Telenursing: A Concept Analysis

Citation: Collada, A. M., Silvestre, A., & Narvaez, R. A. (2023). Telenursing: A concept analysis. Online Journal of Nursing Informatics (OJNI), 26(3). https://www.himss.org/resources/online-journal-nursing-informatics

Abstract

Background: As technology continues to emerge, nurses adapt and apply recent health advancements to increase their efficiency and effectiveness in nursing care and management for their patients. One of these advances is telenursing which is the use of innovative information technology and telecommunications systems to provide nursing care from a distance.

Aim: The aim of this study was to explore the existing knowledge and literature about telenursing in relation to the roles of nurses in the aspects of care, education, and management of illness.

Methods: The Walker & Avant (2019) concept analysis approach was used in this study.

Results: The defining attributes associated with telenursing are (1) use of telecommunication and technology systems in communicating between nurses and patients, (2) nursing care management and continuity of care at a distance, and (3) coordination and support through telecommunication systems. Telenursing provides high quality care, a holistic care approach, accessibility to nursing services, and improved patient health outcomes. Telenursing utilizes knowledge and nursing experience to give health education to patients on preventing diseases, wellness promotion, providing support and empowering patients to take control of their own health with the use of available technology even when face to face interactions is not possible.

Conclusion: The continuous development of technology lays the groundwork towards innovating healthcare systems to reach and effectively serve more patients who need nursing care. Generally, telenursing can alleviate healthcare complexity by rediscovering new and innovative healthcare practices and improving the quality of health services.

Keywords: telenursing, telehealth, nursing, concept analysis, Walker & Avant

Introduction

Nurses have significant roles to fulfill in every part of the healthcare system. These nursing roles include recording patients' medical history, care coordination, carrying out treatment plans, giving medications, follow ups, teaching patients to manage their conditions, exercise, and diet, providing care to people at home and in the community, and so on. A study showed that there is a correlation between the provided nursing interventions and the rate of healing, hospital stay lengths and level of stress of patients and their families (Edirippulige, 2010).  As technology continues to emerge, nurses keep on adapting and applying recent health advancements to increase their efficiency and effectiveness in nursing care and management of their patients.

Communication is a process of understanding how the received and sent messages between people occur, message content, the transmission and people’s response to the message. Effective communication is essential in the roles of health professionals including nurses and it is a part of the daily nursing process from assessment to evaluation to achieve positive patient health outcomes (Barbosa et al., (2016). In addition, establishing good communication increases the quality of treatments and care offered to patients. The integration of technological advances in communication has been reforming nursing practice over the past few years (Kourkouta & Papathanasiou, 2014).

Telehealth is one of the most effective mechanisms in delivering healthcare services, especially in rural and remote areas as stated by the American Nurses Association (Fathi, et al., 2017).  Telehealth technologies allow nurses and other health practitioners to expand their care for patients wherever they are and enable healthcare professionals to manage patients accordingly (Souza-Junior et al., 2016). As a part of telehealth, in telenursing, the nurse uses information technology and telecommunication systems to provide nursing care remotely (Kumar & Snooks, 2011). In the past few years, telenursing has become an important avenue for improving patient care outcomes and allows nurses to interact with their patients remotely in terms of consultation, treatment, monitoring, and patient education (Lister et al., 2018).

Telemedicine as well as telenursing is used mainly on non-urgent cases, however if a patient is in critical condition, it can be used to alert their primary physician to assess, evaluate, and coordinate transfer to the nearest medical facility. In today’s technological landscape, there are faster computer systems, video technologies, wearable sensors, real time data transmissions and high-speed internet which allow healthcare practitioners to deliver quality and timely care from a distance (Schlachta-Fairchild, et al., 2010)

