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Nurse Educator Vol. 40, No. 5, pp. 266-269 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.

Telehealth Education in Nursing Curricula Nagia S. Ali, PhD, RN & Kay Hodson Carlton, EdD, RN, ANEF, FAAN & Omar S. Ali, MSN, RN Telehealth care is a fast-growing avenue of providing health care services at a distance. A descriptive study was conducted to identify trends of telehealth education in 43 schools of nursing. Findings reflected inadequate integration of telehealth in classroom content, simulation, and clinical experiences. Interviews with 4 nursing leaders of telehealth provided some recommendations on how to integrate telehealth education in nursing curricula. Keywords: nursing curricula; nursing education; telehealth; telehealth education


he enactment of the Affordable Care Act has resulted in a growing number of people entering the health care system.1 Telehealth provides health services through the use of telecommunication technologies.2 In addition, shortages of personnel and high workload in critical care units have increased the demand for telehealth applications to ensure safety for critically ill patients.3 Telehealth nursing application includes remote monitoring, patient education, and consultation.4 Telehealth nursing care is applied in any location where telecommunication hardware and software such as videoconferencing, Internet, or videophones are available. These locations could be a physician’s office, hospital, specialty clinic, call center, and home. Telehealth services do not replace traditional care but supplement it for those who are unable to be physically present with a health care provider.5,6

Review of Literature The white paper7 about telehealth nursing set the foundation of policies, procedures, and standards. The evidencebased standards incorporate legal and ethical guidelines to help minimize the nurse’s liability in telehealth practice. A dimension of the practice standards is the Health Insurance Portability and Accountability Act (HIPAA) regulations, which would be followed by a telehealth nurse in the use of patient data. A telehealth nurse should have skills in assessing, using telecommunication technology, communicating with other

Authors Affiliations: Professors of Nursing (Drs Ali and Hodson Carlton), School of Nursing, Ball State University Muncie; and Clinical Educator (Mr Ali), Indiana University Health Methodist Hospital, Indianapolis. The authors declare no conflicts of interest. Correspondence: Dr Ali, School of Nursing, Ball State University, 2000 W University Ave, Muncie, IN 47306 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site ( Accepted for publication: December 19, 2014 Published ahead of print: February 13, 2015 DOI: 10.1097/NNE.0000000000000149


health care providers, teaching patients and families, managing data, and making appropriate decisions when the patient needs to be examined by a health care provider. The Telehealth Nursing Special Interest Group recommended principles of telehealth nursing be included in prelicensure and graduate nursing programs.4 These recommended principles included definition of terms, benefits of telehealth, differences between traditional and telehealth care, policies and regulations, knowledge about information technology and telecommunications, application of HIPAA to telehealth nursing, interstate licensing, and ethical and legal issues of telehealth. Telehealth can be as effective as traditional nursing care. Patients who have difficulty controlling their diabetes were managed with continuous telehealth monitoring of their blood glucose level, HbA1c, weight, and blood pressure.4 Telehealth technology as a mode of educational delivery was well received by nurses in a rural area and viewed as a cost-effective method for continuing professional education and mentoring.8 Perceptions of critical care nurses about the use of telehealth in critical care were examined in another study.9 The authors found that critical care nurses believed telehealth increased patients’ survival, but hindered privacy and did not prevent medical errors. Most nurses preferred to have previously worked with the telehealth physician to facilitate effective use of the technology with the patient. The highest rated attributes of tele-ICU nurses were effective listening, an ability to establish priorities of patients’ issues, skill in fostering collaboration, and the effective use of tele-ICU application tools.10 In a study of faculty needs for training in use of technologies, 77% of the sample never used telehealth application, and 50% of the faculty perceived themselves to be knowledgeable at the novice level.11 An earlier survey of deans and directors of 266 baccalaureate and higher nursing programs in the United States also revealed many gaps in telehealth education at both undergraduate and graduate levels. Less than one-third of the programs addressed telehealth applications.12 In the future, virtual clinical experiences

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that use telehealth technology may be commonplace in nursing education, allowing the students to gain confidence in using the digital telehealth equipment.13 An earlier experiential study was successful in integrating telehealth and telemonitoring content in nursing curricula through the development and implementation of a telehealth course assignment in 5 campuses in a Midwestern institution.14 The literature review indicated the benefits of telehealth applications to the individual, family, community, and health care system. However, it is not clear how much telehealth education is immersed in nursing curricula. Therefore, the purpose of this study was to identify trends of telehealth education in nursing curricula.

