TELEHEALTH and the ADVANCED PRACTICE NURSE by PATRICIA

Home , Advanced practice nurse, Research participant

TELEHEALTH AND ADVANCE PRACTICE

TELEHEALTH AND THE ADVANCED PRACTICE NURSE

PATRICIA McLEAN HOYSON

Submitted in n partial fulfillment of the requirements for the degree of Doctor of Nursing Practice

Committee Chair: Mary Dolansky PhD, RN, FAAN

Frances Payne Bolton School of Nursing CASE WESTERN RESERVE UNIVERSITY

May 2019

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CASE WESTERN RESERVE UNIVERSITY FRANCES PAYNE BOLTON SCHOOL OF NURSING

We hereby approve the scholarly written project of Patricia McLean Hoyson

Committee Chair Mary Dolansky PhD, RN, FAAN

Committee Member Joyce J Fitzpatrick PhD, MBA, RN, FAAN

Committee Member Benjamin M Hayek MD, FACP

Date of Defense April 2, 2019

*We also certify that written approval has been obtained for any proprietary material contained therein.

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Abstract

Statement of Problem: There is evidence demonstrating a relationship between the evolution and accessibility of technology and the use of this technology in the provision of care for improvement of health outcomes. There are established benefits to educating APNs in the use and application of telehealth in order to provide safe quality care for patients. The question that remains is what current competencies

(knowledge and skills) are used by APNs in the workplace and how were they prepared for telehealth practice.

Study Purpose: This study describes the APNs’ use and preparation of telehealth competencies in practice. The study will (1) identify telehealth competencies

(knowledge and skills) used, (2) state the frequency of use, and (3) describe how and where APNs are prepared for the competencies.

Methods: The study design is a descriptive study using a survey method.

Pertinent Findings: The telehealth competencies identified in the study were reported as currently used in practice. The frequency of used varied with a majority of APNs reporting daily use in practice. There is little workplace orientation or competency testing reported. Educational preparation for the competencies was identified by less than half of the APNs and was accomplished evenly between graduate level education and continuing education.

Conclusions: There is a defined need to incorporate more didactic and clinical telehealth education and competency testing in nursing programs in order to better prepare advance practice nurses to use telehealth in providing optimum care for

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patients. The competencies (knowledge and skills) identified in this study of a national population of APNs provides information needed to take the next steps to incorporate telehealth competencies (knowledge and skill) into both didactic and clinical education in nursing.

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Acknowledgements

This DNP scholarly project was made possible through the efforts of several individuals to whom I would like to express my appreciation as their contributions made this project possible.

I would like to thank the American Association of Nurse Practitioners

(AANP) Data Collection Program for allowing me the opportunity to collect my data at the 2016 National Conference in San Antonio Texas. I would also like to thank the conference attendees who participated in my research study.

My appreciation is extended to my scholarly project committee, Dr Joyce

Fitzpatrick who has inspired me to aim forward and reach higher for “my seat at the table” in my professional journey and Dr Ben Hayek who provides me the continued opportunity, friendship, and support to grow and develop in my professional practice.

Their insights, contributions, and expertise were invaluable in the development of this project. A special tribute and thank you to Dr Mary Dolansky, my committee chair, who opened new opportunities for me and has guided me through this process. She gave me encouragement, kept me on task, and prompted me when needed it. It is with her expertise, support, and continued encouragement that this project has been possible.

Finally, there are two people, who without them I would not be where I am today. My Mom, Thelma McLean who instilled in me a deep love of and appreciation for learning and education and my husband and best friend Rick. It is his

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love, support, encouragement and friendship that allows me to accomplish all I set out to do. Together, we continue to do it all….

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TABLE OF CONTENTS

CHAPTER

1 Introduction ...... 1

Telehealth Technology ...... 1

Client/Patient Outcomes ...... 4

Advanced Practice Nurse role in Telehealth ...... 5

Nursing Education for Telehealth ...... 6

Significance ...... 8

Research Problem & Purpose ...... 9

Theoretical Framework ...... 9

Research Questions ...... 13

Definitions of Terms ...... 13

Summary ...... 15

CHAPTER 2

Literature Review ...... 17

Readiness for Practice ...... 18

Telehealth Education / Preparation ...... 22

Telehealth in the Practice Setting ...... 27

Summary ...... 31

CHAPTER

3 Method ...... 31

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Design ...... 44

Sample ...... 33

Sample Access ...... 33

Inclusion & Exclusion Criteria ...... 34

Human Subjects Protection ...... 34

Survey ...... 36

Telehealth Competencies ...... 36

Educational Preparation ...... 37

Procedures ...... 37

Data Analysis ...... 38

CHAPTER

4 Analysis & Findings ...... 39

Descriptive Characteristics ...... 39

Sample ...... 39

Demographics ...... 40

Practice...... 43

Telehealth Practice ...... 46

Certification ...... 47

Telehealth Competencies ...... 48

Telehealth Competencies in Practice ...... 49

Telehealth Competencies Preparation ...... 51

Telehealth Experiences ...... 54

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CHAPTER

5 Discussion ...... 56

Research Questions ...... 56

Education Implications ...... 60

Research Implications ...... 63

Limitations ...... 63

Conclusion ...... 64

REFERENCES ...... 65

APPENDIX A: Study Letter of Introduction ...... 72

APPENDIX B: Study Questionnaire Tool ...... 74

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List of Figures

FIGURE 1: New World Kirkpatrick Model ...... 10

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List of Tables

TABLE 1: Demographics of Study Sample...... 40

TABLE 2: Geographic Distribution of the Study Sample ...... 43

TABLE 3: Practice Characteristics of the Study Sample ...... 44

TABLE 4 Telehealth Practice Status of Reimbursement ...... 47

TABLE 5: Current Certification Status & Interest in Telehealth Certification ...... 48

TABLE 6: Telehealth Competencies (Knowledge & Skills) in Practice ...... 49

TABLE 7: Telehealth Competencies Preparation Reported by APNs ...... 51

TABLE 8: Telehealth Experience Inclusion in Educational Programs ...... 54

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Chapter 1

Introduction

The use of information and communication technology is increasingly evident in our everyday lives. The US Census Bureau reports that households with internet access rose from 18% in 1984 to 42.1% in 1998 and as of 2017, nearly three-fourths

(73%) of households report having internet access at home (U.S Census Bureau, 2012

& Pew Research, 2017). According to a Pew Pole (2017) nearly nine out of ten

Americans are online and this has been a 40% increase since 2000. Over three- quarters (77%) own a smartphone which has more than doubled since 2011 when only about 35% of Americans reported owning a smartphone. In addition, over 90% of healthcare providers identify the internet as their most important source of healthcare information notably a 58% increase since 2006 (Pew Research, 2018;

Podichetty, Booher, Whitfield & Biscup, 2006; Madden & Fox, 2006). A majority of providers (88%) believe electronic health information has the potential to improve the quality and coordination of patient care (American Hospital Association, 2015 &

Bipartisan Policy Center, 2012).

Telehealth Technology

Advances in telecommunication and information technology are changing the delivery of healthcare in the clinical setting for both healthcare providers and clients/patients and are referred to as telemedicine and/or telehealth (American

Telemedicine Association, 2017). Of the two terms, telehealth is the most widely

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used term in the current literature. The Health and Human Services Administration draws a distinct difference between telehealth and telemedicine. Telehealth is more broadly defined as the use of telecommunication technologies supporting long- distance healthcare, public health, health administration, and patient and professional health related education. Telehealth utilizes a variety of technology and communication media (telephones, computers, video streaming, and telemonitoring equipment) for healthcare service delivery. Telemedicine is more narrowly defined as a subset of telehealth defined as remote patient care where medical information is exchanged between sites using electronic communication in order to address the patient’s clinical needs (Board of Health Care Services, 2012). Hebda, Czar &

Mascara (2005) define telehealth as the “provision of information to healthcare providers and consumers as well as the delivery of services to clients at a site separate from the healthcare professional through the use of telecommunication and computer technology” p.451.

With these advances, the barriers of time and distance in healthcare delivery are removed allowing the provider to maintain or improve the quality of care delivered while providing this care to more patients than could be seen in-person

(American Nurses Association, 1999; Board of Health Care Services, 2012; Health

Resource & Service Administration (HRSA), 2017).

The U.S. Department of Veterans Affairs (VA) is at the forefront of developing and using telehealth as a means of providing healthcare to veterans.

Beginning in 2003, the VA began to build a national telehealth program to expand the

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level of care and reach of their healthcare providers while reducing travel costs for veterans. Methods employed include video interactive conferencing (Clinical Video

Telehealth) remotely with patients, videoconferencing (Home Telehealth) with patients in the home, and asynchronous (Store and Forward Telehealth) home monitoring of chronic conditions using devices that collect information about symptoms and vital signs from the patient’s home (US Department of Veterans

Affairs, 2018). There is also technology to allow clinicians to share imaging information with other providers for assistance with diagnosis and care (US

Department of Veterans Affairs, 2018). In 2013, there were more than 600,000 veterans who accessed VA care through telehealth programs. In 2017, the VA provided care to over 702,000 patients via their telehealth modalities, accounting for

12% of all care provided by the VA (US Department of Veterans Affairs, 2018).

From October 2017 through September 2019, Veterans received 2.3 million episodes of telehealth care. In 2018, the VA provided over 1 million video telehealth visits, a

19% increase over 2017 (Department of Veterans Affairs, 2018). In May of 2018, the

VA announced a new federal rule allowing VA physicians, nurses, and other healthcare providers to provide care via telehealth or virtual technology across state lines, regardless of where the provider is located or where the veteran is located. This removed a major barrier to the provision of telehealth care (US Department of

Veterans Affairs, 2019).

In addition to groundbreaking work with telehealth practices being done at the

VA, there are a variety of telehealth technologies that are in use today providing care

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to various patient populations with chronic illness using telehealth home monitoring systems to collect and send data to providers for analysis (McLendon, 2017; Gunter,

Chouinard, Fernandes-Taylor & Wiseman, 2016; Kevdar, Coyne, & Everett, 2014 ).

Telehealth is also helping with patient adherence to medical and treatment regimens by using various prompts as reminders for medication administration and/or treatment schedules (Kevdar, Coyne, & Everett, 2014). Telehealth also offers an opportunity to provide access to healthcare services to patients in rural and underserved areas where barriers to care exist naturally. The use of telehealth technology can overcome the barriers of lack of facilities and providers and lack of transportation due to finances and/or rural location of populations (US Department of Veterans Affairs, 2018;

McLendon, 2017; Rutledge, Haney, Bordelon, Renaud & Fowler, 2014).

Client/Patient Outcome

There is evidence supporting quality patient/client outcomes with the implementation of telehealth. The U.K. Department of Health released results of a major study of individuals with diabetes, chronic obstructive pulmonary disease, and coronary heart disease. Results identified a 45% decrease in mortality, 20% decrease in emergency admissions, 15% decrease in office visits, and 14% decrease in hospital days in persons utilizing a telehealth service (Anguita, 2012). The VA reported improved health outcomes in a study of 5,000 veterans receiving care coordination using home telehealth services. There were 50% fewer hospitalizations, 11% fewer emergency room visits, and a three-day reduction in hospital length of stay

(Broderick, 2012). In fiscal year 2016, the VA noted a 31% decrease in hospital

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admissions and a 59% decrease in bed days of care for Veterans utilizing the Home

Telehealth program. The majority of Veterans were satisfied (88%) with Home

Telehealth care. Veterans participating in Clinical Video Telehealth reported a 92% level of satisfaction, and 94% reported satisfaction with Store and Forward Telehealth

(US Department of Veterans Affairs, 2018). The adoption of telehealth technology has been greatly influenced and impacted by the need for improved individual patient/client access to care, healthcare provider workforce shortages, and has demonstrated improved client/patient care outcomes with the utilization of telehealth modalities (US Department of Veterans Affairs, 2018; American Hospital

Association, 2015; Anguita, 2012).

Advanced Practice Nurses Role in Telehealth

There are over 270,000 Advanced Practice Nurses practicing in the United

States today (American Association of Nurse Practitioners, 2019) and 26,000 nurse practitioners graduated in 2017 (American Association of Colleges of Nursing, 2019).

Advanced practice nurses are at the forefront of the telehealth movement as telehealth practices are becoming integral to providing quality healthcare to patients/clients.

The use of telehealth has been identified as providing patient/client support for a variety of chronic health conditions (diabetes, chronic obstructive lung disease, cardiovascular disease) through the facilitation of a sense of empowerment, independence, and self-efficacy while decreasing overall costs of healthcare

(McFarland, Raugi, & Reiber, 2013; Welch, Balder & Zagarina, 2015; Nagel,

Pomerleau & Penner, 2013). Advanced Practice Nurses (APNs) such as nurse

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practitioners, clinical nurse specialists, and nurse midwives are well positioned to respond to the need for healthcare in diverse and underserved populations

(Henderson, Davis, Smith, & King, 2014; Institute of Medicine, 2010; Patterson,

Osbourne & Gregory, 2004). To be able to respond to this growing need in healthcare, APNs must understand and master the knowledge and technological aspects required to be effective providers in the delivery of telehealth care.

