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The satisfactions of telenursing: A change of direction into telenursing has provided one nurse with work/life balance and job satisfaction.

After 15 years of nursing in various practice areas, including in the British Army, emergency care, primary care and surgical nursing, I have recently embarked on a new path telenursing. I work for Homecare Medical (HCM), which, since November 2015, has run a range of government funded national telehealth services, including Healthline.

Initially, my motivation was personal --a desire for a better work/life balance and employment that was sustainable. However, as I moved through the 10-day training, I realised I was about to start a job that would offer more than that.

Healthline is a nurse-led triage service that uses an internationally renowned clinical decision support system, Odyssey. (1) By following the Calgary-Cambridge consultation model, (2) users are guided and supported by a framework that allows the registered nurse (RN) to integrate their clinical knowledge and experiences with evidential best practice. The evidence is updated through a regular review process endorsed by the National Institute for Clinical Evidence in the United Kingdom. (1)

The tools that support nurses' decision-making are just that, tools. (3) They have been proven internationally as an effective method for prompting a course of questions, but they are still an adjunct to an experienced RN's critical thinking and clinical judgement. (3)

Specialist practice area

One researcher in the field suggests millennials have the skills and cultural background to create a recognised specialist practice area in telenursing. The researcher goes on to state that the nursing profession needs to seriously consider virtual health-care options to meet the challenge of increasing health needs. (4)

Telenursing has provided access to health care for those who, in the past, had limited health-care options. It brings health care and expert advice to rural and remote areas, increasing cardiac arrest survival and improving chronic illness management. (4)

But some still think telenursing is not "real" nursing, as there is no direct face-to-face contact with the patient. However, some researchers suggest that the physical elements of nursing care are often delegated to unregistered support staff. (4) They state that modern nursing is about cognitive ability, the expertise to interpret, critical thinking and comprehending the significance of what is seen or heard.,

In my experience, every patient contact is individualised to that patient's needs. On one shift I may have many patients with the same presenting problem, but each brings its own set of complexities, including the patient's location, their family/peer support, their transport and their understanding of their health needs. It is important to ascertain this information, both for developing a therapeutic relationship and for understanding the patient's perception of their health and well-being.

I am able to deal with one patient at a time, giving them the individual care and advice they require. The introduction phase of the consultation allows the initiation of the therapeutic relationship (2) This is where I have the opportunity to listen to the complaints/needs of the caller, while considering which direction their story may take.

Through an assessment, using my clinical judgement and the Odyssey system to respond to the presenting symptoms, I am able to provide a nursing diagnosis and follow up with appropriate advice and information. Through establishing whether any symptoms are getting worse, by giving advice and confirming the caller has understood I've said, I am able to achieve the implementation and evaluation phases of the nursing process in providing patient-focused care.

Sometimes a patient does not understand the significance of their symptoms; to them they are not a priority, just a hindrance to their daily living. I may think their symptoms need further medical attention, but their priority may be children, family or the cost of care. In such situations, I must collaborate with the patient and develop a plan and achieve a satisfactory outcome, both in terms of any ongoing medical management and the patient's immediate concerns.

Every call is different, whether it be the presenting symptoms, or callers' different psycho-social or environmental situations. Differences include living conditions, societal influences, mental health and health literacy, all of which can have major consequences for health outcomes. (5) Sometimes the caller has had limited access to health care and access to health advice is a new experience.

Communicating just by listening, with no visual cues available, is challenging. Callers' abilities to express and describe their symptoms vary, which means I have to use a range of strategies to get the information I need for a safe and satisfactory consultation. Encounters with patients rely greatly on a therapeutic relationship. An assessment can't be made without first establishing a good relationship with the caller, in which both parties receive and respond to what is being said and understand it.

Calls across the age spectrum

Calls come from around the country and we deal with people of all ages, from mothers of babies to the elderly. Until the first contact is make, we have no warning of the caller's presenting problem. I don't know where the call will take me, or even if I will be able to help. However, assistance is never far away with the click of a button a caller can be put on hold and a senior RN is available to talk to. Each shift has a designated team leader, who provides advice and support. It is great to have that level of backup.