Research Questions The questions were as follows: (1) What are deans and directors’ perceptions of telehealth education? (2) What telehealth content is included in nursing programs? (3) What telehealth clinical and simulation learning experiences are included in nursing programs? (4) What are the academic institution and health care facility support to faculty in providing telehealth education? and (5) What are the barriers to having telehealth education in nursing curricula?

Methods Data were collected from deans and directors of schools of nursing accredited by the Commission on Collegiate Nursing Education (CCNE) that have baccalaureate, master’s, and DNP programs published on the CCNE Web site in March 2014. The choice of including schools that have the 3 programs was to identify the types of programs with telehealth education in a school. There were 130 CCNE schools that met this criterion: they constituted the sample and received the survey electronically. The study used a cross-sectional descriptive survey design. The questionnaire ‘‘Telehealth in Nursing Curricula’’ developed by the researchers contained 15 questions. Of the 15 questions, 3 Likert scale items examined deans’ and directors’ perceptions of the importance of telehealth education. They first asked participants to rank order the importance of 4 technology strategies, with 1 representing the highest and 4 the lowest. These 4 strategies were clinical simulation, online education, telehealth, and flipping the classroom. The second item was to rate ‘‘I believe telehealth should be part of any nursing curriculum at any level—baccalaureate, master’s, DNP’’ on a 5-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree). The third item asked participants to rate their confidence that their faculty would integrate telehealth education in nursing curricula on a 5-point Likert scale that ranged from 1 (not very confident) to 5 (very confident). The remaining 12 questions were either closed- or openended questions. Content and courses in curricula related to telehealth were addressed through 4 questions. These questions inquired about the presence of program(s) with a telehealth component, content and courses, and their awareness of the Telehealth Resource Center in their state. Two questions targeted clinical and simulation learning experiences related to telehealth. Five questions inquired about the academic institution and health care facilities support in providing telehealth education to faculty, the type of support, Nurse Educator

the presence of a faculty development program, involvement of other disciplines, and connections with other telehealth care facilities. Barriers to implementing telehealth educations were addressed in 1 question. Face validity of the questionnaire was developed by 4 experts in telehealth and technology, 1 clinical informatics nurse, 2 professional computer staff, and 1 professional telecommunication technology staff. Suggestions of the experts were used to refine the survey. The study was approved by the university institutional review board. Of the 130 surveys sent electronically, 43 were returned, with a 33% return rate.

Findings Deans’ and Directors’ Perceptions of Telehealth Table 1 shows the rank order of the 4 technology strategies. Online education was ranked highest by most, followed by clinical simulation, then telehealth, and lastly flipping the classroom. Participants’ narrative comments about their chosen rank order included the importance of online education, especially for master’s and DNP students but also for students on campus, the belief in proficiency in online education as a base and foundation for success, and online education as a vehicle to accommodate the busy lifestyles of current learners. With the second rank, clinical simulation was perceived as a key to quality and safety. The strategy was also perceived as critical because clinical placements are difficult to obtain, and simulation helps students gain experience in critical thinking, decision making, teamwork, and communication skills outside the clinical setting. There was an 88.2% agreement (strongly agree and agree combined) to the statement about telehealth being a part of any nursing curriculum at any level—undergraduate, master’s, and DNP. Some participants’ narrative comments indicated that all students should have some experience with telehealth. However, other participants believed telehealth should not be in the undergraduate curriculum but rather included at the master’s and DNP program levels, mainly in the nurse practitioner track. Almost 57% of deans and director were confident (very confident and confident combined) that their faculty will integrate telehealth education in nursing curricula. Participants reported that incorporating telehealth is a challenge with other curriculum demands and overworked faculty. In addition, there is already so much content in the curriculum. Telehealth Content Twenty-two deans and directors (71%) reported having telehealth content in their programs. Examples of content included definition of terms, evidence-based telehealth practice, Table 1. Rank Order of 4 Technological Strategies by Deans and Directorsa Strategy

Rank Order, na (%)

Online education Clinical simulation Telehealth Flipping the classroom

15 14 2 2

(45.5) (42.4) (6.3) (6.3)

Mean (SD) 1.94 1.88 3.16 3.03

(1.06) (.96) (.95) (.90)


n = 33. Mean scores from 1 (high) to 4 (low).