Specific benefits of utilizing telehealth technology have been identified as contributing to the development of distance collaborative practice (American Hospital

Association, 2015; Balestra, 2018; American Hospital Association, 2015; Young &

Ireson, 2003), increased job productivity and satisfaction for healthcare providers and increased autonomy and decision-making competency for both healthcare providers and clients/patients (Lupoli & Rizzo, 2003). An international survey of registered nurses (Grady & Schlachta-Fairchild, 2007) was completed by 719 nurses from 36 countries who self-identified as currently practicing telenursing care with patients with chronic medical problems. Overall, they received “on the job’ training in telehealth technology rather than having had any formal education for telehealth practice. Respondents identified that technology for telehealth should be included in basic nursing curriculum that included both didactic and clinical practice learning environments. There were some respondents who identified telehealth practice as being an APN role that should be taught at a graduate level rather than in an entry level nursing program.

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Nursing Education for Telehealth

Although nursing has recognized educational preparation for the implementation of telehealth as being necessary to the practice of nursing, the pace of adoption of telehealth has allowed little time for practicing nurses and nursing education to incorporate the needed technology education into the practice environment and educational programs (Nagel, Pomerleau & Penner, 2013).

Staggers, Gassert & Curran (2001) identified that the integration of information technology into nursing curriculum has been a slow process lacking in consistent development of curriculum and faculty development to provide the needed instruction

(McNeil, et al., 2003). More recently, nursing leaders have taken a proactive approach. In 2007, The Quality and Safety Education for Nurses (QSEN) included

Information Technology as an essential component for both undergraduate and graduate nursing education (Cronennwett, et al., 2009). In the Institute of Medicine

(IOM) report The Future of Nursing: Leading the Change, Advancing Health (2011) the importance is addressed as both a recommendation for implementation and a research priority for nursing education. Recommendations are to identify and test new technologies to support decision-making and care delivery for nurses while assessing both cost and benefit of the identified technologies. The report encourages nursing to contribute to the design, development, implementation, and evaluation of future technologies in telehealth (Institute of Medicine, 2011). The Essentials of

Master’s Education in Nursing (American Association of Colleges of Nursing, 2011) has identified that all master’s nursing programs must design and utilize innovative

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nursing practices to prepare master’s graduates for contemporary health care delivery and include clinical learning experiences using diverse teaching methods. In addition, the Nurse Practitioners Competencies Document (National Organizations of

Nurse Practitioner Faculties, 2011) includes the need for integration of appropriate technologies and use of technology systems as required competencies for advanced practice nursing. The Institute of Medicine’s Summary of Nursing Education

(Institute of Medicine, 2010) further states that all nursing education programs must incorporate health information technology in the preparation of graduates to practice in the ever-advancing healthcare environment of today’s practicing nurses.

Many of the recommendations calling for the integration of technology into nursing education have been developed more with the focus and using the terminology of nursing informatics than focusing on and using the term telehealth

(Cronennwett, et al., 2007; Institute of Medicine, 2010; National Organizations of

Nurse Practitioner Faculties, 2011). This is noted in the literature, where the terminology and concepts of information technology and telehealth oftentimes become intertwined.

Significance

There is a demonstrated need to identify telehealth competencies and incorporate these into nursing education programs in order to better prepare nursing graduates for the telehealth clinical practice environment. Nurses who are currently practicing in telehealth clinical environments could serve as experts for identifying the knowledge and skills needed to practice in telehealth clinical settings. There is a

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paucity of research exploring the competencies (knowledge and skills) currently utilized and perceived as integral to the practice of telehealth by the APN. Telehealth competencies are important to include in the educational preparation of APNs.

Research Problem & Purpose

The relationship between the evolution and accessibility of technology and its use in improving health outcomes is documented in the literature. In addition, it is well established that there are benefits of educating APN students in the use and application of telehealth to be able to competently care for patients. The question that remains is “what are the current APN competencies used by APNS in practice and how are they prepared for telehealth practice?”

The purpose of this study is to describe the APNs’ use and preparation of telehealth competencies in practice. The study will (1) identify telehealth competencies (knowledge and skills) used by advanced practice nurses in the practice setting, (2) state the frequency of use of the telehealth skills, and (3) describe how and where APNs are prepared for the competencies in telehealth practice

Theoretical Framework

The conceptual framework for this study is the New World Kirkpatrick Model

(Kirkpatrick & Kirkpatrick, 2015). This model represents the latest revision of a model originally developed by Donald Kirkpatrick in 1959. The model provides a framework for the development and evaluation of effective training/education programs. The four levels or steps of the model are: Reaction, Learning, Behavior, and Results. These levels are the same in both the original and latest revisions of the

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model and are used to identify a method to create and evaluate an effective training/education program.

Figure 1 – New World Kirkpatrick Model

The first level in the model is Reaction with the goal at this level being to measure the participant’s reaction to the training program. This assessment of the learner’s reaction to the training is best accomplished immediately at the completion of the program. The major dimensions of this level are satisfaction with the training, the relevance of the training, and the engagement of the participants in contributing to the training program. At this first level satisfaction refers to the participant’s satisfaction with the training experience overall. The engagement of the participant examines the degree of active involvement and contribution of the learner with the training process. The relevance of the training is a very important component in the process. This identifies the level of opportunity the participant will have to apply what they have learned in their work environment.

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The second level, Learning, includes the original concepts of knowledge, skill, and attitude acquisition and the added concepts of confidence and commitment.

Knowledge refers to the gaining of information and skill is the acquisition of the ability to perform a certain task. Attitude refers to the degree to which participants believe what they are learning will be worthwhile in their work. Confidence is the degree to which participants believe they will be able to do what they learned in their job. The degree to which learners intend to apply the knowledge and skills learned during the training is referred to as Commitment. This commitment is the necessary effort needed in order to be able to apply the knowledge and skills learned on a daily basis in their job.

The third level, Behavior, addresses the degree to which participants apply what they learned during training when they are back on the job. This consists of critical behaviors, required drivers, and on –the –job learning. The critical behaviors are actions that if performed consistently will have the greatest impact. Required drivers were added in the New World Model. The drivers include encouraging and reinforcing the work behavior, monitoring the work, and reward or recognition for a well-done job. The last addition to this level is the on-the-job-learning component.

This recognizes that approximately 70% of all learning takes place on the job and personal responsibility and motivation are key to support and reinforcement for optimal performance.

Results are the fourth and final level of the model identifying the degree to which outcomes occur as a direct result of the leaning events and reinforcement

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activities identified in the previous levels (Kirkpatrick & Kirkpatrick, 2015;

Kirkpatrick & Kirkpatrick, 2006). This level may take some time to achieve. It is at this level that the outcomes are indicative of both individual acceptance and valuing of the learning process and resulting outcome as well as the degree of effect the outcomes have on the work environment. At this level not only does the individual embrace (greater job satisfaction) the outcomes, but there is some advantage

(productivity, improved quality) seen in the work environment as well.

This research study is guided by the model and is primarily focusing on the second level of the model, Learning, while recognizing the impact of the third level,

Behavior as well. This study focus is on identifying the telehealth competencies

(knowledge and skills) currently used by advance practice nurse and the frequency

(degree) to which they currently use these in their practice setting. Assessing the frequency of usage of the telehealth knowledge and skills in practice is beginning to address the component of attitude in Learning. This recognizes that the more often a particular knowledge component or skill is utilized in the workplace, the more worthwhile the learning of that knowledge or skill becomes. The study also identifies how or where the APN received education for the telehealth competencies

(knowledge and skills) they are using in practice. Level three, Behavior supports this premise with the recognition that a great degree of learning typically occurs on the job and recognized the importance of personal responsibility and motivation in this learning. It becomes clear that the more often a component of knowledge or skill is

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used in the workplace, the greater the knowledge, attitude, confidence, commitment become for the individual.

In additional to guiding and providing a conceptual framework for this study, the New World Kirkpatrick Model will be a framework to guide future study working toward the goal of developing telehealth competencies for advanced practice nurses and providing structure and guideline for planning educational programs for telehealth education.

Research Questions

1. What telehealth competencies (knowledge and skills) are currently used by

advanced practice nurses in the practice setting?

2. What is the frequency of use of telehealth skills in practice?

3. How and where are advanced practice nurses prepared for telehealth

competencies, (knowledge and skills) they use in practice?

Definition of Terms

Telehealth is defined as the use of telecommunication and computer technology to provide information to healthcare consumers and delivery of services to clients at a site separate from the healthcare professional (Hebda, Czar & Mascara,

2005). Telehealth is operationally defined as the number of episodes that video, audio and or computer technology are used to provide healthcare to patients of all ages.

Telehealth competencies are defined as knowledge and skills necessary for advanced practice nurses in providing quality care to clients utilizing telehealth

(phone, video, email, text) modalities. These competencies include: (1) integrate

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telehealth into nursing practice for client assessment, diagnosis, identification of desired outcomes, plan of care, implementation, evaluation, and referrals, (2) establish a therapeutic relationship which creates a sense of nursing presence that engages the client, (3) assess and adjust communication plans to maximize the nurse client relationship, (4) assess the appropriateness of specific telehealth technologies for individual situation or populations, (5) determine whether client needs can be met with telehealth using concurrent evaluation and make changes to management plans,

(6) ensure that clients are informed about their choices regarding the use of telehealth,

(7) demonstrate skills in seeking, using, and providing consultation, and participate in interdisciplinary collaboration to meet client needs, (8) demonstrate knowledge and skill of specific telehealth technology and relevant telehealth skill, (9) ensure that public and institutional policies related to privacy, confidentiality, informed consent, and security are employed during telehealth use, (10) uses results of telehealth performance outcomes to modify practice, (11) document and integrate into information systems the structure, process, and outcome of telehealth events (Grady

& Schalata-Fairchild, 2007).

Telehealth knowledge is defined as the theoretical or practical awareness and understanding of the elements of the telehealth competencies learned through instruction or experience (Schlacta-Fairchild (2000).

Telehealth skills are defined as the application or usage of the various technologies identified as telehealth. These technologies include computers, internet, television, voice (telephone), video and distance learning devices. When these

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technologies are used in the practice setting, they allow patient care, patient education, and provider contact to occur over long distances (Schlacta-Fairchild

(2000).

An Advanced Practice Nurse (APN) is defined as per the definition of an

Advanced Practice Registered Nurse (APRN) put forth the in the National Council of

State Boards of Nursing (NCSBN) most recent edition of the Consensus Model for

APRN Regulation: Licensure, Accreditation, Certification & Education (2008 p.7).

The definition of an Advanced Practice Registered Nurse (APRN) is a nurse: 1. who has completed an accredited graduate-level education program preparing him/her for one of the four recognized APRN roles; 2. who has passed a national certification examination that measures APRN, role and population-focused competencies and who maintains continued competence as evidenced by recertification in the role and population through the national certification program; 3. who has acquired advanced clinical knowledge and skills preparing him/her to provide direct care to patients, as well as a component of indirect care; however, the defining factor for all APRNs is that a significant component of the education and practice focuses on direct care of individuals; 4. whose practice builds on the competencies of registered nurses (RNs) by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and greater role autonomy; 5. who is educationally prepared to assume responsibility and accountability for health promotion and/or maintenance as well as the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacologic and non-pharmacologic interventions; 6. who has clinical experience of sufficient depth and breadth to reflect the intended license; and 7. who has obtained a license to practice as an APRN in one of the four APRN roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), or certified nurse practitioner (CNP).

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Summary

There is a proliferation of communication technology used in the general population and households across the United States. This proliferation of technology has carried over into the healthcare industry in the form of telehealth using various modes of technology for health care delivery. This telehealth technology is providing opportunities for increased access, cost savings and improved outcomes for patients utilizing the telehealth services. There is an increased opportunity for APNs to serve as healthcare providers within this telehealth framework. However, while nursing recognizes the importance of the emerging role of telehealth in the delivery of healthcare, there is a lack of organized structured curriculum for the development of nursing education competencies necessary to be able to utilize telehealth in the practice setting. The first step in addressing these shortcomings in education preparedness should be the identification of the knowledge and skills necessary to be competent in the delivery of telehealth services. The purpose of this study is to describe the APNs’ use and preparation of telehealth competencies in practice. The study will (1) identify telehealth competencies (knowledge and skills) used by advanced practice nurses in the practice setting, (2) state the frequency of use of the telehealth skills, and (3) describe how and where APNs are prepared for the competencies in telehealth practice

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Chapter 2

Literature Review

It is important to address the existing knowledge gaps between nursing practice and telehealth technology and to create awareness of the evolution of nursing practice and delivery of healthcare. The review of the literature for telehealth education and use in clinical practice for APNs identified a limited number of research studies specific to this area. To provide a background for the implementation of telehealth, the literature was reviewed looking at current educational preparation for telehealth, preparation for telehealth in the practice setting and what impacts an individual’s readiness to adopt telehealth in the practice setting.