Since the start of the coronavirus pandemic in 2019, there has been an increase in the use of telemedicine. Some of the reasons for this is that it increases physical distance by reducing the patient's travel to hospital facilities and it significantly increases the number of people who seek preventive care in their own home (Mohammed et al., 2020). Telecommunication devices have been fully utilized to decrease the spread of viruses, limit unnecessary travel to hospitals and safely allow clinicians to use telecommunication (by video or telephone) to communicate with hospitalized COVID-19 patients and their loved ones. These transitions were not without barriers and learning curves. The pandemic introduced additional challenges to successful serious disease communication, including widespread fear and uncertainty, increased workload for practitioners, maintaining personal protective equipment (PPE) and unexpected use of telecommunication to decrease viral exposure (Flint & Kotwal, 2019). The COVID-19 pandemic has compelled all healthcare services, clinics, and hospitals to quickly incorporate telehealth services, and the health delivery systems of patient care will continue to be irrevocably altered. Healthcare is "becoming virtual" amid a crisis, but health professionals must remember the most critical stages of transition and how to properly use telehealth. Whether or not healthcare organizations are prepared, virtual care is already a reality (Wosik et al., 2020)

Recent studies showed that teaching patients about self-management topics and health interventions can enhance people’s sense of independence and self-worth which can further reduce the need for hospitalization and can lead to decreases in healthcare costs (Snooks et al., 2008). Although research about telemedicine and telehealth are on the rise in the existing literature, telenursing still has limited studies that assess the impact of these processes for communication between patients and nurses (Barbosa et al., 2016).

This study aims to explore the existing knowledge, process, and impact of telenursing in relation to the roles of nurses in patient care, education, and management, through an adaptation of the Walker & Avant (2019) concept analysis process to guide the analysis.

Definitions and Use of Concept

The prefix ‘tele’ means distance was used to create many healthcare services that are provided using telecommunication systems (Schlachta-Fairchild, 2010). Telehealth means the delivery of health services over distance often as Telemedicine or Telenursing. Telemedicine is a medicine practiced at a distance covering radiology, pathology, psychiatry, oncology and more. Telenursing is the delivery of nursing services and care from distant locations (Greenberg, 2000). According to the Medical Dictionary for the Health Professions and Nursing (2012), telenursing is the use of telecommunications technology to provide nursing care at a distance from the patient.

Telenursing includes nurse-health professional, nurse to nurse or nurse-patient interactions, using Information and Communication Technologies (ICT) devices that break the barriers of distances and time in nursing care management. The most used ICTs are telephone, emails, video and audio conferences, computerized information systems and data transferring processes (Barbosa, 2011). Telenursing has already been in the industry for more than 35 years, mostly by telephone, and uses innovative technology to give quality nursing services and implement nursing care remotely (Schlachta-Fairchild, 2010). Telenursing often consists of registered nurses who act as case managers and usually perform different roles such as counseling, health educator, triage, collecting information, and regulating healthcare institution access to decrease the number of patients in the hospitals. Telenursing also has a potential role in giving informational, instrumental, and emotional support to people with chronic conditions by providing health advice, monitoring their health, and listening to their thoughts and feelings (Kamei et al., 2021).

Telephone Triage

The most common use of telenursing is telephone triage  which is considered the origin of modern telemedicine (Peck, 2005). Telephone triage allows for the identification of the patient's condition, situation, and assessing the level of urgency, while ensuring a safe, timely, and effective delivery of needed assistance considering the patient's needs (Montandon et al., 2019). Telephone triage can also provide education to patients, and allows health professionals to make safe appropriate dispositions, and medical opinions (Kuriakose, 2011). Triage telenurses sit at computer terminals, wear headsets, and receive calls from patients with a variety of concerns at healthcare call centers, such as NHS direct. Nonverbal communication has always been crucial in nursing, but telephone triage and advising services may necessitate a higher reliance on nonverbal signs such as respiration rate and background noises relayed over the phone (Purc-Stephenson & Thrasher (2010). Telenurses utilize a variety of decision assistance software packages to provide triage and health care advice to patients over the phone.
Typically, triage advice leads to healthcare advice, an urgent appointment with the local physician, or a referral to the nearest accident and emergency department (Holmström, 2007). In addition, telenurses were assisted in triaging patient’s symptoms by decision support software which consists of symptom-based guidelines. The criteria were created to assist the nurse in ruling out significant illnesses and stopping at the condition identified and they could securely give patients appropriate interventions while also doing documentation, management, analysis and improving quality of services (Kumar & Snooks, 2011). Prehospital emergency telephone triage has been found to be effective. There are three steps: identification of the condition, determining the necessity for healthcare assistance; and prioritizing calls for the rescue squad and needs for dispatch (Montandon et al., 2019). The aim of telephone triage is to provide proper access to healthcare advice and services for those who are unable to receive them, while also eliminating unnecessary travel to healthcare facilities. It is viewed as an innovative approach to solve the problem of Emergency Department congestion in overburdened healthcare systems (Griffin et al., 2017).

