MEDINFO 2019: Health and Wellbeing e-Networks for All 1323 L. Ohno-Machado and B. Séroussi (Eds.) © 2019 International Medical Informatics Association (IMIA) and IOS Press. This article is published online with Open Access by IOS Press and distributed under the terms of the Creative Commons Attribution Non-Commercial License 4.0 (CC BY-NC 4.0). doi:10.3233/SHTI190441

The Barriers and Facilitators for Nurse Educators Using Telehealth for Education

Maria Prendergasta, Michelle Honeyb

a Nurse Educator, Thames Hospital, Waikato District Health Board, Waikato, New Zealand b School of Nursing, University of Auckland, Auckland, New Zealand

Abstract pace and scale expected [10]. The traditional method of gathering as one central group for education does not meet the Telehealth is available world-wide and in addition to clinical needs of rural health professionals [11], hence the growth in uses, it can also be used to provide education for health popularity in the use of telehealth to support their ongoing professionals, supporting e-Networking. However, within education. Barriers to the uptake of telehealth include funding, New Zealand the uptake and widespread use of telehealth time, infrastructure, skills and preference for the traditional remains low, and why telehealth is not used more is not face-to-face approach for education and service [12]. Santos understood. This study describes nurse educators use of [13] recognises the lack of managerial support, lack of access telehealth for education and identifies barriers and facilitators to and relevance of education sessions, and also workplace to increase the uptake of telehealth amongst nurse educators. culture can be barriers to nurses accessing education via An on-line survey administered using Survey Monkey had a telehealth. response rate of 57% (n=19). Equipment that was not user friendly and a lack of initial training were recognised as Within NZ, the Ministry of Health has introduced both the NZ barriers to their uptake of telehealth. Telehealth training and Health Strategy and the Health Information Strategy to guide support, and local champions were identified facilitators to the regional District Health Boards (DHBs) in their increase the uptake of telehealth. Recommendations include introduction and use of telehealth. Despite 17 of the country’s the need for early adopting nurse educators to be recognised 20 DHBs actively using telehealth, a national stocktake in and encouraged, to role model good practice in telehealth, 2014 found the momentum did not reflect the true potential and mentor and support others. available [14]. This stocktake also recognised the most used telehealth equipment was videoconferencing, which can be Keywords: used as an adjunct to support health professional education Surveys and Questionnaires; Telemedicine; Faulty, Nursing [14]. Yet issues about the use of telehealth, and specifically videoconferencing for educational use, within the DHBs have Introduction not been explored. This study will investigate such issues, and form recommendations for future use. Telehealth and telemedicine are terms often used interchangeably to describe health services provided across Methods distance to both healthcare providers and their clients [1]. Telehealth is available world-wide to support long distance To explore barriers and facilitators for nurse educators using health care and education to both patients’ and health videoconferencing, a mixed methods approach was selected as professionals [2] but internationally, the uptake and use of it can provide descriptive data including demographics, telehealth remains disappointing [3]. Within the European attitudes and behaviour from a selected group [15]. The Union the expectations of both policy makers and stakeholders participants, employed within one District Health Board in fall short [4], whilst in Norway the use of their telehealth New Zealand, were using videoconferencing as part of their system and services is much lower compared to face-to-face education role. With a population of over 400,000 people, this options [5]. In Canada, however, telehealth is rapidly District Health Board represents the fourth largest region in increasing in quality, accessibility and popularity [6]. Within New Zealand, but over 60% of the people live outside the New Zealand (NZ), the introduction of ultra-fast broadband is main city, hence there are a number of small satellite rural expected to increase the accessibility of telehealth for New hospitals. The nursing staff in these rural hospitals can be Zealanders [7]. To maximise the true potential for telehealth, disadvanatged by being unable to access continuing nursing it is necessary to understand the barriers and facilitators that education. will lead to an increase in telehealth uptake, not just for service delivery, but also for health professional education. For data collection, a questionnaire was created with 13 questions developed, drawing on the available literature. The questions were piloted by three colleagues who did not Background participate in the survey, and their feedback was used to refine and clarify the questions, finalise the order of questions and Internationally, there remains a preference for face-to-face also to determine the time needed to complete the survey. education when compared to providing education via Ethical approval was gained from the University Ethics videoconferencing [8]. The term video-conferencing describes Committee (Ref. 018105) and the associated DHB (RD: real-time, synchronous, two way transmission of digitalised 016114) before the questionnaire was distributed on-line in audio and video images between two or more locations [9]. late 2016, using a commercial survey tool, Survey Monkey. The use of telehealth for education has not developed at the 1324 M. Prendergast and M. Honey / The Barriers and Facilitators for Nurse Educators Using Telehealth for Education