During the literature review, education and preparation for using the required telehealth skills in the practice setting emerged as consistent themes. Subsequently, current research is presented focusing on studies specific to telehealth readiness to practice, nursing education and preparation for using telehealth in practice, and the telehealth knowledge and skill preparation currently utilized in the practice setting.

In reviewing the literature, there is a paucity of research specific to telehealth competencies for advanced practice nurses and/or registered nurses. There have been competencies identified for information technology by the American Nurses

Association (ANA), the American Association of Colleges of Nursing (AACN),

Quality and Safety Education for Nursing (QSEN), and Technology Informatics

Guiding Educational Reform (TIGER). The ANA competencies are primarily focused on information theory, information systems, privacy concerns, and using

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technology to facilitate the nursing process in the care of the client (American Nurses

Association, 2008). The AACN addressed computer skills, electronic health records, bedside care technologies (pumps and monitors) and using technology for information retrieval, and clinical decision making (America Association of Colleges of Nursing, 2011). The focus of QSEN is primarily on employing information technology and technological skills in the application of quality and safe patient care.

In addition, there is a focus on information literacy and literacy competencies to utilize quality electronic sources of healthcare information. The terminology is more focused on informatics rather than telehealth (Quality and Safety Education for

Nursing, 2012). The TIGER competencies focus mainly on basic computer competencies, information management, and information literacy competencies

(Technology Informatics Guiding Educational Reform, 2009). In the most recently published TIGER Initiative (2018), the focus continues to be more directed at electronic health records and on-line resources for practice (O’Connor, Hubner,

Shaw, Blake, & Ball, 2017). While each of the organizations provide valuable information and ideas that could be used as a foundation on which to begin to build competencies specific to telehealth, there are no specific competencies identified for the APNs use of telehealth in the practice setting (Dulong, 2008).

Readiness for Practice

Studies identified in the literature attempted to examine the readiness of nurses for telehealth practice focusing on the nurses’ knowledge, attitude, and expectations for utilizing telehealth knowledge and skills in their practice settings. A

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descriptive exploratory study of 39 subjects conducted in a not for profit US health system identified nurses’ readiness to implement telehealth in their practice; specific adopter characteristics of the nurses; and relationship between the adopter characteristics and readiness. A purposive sampling approach was used and study instruments consisted of a single item indicator measuring overall readiness on a 0-

100 Visual Analog Scale (VAS) and an abbreviated 25-item version of the Perceived

Characteristics of Innovation (PCI) instrument. The PCI identifies voluntariness, relative advantage, compatibility, image, ease of use, results demonstrably, visibility, and trainability on a 7-point Likert scale. Correlations were calculated between nurses readiness as measured by the VAS and PCI (total score) and adopter characteristics (age, highest education, years of service, and how quickly nurses adopt new technology). The only statistically significant correlation found was between nurses readiness and rate of technology adoption measured by the VAS (r= -0.61, p=

0.01) and the PCI total score (r= -.41, p= 0.01) with the subjects identified as quicker adopters having higher readiness scores (Browning, Tullai, Madigan, Struk, 2009).

Readiness has been identified as an important factor in repeated studies on the implementation of telehealth in practice (Ali, Carlton, & Ali, 2015; Zayapragassarzan

& Kumar, 2016; Muttitt, Vigneault, & Loewen, 2004; Jennett & Andruchuk, 2001;

Bangert & Doktor, 2003). Telehealth readiness is defined as degree to which a community is prepared to participate and succeed in telehealth (Information

Technologies Group, 2006). This measure is a key indicator to assess prior to implementing telehealth in a practice setting. Gagnon & Brandstadt (2005) identified

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studies assessing telehealth readiness for nurse providers working in both rural and remote practice settings. These were qualitative studies using semi-structured interviews, focus groups, and researcher developed questionnaires. Themes reported in the studies include the importance of strong leadership in implementing telehealth into the practice setting and the practitioners’ perceived need to improve the practice.

These themes were identified as key indicators in the telehealth readiness of the practice setting. Noted barriers identified in the implementation of telehealth were resistance to change, a sense of personal risk in the process, insufficient preparation and education regarding telehealth and inefficient telehealth technology (Muttitt,

Vigneault, & Loewen, 2004; Jennett & Andruchuk, 2001; & Bangert & Doktor,

2003).

Campbell, Harris & Hodge (2001) identified similar indicators impacting the readiness to implement telehealth in a qualitative study conducted in an outpatient practice setting. Study participants (N=33) included 13 physicians and 20 nurse practitioners who were interviewed using six open ended questions to investigate their perception of telehealth/telemedicine and assess their level of readiness for adoption of the telehealth skill set in practice. In the course of the study, there were six themes that emerged as relevant to readiness and they were: efficacy in their ability to succeed, practice context, apprehension related to change, time to learn the new telehealth skill set, sense of risk/turf, and ownership. Each of these were found to impact readiness to adopt telehealth/telemedicine in the practice setting.

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Jennett, Yeo, Pauls, & Grahams (2003) supported the above findings in a study (N=16) consisting of semi-structured interviews with persons holding management and/or administrative positions in organizations utilizing telehealth in their practice. Similar themes (leadership, staff preparation, and technical readiness, access to equipment, communication and participation) were identified as integral to successful planning for and leading the adoption of telehealth in the workplace. The identified barriers (lack of buy-in, lack of staff preparation, and resistance to change) were similar to those identified in previous studies (Muttitt, Vigneault, & Loewen,

2004; Jennett & Andruchuk, 2001; & Bangert & Doktor, 2003).

Another consideration impacting readiness for telehealth practice is legislation ensuring both reimbursement and ability to legally provide care remotely. The

Enhanced Nurse Legislation Compact (eNLC) was introduced to allow registered nurses (RNs) the ability to have a multistate license enabling practice in another state.

Originally implemented in 2000 it included 25 states by 2015. In January 2018, multistate licenses were issued to nurses in the 31 states currently participating. There are four states with currently pending legislation. Although the eNLC does not pertain to advanced practice, an APN with a eNLC registered nurse license issued prior to 7/2017 was granted multistate privileges in all eNLC states as of 1/2018.

Restrictions apply if the RN license was granted after 7/2017 and RN and APNs residing in states that are not members of the NLC are not permitted multistate practice Enhanced Nurse licensure (National Council of State Boards of Nursing,

2018).

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Telehealth Education/Preparation

Conde, et al., (2010) identified the importance of telehealth information in education programs for graduate and post-graduate education in the health professions and health education for patients and clients.

A growing number of medical schools have begun to offer telemedicine as part of their classroom and clinical instruction. According to the American

Association of Medical Colleges, in the 2016-2017 academic year, approximately

58% of medical schools (n=84) included telemedicine as a topic in either required or elective courses during in classroom and clinical instruction. This was an increase over the 2013-2014 academic year when 41% (n=57) of schools offered the topic

(American Association of Medical Colleges, 2018).

Although telehealth has been identified as an important topic and skill for educational curricula, there is a limited research addressing telehealth education in nursing and even less address specifically the education of advanced practice nurses in telehealth modalities.

Two studies explored undergraduate nursing students’ perception of their information and technology educational preparation. The information and technology education in both studies focused on computer usage, internet access, and use of spreadsheet and word processing. A majority (50%) of students reported feeling very confident in the use of word processing programs, and 69% were very confident accessing and using the internet programs (Levett-Jones, et al., 2009). Bembridge,

Levett-Jones & Yeun-Sim Jeong (2011) in a qualitative study identified that the

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information and communication technology skills, knowledge, and self-efficacy were transferrable from the university to the workplace. Telehealth was not addressed specifically in either of these studies.

Two studies were identified that explored the information technology educational needs of new gradate nurses from the administrative perspective (McNeal et al, 2003; McCannon, & O’Neal, 2003). The first study surveyed Deans and

Directors of 236 nursing education programs to identify current curriculum program preparation needs to prepare future nurses and nurse educators (McNeal et al, 2003).

Findings indicate that current programming focuses more on computer literacy skills rather than technology information literacy skills. There were gaps identified in information technology curriculum at both the graduate and undergraduate levels. An additional gap was identified in the knowledge of nursing faculty to prepare/educate nurses on technology in practice. The second study was a national survey consisting of 752 registered nurses who were members of the American Organization of Nurse

Executives (McCannon, & O’Neal, 2003). The study identified information technology skills necessary for nurses entering the workforce. Skills identified by the nurse executives as important to be integrated into nursing education programs included computer skills for data base searches and computerized documentation skills.

Bembridge, Levett-Jones & Jeong (2011) conducted a qualitative study in

Australia exploring whether information and communication technology (ICT) skills acquired during university education were transferrable to the practice environment.

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ICT equipment was defined as any computer-based system that accumulated, retrieved, controlled, accepted, or manipulated information to support practice and delivery of care (Graves & Corcoran, 2007. p.227). During the study, it was identified the ICT skills learned were not formally taught, but were embedded in course content and were skills required to complete the requirements for assignments. During the study, semi-structured interviews were conducted with participants (N=8) identifying how they gained the ICT knowledge and skills. The study identified that the participants’ university experience helped them to develop a level of self-efficacy that facilitated the transfer of the ICT skills to the workplace environment. Self-efficacy has long been associated with and has a direct relationship with an individual’s confidence in their ability to successfully complete a task, task performance, and the decision to engage in various behaviors, such as learning to use computers (Barling &

Beattie, 1983; Wood & Locke, 1987; Hill, Smith & Mann, 1987). This study identified the importance of providing learning opportunities in curricula that include incorporation of the learning, not only didactic instruction with a focus on the ability to use the technology to affect positive patient outcomes.

Glinkowski, Pawlowski, & Kolowska (2013) conducted a study in Poland evaluating nursing students (N=308) knowledge of and attitudes toward telenursing using an author-developed 32 multiple-choice and four (4) open-ended web based questionnaire. The questionnaire evaluated attitude, willingness, education status, computer and internet access, and general attitude and knowledge regarding telehealth/telenursing. Of the study respondents, two hundred (71%) expressed a

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desire to utilize and/or practice telenursing in their future work in patient care. With over 90% identifying telenursing as being important in facilitating patient provider contact while reducing the cost and improving the efficacy of patient care. A majority (69.5%) of the students identified they would like (39.9%) or rather like

(29.55%) to have telenursing/telehealth instruction included in their nursing curriculum. There were 142 students (66%) who stated telehealth instruction should be included in the curriculum, felt the content should be included in all medical specialty courses and 112 students (52%) who were in favor of including content in the curriculum, identified only advantages in including the content in the curriculum and had a positive attitude toward using the technology in their future nursing practice.

Reierson, Solli, & Bjork (2015) conducted exploratory focused interviews with undergraduate nursing students following a program simulating three telehealth nursing scenarios using video and audio technology. The study sample was 32 undergraduate nursing students who completed one of three simulated telehealth patient care experiences utilizing video technology to see the patient and compete the interaction. Focus group interviews were conducted at the completion of the simulations. Student feedback was overall positive for the telehealth simulated experience. Some unease was identified in performing assessments, making decisions, and directing care without being in the patient’s physical presence.

Recommendations were to further integrate telehealth simulation actives into the nursing curriculum.

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Erickson, Fauchald, & Ideker, (2015) developed a program to integrate telehealth education and skills into a nurse practitioner curriculum, The program consisted of a one hour didactic session presenting telehealth technology and skill, followed by a four hour clinical experience with a preceptor who provided care using telehealth technology. The study goal was to determine if the experience would enhance the students’ interest in and satisfaction with using telehealth. The sample consisted of 72 nurse practitioner students and the overall finding and recommendation was that the experience did increase student knowledge of telehealth and the content should be included in the graduate curriculum.

Rutledge, Haney, Bordelon, Renaud, & Fowler (2014) developed a telehealth workshop for Advanced Practice Registered Nurse-Doctor of Nursing Practice

(APRN-DNP) students (N=60) at a large university. The workshop consisted of a telehealth program embedded into the curriculum with a goal to determine benefits and barriers to the implementation of telehealth in the APRN-DNP students’ practice environment. The program included hands-on telehealth experience with standardized patient scenarios, a telehealth clinical practice immersion experience, and student projects. The student project consisted of the development of a paper addressing the role of telehealth for provider site and recipient site, the technology used in provision of services, benefits and barriers to the use of telehealth in their clinical practice experience. As a result of the positive feedback from this experience from the students, plans are to increase the number of clinical experiences to allow students to take a more active role with telehealth in practice.

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Telehealth in the practice setting

There have been studies conducted examining the education and preparation or training for telehealth in the practice setting. Although the majority of these studies are conducted with a population of registered nurses, physicians and advanced practice nurses have been studied as well. As with the educational research, there are both national and international studies presented in this review.

Beste et al., (2016) conducted a survey of primary care team members (n=78) working with Veterans Affairs who participated in a longitudinal telemedicine mentorship program as a part of the Specialty Care Access Network–Extension for

Community Healthcare Outcomes (SCAN-ECHO). There were weekly conferences held with the participants focusing on hepatology, nephrology, pulmonary, and infectious disease specialties. Conferences consisted of a 20-30-minute focused didactic presentation by a specialist followed by an interactive case study discussion.

Respondent characteristics were assessed with chi-square analysis and logistic regression was used to compare data based on length of participation in the program.