Community and Home Care Telenursing

Telenursing has been used and well known in general and community nursing practice (Snooks et al., 2008). According to Kumar (2011), registered nurses use ICT devices to reach patients that are disabled, patients who live in remote areas, and who have chronic illnesses to monitor their status and manage their care remotely. Furthermore, telenursing also provides health teaching, remote consultations, review of diagnostic results, and aids other healthcare providers to add to medical treatment plans. Telenurses analyze callers' concerns then provide therapeutic care with appropriate interventions or referrals and evaluate their nursing activities using the nursing process (Lorentz, 2008). In recent years, monitoring systems for chronically ill patients such as those with diabetes, hypertension, pulmonary disorders, and other chronic diseases can record the patient's vital signs remotely using monitoring devices at home that can alert healthcare practitioners to provide immediate assessment and manage their symptoms and complications before they get worse (Schlachta-Fairchild, 2010). In the implementation of telenursing in residential homes that use video conferences, found that there is an improvement in terms of engagement with the patients and their health providers (Chan & Hjelm, 2001). The virtual health teachings and consulting approach in home nursing encourages patients to engage in active learning and to use web-based resources developed within learning communities involving patients and their healthcare providers. As well, community-based nurses often make use of web cameras to document wounds, creating an archive for them to check on the wound healing process over time (Jönsson & Willman, 2008)

Telenursing can also be used for palliative care for people who prefer to spend their final months of life at home. Whether the sick person stays at home for a few days or several months, they rely on family or friends to provide primary care, which is aided by home-based services and telenursing. Based on a study, most calls were for the treatment of symptoms such as pain, confusion, nausea, and shortness of breath. To guide the family in these situations, the expertise of a palliative care nurse is very helpful (Roberts et al., 2007), to ensure proper assessment and well-developed communication skills that support optimal end-of-life care (Benhuri (2010).

Telemental Health Nursing

Telenursing can also be used in mental health care. According to Bjorkman & Salzmann-Erikson (2018), the prevalence of mental illness is on the rise in today's culture in Sweden (and worldwide), particularly in adolescent and elderly populations. It implies that there is a demand for preventive actions and that the healthcare system needs improvements to aid, support, and give necessary assistance, and provision of care for those who struggle with mental illness.

Assessment, treatment, education, monitoring, and coordination are all part of mental health interventions. Patients can be seen in hospitals, clinics, schools, nursing homes, jails, and in private residences. It is recommended to have two-way, interactive videoconferencing as an alternative medium for healthcare providers and patients with mental health issues to communicate directly (Grady et al., 2011). Schizophrenia, depression, suicide prevention, dementia prevention, posttraumatic stress, substance abuse, panic disorders, eating disorders, and substance use such as smoking have been managed effectively using telemental health services (Hailey et al., 2008).  Using telenursing in a psychiatric care area is a part of a multidisciplinary team who monitors the patient whereas one full-time nurse practitioner could follow patients who were utilizing a home messaging device (Godleski et al., 2011). Psychiatric nurses can continue providing quality psychological treatment using new and unconventional ways while making it more accessible by leveraging the power of technology and combining it with their experience in evidence-based mental health care (Ellington & Repique, 2013).

Telepsychiatry activities also serve patients in prisons or correctional facilities and the veteran population at large. In the case of prisoners, telemental health services offer an extra benefit of lowering the risk of having to go out in public. However, with geriatric patients, given the recent growth in the use of modern technology and sensory deficits, the potential for discomfort with telepsychiatry equipment is a cause for concern. Still, it has been proven that telepsychiatry services improved these patients' access to medical healthcare providers and mental health care services (Monnier et al., 2003)