I find the balance of "power" between nurse and patient is more evenly distributed in telenursing than in direct-contact nursing. The concept of "power sharing" is a fundamental aspect of modern health care that places the patient at the centre of decision-making (6) and telenursing certainly enables this. The caller has chosen to contact Health-line, often from the comfort of their own home or an environment they know. Patients who go to hospitals or general practices or other health providers are going into an environment that may be alien to them, where they may feel uncomfortable or disempowered.

I work from a call centre, which is certainly different from working in a conventional hospital or health clinic. I work alongside staff from smoking cessation, mental health and addictions, and bowel screening virtual services. Some HCM nurses work from home if they live beyond travelling distance to a call centre. We are all connected virtually and have an open chat throughout the shifts to allow everybody to feel connected and reduce any feelings of isolation.

I have regular coaching sessions with my manager and monthly call reviews, where I do a self review. A senior nurse also does a review and we discuss our findings. It is great to have this level of support and collegial discussions. Knowing there is assistance and advice immediately available has certainly helped my enjoyment and satisfaction in the role.

Making a difference

I embarked on telenursing a year ago and have found it to be a job where I finish the day satisfied I have been able to make a difference to someone, without jeopardising my own health and well-being.

The aspects that contribute to my positive work experience are supported by research. A systematic literature review of the relationship between nurses' empowerment and job satisfaction concluded that a sense of control over the structure of work (one call at a time) and the support available to improve performance and competence were closely related to work satisfaction and retention. (7)

Delivering the national telehealth service

HOMECARE MEDICAL (HCM) delivers the national telehealth services and is owned by two primary-health care organisations, ProCare and Pegasus Health.

The national service delivered by HCM began in November 2015, after several helplines run by different organisations were integrated. HCM has a 10-year contract valued at $257.6 million and is funded by the Ministries of Health and Social Development, the Accident Compensation Corporation, the Department of Corrections, the Health Promotion Agency and district health boards.

It employs 350 staff, including 122 registered nurses and in two new roles, 19 specialist emergency triage nurses and 22 early mental health response nurses. Staff work from contact centres in Auckland, Wellington, Christchurch and Dunedin and from home offices.

According to its website, in the year ending June 30, 2017, its telehealth services received more than half a million contacts from nearly 420,000 people. Nurses advised 288,000 people, emergency triage nurses triaged nearly 30,000 and the mental health team supported 45,000 people.

On June 1 this year, HCM launched the helpline Safe to Talk He pai ki te korero for people who have experienced trauma or sexual harm.

Aura Sanderson, RN, BN, works as a triage nurse for Homecare Medical, based in a call centre in Wellington.

References

(1) Advanced. (n.d.). Odyssey: clinical decision support solution. Retrieved from www.oneadvanced.com/products/odyssey/

(2) Kaufman, G. (2008). Patient assessment: effective consultation and history taking. Nursing Standard, 23(4), 50-56.

(3) Rutenberg, C., & Greenberg, M. (2012). The Art and Science of Telephone Triage. How to Practice Nursing over the Phone. New Jersey: Anthony J. Jannetti Inc.

(4) Mugavin, M. (2014). Millennials usher us in: Nursing and the emerging virtual environment of care. Journal of Nursing and Practice, 4(9), 69-76.

(5) Macleod, J., & Smith, G. D. (2003). Psychosocial factors and public health: a suitable case for treatment? Journal of Epidemiology and Community Health, 57, 565-570.

(6) Nimmon, T., & Stenfors-Hayes, T. (2016). The "Handling" of power in the physician-patient encounter: perceptions from experienced physicians. BMC Medical Education, 16, 114. Retrieved from https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-0160634-0

(7) Cocolini, G., Comparcini, D., & Simonetti, V. (2014). Workplace empowerment and nurses' job satisfaction: a systematic literature review. Journal of Nursing Management, 22(7), 855-871.

Caption: Communicating just by listening, with no visual cues available, is challenging.
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Title Annotation:viewpoint
Author:Sanderson, Aura
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Aug 1, 2018
Words:1610
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