Participants who were involved in the mentorship program for longer than one year reported increased self-perception of knowledge and competencies. Findings in this study support previous study that provider mentorship programs enhance clinical practice and professionalism while improving patient care (Aurora et al, 2011; Salgia, et al, 2014). Overall the mentorship program, while identified as time-consuming for the primary care providers, indicate that benefits of the mentorship activity continue to grow over time. Study recommendation indicate that further research should be

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done to determine the persistence of benefits when the primary care providers complete their participation in the SCAN-ECHO program.

Henderson, Davis, Smith & King (2014) detail an on-going hospital-based telehealth program that began in 2003 that allows for nurse practitioners in distant rural health care sites to have direct communication with physicians in level 1 trauma centers for improved patient care. The program consists of a three-to-six-month training program focused on clinical knowledge and skills needed to work with the telemedicine equipment enabling the long-distance collaboration for patient care. The content is taught through combination of didactic classes, on-line modules, laboratory simulations. After completion of the program, the equipment used provided bidirectional audio and video conferencing for remote collaboration with emergency room physicians. Program analysis revealed a 25% decrease in provider staffing costs in the tele-emergency program.

In the last ten years there have been two major studies that have explored perceived telehealth educational needs identified by registered nurses as important for use in the practice setting (Grady & Schlachta-Fairchild, 2007; Carter, Horrigan &

Hudyma, 2010). In the first study, Grady & Schlachta-Fairchild (2007) conducted a web-based survey (2004-2005 International Telehealth Survey) of 719 registered nurses from 36 countries currently working in telehealth settings. The web-based survey was developed by nursing informatics and telehealth experts for use in the study. The study identified characteristics of nurses practicing in telehealth, their level of satisfaction with their current role/position and specific knowledge and skills

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used by the nurses in their current positions and how these competencies were obtained. Of the 719 persons completing the study, 68% of respondents were from the United States. The study detailed general demographics and characteristics of the nurse working in a telehealth setting. Findings indicated a majority (89.2%) of respondents felt telehealth technology instruction should be included in the basic nursing curriculum and that preparation should include both didactic learning as well as clinical experiences. Forty-seven respondents felt the education for telehealth should not be in a basic nursing program and of those, ten respondents felt telehealth to be an advanced practice role. Narrative responses (n=116) delineated the importance of clinical as well as didactic experience with telehealth. Respondents indicated the technology they use most often in their practice setting includes remote monitoring devices, handheld devices, and online consumer health tools. The authors identify that a “majority of respondents indicated they had learned the tasks and skills necessary for their positions “on the job” rather than in a formal education setting”

(Grady & Schlachta-Fairchild, 2007 p 270). There was no percentage or number of respondents provided with this quoted statement.

The second study was a Canadian study of 138 practicing nurses self- identified as currently working or having recently worked in telehealth (Carter,

Horrigan & Hudyma, 2010). Primarily, the participants were experienced nurses, with a majority (87%) having been employed for a minimum of 10 years. Many reported experience with telehealth with one-third (33%) having 5-9 years of experience in a telehealth setting. More than a third (41%) currently work in a

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telehealth setting. Most participants identified as either diploma (41%) or baccalaureate prepared (36%). There were 7% of the participants with a master’s degree in nursing and 3% were prepared at the doctoral level. Almost 40% of study participants identified they had never had any educational instruction specific to telehealth.

The study was a descriptive exploratory purposively sampling survey using 14 item open-ended questionnaire exploring four core categories of telehealth – effectiveness, daily activities, readiness for practice and suggested knowledge, skills, and attitudes of the telehealth nurse. Study results were reported anecdotally with regards to educational needs. Two keys points that emerged were that although some educational needs can be met through experience, others should be met through education and education aimed at measuring competence and confidence with technology is increasingly necessary. It was reported that participants commented on continuing education being delivered through technology based educational opportunities covering content areas of theoretical knowledge about telehealth, professional competency expectations, clinical practicum in telehealth settings.

Therapeutic communication techniques, and physical assessment skills using telehealth technology; and hands-on practice with technology were identified as important concepts. These findings supported findings identified in an earlier study by Grady & Schlachta-Fairchild (2007).

Key themes identified in the study were that new graduates are not ready for telehealth practice and that prior nursing experience was identified as important in

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achieving readiness for telehealth practice. In addition, including telehealth education in nursing curricula and continuing education activities were perceived as being important in the development of telehealth competencies.

Summary

It is evident in reviewing the literature on telehealth and nursing practice that much of what has been done is primarily qualitative or survey research. It is also apparent that little research is specific to APNs in the United States.

The American Nurses Association (ANA) and the American Association of

Colleges of Nursing (ANCC) recommend inclusion of telehealth technology into nursing curriculum (ANA, 2010; ANCC, 2008). Nursing education in telehealth must incorporate technological proficiency in using common telehealth modalities and the knowledge needed to integrate telehealth into practice. The American Association of

Colleges of Nursing (AACN) has included informatics as an essential of graduate nursing curriculum (AACN, 2011). Typically telehealth may be included as a discussion topic in the informatics curriculum, but the literature identifies that present educational programs are not preparing nurses for telehealth practice (Erickson,

Fauchald, & Ideker, 2015; Phillippi & Wyatt, 2011).

There is an identified need to incorporate more didactic and clinical technology education in nursing programs in order to better prepare nursing graduates for the clinical practice environment. Nurses who are currently practicing in telehealth clinical environments could serve as resources for identifying the telehealth knowledge and skills currently used in the practice setting. There is currently a

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paucity of research exploring the telehealth knowledge and skills utilized and perceived as important to the practice of telehealth nursing by the APN. This study will identify the current status and practice of telehealth in a national population of

APNs in the United States and will be a step in the process of identifying the competencies (knowledge and skills) utilized by APNs in the practice of telehealth/working in the telehealth practice setting; how often these telehealth skills are used in practice; and how/where APNs are prepared for the competences

(knowledge, skills) utilized in the practice of telehealth.

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Chapter 3

Method

In this chapter, the methodology of the study is presented. The study design, setting and sampling are described. This will be followed by an explanation of the sample recruitment, inclusion and exclusion criteria, human subject’s protection, instrumentation used in the study and the procedures to analyze the data.

Design

The study design is a descriptive study using a survey containing demographic information and questions to identify telehealth competencies (knowledge and skills) used by APNs in the practice setting, state the frequency of use of the telehealth skill, and describe how and where APNs are prepared for the competence used in telehealth practice. The survey is identified as a method to gather information about a particular population (Burns & Grove, 2009). Leedy & Ormorod, (2005, p 183) identify the goals of survey research as “learning about a populations’ characteristics, opinions, attitudes, or previous experiences”. In this study the survey method was used to identify the preparation for and practice of telehealth utilization of APNs.

Sample

Sample access

A convenience sample of advanced practice nurses (APNs) was obtained from the population of APNs attending the American Association of Nurse Practitioners

(AANP) 2016 National Conference in San Antonio, Texas between the dates of June

21-26, 2016. The conference attendance was reported to be 4,575 participants.

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The conference afforded the opportunity to recruit a qualified sample that met study inclusion criteria. A power analysis was done using the G Power statistical analysis program identifying a sample size of 143 subjects to be sufficient utilizing the standard power (1-β) = 0.80, medium effect size (r-.50) and (α = .05) (Burns &

Grove, 2008).

Inclusion and Exclusion Criteria

Inclusion criteria included advanced practice (nurse practitioner and clinical nurse specialist) nurses currently practicing and utilizing telehealth in their practice setting, ability to read and write in English, and complete a pencil-paper questionnaire. Excluded from the study were: APNs not utilizing telehealth in their practice and physician assistants (PAs) utilizing telehealth in their practices.

Recognizing that although in the study region, the practice settings for APNs and physician assistants are similar, the focus of this study is preparation of APNs, thereby supporting the exclusion of physician assistants from the study.

Human Subjects Protection

Prior to the start of the study, the research was reviewed and approved by the

Institutional Review Board (IRB) of Case Western Reserve University and the Data

Collection Review Committee of the American Association of Nurse Practitioners

(AANP). Identification of participants was accomplished with the cooperation of the

AANP. All participants received an explanation of the study via the written invitation to participate (Appendix A) prior to agreeing to participate. At this time, they were assured of confidentiality and that participation was purely voluntary and informed of

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their right to withdraw from the study at any time. The participants were provided with a comprehensive explanation of the study including purpose, benefits, and perceived risks, and assurance of confidentiality and anonymity. Also included was the investigator’s name, email, and telephone number to call if participants had questions regarding the study. Prior to completing the questionnaires, the following questions were asked to verify the participants’ active practice in telehealth: (1) I am an advanced practice nurse involved in using telehealth (voice and/or video and/or data) in my practice (“yes” or “no”). If participants answer yes, they were invited to proceed with the survey questionnaires. A signed consent form was not required as completion of the questionnaires were regarded as informed consent. Data were collected over the first four days of the conference.

The risks to the participants were minimal. The completion of the survey was estimated to take 25 minutes of time and contained no identifiable data unless the participant wished to receive an email summarizing the study results. This request for follow-up information was the last question on the form. There were no requests for information.

Anonymity and confidentiality of participants was assured throughout the study by using only coded numbers to identify each individual’s data and responses.

No names or individual personal identifying information were found either in the data analysis or discussion of the results. All questionnaires were filed and stored in locked file cabinets during the study. All records will be destroyed in seven years.

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Survey

Data for this study were collected using portions of The 2004-2005

International Telenursing Survey (Grady & Schlachta-Fairchild, 2007). This survey was utilized to gather information on telehealth/ telenursing internationally from registered nurses in an on-line format. The survey is a 45-item self-administered paper-pencil questionnaire incorporating questions from the international survey with a focus on advanced practice nursing. A copy of the survey is located in Appendix B.

The Demographic portion of the survey is a self-report tool used to identify information related to the study participants’ age, gender, education, practice setting, years in practice, and number of patients seen annually. The survey consists mainly of closed ended questions yielding primarily discrete and categorical level data with some narrative responses. This portion identifies the frequency of use and educational preparation for the competencies, knowledge and skills utilized in the practice of telehealth. This survey is used in this study with permission of the developer.

Telehealth Competencies

Measurement of telehealth competencies (knowledge and skills) currently used by APNs in the practice setting were measured by eleven items in section 5.2 specific to current competencies stemming from information theory and participants were asked to respond if they are familiar with all, some, or none of the eleven identified competencies. The competencies identify the following: integration of the nursing process, establishment of a therapeutic relationship, communication, collaboration, technology selection and skill of usage, confidentiality, client choice,

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and utilization of outcomes to modify practice. Participants were asked to identify their familiarity (all, some, none) with each of the competencies listed.

Educational Preparation

Educational preparation for the competencies (knowledge and skills) were measured by asking the advanced practice nurses if they were prepared for telehealth competencies on the job (yes or no) or if they had formal education (undergraduate, undergraduate, or continuing education) related to the telehealth competencies found in section 5.2 of the questionnaire. In addition, question 2.16 asks the participant about the type(s) of strategies (orientation, periodic training updates, other) in their respective organizations to assure telehealth technology competence.

Procedures

Conference policy and procedures dictated specific procedures for data collection at the conference. A table and poster were permitted in a “designated high traffic area” in the exhibit hall. The poster identified the study as a Doctorate of

Nursing Practice (DNP) study being conducted by a doctoral student from Case

Western Reserve University. At the table telehealth data system materials were available consisting of a patient and provider computer monitor, an electronic blood pressure machine, blood glucose meter, and scale each of which is capable of transmitting data to the provider monitor. The poster and table display drew attention to the survey and contained information about the survey and completion procedures. Clipboards and four chairs were available at the table for participants to complete the study questionnaire at that time. Participants were given pens to

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complete the survey questionnaire which had printed on them the study title and researcher contact information. Attached by a paperclip to each survey was an 8”x 3” standard white business envelope for participants to place their completed questionnaires into prior to placing them in the collection box at the corner of the display table. The questionnaires were stored in a locked briefcase in the researcher’s hotel room during the conference and were carry-on luggage on the flight home. All questionnaires were filed and stored in locked file cabinets during the study. Data will be stored electronically in an encrypted and password protected file for seven years.

Data Analysis

Questionnaire results were analyzed utilizing the Statistical Package for the

Social Sciences (SPSS) program. Data analysis consisted of descriptive statistics on all demographic variables to determine the characteristics of the sample and to generate a participant profile. Frequency and percentage distributions were obtained and analyzed using SPSS for the following research questions:

1. What telehealth competencies (knowledge and skills) are currently utilized by

advanced practice nurses in the practice setting?

2. What is the frequency of use of telehealth skills in practice?

3. How and where are advanced practice nurses prepared for telehealth

competencies, (knowledge and skills) they use in practice?

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Chapter 4

Analysis and Findings

In the previous chapter, the methods for data collection and analysis were presented. The data used in this study were collected from a population of advanced practice nurses attending a national conference for advanced practice. The following results are an analysis of the study data. In this chapter, the main results of this study are summarized and presented in two sections: the first section is a description of the sample; and the second section presents the results associated with the research questions of the study. The data were collected in an effort to identify telehealth competencies (knowledge and skills) used by advanced practice nurses along with the frequency of use of these competencies and how/where the APN were prepared for the telehealth competencies.