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telehealth policies, telehealth standards, and ethical guidelines (Table, Supplemental Digital Content 1, NE/A213). Less than half of participants (45.2%) reported awareness of the Telehealth Resource Center for their state. More than half of the sample (61.3%) reported having an informatics course that included a telehealth component, and only 9.7% reported having a separate elective course about telehealth. Other courses with components in telehealth were acute care, adult health, community health nursing, nursing capstone, leadership, and assessment.

Telehealth Clinical and Simulation Learning Experiences Forty-two percent of participants reported having a telehealth learning experience through the use of a remote telehealth unit. Participants’ comments about the unit included developing students’ skills in remote examination, partnerships with community facilities and schools, remote assessment of patients in nursing homes in rural areas, and monitoring of home health patients. Other types of clinical and simulation experiences were reported (Table 2). Faculty Support in Telehealth Education Fifty-two percent of participants reported having academic institutional support, whereas only 24% received health care facility support. Examples of support included pedagogical, administrative, and technical (Table, Supplemental Digital Content 2, Narrative comments about the support included attending telehealth education to obtain certification in telehealth presentation, training of all faculty involved in telehealth in the use of the equipment, and providing faculty with opportunities to present their research findings about telehealth at national meetings. Forty-five percent of participating schools were partners with other disciplines in telehealth education, and 48% were partners with health care facilities that provide telehealth services. Table 2. Telehealth Clinical and Simulation Experiences Percent of Responsesa

Type of Experience Telehealth tools (ie, real-time video or audio for nurse-patient encounter) Patient education Remote patient monitoring devices (ie, machines that monitor heart functions such as pulse, blood pressure, etc) Distance education Store-and-forward telehealth transmission (ie, digital images, video, audio, clinical data) Real-time or interactive telehealth communication link between involved parties Grand rounds Administrative uses, eg, meetings Research Telephony (ie, telephone interfaced to computer for health data, disease prevention, and health promotion) a

100 75 63

63 63 63 50 38 38 38

More than 1 option was chosen.


Table 3. Barriers to Integrating Telehealth in Nursing Curricula Responsesa n (%)

Barriers Lack of telehealth training for faculty Full curriculum with no room for telehealth content Lack of knowledge and skills of faculty about telehealth Inadequate time to learn telehealth delivery Cost of telecommunication technology equipment Complexity of use of telehealth technology hardware Lack of demographic or geographic market for telehealth nurses in respondent’s vicinity

10 9 9 9 8 3 2

(77) (69) (69) (69) (62) (23) (15)


More than 1 option was chosen.

Barriers to Integrating Telehealth Identifiable barriers included lack of telehealth training for faculty, inadequate time to learn telehealth delivery, full curriculum, and cost of telecommunication technology equipment (Table 3). Phone Interview Findings Four participants agreed to phone interviews. Interview questions were about initiation of telehealth in nursing curricula, role of the nurse in telehealth practice, and advice on telehealth integration. All 4 faculty participants reported that initial telehealth integration began with funding from a Health Resources and Services Administration grant. The grant was either specific to telehealth education or to other purposes that contained telehealth components. In addition, donors’ monies were often used to purchase telehealth devices. Integration of telehealth started by incorporating telehealth in a hospital affiliated with the school of nursing, simulating telehealth experiences, developing a separate telehealth course, or using a telehealth remote presence robot. There was an agreement that telehealth education is ‘‘still a hit and miss’’ experience because not everyone is getting it. Another aspect mentioned during the interviews was about developing partnerships in telehealth education. Partnerships with other disciplines and health care facilities that use telehealth should be sought initially in the local area. The partners’ needs and learning objectives should be identified before telehealth application occurs. Deans and directors interviewed also indicated that students should be taught ‘‘telehealth etiquette’’ and should be comfortable in the new environment with the telecommunication tools and with their assessment skills when the patient is not in the room. All 4 participants indicated that 1 or more champions should take the lead to start examining the curriculum and identifying where telehealth could be integrated.

