708418
research-article2017
NSQXXX10.1177/0894318417708418Nursing Science QuarterlyYancey / Teaching-Learning Processes
Teaching-Learning Processes
Enhancing Telehealth Education in Nursing: Applying King’s Conceptual Framework and Theory of Goal Attainment
Nursing Science Quarterly 2017, Vol. 30(3) 209–213 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav https://doi.org/10.1177/0894318417708418 DOI: 10.1177/0894318417708418 journals.sagepub.com/home/nsq
Ann E. Fronczek, RN; PhD,1 Nicole A. Rouhana, RN; PhD,1 and Judy M. Kitchin, RN; MS1
Abstract Telehealth technologies are increasingly used in the provision of nursing care to clients and populations. The education of nurses must include content and practice with telehealth technologies. The authors of this article discuss how one school of nursing has infused telehealth content and resources into undergraduate and graduate curricula using King’s conceptual system and theory of goal attainment as a guide. Keywords King, nursing, teaching-learning, telehealth Nurses are providing nursing care in environments that are increasingly innovative and complex. There is a continuous evolution in telecommunications and healthcare technologies that expand nursing practice and the potential ways that nurses interact with their clients. One area of growth that continually evolves and expands access to healthcare for clients, families, and systems is in the area of telehealth. Telehealth is defined as “a collection of means or methods for enhancing healthcare, public health, and health education delivery and support using telecommunications technology” (Telehealth Resource Centers, 2016). Telehealth technologies include live video conferencing, store and forward, remote patient monitoring, and mobile health (mHealth) devices. The main reason for the emergence of telehealth use is to provide equitable access to healthcare and education for those who live and work in remote areas, where these provisions have been clearly established to be insufficient. Therefore, nurse education leaders play a critical role in incorporating technology into the curriculum along with an increasing responsibility to prepare graduates to work with technologies surrounding healthcare. Nurses “should have skills in assessing using telecommunications technology, communicating with other healthcare providers, teaching clients and families, managing data, and making appropriate decisions when the clients need to be examined by a healthcare provider” (Ali, Carlton, & Ali, 2015, p. 266). The purpose of this article is to discuss how a school of nursing has infused telehealth content and resources into both undergraduate and graduate nursing curricula using King’s conceptual system and theory of goal attainment as the underpinning.
Overview of King’s Conceptual Framework and Theory of Goal Attainment It is already well-known that King’s conceptual framework is a systems framework consisting of personal, interpersonal, and social systems that interact to meet health needs (Gulitz & King, 1988; King, 1981, 2007). The personal system focuses on the individual, the interpersonal system focuses on groups of individuals and interactions, and the social system focuses on systems with common goals and interests such as an educational system or workplace. Nursing practice focuses on health needs and wants of the social system through mutual goal-setting, planning of programs that address patient needs, and evaluation of outcomes. King’s theory of goal attainment focuses on perceptions, communications, interactions, and transactions between nurses and clients as part of the process of mutual goal-setting to achieve a state of health (King, 2007). To reach a state of mutual goal-setting, nurses must be proficient in the application of the nursing process including skills in assessment, diagnosis, planning, implementation, and evaluation of nursing care. Much of this proficiency lies in excellent listening and 1
Decker School of Nursing, Binghamton University, NY, USA
Contributing Editor: Nan Russell Yancey, RN, PhD, Dean of Graduate, Professional, & Continuing Education, Professor of Nursing, Lewis University, One University Parkway, Romeoville, IL 60446, USA. Email:
[email protected]
210 communication skills and having specialized nursing knowledge and skills in providing care through education in order to maintain and restore health to an individual or setting. These factors, when coupled with health promotion and disease prevention efforts that are mutually agreeable and attainable, can positively influence patient outcomes. One facet of healthcare that is becoming a more pervasive element that is influencing all three of King’s systems and the process of goal attainment is technology. In the increasingly technological world, nurses and clients are using healthcare technologies to support health outcomes. Nurses at all levels of practice need to have some educational foundation in the use of technologies, including telehealth technologies, and how they can best be used to facilitate nursing process, goal-setting, and patient care outcomes. Nurses must also be educated in how technologies are being used by the clients they serve to move to a state of well-being. Interactions through the personal, interpersonal, and social systems, as described by King, are increasingly being facilitated by technology. Internal and external systems, such as accreditation bodies in healthcare with authority, decisionmaking, and power, are already influencing nursing curricula. King’s systems are rapidly establishing competencies in the area of technology at multiple levels of nursing practice. Faculties now recognize a specific educational responsibility to prepare students for technological advancements and their applications to practice via their respective undergraduate and graduate curriculum. Although faculties have multiple goals for concepts related to technology, the authors in this article specifically focus on telehealth technology related to nurse education.