This chapter describes the sample and presents a discussion of the analyses and findings for each of the study research questions. Data analysis was completed using the Statistical Program for the Social Sciences (SPSS for Windows V25, 2017).

Descriptive statistics were used to examine the data for normal distribution. There was a minimal amount of missing data in this study and no substitutions for data were made.

Descriptive Characteristics

Sample

Initial study recruitment efforts resulted in 210 questionnaires distributed to advanced practice nurses attending the conference and initially agreeing to consider

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participating in the study, of these 189 returned the completed questionnaire for inclusion in the study. There was no opportunity to identify the reasons for individuals deciding to not complete and return the questionnaire. At the start of this research study, there were 189 persons participating in the study. With this sample size (N=189), there was no study attrition as the questionnaire was completed only one time and returned to the researcher for inclusion in the study. As a result, the data analysis was conducted on the information provided by the189 participants who completed the study questionnaire.

Demographics

Participants’ ages ranged from 27 to 71 years, with the average age of the participants in this study being 49 years 3 months old (X=49.3). A demographic profile of the sample is presented in Table 1. The majority of the sample was female with 174 (92.1%) females and 15 (7.9%) males.

Table 1: Demographics of Study Sample

Characteristic (n) (%) Gender Females 174 92.1 Males 15 7.9 Education Master’s 120 62.8 Post Master’s 21 11.2 DNP 33 17.6 PhD 9 4.8 Other 7 3.7

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Characteristic (n) (%) Certification FNP 129 67.9 CNP 23 12.1 ANP 23 12.1 AGNP 14 7.4 ACNP 11 5.8 WHNP 5 2.6 Note: DNP= Doctor of Nursing Practice, PhD=Doctor of Philosophy, FNP= Family Nurse Practitioner, CNP= Certified Nurse Practitioner, ANP= Adult Nurse Practitioner, AGNP= Adult Gerontology Nurse Practitioner, ACNP= Acute Care Nurse Practitioner, WHNP= Women’s Health Nurse Practitioner

Four levels of education were identified: Master’s, Post-Master’s, Doctor of

Nursing Practice (DNP), and Doctor of Philosophy (PhD). The largest (n= 118) group of subjects (62.8%) reported having a Master’s degree. The distribution between the number of subjects completing a DNP and Post-Master’s was 33 subjects

(17.6%) having a DNP and 21 (11.2%) having completed a Post-Master’s Degree.

There were nine subjects (4.8%) with a PhD. Seven participants (3.7%) identified other educational preparation that included a Doctorate in Education, Juris Doctorate,

Doctorate in Health Administration, and Doctor of Nursing Practice student. Two subjects reported having more than one level of education.

The majority 97.4% reported certification as a nurse practitioner (n =184) and

2.6% reported certification as a clinical nurse specialist (n=5). Of those identifying as nurse practitioners, several participants identified as having more than one specialty certification. The majority (67.9%) identified as being a family nurse practitioner

(FNP) (n=129), the second largest group was an even distribution of 23 participants

(12.1%) identifying as Certified Nurse Practitioner and an equal number (n=23) of

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participants (12.1%) identifying as Adult Nurse Practitioners (ANP). The next distribution of certification was close with 14 participants (5.8%) reporting certification in Acute Care (ACNP) and 11particiapants (5.8%) identifying as Adult

Gerontology (AGNP) nurse practitioners. There were five participants (2.6%) who identified as Women’s Health (WHNP) nurse practitioners.

Study participants represented the following four geographic areas in the

United States: South, Midwest, North East, and West. There is also representation from one US Commonwealth Territory. Table 2 lists the geographic distribution by specific geographic areas and individual states included in each of the geographic areas. The largest group (52.0%) of participants lived in the South; 39 subjects

(21.8%) lived in the Midwest area of the United States. There were 27 participants

(13.9%) from the West and 23 participants (11.8%) representing the Northeast area of the United States. There was one participant (0.5%) from the Northern Marina

Islands in the US Commonwealth Territory. A little less than a quarter (21.3%) of participants (n=40) were from states where advanced practice nurses have full practice authority. The largest number (n=80) of participants (42.3%) were from states with a more restricted scope of practice for advanced practice nurses.

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Table 2: Geographic Distribution of the Study Sample

Region & States (n) (%) South: 98 52.0 Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia Midwest: 39 21.8 Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin West: 27 13.9 Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington North East: 23 11.8 Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont

US Commonwealth Territories: 1 0.5 Northern Marina Islands

Practice

Table 3 is a profile of variables related to the status of employment and area(s) of practice of the individual participants. Examination of employment revealed the largest group (90.0%) reported full-time employment and 15 subjects (7.9%) reported working part-time as APNs with 2.1% of participants (n=3) identified as not being currently employed.

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Table 3: Practice Characteristics of the Study Sample

Practice Characteristic (n) (%) Employment Full Time 171 90.0 Part Time 15 7.9 Not Currently Employed 3 2.1 Setting Clinic 79 41.6 Hospital 46 24.3 Private Practice 32 16.8 University 20 10.5 Ambulatory Care 12 6.6 Home Care 8 4.2 Long-term Care 8 4.2 Public Health 6 3.3 School 5 2.6 Military 5 2.6 Occupational Health, 4 2.1 Telehealth 0% Time 24 12.6 5-10% 49 25.8 11-30% 63 33.3 40-60% 41 21.6 Greater than 75% 12 6.4 Types of Patients Chronic Care 102 57.3 Medical-Surgical 49 25.8 Gerontology 35 1 8.4 Pediatrics 23 12.1 Obstetrics/Gynecology 18 9.5 Orthopedic 18 9.5 Neurology 17 8.9 Cardiac/Coronary Care 16 8.4 Rehabilitation 6 3.2 Competency Orientation 83 43.9 Periodic Training 67 35.4 None 79 41.6

Employment setting varied with a little less than half (41.6%) reported working in a clinic setting, one-fourth (24.3%) working in a hospital setting, one-

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sixth (16.8%) working in a private practice setting, 10.5% reported university employment, and 6.6% report working in ambulatory care. There was an even distribution (4.2%) of subjects working in homecare and long-term care with the remaining (10%) employed in public health (3.3%), school health (2.6%), occupational health (2.6%), and the military (2.1%).

In their respective work environment, 165 participants (87%) reported some percentage of their work day spent in non-face-to-face patient encounters. The percentage of time spent with telehealth (phone, video, email, text) patient care activities ranged between 0-85% of the day. Twenty-four participants (12.6%) identified no time spent with telehealth activities in their work day. The largest group, over one-third (33.3%) reported spending between 5-10% of time in telehealth activities. The second largest group (25.8%) reported telehealth activities during 11-

30% of their work day, and third largest group (21.6%) spent between 40-60% of the day in telehealth activities. Twelve participants (6.4%) identified spending over 75% of their day in telehealth activities.

The types of patients cared for varied with over half (57%) identifying working with chronically ill individuals. Approximately one-fourth (25.8%) of participants identified working with patients in medical-surgical setting. A gerontological work setting was identified by 18.4% of participants and 12.1% reported working with pediatric populations. There was an even distribution of subjects who identified working with patient in specialty practice areas of neurology

(8.9%), obstetrics/gynecology (9.5%), orthopedic (9.5%) settings and

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cardiac/coronary care (8.4%). The remaining (3.2%) reported working with patients in rehabilitation settings. In some instances, study participants identified more than one type of patient area.

Of the participants who utilize telehealth (phone, video, email, text) technology in their practice setting, there were several strategies identified as to how the participants were prepared in their workplace setting for the practice of telehealth.

The preparation included workplace orientation and periodic training. Eighty-three

(43.9%) report having an orientation program offered for the use of telehealth technology in their workplace. Over one third (n=67) report periodic training for telehealth, while 79 participants (41.6%) reported no strategies are employed in the workplace to assure competency with telehealth technology.

Telehealth Practice

Participants were asked to identify their perceptions of the current status of telehealth in their state of practice. Table 4 presents the respondents’ perception as to the current status of Advanced Practice Nurse (APR) billing for non-face to face services in their state and their knowledge of APNs providing non-face to face patient encounters. Over half (51%) report no knowledge of face-to face encounters in their state of practice. A little less than half (43.7%) of respondents identified knowing

APNs are providing non-face to face encounters in their practice state. Seventy-five percent (n=142) reported not knowing if non-face to face encounters are a billable service in the state in which they practice. There were 17.5% of respondents (n=33)

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who identified knowing that non-face to face encounters are billable services in their state of practice.

Table 4: Telehealth Practice Status of Reimbursement

Telehealth Practice (n) (%) APN Non-face-to- Yes 83 43.7 face Encounters No 10 5.3 I do not know 96 51.0 APN Non-face-to- Yes 33 17.5 face Billing No 14 7.4 I do not know 142 75.1 Note: APN= Advanced Practice Nurse

Certification

There are existing programs of study and certification opportunities for informatics in nursing. Currently there is no offering for a specific certification program in telehealth for either nursing or advanced practice nursing. Table 5 presents both the respondent’s current status and future interest in a certification in telehealth. There were three respondents (1.6%) who identified holding some type of certification in telehealth with the majority (98.4%) of respondents not holding certification in telehealth. There is interest in telehealth certification with over half

(56.1%) of respondents expressing interest in certification. Over one-third (37.6%) identified not being interested in certification and 6.3% (n=12) identifying as possibly/not sure of an interest in certification in telehealth.

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Table 5: Current Certification Status and Interest in Telehealth Certification

Certification (n) (%) Current Telehealth Yes 3 1.6 Certification No 186 98.4 Interested in Yes 106 56.1 Telehealth No 71 37.6 Certification Not Sure/Maybe 12 6.3

Telehealth Competences

There are specific telehealth competencies (knowledge and skills) for advanced practice nurses in providing care to clients utilizing telehealth (phone, video, email, text) modalities. These competencies include: (1) integrate telehealth into nursing practice for client assessment, diagnosis, identification of desired outcomes, plan of care, implementation, evaluation, and referrals, (2) establish a therapeutic relationship which creates a sense of nursing presence that engages the client, (3) assess and adjust communication plans to maximize the nurse client relationship, (4) assess the appropriateness of specific telehealth technologies for individual situation or populations, (5) determine whether client needs can be met with telehealth using concurrent evaluation and make changes to management plans,

(6) ensure that clients are informed about their choices regarding the use of telehealth,

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and security are employed during telehealth use, (10) uses results of telehealth performance outcomes to modify practice, (11) document and integrate into information systems the structure, process, and outcome of telehealth events (Grady

& Schalata-Fairchild, 2007).

Telehealth Competencies in Practice

The above competencies (knowledge and skills) were identified as being currently used by advanced practice nurses in providing care to clients utilizing telehealth (phone, video, email, text) modalities. Table 6 identifies each of the competencies and the percentage of respondents who utilize the competencies in their practice setting.

Table 6: Telehealth Competencies (knowledge and skills) used in Practice

Competency In Practice (n) (%) Communication Plan Yes 119 86.2 Therapeutic Relationship Yes 121 85.8 Privacy, Confidentiality, Informed Yes 115 83.9 Consent Policies Interdisciplinary Collaboration Skills Yes 103 78.3 Integration into Practice Yes 119 77.8 Knowledge & Skill with Technology Yes 91 70.0

Telehealth Performance Outcomes Yes 77 67.0

Meet Client Needs with Telehealth Yes 82 66.1 Informed Clients Yes 81 64.8 Assess Specific Technologies Yes 77 62.6 Documentation & Integration Yes 91 47.9

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Over half (62.6% - 86.2%) of respondents identified as working with and having learned the competency in their advanced practice environment. The majority

(86.2%) of respondents identified assessing and adjusting communication plans to maximize the nurse client relationship (Communication Plan) as being learned and used in practice. This was followed closely by 85.8% identifying the importance of establishing a therapeutic relationship which created a sense of nursing presence that engages the client (Therapeutic Relationship). In addition, 83.9% identified ensuring policies related to privacy, confidentiality, and informed consent and security

(Privacy, Confidentiality, and Informed Consent Policies) as being leaned and employed in the practice setting. Over two-thirds (78.3%) of respondents identified demonstrating skill in consultation and interdisciplinary collaboration to meet client needs (Interdisciplinary Collaboration Skills) as a competency in practice.

Integrating telehealth into nursing practice for client assessment, diagnosis, and treatment (Integration into Practice) were identified as being used in practice by

77.8% of respondents. The demonstration of knowledge and skills of specific telehealth technology and skills (Knowledge & Skill with Technology) was identified by 70% of respondents and identifying using results of performance outcomes to modify practice in relation to telehealth (Telehealth Performance Outcomes) was identified as a practice competency by 67%. Determining if client needs can be met with telehealth and making changes in plan as needed (Meet Client Needs with

Telehealth) was identified by 66.1% and assessing the appropriateness of specific telehealth technologies (Assess Specific Technologies) for individual

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situations/populations was identified by 62.6% of respondents. Ensuring clients are informed about choices (Informed Clients) regarding the use of telehealth was identified by 64.8% of respondents. Documenting and integrating the structure, process, and outcomes of telehealth events (Documentation & Integration) was identified by almost one-half (47.9%) of respondents as having been learned and utilized in practice.