Telenursing in ICU

Another use of telenursing is on Intensive Care units (ICU) within hospitals. The telenursing ICU is an area where informatics and telecommunications technologies, as well as telemedicine and telenursing, are combined to improve care for critically ill patients. Evidence-based studies are applied to offer cutting edge services for the treatment and monitoring of critically ill patients (Lilly & Thomas, 2009). Telenursing ICU, nurses and physicians help monitor critical patients and communicate using audio and video technology. It can monitor and assess a number of patients through cameras and continuous monitoring of hemodynamic values and provides access to readily available diagnostics and medical records. A tele-ICU nurse monitors patients virtually through cameras and reposts to bedside nurses if they see anything unusual (Williams et al., (2012).  Telenursing ICU operations have been a staple of excellent critical care outcomes for quite some time. Tele-ICUs working under a centralized hub with auxiliary resources can fully enhance family-centered care outcomes, and coordinated patient visits, collaboration, patient education, and care coordination are just a few of the connected health options for intensive care (Huffenberger et al., 2019).

In Neonatal Intensive Care Units (NICU), several therapies aiming at lowering parental stress have been investigated. Educational programs, empowerment strategies, behavioral tactics, psychiatric therapies, and peer support are just a few of the available options. Furthermore, increasing parents' engagement in newborn care and interaction, keeping moms and babies together has been demonstrated to reduce stress and enhance outcomes. However, circumstances sometimes develop that hinder parents and their newborn from remaining together, particularly when children are critically ill or require lengthy hospitalizations (Gutmann et al., 2020). It improves maternal and newborn connection while also reducing stress of the postpartum mothers especially of preterm babies (Jafarzadeh et al., 2019). Nurses utilize telecommunication systems to give more educational support to the parents because of its easy application, round-the-clock access to selected users and at the same time, cheap cost, and speedy data transfer.

As a result, safety, cost reduction, and improved patients’ outcomes were obtained using telenursing in ICU. As well, some providers may attend unit rounds through robotic devices or cameras from a conference room or even an off-unit location; this strategy has been effective in allowing more staff members to be "on rounds" when space is restricted (Lilly & Thomas, 2009). ICU telemedicine or telenursing are linked to considerable health benefits and improvements in ICU mortality and length of stay, improving the care for both patients and families (Young et al., 2011).

Telenursing during the COVID-19 Pandemic

Coronavirus disease 2019 (COVID-19) was first disclosed in December 2019 and has been declared a worldwide pandemic (World Health Organization, 2020). Many nations instituted a quarantine strategy, which is a physical or social separation, to restrict the spread of the virus (Rakhmawati, 2020). During the pandemic, the use of telehealth initiatives skyrocketed. There is significant evidence that telehealth will continue to have a substantial impact on health care advancement in the future. However, to attain its potential and improve health care for the world's population, the feasibility and use of telehealth in resource-constrained settings and low- and middle-income nations must be established (Doraiswamy et al., 2020)
During the pandemic, healthcare systems used telemedicine to keep outpatient patient care going while decreasing community and nosocomial spread. It also assisted in the control of supply and demand for healthcare services across the country, PPE usage, and monitoring the number of isolated patients (Wosik et al., 2020). The COVID-19 pandemic brought to light the importance of telenursing and telemedicine in patient health. Telenursing is useful for delivering personalized, high-quality care through telemonitoring and video conversations (Kamei, et al., 2021). Furthermore, during a pandemic, the usefulness of information technology–based telenursing becomes even more important since individuals could access this service from the comfort and safety of their own homes.

Telehealth and associated technologies became more common in all health care settings prior and during the COVID-19 issue and such technologies have been crucial in delivering family and patient-centered care since the outbreak of the epidemic. Telemedicine and other telehealth modalities are thought to have the potential to improve connectivity and so reduce parent stress during protracted hospitalizations (Gutmann et al., 2020). As a result, telehealth as well as telenursing is well adapted to address the needs of patient care while also decreasing viral transmission, extending technical resources as well as human resources, and safeguarding healthcare personnel and patients  (Wosik et al., 2020).