Background of the Project There were two major purposes for enhancing content in telehealth and its infrastructure within both undergraduate and graduate nursing programs. The first purpose was to ensure compliance with the school’s accreditation and regulatory agencies by creating opportunities for students to become competent in assessment through multiple approaches as well as information management and patient care technologies. Both the American Association Colleges of Nursing (AACN) and National Organization of Nurse Practitioner Faculty (NONPF) require content related to new patient care technologies, along with using data to influence evidenced-based changes in care. This content is used to guide nurse educators, on both the baccalaureate and graduate level, to ensure current competencies. Using King’s perspective, along with ensuring Commission on Collegiate Nursing Education (CCNE) required standards are met, AACN and NONPF were sources of power and authority that influenced a move forward in this area. Faculty in the school had the authority to meet the accreditation goals in the manner in which they felt was best for the both the undergraduate and graduate programs. Faculty recognized early that telehealth technologies
Nursing Science Quarterly 30(3) are specific areas that many students may not have significant exposure to in the curriculum. Students and faculty must be familiar with using telehealth and remote monitoring equipment to support communication and assessment skills for monitoring clients. The faculty recognized the importance of acknowledging that technology, including telehealth, should be included as an essential element of curricula at the undergraduate and graduate levels. The AACN (2008) Essentials of Baccalaureate Nursing Practice Essential IV: Information Management & Application of Patient Care Technology does address some of the technological competencies that are needed. The technology competencies that students are expected to have at the time of graduation include use of “applications of patient care technologies that are mainly described as monitors, data gathering devices, or other supports for patient care interventions” (AACN, 2008, p. 17), as well as the following: 1. Demonstrate skills in using patient care technology, information systems, and communication devices to support safe nursing practice. 2. Use telecommunication technologies to assist in effective communication in a variety of healthcare settings. 3. Apply patient care technologies as appropriate to address needs of a diverse patient population.(AACN, p. 18) These competencies are fairly broad and do not include specific language related to telehealth and are aimed primarily at nurses working in mostly traditional healthcare settings. Building on the foundation of baccalaureate knowledge and competencies, the master’s-prepared nurse must develop skills for critical analysis and increasing autonomy as the role continues to expand in complexity. The AACN Essentials of Master’s Education in Nursing Essential V: Informatics and Healthcare Technologies provides clear direction and rationale for content and skills related to technology and systems management (AACN, 2011). Essential V requires that the master’s-prepared nurse will utilize patient-care technologies to both deliver and improve care while simultaneously using communication technologies to integrate and coordinate care. These skills are critical as they also support improving healthcare outcomes as recommended by the Institute of Medicine (2003). The master’s-prepared nurse must not only demonstrate competencies in technology to ethically collect, manage, and analyze data but also to share outcomes publicly in an effort to initiate program evaluation and revision. Specific examples of master’s-level technology competencies include: 1. Analyze current and emerging technologies to support safe practice environments, and to optimize patient safety, cost-effectiveness, and health outcomes.