Telehealth Competencies Preparation

For competencies to be effectively utilized in practice, preparation for the competencies is important to assure that the practitioner has the requisite knowledge required for competency in practice. It is therefore initially important to identify how/where advanced practice nurses are prepared for the competencies, they utilize in their practice environment. Table 7 illustrates formal educational preparation environments where respondents identify having received preparation for the competencies they employed in providing care to clients utilizing telehealth (phone, video, email, text) modalities. Participants had the option of selecting more than one option for educational preparation

Table 7: Telehealth Competencies Preparation reported by Advanced Practice Nurses

Competency Level of Preparation (n) (%) Integration into Practice Graduate 38 43.7 Undergraduate 5 5.7 Continuing Education 28 32.2 Combination 16 18.3

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Competency Level of Preparation (n) (%) Therapeutic Relationship Graduate 40 38.8 Undergraduate 9 8.7 Continuing Education 16 15.5 Combination 38 36.8 Communication Plan Graduate 42 42.9 Undergraduate 8 8.2 Continuing Education 15 15.3 Combination 26 23.6 Assess Specific Technologies Graduate 31 49.2 Undergraduate 4 8.2 Continuing Education 16 25.4 Combination 12 18.4 Meet Client Needs with Telehealth Graduate 31 47.7 Undergraduate 6 9.2 Continuing Education 17 26.2 Combination 11 17.0 Informed Clients Graduate 32 48.5 Undergraduate 4 6.1 Continuing Education 19 28.8 Combination 11 16.7 Interdisciplinary Collaboration Graduate 48 54.5 Skills Undergraduate 6 6.8 Continuing Education 14 15.9 Combination 11 21.6 Knowledge & Skill with Graduate 35 47.9 Technology Undergraduate 6 8.2 Continuing Education 21 28.2 Combination 11 15.0 Privacy, Confidentiality, Informed Graduate 30 40.5 Consent Policies Undergraduate 3 4.1 Continuing Education 23 31.1 Combination 18 24.4 Telehealth Performance Outcomes Graduate 29 48.3 Undergraduate 3 5.0 Continuing Education 21 25.0 Combination 7 11.7

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Competency Level of Preparation (n) (%) Documentation & Integration Graduate 29 47.5 Undergraduate 3 4.9 Continuing Education 21 34.4 Combination 8 13.1

The majority (38.8% - 54.5%) of each of the competencies were identified as learned through educational preparation at the graduate level. The competency most highly identified as having graduate level preparation was Interdisciplinary

Collaboration Skills (54.5%) and the lowest was Therapeutic Relationship (38.8%).

Continuing education programs was the next most frequently identified method of preparation for the competencies (15.5% – 32.2%). The competency identified by most respondents as being learned through continuing education was Integration into

Practice (32.2%) followed closely by Confidentiality, and Informed Consent Policies

(31.1%). The competency identified by the lowest number of respondents as being learned through continuing education was Communication Plan (15.3%). The next type of preparation identified by 15.0% - 36.8% of respondents was the combination of both graduate education programs and continuing education. The competency listed as most prepared in this manner was Therapeutic Relationship (36.8%) and the lowest was Knowledge and Skill with Technology (15%). The lowest level of preparation for the competencies was identified at the undergraduate educational level

(5.7% - 9.2%). The competency identified as being most prepared at the undergraduate level was Therapeutic Relationship (8.7%). Table 7 lists the specific

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telehealth competencies individually with percentages identifying where respondents obtained the educational preparation for the specific competency.

Telehealth Experience

Table 8 presents the data illustrating APNs perception of whether educational program preparing advanced practice nurses should include information on telehealth in the curriculum. The second question asks at which levels of nursing education curricula telehealth clinical experiences with telehealth should be included.

An overwhelming majority (97.8%) of respondents (n=186) identified that information on the practice of telehealth information should be included in educational curriculum for the preparation of advanced practice nurses. There were only four (2.2%) of respondents who identified that telehealth experience should not be included in the educational experience or advanced practice nurses.

Table 8 Telehealth Experience Inclusion in Educational Programs

Experience (n) (%) Telehealth Yes 186 97.8 Inclusion in APN No 4 2.2 Curriculum Telehealth Clinical Undergraduate (Entry Level) 139 74.0 Experiences Master’s Degree - APN 164 87.3 Doctoral Degree - DNP 102 57.1 Doctoral Degree - PhD 76 40.0 Note: APN= Advanced Practice Nurse, DNP= Doctor of Nursing Practice, PhD= Doctor of Philosophy

Respondents were asked to identify any and all levels they would recommend including clinical experiences with telehealth and the recommendations were to include clinical telehealth experiences at all levels of educational preparation.

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Undergraduate (Entry Level) clinical experience was recommended by almost three- fourth (74%) of respondents. A majority (87.3%) of respondents recommended in including experiences at the Master’s degree – APN level of preparation. A little over half (57.1%) recommend inclusion at the Doctoral Degree – DNP educational program level. The least identified (40%) level for clinical inclusion was at the

Doctoral Degree - PhD level of educational preparation.

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Chapter 5

Discussion

This chapter provides a discussion of the study, including the purpose and methods and procedures. A summary of the findings from the study is presented. The limitations of the study are discussed and recommendations for practice and further research are made.

The purpose of this study is to describe the APNs’ use and preparation of telehealth competencies in practice. The study aimed to (1) identify telehealth competencies (knowledge and skills) used by advanced practice nurses in the practice setting, (2) state the frequency of use of the telehealth skills, and (3) describe how and where APNs are prepared for the competencies in telehealth practice

Research Questions

1. What telehealth competencies (knowledge and skills) are currently used by advanced practice nurses in the practice setting?

Each of the eleven telehealth competencies (knowledge and skills) identified in the study were reported as being used in practice by a majority of the APNs in the study except for one: Documenting and integrating the structure, process, and outcomes of telehealth events. In reviewing this particular competency, the wording of the competency could be revised for clarity. The overall agreement with the remaining competencies identified by respondents in the study supports the work and findings of Grady & Schlachta-Fairchild (2007) who initially developed the survey questionnaire used in the study. The competencies identified as being used in and

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learned in the advanced practice environment are listed in order of most to least used and include the following: (1) assessing and adjusting communication to maximize the nurse client relationship (Communication Plan), (2) establishing a therapeutic relationship which created a sense of nursing presence that engages the client

(Therapeutic Relationship), (3) ensuring policies related to privacy, confidentiality, and informed consent and security (Privacy, Confidentiality, and Informed Consent

Policies), (4) demonstrating skill in consultation and interdisciplinary collaboration to meet client needs (Interdisciplinary Collaboration Skills), (5) integrating telehealth into nursing practice for client assessment, diagnosis, and treatment (Integration into

Practice), (6) demonstration of knowledge and skills of specific telehealth technology and skills (Knowledge & Skill with Technology), (7) using results of performance outcomes to modify practice in relation to telehealth (Telehealth Performance

Outcomes), (8) determining if client needs can be met with telehealth and making changes in plan as needed (Meet Client Needs with Telehealth), (9) assessing the appropriateness of specific telehealth technologies (Assess Specific Technologies),

(10) ensuring clients are informed about choices (Informed Clients) regarding the use of telehealth, (11) documenting and integrating the structure, process, and outcomes of telehealth events (Documentation & Integration).

The identification of competencies used by advanced practice nurses practicing in a telehealth environment is integral to the development of educational program and preparation for the requisite competencies. This preparation or lack of preparation and learning the competency in the practice setting has been identified in

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the literature as one of the significant barriers impacting readiness to implementing telehealth practice (Muttitt, Vigneault, & Loween, 2004; Jennett & Andruchuk, 2001;

Bangert & Doktor, 2003). Carter, Horrigan & Hudyma (2010) identified readiness for telehealth practice was impacted by prior experience or lack of prior experience with the knowledge or skill.

2. What is the frequency of use of telehealth skills in practice?

Identifying the frequency that telehealth competencies used in practice is important when developing and prioritizing educational instruction for programs of instruction. In the study, over three-fourths of respondents reported some percentage of their work day spent in in some telehealth (computers, internet, voice/telephone, video, distance learning devices) activities in their practice. The majority (59%) reported spending between 5-60% of their day with telehealth modalities. These study findings support the findings of Grady & Schlachta-Fairchild (2007) and are similar to study findings by Carter, Horrigan, & Hudyma (2010).

3. How and where are advanced practice nurses prepared for telehealth competencies (knowledge and skills) they use in practice?

To better prepare advanced practice nurses for the telehealth clinical practice environment it is important to identify how and where currently practicing APNs are/were prepared for the competencies (knowledge and skills) they currently use in the practice setting.

Of the participants who utilize telehealth (phone, video, email, text) technology in their practice setting, there were several strategies identified as to how

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the participants were prepared for the practice of telehealth. This included both workplace and formal educational preparation.

In the workplace, preparation included workplace orientation and periodic training. Eighty-three (43.9%) report having an orientation program offered for the use of telehealth technology in their workplace. Over one third (n=67) report periodic training for telehealth, while 79 participants (41.6%) report no strategies are employed in the workplace to assure competency with telehealth technology.

In those reporting formal educational preparation, participants reported receiving training in the competencies in only 38.8 -54.5 % of their APN programs.

The majority of each of the competencies were identified as having been learned through educational preparation at the graduate level, although there was only a minimal difference between the number/percentage who identified preparation at the graduate level as compared to those identifying preparation through continuing education. Continuing education programs were the next most frequently identified method of preparation for the competencies. Less than one-third of respondents identified preparation through a combination of both graduate education programs and continuing education. Less than 10% of respondents identified preparation for any of the competencies at the undergraduate level.

The findings in this study indicate that preparation for telehealth competencies

(knowledge and skills) for advanced practice nurses is accomplished evenly between graduate level education and continuing education with limited preparation at the undergraduate level. This finding is supported in the literature addressing the current

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state of telehealth content and preparation in graduate and undergraduate educational programs today (Erickson, Fauchald, & Ideker, 2015; Glinkowski, Pawlowski, &

Kolowska, 2013; Phillippi & Wyatt, 2011; Grady & Schlachta-Fairchild, 2007).

Education Implications

Many educational implications are indicated due to the findings that only 43% receive on the job training and 41.6% report no strategies are employed in the workplace to assure competency with telehealth technology. The need is great at the advanced practice level because of the many opportunities there are and there will be for advanced practice nurse to practice in telehealth environments providing care to underserved and rural populations. There is a need to incorporate some telehealth instruction at the undergraduate level because registered nurses may find themselves practicing in an area where telehealth practice is occurring.

To develop appropriate telehealth content for educational program instruction it is imperative to identify the requisite telehealth competencies (knowledge and skills) with telehealth technology currently used in practice by advanced practice nurses. This study, through a national sample of advance practice nurses has identified the telehealth competencies (knowledge and skills) used by nurses.

Educational program content should be developed to include aspects from each of the eleven telehealth competencies identified in this study as being used in practice by

APRNs. These competencies include: (1) integrate telehealth into nursing practice for client assessment, diagnosis, identification of desired outcomes, plan of care, implementation, evaluation, and referrals, (2) establish a therapeutic relationship

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which creates a sense of nursing presence that engages the client, (3) assess and adjust communication plans to maximize the nurse client relationship, (4) assess the appropriateness of specific telehealth technologies for individual situation or populations, (5) determine whether client needs can be met with telehealth using concurrent evaluation and make changes to management plans, (6) ensure that clients are informed about their choices regarding the use of telehealth, (7) demonstrate skills in seeking, using, and providing consultation, and participate in interdisciplinary collaboration to meet client needs, (8) demonstrate knowledge and skill of specific telehealth technology and relevant telehealth skill, (9) ensure that public and institutional policies related to privacy, confidentiality, informed consent, and security are employed during telehealth use, (10) uses results of telehealth performance outcomes to modify practice, (11) document and integrate into information systems the structure, process, and outcome of telehealth events.

The study findings highlight the need to identify the level and amount of preparation advanced practice nurses have obtained for the competencies (knowledge and skills) required to practice telehealth. There is need for integrating this information into educational programs. The study respondents (97.8%) overwhelmingly identified the need to incorporate telehealth education in to the graduate curriculum for advanced practice nurses.

Curriculum for telehealth education should include both didactic and experiential education. The didactic education would include content based on the competencies for telehealth practice. It is important to address the differences in

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provision of care as it changes from an in-person environment to one using telehealth technology. The use of experiential simulation would provide an opportunity to introduce and practice real-time patient interactions. Simulation experiential learning provides a safe environment for learning the new skill sets needed for providing telehealth care. A variety of clinical simulation cases could be developed and implemented with either students adopting the role of patient and provider or using simulated patients that have been coached in the various patient roles.