Survey Monkey was selected for the on-line survey because it 100 was easy to use and familiar to respondents. An email with 90 the link to the survey was sent to all 33 nurse educators who work within one DHB. One reminder email was also sent. 80 70 Collation of the responses occurred automatically. Analysis 60 of the numerical data was completed using an Excel spreadsheet, with graphs to present the data. The responses to 50 the open-ended question “Please add any further feedback you 40 would like to share” were thematically analysed based on the 30 % response rate response % process described by Braun and Clarke [16]. The results 20 presented below report the demographics, nurse educators’ experience of telehealth, and factors that impact on their 10 engagement with telehealth. 0 NotNo SomewhatSomewhat Important Important Very important important important Results important important Important

In total, 19 out of 33 nurse educators completed the survey, Figure 1- Importance of telehealth for nurse educator role giving a response rate of 57%.

Demographics important.” Respondents were also asked to rate their skill when engaging The nurse educators ranged from 31 to over 50 years of age, in telehealth as either novice, competent, proficient or expert, and the majority (74%) had more than 15 years nursing based on the scale of Benner’s terms [17]. Approximately two experience (Table 1). thirds (68%, n=13) of the nurse educators viewed themselves at novice level; 21% (n=4) as competent, and 11% (n=2) rated Table 1- Nurse educator demographics (n = 19) themselves as proficient. No one considered they are practicing telehealth at an expert level. Demographic n % Age Factors for engaging with telehealth < 30 years 0 0 31-40 years 5 26 A list of factors that influence staff engagement with 41-50 years 10 53 telehealth was compiled from the relevant literature, and >51 years 4 21 respondents were asked to identify any factors that applied to Experience as a nurse them. There was only one statement that all respondents < 5 years 0 0 indicated and this was for telehealth equipment to be easy-to- 6-10 years 1 5 use and reliable (Figure 2). The second most important factor 11-15 years 4 21 was the need for training and support, with strong leadership >16 years 14 74 and the need to recruit local champions being viewed as third most important. The least important factors identified by the Experience of telehealth respondents were negative impact on service change and negative impact on staff. The majority, (90%, n=17) of the nurse educators had not experienced telehealth during their initial nursing education. Themes from further comments When asked about their current use of telehealth in their role, Only seven (37%) respondents made further comments in the nearly two-thirds (63%, n=12) of the nurse educators free text question: “Please add any further feedback you responded that they were not using telehealth and 31% (n=6) would like to share”. To analyse these comments, words with responded that they were using telehealth to some degree; and the same or similar meaning were bracketed, then grouped, one respondent (5%) was uncertain. However, nearly 80% and from this three themes emerged. These were: engagement (n=13) of the nurse educators felt telehealth was “somewhat in telehealth, the importance of telehealth, and technology. important” or “important” for their role (Figure 1). Engagement in telehealth was the most common theme to Of the 19 respondents, 42% (n=8) reported having had “a emerge in the comments, such as “Will need to engage in little” experience with telehealth. Although 31% (n=6) of the order to be effective” and, “I will engage more and more over nurse educators had either “some” or “quite a lot” of time”. The importance of telehealth was another theme, with experience, there was still 26% (n=5) of the group who had statements such as: “Telehealth use is very important”. The not experienced telehealth at all. When asked to rate their third theme indicated feelingsabout the importance of understanding of telehealth, the majority of respondents telehealth technology, with comments such as, “vital (n=13, 68%) reported being “knowledgeable” or “somewhat technology” and “equipment and technology is a positive knowledgeable”. There is however, 32% (n=6) of the group change”. who considered themselves “not knowledgeable” at all in the use of telehealth. Furthermore, when asked about the The positive comments saw telehealth as “the way of the importance of gaining competence in using telehealth, two future”, “will achieve bang for our educational buck” and thirds (67%) believed gaining competence is either “likely to improve patient outcomes”. However, the “important” or “very important”. challenges identified by the respondents included the need to “grow in confidence” and “it will take time and support to Although no respondents felt gaining competence was not make it work”. important at all, there was still nearly one-third (33%, n=6) of the group who see gaining competence as only “somewhat M. Prendergast and M. Honey / The Barriers and Facilitators for Nurse Educators Using Telehealth for Education 1325