Methods

Design
This study used Walker and Avant’s (2019) method as a guide in the analysis of relevant concepts. As shown on Table 1, this eight-step approach explores the basic features of the concepts studied, and is a useful tool for clarifying concepts that are overused and may have ambiguous meaning, often common in the nursing profession (Walker and Avant, 2019)

Search Strategy

A structured literature search was initiated to find deeper understanding and context about telenursing in five databases in accordance with PRISMA guidelines (Moher et al., 2009) (see Figure 1). The researchers used electronic databases and search engines primarily in EBSCOhost, NCBI, PubMed, ResearchGate and Google Scholar. The search was filtered according to keywords and 850 related articles were found. Articles that did not meet the indicators were excluded, such as editorials and commentaries and duplicates were removed, which reduced the number to 450 articles. The abstracts were reviewed, then 250 articles that were not in the English language, published earlier than 2000 or not related to telenursing were excluded. Afterwards, 150 full text articles were reviewed and filtered, excluding another 106 articles where calls and care management were not provided by nurses, or they were not relevant to case analysis. From the different articles and journals, a total of 44 articles and studies were included in the final selection that addressed the relevant concepts.

Defining Attributes

The identified attributes that define the concept of telenursing are shown in Figure 2. This stage defines the attributes that define the concept, which is important since defining attributes is considered the heart of concept analysis. This list of defining attributes functions very much like the criteria for making differential diagnoses in medicine (Walker & Avant, 2019). It summarizes the uses and existing features of the selected concept. These features are likely to occur repeatedly when described.

Telenursing functions in four ways: to assess, give nursing advice, to strengthen, and to teach and facilitate the patient's learning which supports Orem’s Theory of Self-Care (Kaminsky et al., 2009).  The use of telecommunication information systems utilizes the available technology to gather information and to communicate with patients despite the distance. It includes the use of telephones (mobile and landline) calls, websites, emails, video communications, and other data communication systems. Telenursing uses these features to communicate with their patients to identify and provide for their healthcare needs (Souza-Junior et al., 2016)

Providing nursing care management is the principal function of telenursing. Care management is essential in maintaining good health outcomes by teaching patients about self-care management, such as ways to check and manage their condition, attain emergency contact lists, as well as making health care decisions (Lamb et al., 2015). Coordinating the collected necessary information for other healthcare personnel and giving nursing interventions through wires is not a new role for nurses (Peck, 2005). Nurses are a vital part of care coordination in interdisciplinary teams. This is often useful in triaging, making referrals, and providing support to patients, their families, and communities (Luther et al., 2019)

Case Studies

Model Case and Analysis

A model case is an event that contains all the defining attributes of the concept (Walker & Avant, 2019). The following is a model case for telenursing.

Joe, a 36-year-old male worked as a mechanic in a factory. Joe had an accident during his work two weeks ago and underwent a bilateral lower leg amputation in a nearby hospital. Joe lives in a residential building together with his wife and children. The nurse calls John through his mobile phone to remind him of his follow-up check up with his doctor. Joe verbalizes that he is unable to come to the clinic for his follow up consultation. He does not want to leave his children unattended as his wife is at work on that date and wishes to reschedule the consultation to better suit her availability. Joe also said that he noticed something unusual on his wound. Using a camera from his mobile phone, Joe uploads a photo of his surgical wound in the electronic health record system and reports that he found a yellowish discharge on his left leg and that he is still experiencing moderate pain on the surgical site. Joe also verbalized that he felt hopeless that he would not be able to provide for the needs of his family due to his amputation. The nurse can view the image through the electronic record and assess the amount, color, and location of the discharge and checks for any other complications. The nurse previously taught John together with his wife the proper procedure of cleaning his wound, symptoms of infections, dietary advice and when to call for an emergency. The nurse listens to his feelings and concerns and determines the patient's social support system and asks his wife and significant others to get involved and support the patient throughout the process. The nurse facilitated the patient’s referral to physical medicine for rehabilitation and psychiatry services. The nurse reported this incident to the patient’s primary physician. The nurse calls Joe back to give him a new prescription for pain and instructs him about the newly prescribed medications. The nurse also informed Joe that they will reschedule the consultation with his physician on the next available date or will schedule a videoconference with his doctors for evaluation and will check on Joe’s condition in the next few days.

