By Traci Haynes, MSN, RN, BA, CEN
Health advice has been telephonically dispensed since the advent of the telephone. An often-told story identifies the first telehealth interaction occurring when Alexander Graham Bell placed a call to Mr. Watson, his assistant, requesting Watson to come help him with an injury to his hand.
Today, in our ever-changing healthcare environment coupled with advancing technologies, new methods of interacting with patients and delivering care continue to evolve. Telehealth, in support of the Institute for Healthcare Improvement’s (IHI) triple aim, has demonstrated improved access, quality, and cost-efficiency of healthcare delivery and has resulted in an increased demand for telehealth nursing practice (TNP).
Although TNP had not been recognized as a distinct practice area early on, the breadth and scope has advanced throughout the years. TNP has had a major presence in the United States since the 60s, in Canada since the 70s, and the UK beginning in the 90s.
In the last half of the 70s, health maintenance organizations (HMOs) began using telephone triage and advice services as a gatekeeper, in an effort to control consumer access to care. In the 80s hospital marketing departments used telephone triage as well as physician and service referrals, class registration, and health education and information services to attract and retain their market share. And once again in the early to mid-90s, managed care organizations further expanded telehealth services for demand management, recertification, and referral authorization.
Present day, the ever-increasing incidence of chronic illness and multi-morbidities, as well as the associated rise in healthcare costs, has led to the role of telehealth nurses providing surveillance and monitoring for disease management, care management, case management, care coordination, and clinical prevention programs.
The registered nurse is the appropriate provider of telehealth nursing services as recognized by both the American Nurses Association (ANA) and the American Academy of Ambulatory Care Nursing (AAACN) who also recognize TNP as a nursing subspecialty of ambulatory care nursing. The application of the nursing process when providing patient care has always pointed to professional nursing practice.
Telehealth is used as an umbrella term to describe the wide range of services delivered across distances by all health-related disciplines. The following definitions were approved and adopted by the AAACN’s Telehealth Nursing Practice Special Interest Group (TNP-SIG) in 2003:
- Telehealth: “The delivery, management, and coordination of health services that integrate electronic information and telecommunications technologies to increase access, improve outcomes, and contain or reduce costs of healthcare” (Greenberg, M., Espensen, M., Becker, C., & Cartwright, J., 2003. Telehealth nursing practice SIG adopts teleterms. AAACN Viewpoint, 25(1), 8-10).
- Telehealth Nursing: “The delivery, management, and coordination of care and services provided via telecommunications technology within the domain of nursing” (Greenberg, Espensen, Becker, & Cartwright). Telehealth nursing encompasses all types of nursing care and services using one or more types of telecommunications technologies: telephone, fax, electronic mail, internet, video monitoring, and interactive video.
- Telephone Nursing: “All care and services within the scope of nursing practice that are delivered over the telephone” (Greenberg, Espensen, Becker, & Cartwright).
- Telephone Triage: “An interactive process between nurse and client that occurs over the telephone and involves identifying the nature and urgency of client healthcare needs and determining the appropriate disposition” (Greenberg, Espensen, Becker, & Cartwright).
State boards of nursing define the scope of nursing practice for each state. Each nurse must be knowledgeable of their state’s Nurse Practice Act and the rules and regulations involving their practice within their state of residence.
In 1999, the National Council of State Boards of Nursing (NCSBN) proposed the Nurse Licensure Compact (NLC), allowing “mutual recognition” of a nursing license between member states. Enacted into law by each participating state, member states allow a nurse that resides in and possesses a current nursing license in a state that is a member of the NLC to practice in any of the other member states without obtaining additional licensure in that state. An excellent video provided by the NCSBN can be found on their website and is titled “The Nurse Licensure Compact Explained.” Currently, twenty-five states are involved in the NLC.
Telephone Nursing Practice certification was offered by the National Certification Corporation (NCC) from 2001 to 2007. In all, over 1,200 nurses were nationally certified. Nurses who are currently certified through NCC can maintain their certification by meeting NCC’s recertification requirements.
In 2007 AAACN adopted the position that TNP has been and continues to be an integral element of ambulatory nursing. In their role as an industry leader, AAACN continues their support of TNP. Today the Ambulatory Certification Review Course and the Ambulatory Care certification exam include a telehealth component.
AAACN further supports TNP with its own telehealth track at their annual conference, as well as providing many resources for TNP including:
- Scope and Standards of Practice for Professional Telehealth Nursing (American Academy of Ambulatory Care Nursing (AAACN), 2011. Scope and standards of practice for professional telehealth nursing (5th). Pitman, NJ: Author.)
- Telehealth Nursing Practice Special Interest Group
- Telehealth Nursing Practice Toolkit
- Telehealth Nursing Practice Essentials Textbook
- Telehealth Manager’s Toolkit
- Endorsement of “The Art and Science of Telephone Triage: How to Practice Nursing Over the Phone,” written by Carol Rutenberg, RN-B, C-TNP, MNSc and M. Elizabeth Greenberg, RN-BC, C-TNP, PhD.
Competencies for TNP as defined by AAACN in 2004 identify the behaviors and outcomes specific to providing efficient, effective, evidence-based care. These include:
- Professional Knowledge: managing clinical calls using the nursing process and demonstrating critical thinking skills in assessing the needs of the caller.
- Interpersonal Skills: establishing a trusting relation in order to elicit accurate information and using effective interpersonal communication skills to engage in a therapeutic interaction.
- Technical Skills: adapting to equipment efficiently in order to perform the TNP role and using decision support tools (such as, guidelines, protocols, algorithms, and care pathways) to address caller needs to identify actual and potential health risks.
- Documentation of Telehealth Encounters: accurately recording the interaction reflecting the actual or potential health needs, which become part of the EHR.
- Personal and Professional Development: responsibility for attaining and maintaining the knowledge and skills necessary to function in the TNP role (AAACN, 2011).
TNP improves access to healthcare for our patient populations. It increases the quality of healthcare outcomes through patient-centered, collaborative care, and decreases the cost of care by meeting the needs of patients with timely and appropriate resources.
Traci Haynes, MSN, RN, BA, CEN, is the director, clinical services at LVM Systems, Inc.