Important factors when engaging in Telehealth

Negative impact on service change Negative impact on staff Low expectations of outcomes/needs Impersonal Security & confidentiality Poor change management Lack of time Not a strong practice culture Integration into routine practice Lack of training Trust in technology Lack of confidence in technology Concerns about user friendliness Collaboration Flexible & responsive to working practice Communication issues Strong leadership & local champions Training & support Easy-to-use, reliable equipment

0 20406080100120 % response rate

Figure 2: Important factors when engaging in telehealth

Discussion providing training and support has been shown to improve staff confidence and engagement in the usage of telehealth The results of this survey provide insight into nurse educators’ [19]. In this study, the nurse educators were not very use of telehealth within one DHB. Overall, the results reflect experienced telehealth users. However, it is essential to results found in the literature concerning the lack of telehealth acknowledge staff who have more experience as they could be uptake, but there is evidence that some of the nurse educators recognised as innovators and possible clinical champions in are keen to engage and use telehealth within their role. the future [24]. Telehealth will never remain static, rather it is becoming an increasingly essential element of healthcare [18], so it is Leadership and local champions important for the nurse educators to become further involved Successful implementation of telehealth also requires strong as it provides another format for the provision of education to leadership and local champions, a finding from this survey and nurses. Additionally, telehealth has been shown to improve supported by the literature, where champions contribute to the access to educational opportunities for rural and isolated successful implementation [25]. These individuals can be health professionals [11,12]. facilitators for the adoption of telehealth [10]. Using telehealth Success of telehealth depends on the competency of the Telehealth equipment which is reliable and easy-to-use was nursing staff [26]. From this survey, nearly two-thirds of the recognised as the most important factor in this study, and this nurse educators felt it was important or very important to gain is similar to literature that found it to be instrumental in staff competence in telehealth, but with a similar proportion rating acceptance of telehealth [10,19]. Possible issues, echoed in the themselves as a telehealth novice. Based on these findings, results of this survey and reflected in the literature, which further education needs to be planned and implemented. The prevent staff from engaging in telehealth include a lack of use of telehealth competencies, including topics such as adequate equipment [20], and lack of appropriate training communication, use of the technology, ethics and coaching [21]. Sligo, Gauld, Roberts, and Villa [22] however, believe skills may be helpful to increase users’ skills [27]. Grading the there should be a good fit between the technology and the competencies into novice, competent, proficient and expert users from the beginning, and the technology should be levels may allow the nurse educators to develop their technical intuitive so that little staff training is required. Training and skills in a manner that grows their confidence and competence support was identified in this study as an important factor for in a timely manner [28]. successful implementation of telehealth, both initially and in the longer term. To improve the uptake and sustainability of Limitations and areas for further research telehealth use, training should be held in the workplace with Although a good response rate for this survey was achieved, staff trained to troubleshoot technical issues [21]. There also there are still nearly half of the nurse educators who did not needs to be dedicated technical support during the respond and their perceptions on telehealth remain unknown. implementation phase [19], as well as later, to consolidate The results presented here indicate the experience and staff knowledge and technological skills [23]. Additionally, perceptions of the nurse educators in one region of New Zealand, therefore repeating this study across a wider area is 1326 M. Prendergast and M. Honey / The Barriers and Facilitators for Nurse Educators Using Telehealth for Education warranted. Additionally, further research is needed to explore [12] J. Moffatt, D. Eley, Barriers to the uptake of telemedicine in nurse educators’ perceptions as this may indicate strategies Australia - a view from providers, Rural and Remote Health that would improve telehealth use for education. A qualitative 11, (2011), 1-6. approach, perhaps using focus group interviews, is [13] M.C. 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