Yancey / Teaching-Learning Processes 2. Evaluate outcome data using current communication technologies, information systems, and statistical principles to develop strategies to reduce risks and improve health outcomes. . . . 3. Provide oversight and guidance in the integration of technologies to document patient care and improve patient outcomes. . . . 4. Use current and emerging technologies in the care environment to support lifelong learning for self and others. (AACN, 2011, p. 19) Optimally, the master’s-prepared nurse will become a lifelong learner and maintain currency with evolving technological advancements in the healthcare arena and act as a role model to enhance other nurses’ technology skills. At the Doctor of Nursing Practice (DNP) level, education specific to technology builds on individual competencies used in direct patient care. This includes advanced data analysis and synthesis in addition to developing leadership skills related to program evaluation that contribute to improving population health outcomes. AACN (2006) DNP Essential IV: Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care states that DNP graduates are expected to: 1. Design, select, use, and evaluate programs that evaluate and monitor outcomes of care, care systems, and quality improvement. 2. Analyze and communicate critical elements necessary to the selection, use and evaluation of healthcare information systems and patient care technology. 3. Demonstrate the conceptual ability and technical skills to develop and execute an evaluation plan involving data extraction from practice information systems and databases. 4. Provide leadership in the evaluation and resolution of ethical and legal issues within healthcare systems relating to the use of information, information technology, communication networks, and patient care technology. 5. Evaluate consumer health information sources for accuracy, timeliness, and appropriateness. (AACN, 2006, p. 12) King’s conceptual framework can be used to support curriculum and curriculum decisions. In one school, the mission and philosophy stresses the importance of the connections and interrelationships between personal, interpersonal, and social systems and how to use them to fulfill the mission in caring for rural and vulnerable populations (Decker School of Nursing, 2016). From this mission and philosophy, the faculty set forth end-of-program outcomes for the baccalaureate, master’s, and doctoral programs that were influenced by faculty’s values and the external influence of the accreditation body. These end-of-program outcomes are fulfilled
211 through courses and course objectives that provide direction for the key values and fundamental skills that graduates must have to function in the diverse environments in which they will practice. In this specific case, faculty can trace the major concept of telehealth and how it evolved and how it is now threaded throughout the baccalaureate, master’s, and DNP programs. However, to bring the school’s telehealth content to a higher level across all three levels of program, a variety of infrastructure supports were enhanced to provide nursing students additional opportunities to function in environments where telehealth is being utilized. In the process of assessing and strengthening content in telehealth, the school had the opportunity to participate in a collaboration and grant-funding opportunity between the Decker School of Nursing and the Thomas J. Watson School of Engineering and Applied Sciences at Binghamton University to design a telehealth education and research center that would meet telehealth service needs of the university community and surrounding clinical agencies. Binghamton University, encompassing the schools of nursing and engineering, in partnership with regional healthcare providers, took advantage of the significant regional expertise in healthcare-related research, development, and education to develop the Southern Tier Telemedicine and Mobile Health Research, Development and Training Center. Consistent with King, this collaboration demonstrated how faculty and leaders from the community worked closely in both interpersonal networks and interacting social systems to create a supportive environment to discuss possibilities for telehealth. The grant provided capital funds to purchase equipment and infrastructure needs to create the center and provide technological supports and education spaces to enhance the curriculum. The center currently houses two education spaces and a research collaboration space. The education spaces include a classroom that has multiple educational technologies embedded to provide faculty and students with the ability to participate in educational initiatives both live and virtually. There is a second space that has a primary care set-up with telemedicine technology at the bedside to provide students with an opportunity to have handson or simulated experiences by participating in virtual visits. Through practicing elements of telehealth encounters in a simulated environment, students are able to refine and develop telehealth competencies before entering a practice environment. Although this infrastructure development and grant collaboration allowed faculty to create learning spaces for students to practice with telehealth technologies, it also led to a partnership and collaboration with a critical access facility to help the system start a telehealth program. Through the infrastructure development, faculties are able to meet a societal health need. The thrust supports King’s (2007) statement related to technology: As the explosion of knowledge and advances in technology continue to increase, it is important for professionals in the
212 healthcare system to function in multidisciplinary teams and to deliver healthcare to individuals and families. Interdisciplinary collaboration among healthcare providers is important to provide care in the 21st century. (p. 111)
The transaction process among disciplines can lead to “quality care and evidence based practice” (King, 2007, p. 111). These two schools and their related programs now have expanded opportunities to learn with and among each other by conducting research in the area of telehealth. Faculty will plan experiences with healthcare facilities that are using or pursuing the incorporation of telehealth technologies.