A majority also identify the importance of telehealth clinical experience at both graduate and undergraduate levels of education. The clinical experience at the graduate level could be accomplished through practicum experiences where telehealth is used. Practicum sites using telehealth modalities would be an excellent method of incorporating the simulation content into the clinical setting. At the undergraduate level, exposure to clinical experiences where telehealth is used would provide excellent clinical learning opportunities.

An unanticipated finding of importance was that the majority of advanced practice nurses working in a telehealth environment identify having no on-going competency evaluation. Competency could be better assured in the workplace with periodic skills testing from a peer or supervisor and telehealth technology updates in the workplace. Patient surveys would be another method of providing feedback on the telehealth experience to the provider.

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Research Implications

Currently there are no standardized competencies identified for telehealth education and practice. There is a demonstrated need to identify competencies to direct the education of nurse practitioners in providing patient care utilizing best practices in a telehealth practice setting. It is also imperative to develop evaluation methods to assure nurse practitioners have the requisite knowledge and skill level needed to provide high quality safe patient care. There is also a need for the development of an evaluation tool to measure competency in both the educational and practice environments. With the rapidly changing technological advances, on-going education and evaluation is integral to assure quality telehealth patient care.

Limitations

There were several limitations identified in the course of the study. The sample, consisted of 4% (189/4575) of total conference attendees, was self-selected and limited to those advanced practice nurses who attended the four-day national conference. The sample was a national sample but had greater representation from

APNs in the southern geographic region of the United States. There was no opportunity to identify why a number of individuals chose not to complete and return the questionnaire. The survey questionnaire was long, detailed, and time-consuming to complete. These factors may have contributed to the non-return rate of 10%. A pilot study using the tool would be recommended after validation by experts in the area of telehealth.

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Conclusion

There is a defined need to incorporate more didactic and clinical telehealth education and competency testing in nursing programs in order to better prepare advance practice nurses to use telehealth in providing optimum care for patients.

Nurses who are currently practicing in telehealth clinical environments are an important resource to identify knowledge and skills currently being utilized in the practice setting. There is currently little research exploring the telehealth knowledge and skills utilized and perceived as important to the practice of telehealth nursing.

This study identified the current status and practice of telehealth in a national population of APNs in the United States and validated competencies, knowledge and skills reported as being used by advance practice nursing using telehealth n their practice. It will be important to utilize the information gleaned in this research study to take the next steps to incorporate telehealth competencies, knowledge and skill into both didactic and clinical education in nursing.

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& King, M. (2014). Nurse practitioners in telehealth: bridging the gap in healthcare delivery. Journal of Nurse Practitioners 10(10), 845-850. Hill, T., Smith, N. & Mann, M. (1987). Role of efficacy expectations in predicting the decision to use advanced technologies: The case of computers. Journal of Applied Psychology, 72(2), 307-313. Information Technologies Group, Center for International Development (2006). Readiness for the Networked World: A guide for Developing countries. Cambridge MA: Harvard University Institute of Medicine. (2011). The future of nursing, Leading the change, Advancing health. Washington, DC: The National Academies Press. Institute of Medicine. (2010). A summary of the February 2010 forum on the future of nursing education. Washington, DC: Institute of Medicine. Jennette, P & Andruchuk, K. (2001). Telehealth: ‘Real-life’ implementation issues. Computer Methods Programs Biomed 64, 169-174. Jennette, P., Yeo, M., Pauls, M., & Graham, J. (2003). Organizational readiness for telemedicine: Implication for success and failure. Journal of Telemedicine Telecare 9, (Supp. 2), 27-20. Kvedar, J., Coye, M & Everett, W. (2014). “Connected Health: A Review of Technologies and Strategies to Improve Patient Care with Telemedicine and Telehealth.” Health Affairs (Millwood) 33.2 (2014): 194-9. Kirkpatrick, D. & Kirkpatrick, J (2006). Evaluating training programs; The four levels. San Francisco, CA: Berrett-Koehler Kirkpatrick, J. & Kirkpatrick, W (2015). An introduction to the New World Kirkpatrick Model. Newman, GA: Kirkpatrick Partners Leedy, P & Ormorod, J. (2005) Practical research: Planning and design. Upper Saddle River N.J.: Prentice Hall. Levett-Jones, T., Kenny, R., Van der Riet, P., Hazelton, M., Kable, A., Bourgeois, S., Luxford, Y. (2009). Exploring the information and communication technology competence and confidence of nursing students and their perception of its relevance to clinical practice. Nurse Education Today 29, 612-616. Lupoli, J. & Rizzo, V. (2003). The impact of technology on the “older” nurse. Home Healthcare Nurse 22 (10), 668-670. Madden, M., & Fox, S. (2006). Finding answers online in sickness and in health. Pew Internet and American life project. Pew Foundation, Washington, DC.

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McCannon, M. & O’Neal, P. (2003). Results of a national survey indicting information technology skills needed by nurses at time of entry into the work force. Journal of Nursing Education 42 (8), 337-340. McFarland, L., Raugi, G., & Reiber. G. (2013). Primary care provider and imagining technician satisfaction with a teledermatology project in rural Veterans Health Administration clinics. Telemedicine Journal and e-Health 19(11), 815-825. McLendon, S. (2017). Interactive video telehealth models to improve access to diabetes specialty care and education in the rural setting: A systematic review. Spectrum.Diabetesjournals.org. doi: 10.2337/ds16-0004. McNeil B., Elfrink, V., Bickford, C., Pierce, S., Beyers, S., Averill, C., & Klappenbach, C. (2003). Nursing information technology knowledge, skills, and preparation of student nurses, nursing faculty, and clinicians: A U.S. survey. Journal of Nursing Education 42 (8), 341-349. Muttitt S., Vigneault, R. & Loewen, L. (2004) Integrating telehealth into Aboriginal healthcare: The Canadian experience, International Journal of Circumpolar Health, 63(4), 401-414, doi: 10.3402/ijch.v63i4.17757 Nagel, D., Pomerleau, S., Penner, J. (2013). Knowing, caring, and telehealth technology. Journal of Holistic Nursing 312 (2), 104-112. National Council of State Boards of Nursing (NCSBN).(2018). Enhanced nurse licensure News Release (1-19-18). Retrieved from: https://www.ncsbn.org National Council of State Boards of Nursing (NCSBN). (2008) Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. Retrieved from: https://www.ncsbn.org National Organizations of Nurse Practitioner Faculties (NONPF). (2011). Nurse practitioner core competencies 2011. Washington D.C: NONPF. O’Connor, S., Hubner, U., Shaw, T., Blake, R. & Ball, M. (2017). Time for TIGER to ROAR! Technology informatics guiding education. Nursing Education Today 58, 78-81. doi:10.1016/j.nedt.2017.07.014. Patterson, C., Osborne, M. & Gregory, D. (2004). How different can you be and still survive? Homogeneity and difference in clinical nursing education. International Journal of Nursing Education, Scholarship, 1(1), 1-13. Pew Research Center (2017). Facttank: News in the numbers. Retrieved from: www.pewresearch.org/fact-tank Pew Research Center (2018). Mobile fact sheet. Retrieved from: www.pewinterest.org/fact-sheet

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Phillippi, J. & Wyatt, T. (2011). Smartphones in nursing education. Computers, Informatics, Nursing 29(8). 449-454. doi: 10.1097/NCN/)b013e3181fc411f. Podichetty, V., Booher, J. & Whitfield, M. (2006). Assessment of internet use and effects among healthcare professionals: A cross sectional survey. Postgraduate Medical Journal, 82(966), 274-279. Quality and Safety Education for Nurses (QSEN), (2012). Graduate-level competencies: Knowledge, skills and attitudes. Retrieved from: www.qsen.org/competencies/graduate-ksas Reierson, I, Solli, H., & Bjork, I. (2015). Nursing students’ perspectives on telenursing in patient care after simulation. Clinical Simulation in Nursing, 11(4), 244-250. Rutledge, C.M., Haney, T., Bordelon, M., Renaud, M., & Fowler, C. (2014). Telehealth: Preparing advanced practice nurses to address healthcare needs in rural and underserved populations. International Journal of Nursing Education Scholarship, 11(1). doi: 10.1515/ ijnes-2013-0061. Salgia, R., Mullan, P., McCurdy, H., Sales, A., Mosley, R., & Su, G. (2014). The educational impact of the specialty care access network – extension of community healthcare outcomes program. Telemedicine Journal and e- Health, 20(11). 1004-1008. doi: 10.1089/tmj.2013.0302. Schlacta-Fairchild, L. (2000). An Examination of telenursing: Description of the professional role and predictors of role stress, role ambiguity, and role conflict. (Doctoral dissertation). Retrieved from: UMI (9987966). Staggers, N, Gassert, C., & Curran, C. (2001). Informatics competencies for nurses at four levels of practice. Journal of Nursing Education 40, 303-316. Technology Informatics Guiding Education Reform (TIGER). (2009). The Tiger Initiative. Retrieved from: www.thetigerintiative.com U.S. Census Bureau (2012). Fact finder sheet. Retrieved from www.census.gov/cps/methopdology/techdocs.html). U.S. Department of Veterans Affairs (2018). Fact sheet – Veterans association telehealth services. Retrieved from: www.telehealth.va.gov U.S. Department of Veterans Affairs (2019). News Release. Retrieved from: www.va.gov.opa.pressrelease Wood, R. & Locke, E. (1987). The relation of self-efficacy and grade goals to academic performance. Educational and Psychological Measurement. 47(4), 1013-1024.

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Young, T & Ireson, C. (2003). Effectiveness of school-based telehealth care in urban and rural elementary schools. Pediatrics 112 (5), 1088-1094. Welch, G., Balder, A. & Zagarina, S. (2015). Telehealth program for type 2 diabetes usability, satisfaction, and clinical usefulness in an urban community health center. Telemedicine Journal and eHealth 21(5), 395-403. Zayapragassarzan, Z. & Kumar, S. (2016). Awareness, knowledge, attitude and skills of telemedicine among heath professional faculty working in teaching hospitals. Journal of Clinical Diagnostic Research 10(3), 266-269.

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APPENDIX A

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Telehealth and the Advanced Practice Nurse

Dear Advance Practice Nurse:

I am a Doctoral of Nursing Practice student at the Case Western Reserve University (CWRU) Frances Payne Bolton School of Nursing in Cleveland, Ohio. I am inviting you to participate in a research study titled “Telehealth and the Advanced Practice Nurse”. This study is being conducted by myself and Dr Mary Dolansky, Associate Professor at CWRU. The purpose of this study is to identify telehealth competencies, knowledge and skills being utilized by advanced practice nurses in the practice setting and how frequently they are utilized in practice. The preparation of advanced practice nurses for the telehealth competencies, knowledge, and skills they utilize in practice will also be identified.

In this study, you will be asked to complete a paper survey questionnaire. Your participation in this study is voluntary and you are free to withdraw your participation from this study at any time. The survey should take only approximately 20 minutes to complete.

This survey has been approved by the Institutional Review Board (IRB) of Case Western Reserve University and the AANP Research and Education Department. There are no risks associated with participating in this study. The survey collects no identifying information and all of the response in the survey will be recorded anonymously.

While you will not experience any direct benefits from participation, information collected in this study may benefit the profession of advanced practice nursing in the future by better understanding the telehealth competencies, knowledge and skills used by advanced practice nurses.

If you have any questions regarding the survey or this research project in general, please contact Mary Dolansky at [email protected] and/or Patricia Hoyson at [email protected]. If you have any questions concerning your rights as a research participant, please contact Case Western Reserve University’s Institutional Review Board at 216-368-4514 or by mail to 10900 Euclid Avenue, Cleveland, OH 44106-7230.

By completing and submitting this survey, you are indicating your consent to participate in the study. Your participation is very much appreciated.

Thank you,

Patricia McLean Hoyson

Patricia Hoyson PhD, FNP-BC, CDE DNP Student, Case Western Reserve University 330-941-1448 [email protected]

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APPENDIX B

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Telehealth & the Advanced Practice Nurse

Welcome to this important effort to describe the current state and future direction of telehealth and Advanced Practice Nursing (APN) practice. Your participation is important and very much appreciated.

The purpose of this survey is to identify:

1. What telehealth competencies (knowledge and skills) are currently utilized by advanced practice nurses in the practice setting?

2. What is the frequency of use of telehealth skills in practice?

3. How and where are advanced practice nurses prepared for the telehealth competencies (knowledge and skills) they utilize in practice?

Your input is invaluable to helping us understand the role and preparation of APNs in telehealth.

The following definitions are provided to assist in guiding your answers:

Telehealth Technology: The computers, Internet, televisions, voice (telephone), video and distance learning devices, which, when coupled with communications lines, enable patient care, education and/or provider contact to occur over long distances (Schlachta-Fairchild, 2000).

Telehealth: The removal of time and distance barriers for the delivery of health care services or related health care activities (American Nurses Association, 1997).

All information is anonymous and confidential and information will be reported as aggregate data. Your completion and return of this survey implies your consent to participate. At the end of the survey you can list your email address if you wish to receive a summary of findings for the survey.