This case is the Model case which contains all the defined attributes of the analysis. The nurse communicates with Joe using his mobile phone as the ICT device. The patient also has a concern regarding his condition but was not able to attend a face-to-face consultation due to certain circumstances. Nursing management was also seen in this case when the nurse reminded the patient to follow up, assessed and addressed the patients' concerns, promoted self-care, and identified support systems for the patient. Continuity of care is also present as the nurse follows up regarding his condition and for future management. The attribute of coordination was done by informing the patient’s primary caregiver and facilitating referrals to other healthcare providers to promote positive health outcomes that will benefit the patient.

Borderline Case and Analysis

Borderline cases are examples or events that contain most of the defined attributes or elements as a model case, however one or more of the defining attributes are not presented. They may contain most or even all the defining characteristics but differ in just one of them, such as length of time or intensity of occurrence (Walker & Avant, 2019)

Miriam, a 58-year-old female was newly diagnosed with type 2 Diabetes Mellitus. She lives with her husband and grandchildren in a remote area. She was advised to buy her own blood glucose monitoring device to monitor her blood glucose every day and record the results for monitoring purposes. Miriam used the internet and called the telenursing support of the clinic to ask how to use the blood glucose monitoring device that she just bought. Using a video call, the nurse demonstrates and teaches the patient about how to measure her blood glucose and asks her to do it in front of the camera under her guidance. The nurse also teaches her the correct timing, proper disposal of sharps, and the abnormal glucose levels that she needs to be aware of and how to manage them and to call for help and assistance immediately if needed.
This case is the borderline case which contains events that include some attributes but not all of them. The nurse and patient used a video call as a telecommunication system and the nurse taught the patient about proper glucose monitoring and self-care interventions as part of nursing care management. There was no coordination required as the main goal was to teach skills and self-care management to the patient.

 Related Case

Related cases are examples or events that demonstrate similarities to the concept being studied but do not contain all the defining attributes (Walker & Avant, 2019).

Jack is a 25-year-old male who just got his Reverse transcription Polymerase chain reaction (RT PCR) result, a test to detect coronavirus COVID 19, and the result was positive. The patient calls an Emergency Room (ER) hotline to seek advice as he was vaccinated and asymptomatic. Jack is aware that he needs to be quarantined but is not aware of other health protocols for positive patients. The ER telephone operator informs Jack of the current health protocol for patients who have COVID 19 that are asymptomatic and advises him to coordinate with their city health department for contact tracing and proper monitoring of his condition.
This case is a related case as a patient seeks guidance from a non-nursing hospital staff through an ER hotline. The case does not contain nursing care management and coordination but was given correct guidelines regarding his inquiry.

Contrary Case

Contrary cases are examples or events that do not define the concept. (Walker & Avant, 2019).

Divine is a 24-year-old postpartum patient who delivered her newborn baby girl via normal vaginal delivery. The patient is stable and is about to be discharged from the hospital. The nurse gives her home instructions including her medications, date of scheduled follow up check set by her primary physician, and instructions on proper postpartum and newborn care.

This case is a contrary case since it is an event that does not have any of the attributes. It does not contain the use of telecommunication technology as the nurse is giving home instructions in a face-to-face interaction. There is no nursing management done by distance or even coordination for referral and support with the use of telecommunications technology.

Antecedents

Antecedents are events that occur before the occurrence of the concept (Walker & Avant, 2019). An increase in the aging population and number of patients living with chronic illness, the demand for increased healthcare coverage in rural and remote populations, increased number of people who use telecommunications technology regularly, and the demand for telehealth care continues to grow and are all antecedents for telenursing. Telenursing is possible if there is a presence of health-related concerns of a patient, distance to healthcare institutions, and the use of current technology in communication, coordination and care management are involved. This requires telecommunication devices for both nurse and the patient for proper communication and assessment. Telenurses must be able to employ technology effectively while providing nursing care and communicate well with patients at a distance who have limited access to healthcare (Hafermalz & Riemer, 2016).