Discussion The purpose of this study was to explore what schools of nursing are teaching about telehealth, support and strategies for telehealth integration and use, and the barriers to the implementation of telehealth. Online education and simulation were perceived as priorities by most participants. Online education is a basic technological avenue to teaching and learning for many students, but telehealth is a technological strategy that will improve nursing practice and make

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health care delivery accessible to people outside the acute care setting. Although more than half of participants agreed that telehealth is part of nursing curricula, less than half were unsure or not confident that their faculty will integrate telehealth education. Faculty participants have not yet perceived that preparing future nurses should include education about the emerging telehealth technology. The fast spread of telehealth services in different avenues of health care systems, disciplines, and across the country requires that schools of nursing start to integrate telehealth components in the curricula across all academic programs. Currently, the traditional face-to-face nursing practice encounters need to be supplemented with virtual and electronic practice connections. Students need to learn how to be comfortable in this new virtual environment, and this should happen initially in nursing programs. Essential V Informatics and Healthcare Technologies of Master’s Education in nursing addresses technologies in general, but not telehealth specifically. The descriptive findings reflected inadequate integration of telehealth in nursing curricula, simulation, and clinical experiences. The phone interview findings indicated that telehealth integration can be accomplished in different ways and would yield positive outcomes, similar to what has happened in simulation. Barriers to integrating telehealth in nursing curricula can be resolved. Conversations with faculty members who have coordinated or championed telehealth education in their schools confirm that telehealth can be successfully implemented. Nurse educators do not need a mandate to integrate telehealth in curricula: they can start now.

Limitations This study has several limitations. First, the response rate was only one-third, yielding a small sample size. Nonrespondents may not have had telehealth in their program, or the telehealth components may be inadequately reflected in their curricula. The small sample size limits the generalization of the study findings to other schools. Second, the technological terms used in the questionnaire may have deterred potential participants to complete the survey. Third, the interpretation of telehealth as a less important technological strategy may have contributed to inadequate completion of the questionnaire.

Conclusion To prepare students to practice telehealth care, nurse educators should integrate telehealth content and skills across all academic program levels. Integration does not need to

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involve a massive curriculum revision. Faculty can examine their curricula and identify where telehealth concepts can be incorporated, explore institutional resources related to telehealth, consider linking with other disciplines and clinical agencies that are already implementing telehealth, and talk with faculty who have already implemented telehealth care in their nursing programs.

References 1. US Department of Health and Human Services. The Affordable Care Act. 2011. Published October 2011. Accessed May 2014. 2. 2013 American Telemedicine Association. Examples of research outcomes: telemedicine’s impact on healthcare cost and quality. Published April 2013. Accessed March 2014. 3. Yeo W, Ahrens SL, Wright T. A new era in the ICU: the case for telemedicine. Crit Care Nurs Q. 2012;35(4):316-321. 4. 2011 Telehealth Nursing Special Interest Group. Telehealth nursing fact sheet. Published April 2011. Accessed March 2014. 5. McGonigle D, Mastrian K. Nursing Informatics and the Foundation of Knowledge. 3rd ed. Burlington, MA: Jones & Bartlett, LLC; 2015. 6. Kamei T. Information and communication technology for home care in the future. Japan J Nurs Sci. 2013;10(2):154-161. 7. Telehealth Nursing Special Interest Group. Telehealth nursing: a white paper developed and accepted by the telehealth special interest group. 2008. nursing. Published April 17, 2008. Accessed March 2014. 8. Sevean P, Dampier S, Spadoni M, Strickland S, Pilatzke S. Bridging the distance: educating nurses for telehealth practice. J Contin Educ Nurs. 2008;39(9):413-418. 9. Mullen-Fortino M, DiMartino J, Entrikin L, Mulliner S, Hanson W, Kahn JM. Beside nurses’ perceptions of intensive care unit telemedicine. Am J Crit Care. 2012;21(1):24-31. 10. Goran S. A new view: tele-intensive care unit competencies. Crit Care Nurs. 2011;31(5):17-29. 11. Nguyen DN, Zierler B, Nguyen HQ. A survey of nursing faculty needs for training in use of new technologies for education and practice. J Nurs Educ. 2011;50(4):181-189. 12. McNeil BJ, Elfrink VL, Bickford CJ, et al. Nursing information technology knowledge, skills, and preparation of student nurses, nursing faculty, and clinicians: a US survey. J Nurs Educ. 2003; 42(8):341-349. 13. Grady J. The virtual clinical practicum: an innovative telehealth model for clinical nursing education. Nurs Educ Perspect. 2011; 32(3):189-194. 14. Gallagher-Lepak S, Scheibel P, Gibson C. Integrating telehealth in nursing curricula: can you hear me now? Online J Nurs Inform. 2011;13(2):1-16.

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Telehealth Education in Nursing Curricula.

Telehealth care is a fast-growing avenue of providing health care services at a distance. A descriptive study was conducted to identify trends of tele...
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