to-face. You will not be able to touch the patient and will be restricted to communicating through sound and (usually) vision. It means that you need to be on top of your game when it comes to practicing your active listening skills. Remember that most of your body will not be visible and that hands raised close to the screen can give the impression of intruding into the viewer’s personal space.

Focus on communicating using facial expression and small head movements, and use small noises to demonstrate your interest and manage the mood. Practice with friends so that you can get used to the different way that time seems to pass in virtual spaces, so that you are not moving discussions along too fast but nonetheless able to fill silences before they start to feel uncomfortable.

Remote examination

Examining a patient remotely can never be as thorough as doing so in person, but there is nevertheless a lot that you can do, and the tools available to help you are constantly improving. A Bluetooth stethoscope can enable you to listen to the patient’s chest, and simple, low-cost mobile phone attachments can let you take a pulse remotely. Most patients can learn to use a blood pressure monitor without much difficulty.

Be cautious about matters like weight, where patients may be tempted to give inaccurate answers, either because they feel ashamed or want to please you. Examination is obviously much easier with fully competent patients who have a good understanding of their own anatomy and can accurately report pain, swelling, etc., but part of your job is to talk through the process in simple terms, one body part at a time, to identify any worrying symptoms. Depending on the quality of the camera and connection, you may also be able to detect symptoms visually, and as an aid to this, you can ask the patient or a caregiver to take photographs of any damaged or swollen tissue and send them to you.

Remote monitoring

Thanks to advances in technology, there are now many ways to carry out day-to-day monitoring of a patient remotely. Simple bracelets can monitor blood pressure and heart function, alerting you directly to any worrying changes, and they’re suitable even for patients who would struggle to take measurements themselves. For a more thorough investigation, you can ask a patient to wear a Holter monitor for 24 hours as long as they understand the importance of not getting it wet. Blood glucose monitoring is slightly more complicated, but most patients can manage it, finding it easier with practice. Wearables are useful again when it comes to tracking how much exercise a patient is getting, and they actually make this easier than it has traditionally been in a hospital ward.

Phone apps are available to alert patients when it’s time to take medication, and some require patients to report when they have done so, transmitting this information directly to you. You should note, however, that some patients get into the habit of reporting this as soon as they receive the alert and then forget to actually take the medicine, so it’s still a good idea to speak at frequent intervals, and in some cases, you may need to watch them take it during a Zoom call.

Addressing self-care deficits

It is obviously impracticable to perform physical tasks on behalf of patients over the phone, and in many cases, you will not realistically be able to watch them undertake key activities, but you can still provide advice and encouragement. Telehealth care of this sort is particularly useful in contexts where a patient retains a good level of physical ability but is struggling due to cognitive impairments, such as stroke patients and those living with dementia. You can provide reminders about important activities, discuss and aim to resolve any anxiety issues pertaining to them, and provide motivation. For patients living alone, just knowing that they are going to meet with you online at an agreed time can be a reason to get out of bed and attend to personal grooming. Positive feedback from you can help cement these good habits.

Care coordination and videoconferencing

One of the great things about telehealth is that it makes it much easier to bring different experts together to focus on complex cases. If the patient is going to be present during the discussion, take the time beforehand to explain how it will work and to reassure them that you will be advocating for them throughout. Discuss any concerns and make sure that the other people participating are aware of any difficulties that the patient is likely to have, such as trouble understanding rapid speech or a tendency to get emotionally overwhelmed. As well as making sure that the technology works properly, you will need to chair the meeting in a careful way so that the patient has ample time to express any concerns but doesn’t feel pressured to speak.

Family-focused care

In a similar manner, you can use videoconferencing to speak to a patient in a family setting, potentially looping in family members who live far away. This can be helpful in situations where the patient is not competent to give consent and therefore needs a relative to step in to help with that process. It can be useful when discussing care requirements and addressing environmental issues; a family member may, for instance, be willing to fund home safety adaptations that would be difficult for the patient to obtain otherwise. Finally, it can be a good way to repair and maintain family bonds. Sometimes estranged family members actually find it easier to reconnect online, where they can rebuild their relationships in short bursts with minimal pressure.

Encouraging engagement in elderly patients

While the experience of COVID lockdowns persuaded most people to take the leap and explore new technologies even if they had been hesitant to do so before, people—especially the elderly—continued to resist. The key to getting them to try it is usually to establish how much more freedom it will give them and how much easier it will make a lot of the routine business of managing their health concerns.

Today, if you study for an online Master of Science in Nursing-Adult-Gerontology at a forward-thinking institution like the University of Indianapolis, you’ll find that learning how to conduct this type of negotiation is a key part of the learning process. You’ll build on your existing skills to understand the particular psychological barriers that commonly affect older people and how to work around them in positive, supportive ways to everyone’s eventual benefit. In the process, you’ll not only put your patients in a better position to enjoy good health, but you’ll also make it easier for them to avoid becoming isolated as they age, reducing their long-term risk profiles.

Although there are some patients for whom it will never be appropriate, most people in the sector now see telehealth as the way of the future. It allows for much more inclusive care, gives people with chronic illnesses greater freedom in regard to where they live and what they do, and reduces the risks of infection associated with bringing large numbers of vulnerable people together in one place. It enables healthcare providers to do a lot more when time and resources are under strain, and it opens the door to much more easily accessible care, with more frequent check-ups available to everyone, enabling more illnesses to be identified at an early stage and treated more effectively. Developing your skills in this area today will put you in a strong position in the years to come.

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