Consequences

Consequences are events that occur because of the outcomes of a concept (Walker & Avant, 2019). Some benefits of telenursing is that it may contribute to solving the increasing shortages of nurses, reducing the travel distance and travel time to hospitals for patients, and helps to keep patients out of hospitals. Telenursing can also decrease the healthcare costs for patients while improving access and quality of care (Kumar & Snooks, 2011). According to Peck (2005), one nurse can accommodate up to 425 patients with the use of telehealth and telenursing and can offer nursing care from a distance. According to Greenberg (2011), telenursing has significant potential to improve disease management outcomes. Telenursing can enhance access and continuity of care to patients and can improve patients’ quality of life, promoting self-care and independence, while providing new opportunities for nurses.
There are barriers to telenursing and telecommunications, such as lack of financial capacity, physical frailty, language differences, socio-economic status, and lack of skills (Arnaert & Delesie, 2011). There are fears that the lack of face-to-face interactions or direct patient assessments will degrade health care quality.  It can potentially increase risks of liability, including increased risks to the confidentiality and security of patient’s health records and information, healthcare practitioners' ability to perform outside of their scope of practice, the chances of failures in technology use, and the lack or difficulty in providing information to patients that allows them to make their own health decisions (Kuriakose, 2011). The inability to use technology owing to a lack of instruction, education, and assistance can be a major issue for both nurses and patients. Also, it may confront technological failure, a threat to patient safety, and malpractice. In telenursing, ensuring confidentiality and informed consent is also a challenge. Invasion of privacy may also be a concern when cameras are installed in the home (Mohammed et al., 2020).

 Empirical Referents

Empirical referents give evidence that substantiates a concept. The existing literature does not report any empirical referents directly for telenursing (Walker & Avant, 2019). However, measures related to the concept are available that may evaluate the process, patient satisfaction, and outcomes of telenursing practice. Some of these include:

The Telenursing interaction and satisfaction questionnaire (TISQ) that was developed by Mattisson et al. (2019) consisted of 60 questions which reviewed the caller's appraisal of the situation and expectations, perceived interaction with the nurse, and overall patient satisfaction with the service. A similar study with pretested questionnaire and distance-listening quality control procedures by Hagan et al. (2000) aimed to address the accessibility, cost efficiency, development of self-care abilities, and patient satisfaction with care done through telenursing. To evaluate strategy development, feasibility and patient satisfaction of telenursing, Yun & Park (2007) used a three round Delphi survey and SWOT analysis. Lastly, The P.A.T.C.H. assessment scale v. 3 developed by Kaminski (2011), was used to assess attitudes of nurses towards technology such as computers, health, and mobile technology in healthcare (Adams, 2015).

Discussion

Advanced Technology has already had a big impact on the health care system, many patients are well informed and have knowledge about their health concerns. Every healthcare institution that requires professional specialists suffers a possible shortage of nursing care providers as the demand for care increases. Telenursing uses technology that can help every health care institution as a response to nursing shortages. Telenursing enables patients to connect with their nurses through mobile devices, computers, mobile apps, and video technology. It provides a chance for nurses with honed knowledge to practice and facilitate telenursing and continue to develop their skills as healthcare professionals (Greenberg, 2011)
Telenursing can also give more opportunities to nurses to specialize in their profession and provide care to a larger number of patients as a solution for nursing shortages (Grisot et al., 2019). Telenursing uses technology more conveniently than face to face even though many patients are interested and familiar in direct interactions with their healthcare providers, especially the elderly (Botsis & Hartvitsgen, 2008).

Telenursing can be one of the most accessible methods in terms of healthcare intervention and innovation. Providing nursing care via the internet and mobile devices can support continuous medical interventions and improve patient quality of life by preventing possible complications of disease or treatments, enhancing patient expectations, and developing optimal health and service standards. The general objectives of telenursing programs are to support self-care behavior, decision-making information and problem solving, stabilize coordination and cooperation with other healthcare services, and improve quality of life and health condition of patients while utilizing fewer health resources, saving time, and reducing costs and transportation needs (Snooks et al., 2008)

Some people, especially the elderly, are resistant to the use of modern technology, however, manufacturers are still finding ways to accommodate this kind of potential user. They continue to develop user-friendly technology to meet diverse consumer needs. It is suggested by Arnaert & Delesie (2001), that as the needs of the elderly increase with age, the start of the elderly phase is the right time to introduce and teach the new versions of technologies. The elderly tends to have physical and functional problems; thus, telenursing is an advantage and allows them to facilitate these services to minimize traveling from their location. A study in Iranian elderly that compared telenursing and in-person follow up states that after applying telephone intervention to the elderly, the effectiveness of telephonic follow up interventions has improved (Sadeghmoghadam et al., 2019). In the study by Botsis & Hartvitsgen (2008), on the effect of telenursing on elderly people with chronic diseases, it was found that the elderly had improvements in their condition with telenursing, but a hybrid combination of telenursing and traditional home care was preferred.