Please direct any questions regarding this survey to: Mary A Dolansky PhD, RN Patricia Mclean Hoyson PhD, FNP-BC, CDE Principal Investigator Co-Investigator Email: [email protected] Email: [email protected]

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I. INTRODUCTION # ______

1.0 I am a advanced practice nurse (APN) who is involved in using telehealth (voice and/or video and/or electronically obtained patient data) in my practice or job Yes No

1.1 I am a advanced practice nurse (APN) working in a telehealth program, institution or company Yes No

If you have answered “yes” to one or both of the above questions, you are eligible to proceed to the survey. Thank you!

II. INDIVIDUAL CHARACTERISTICS

This section asks questions about you and your professional nursing background. Results will be combined with other subjects’ responses. No individual data will be reported.

2.0 I am a: ___ Male ___Female

2.1 What year were you born? _____

2.2 My highest degree attained is: ___ Diploma ___ Post-Master’s Certificate ___ Associate Degree ___ Doctorate - DNP ___ Baccalaureate Degree ___ Doctorate - PhD ___ Master’s Degree ___ Other ______

2.3 I graduated with my initial advanced practice degree in the year: ______

2.4 I have other non-nursing degrees ___Yes ___ No 2.5 If yes, please specify:______

2.6 My advanced practice certification specialty is (select all that apply): ___ Clinical nurse specialist ___ Nurse anesthetist ___ Nurse midwife ___ Nurse practitioner - 2.7 Specific Certification(s): ______Other – please specify

2.8 Where are you employed? ______State ______Country

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2.9 My current position title is: ______

2.10 I am employed: Full-time ______Part-time ______

2.11 My Employer is (Select all that apply). If employed in more than one setting – please specify hours/ week in each setting: ___ Hospital ____ Hours per week ___ Clinic ____ Hours per week ___ College/University ____ Hours per week ___ School Health (Children) ____ Hours per week ___ Long-term care/Elderly setting ____ Hours per week ___ Community/Public Health ____ Hours per week ___ Home Care/Visiting Nurse ____ Hours per week ___ Occupational Health ____ Hours per week ___ Ambulatory Care ____ Hours per week ___ Private Office ____ Hours per week ___ Prison/Correctional Facility ____ Hours per week ___ Software/Hardware vendor ____ Hours per week ___ Call Center ____ Hours per week ___ Insurance Company ____ Hours per week ___ Military ____ Hours per week ___ Government Agency ____ Hours per week ___ Policy Organization ____ Hours per week ___ Other (please specify)______Hours per week

2.12 I work full time in telehealth ___ Yes ___ No

2.13 If no, what percentage of your time do you work in/with telehealth? _____

2.14 I spent the following approximate percentage of time in the following areas of my usual work week (percentage should add up to 100): ___ Administration ___ Consultation ___ In-person/face to face direct patient care (not supervising others) ___ Telehealth (phone, video, email, text) direct patient care ___ Research ___ Supervision ___ Teaching nursing or other students in health care occupations ___ Other Please specify what other is ______

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2.15 The types of patients primarily treated by telehealth in my job/practice are: (Select all that apply) ___ Chronic care ___ Coronary care ___ Neurological ___ Newborn ___ Obstetrics/gynecological ___ Gerontologic ___ Orthopedic ___ Pediatric ___ Rehabilitation ___ Basic Medical/surgical (or a combination of patients) ___ Other: Please specify ______

2.16 What strategy/strategies does your organization utilize to assure user competence in operating Telehealth technology? (Select all that Apply): ___ Orientation Program ___ Periodic Training ___ None ___ Other: Please specify ______

2.17 Please describe further the details of the strategy (strategies) used to prepare you for your role in telehealth

2.18 Describe strategies used to assure patient safety in the use of telehealth technology:

2.19 My annual earnings for my position is: (Please specify total annual salary before any deductions) ___ $15,000 or less ___ $15,001 to $25,000 ___ $25,001 to $35,000 ___ $35,001 to $50,000 ___ $50,001 to $75,000 ___ $75,001 to $100,000 ___ $100,001 to $150,000 ___ More than $150,000

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IV. CURRENT AND PROJECTED NEED FOR TELEHEALLTH ADVANCED PRACTICE NURSES (APNs)

4. 1 Perception of Current Need for telehealth APNs

4.1a. In my region, APNs can bill for telehealth patient services ___ Yes ___ No ___ Do Not Know

4.1 a. In my region, I am aware of other APNs who are employed in telehealth roles ___ Yes ___ No ___ Do Not Know

4.1 b. In my region, the current need for telehealth providers is (Select one): ___ None ___ Low ___ Moderate ___ High ___ Do Not Know Please explain your response:

4.1 c. In my region, what types of populations would best benefit from the use of telehealth?

4.2 a. I am certified in Telehealth ___ Yes ____ No

4.2 b I am certified in Nursing Informatics___ Yes ____ No

4.2 c. My opinion about the importance of telehealth certification for APNs is:

4.2 d. If a certification for Telehealth existed, it would need to include the following (name at least three components):

4.2 e. If a certification for Telehealth existed, I would be interested in becoming certified: _____Yes ______No

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V. EDUCATION/ TRAINING 5.1 Informatics knowledge/competencies The following questions are specific to general health care informatics and competencies. Please identify if you are familiar with (All, Some, None) of the listed knowledge & competencies, if you have learned and use them on the job (Yes, No) or if you were taught this information in a formal education (Undergraduate, Graduate, Continuing Education) program. Note that the non-bolded answers are examples within the larger category.

Informatics Knowledge & Competencies Familiar with On the job Formal education Informatics Theory: ____ All ____ Yes ___Graduate Definition/State of the science ____ Some ____ No ___Undergraduate Expected competencies ____ None ___Continuing Education Computer technology: ____ All ____ Yes ___Graduate Types/functions of hardware and software ____ Some ____ No ___Undergraduate Networks (configurations and usage) ____ None ___Continuing Education Information processing: ____ All ____ Yes ___Graduate Accessing electronic resources ____ Some ____ No ___Undergraduate General systems theory ____ None ___Continuing Education Information processing frameworks/research studies Adoption-of-innovation theories Information systems for practice, education, management, research: ____ All ____ Yes ___Graduate Types and applications ____ Some ____ No ___Undergraduate Computer-based patient record ____ None ___Continuing Education Standardized language and classification systems National health data bases Life cycle of an information system: ____ All ____ Yes ___Graduate Roles of health care team members ____ Some ____ No ___Undergraduate Planning, implementing, evaluating, & upgrading a system ____ None ___Continuing Education Professional Issues: ____ All ____ Yes ___Graduate Ethical use of information and information systems – ____ Some ____ No ___Undergraduate Privacy, Confidentiality and Security ____ None ___Continuing Education Professional informatics organizations Legislative issues (HIPAA, etc)

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5.2 Telehealth education/training The following questions are specific to general health care informatics and competencies. Please identify if you are familiar with all, some, or none of the listed knowledge & competencies, if you have learned and use them on the job (Yes, No) or if you were taught this information in a formal nursing education (Undergraduate, Graduate, Continuing Education) program. Note that the non-bolded answers are examples within the larger category.

Competencies Familiar with On the job Formal education Integrates telehealth into nursing practice for client assessment, ____ All ____ Yes Graduate diagnosis, identification of desired outcomes, plan of care, ____ Some ____ No Undergraduate implementation, evaluation and referrals. ____ None Continuing Education Establishes a therapeutic relationship which creates a sense of nursing ____ All ____ Yes ___Graduate presence that engages the client. ____ Some ____ No ___Undergraduate ____ None ___Continuing Education Assesses and adjusts communication plans to maximize the nurse client ____ All ____ Yes ___Graduate relationship. ____ Some ____ No ___Undergraduate ____ None ___Continuing Education Assesses the appropriateness of specific telehealth technologies for ____ All ____ Yes ___Graduate individual situations or populations. ____ Some ____ No ___Undergraduate ____ None ___Continuing Education Determines whether client needs can be met with telehealth using ____ All ____ Yes ___Graduate concurrent evaluation and make changes to management plan. ____ Some ____ No ___Undergraduate ____ None ___Continuing Education Ensures that clients are informed about their choices regarding the use of ____ All ____ Yes ___Graduate telehealth ____ Some ____ No ___Undergraduate ____ None ___Continuing Education Demonstrates skills in seeking, using and providing consultation, and ____ All ____ Yes ___Graduate participates in interdisciplinary collaboration to meet client’s needs. ____ Some ____ No ___Undergraduate ____ None ___Continuing Education Demonstrates knowledge and skill of specific telehealth technology and ____ All ____ Yes ___Graduate relevant telehealth skills. ____ Some ____ No ___Undergraduate ____ None ___Continuing Education

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Competencies Familiar with On the job Formal education Ensures that public and institutional policies related to privacy, ____ All ____ Yes ___Graduate confidentiality, informed consent and security are employed during ____ Some ____ No ___Undergraduate telehealth use. ____ None ___Continuing Education Uses results of telehealth performance outcomes to modify practice. ____ All ____ Yes ___Graduate ____ Some ____ No ___Undergraduate ____ None ___Continuing Education Documents and integrates into information systems the structure, process ____ All ____ Yes ___Graduate and outcomes of telehealth events ____ Some ____ No ___Undergraduate ____ None ___Continuing Education

VI. TELEHEALTH TOOLS, USE & EDUCATION

5.3. Telehealth tools – Usage and Education

Please identify if you currently use the technology (Yes or No), the percentage (%) of time you use daily, if you do not currently use but think you will use in the next three years (Yes, No) and if you have learned this information on the job or had formal education (Graduate, Undergraduate, or Continuing Education) related to the use of these tools.

Telehealth / Information Technology Tool Currently Percent Use in 3 On the job Formal education use % years of day Telehealth tools (real time video or audio ____ Yes ____ Yes ____ Yes Graduate practitioner/patient encounters) ____ No ____ No ____ No Undergraduate Continuing Education

Remote monitoring devices (ie, machines that monitor a ____ Yes ____ Yes ____ Yes Graduate single function such ECGs, TPR, BP, BGM at a remote ____ No ____ No ____ No Undergraduate site such as the patient’s home) Continuing Education Telephone patient encounter(s) ____ Yes ____ Yes ____ Yes Graduate ____ No ____ No ____ No Undergraduate Continuing Education

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Telehealth / Information Technology Tool Currently Percent Use in 3 On the job Formal education use % years of day Handheld computers used to document care or retrieve ____ Yes ____ Yes ____ Yes Graduate health related information at the point of care/patient ____ No ____ No ____ No Undergraduate visit Continuing Education Mobile computers capable of wireless and other remote ____ Yes ____ Yes ____ Yes Graduate forms of connecting to information systems or health ____ No ____ No ____ No Undergraduate care information. Continuing Education Electronic medication prescribing ____ Yes ____ Yes ____ Yes Graduate ____ No ____ No ____ No Undergraduate Continuing Education Electronic Orders/Consults/Referrals ____ Yes ____ Yes ____ Yes Graduate ____ No ____ No ____ No Undergraduate Continuing Education Electronic acquisition & review of patient data – labs, ____ Yes ____ Yes ____ Yes Graduate test results ____ No ____ No ____ No Undergraduate Continuing Education Electronic (email) communications with ____ Yes ____ Yes ____ Yes Graduate patients/families ____ No ____ No ____ No Undergraduate Continuing Education Telecommunities or the online support of patients and ____ Yes ____ Yes ____ Yes Graduate family members using computer linkages ____ No ____ No ____ No Undergraduate Continuing Education Online Consumer health or the ability to access and ____ Yes ____ Yes ____ Yes Graduate evaluate online healthcare resources. ____ No ____ No ____ No Undergraduate Continuing Education Robots or the ability to manage a patient’s healthcare ____ Yes ____ Yes ____ Yes Graduate condition using machines that integrate multiple ____ No ____ No ____ No Undergraduate functions and simulate portions of a nurse/patient Continuing Education encounter. Decision Support Tools or the ability to use technology ____ Yes ____ Yes ____ Yes Graduate tools such as software packages that can mine data or ____ No ____ No ____ No Undergraduate applications that can access online information to form Continuing Education evidence-based healthcare decisions.

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5.4. How popular do you believe the above telehealth tools will be in APNs practice within the next three years? (Please check only one) ___ 0-25% ___ 26-50% ___ 51-75% ___ 76-100%

5.5. Do you believe that clinical experiences related to the use of the above information and telehealth technology tools should be included in advanced practice nursing curriculum? (Please check only one) ___ Yes ___ No

5.6 If no, please explain your answer in the space provided below.

5.7. At what level of nursing education do you believe that the above activities should be included as clinical experiences? (Please check all that apply) ___ Undergraduate - entry level program ___ Master’s degree - Advanced Practice nursing degree ___ Doctoral degree - DNP ___ Doctoral degree – PhD

5.8. Briefly describe below how you believe the clinical experiences related to the use of the above information technology/telehealth tools should be included in the curriculum:

5.9 Please tell about a situation in your experience where the significance or effectiveness of telehealth became crystal clear for you.

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Thank you! You are finished with the survey. If you have any questions regarding this survey please contact: [email protected] or [email protected].