 Implication for Nursing Practice

With continuous advancement in technology, many changes in the healthcare delivery system and care services have occurred. New advances in telecommunications have rapidly progressed in healthcare which gives more opportunities for research and enhancement, broadens clinical nursing practice and advances education, especially for nurses in the informatics field. Computer systems and Information technology have a significant role to play, especially in the field of healthcare. The integration of nursing informatics into telenursing can provide more opportunities to develop data communication systems, coupled with nursing management to improve patient care as well as advance innovations in the healthcare system. It helps to optimize the services, saves time, and increases efficiency in healthcare delivery. This provides a high quality of care, a holistic care approach, better accessibility to nursing services, and improves patients' health outcomes. It can provide more opportunities through training for nurses to provide nursing care that serves more patients who are in need despite time or distance. Telenursing is an emerging scope of nursing and standards for telenursing practice can be developed to further enhance the quality and services it provides.

Telenursing also utilizes knowledge and nursing experience to give health education to patients on preventing diseases, wellness promotion, providing support and empowering patients to take control of their own health with the use of available technology even when face to face interactions is not possible. Future telenursing expansion will require high-quality telenursing research to lay the groundwork for ongoing assessment of telenursing applications, which can lead to the development, identification, and implementation of evidence-based practices (Mohammed et al., 2020).

Limitations and Recommendations

There are several limitations in this study. The concept analysis of telenursing was obtained using limited electronic resources and needs further study on how telenursing will contribute to the shortages of nurses, how it can reduce patient visits to healthcare institutions, increase the quality of care depending on the patients’ needs and condition and disease management as well as its potential to increase independence in patients with chronic illnesses and improve their quality of life. The search strategy is based on existing studies published on the internet by credible sources. In selecting resources, the researchers limited the resources to ones that could emphasize the analysis of telenursing concepts. Further discussion is needed regarding the benefits and barriers of telenursing. The results show the need for further studies of telenursing uses depending on the need and capacity of each country and the need for standards and protocol in telenursing.

Conclusion

The concept analysis of telenursing provided further understanding of the concept by exploring and organizing its feature attributes. Furthermore, the concept analysis provided appreciation of the development and use of telenursing in different situations depending on the needs of the patient. Technology in today's world is becoming popular as it provides convenience, especially for communication across distance. In telenursing, nurses and their patients need to have access and knowledge of these kinds of technologies to meet their needs for care. This includes telecommunication devices and the capacity of nurses, patients, and their significant others in using this kind of technology. Those patients that are unable to avail themselves of the appropriate technology will not benefit from telenursing. The continuous development of technology lays the groundwork towards innovating healthcare systems to reach and effectively serve more patients who need nursing care. Generally, telenursing can alleviate healthcare complexity by rediscovering new and innovative healthcare practices and improving the quality of health services.

Telenursing is an intervention of nursing, not a specialty; it is a technique that nurses incorporate to provide better care to a larger number of people across distance (Arnaert & Delesie, 2001). Telenurses should have a wide range of skills, including pharmacology, psychology, communication, and other nursing related skills. Telenurses must also be taught how to deal with overt and subtle power messages. The importance of hands-on nursing has been highlighted, as well as technology training to boost efficiency (Kumar, 2011).

To conclude, this study indicates that seeking medical expertise or other health specialist advice from remote areas via mobile devices, computers, and internet for nursing interventions is possible. Telenursing is a technology-based nursing practice service that was created to make healthcare accessible for every patient in need. Telenursing recently became an essential component in delivering health care, to continue comprehensive treatment during COVID 19 pandemic to every patient. In consideration of the pandemic, technology had a big role in developing the healthcare system to provide more patient accessibility and receive better services through telenursing systems. Telenursing can make health services better by creating advanced and improved models of healthcare delivery. Telenursing is one of the solutions to support healthcare to become efficient and deliver quality service to diverse patients wherever they are located.