Telehealth Content in the Nursing Program King’s general systems model has applications in curriculum development. There are many facets to curriculum development, but as Gulitz and King (1991) stated, the three systems “are operationalized through knowledge of concepts, professional values, skills, axioms, and disturbances in health status that have been identified as essential to nursing practice” (p. 130). As students move through the baccalaureate, master’s, and doctoral levels, the concepts of informatics and healthcare technologies are leveled and increase in complexity. Recognition that telehealth technologies need to be emphasized as an important part of this technology discussion has been recognized by faculty. In the curriculum, the educators’ intent is to help students not only build skill in using telehealth technology but also reflect upon personal and professional values, decision-making, and telehealth technology’s role in facilitating nursing outcomes. The integration of telehealth information at the Decker School of Nursing undergraduate level consists of the introduction of the concept of telehealth technologies into the care of clients. Students at this level learn the foundation of telehealth technology, its principles, and typical uses in client care through integration in course lectures, discussions, and simulated lab experiences. Undergraduate students learn to use therapeutic communication skills and the importance of effective listening, a hallmark of King’s work. Opportunities to learn about, see, touch, and use telehealth communication tools are incorporated into undergraduate clinical assessment skills simulated lab experiences. In doing so, students begin to establish a comfort level with new technology and gain knowledge of telehealth tools. In one introductory professional socialization course, students learn about telehealth applications through an introductory overview of telehealth and information technology. Students are shown examples of companies that offer health services via telecommunications and videoconferencing. This discussion is followed by a reflection on how they would feel as practitioners practicing remotely and on the client’s perspective as to how they would feel seeing a practitioner through a web camera. In a later medical-surgical
Nursing Science Quarterly 30(3) course, the cardiac didactic content includes discussion about remote blood pressure monitoring, telephone pacemaker and implantable cardioverter defibrillator device checks, and loop recorders. The community health course includes discussion on use of telehealth monitoring and the effect it can have on readmission and improved patient outcomes. Some students will have the opportunity to see telehealth monitoring in use during community clinical experiences. These experiences give the student an opportunity to explore how telehealth technologies can be used to enhance the nursing process and explore how they may alleviate or create disturbances in health status. Students can also explore the relationship of telehealth technologies to their professional values. All of these course examples show some aspects of how students may specifically influence King’s personal and interpersonal systems through telehealth avenues, but they also provide a glimpse into the role telehealth technology plays in the social system. The master’s level nursing students are provided with opportunities to use technology early in the program, beginning with advanced health assessment. Physical assessments with diverse standardized clients are performed and recorded and later used for self, peer, and faculty evaluations. Simulated electronic medical records (EMRs) are created for outpatient primary care settings that mirror common EMR platforms used in the clinical settings. A portion of this includes “e-prescribing” capabilities to introduce the student to electronic prescribing experiences prior to entering the clinical site. Simulated patient assessment and management is performed using Shadow Health™, a web-based clinical simulation experience that provides avatars that electronically respond to advanced practice nursing students’ inquiries regarding detailed histories and physicals. An imperative essential of masters’-level education includes the evaluation of outcome data using technologies and information systems. To meet this objective, evaluation data management programs are incorporated into two existing research courses and a health policy course. Common applications include entering and analyzing data using Excel™, statistical software such as SPSS™, and others. Again, students gain an additional skill set in telehealth, but now there is a greater emphasis on patient outcomes and social implications of technology. At the DNP level, “Information Systems and Technology in Healthcare” is a course that enables students to become proficient in the use of information systems and technology resources to implement quality improvement initiatives and support practice decision-making, one very important concept in King’s work. The main focus of this course would address elements of King’s social system as it takes more of a societal point of view of telehealth and technology. For example, students in this course identify a selected health issue and must analyze an existing clinical information system in relation to data input, quality, storage, retrieval, and management, identifying at least one critical area for
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Yancey / Teaching-Learning Processes improvement or expansion. Applying quality improvement principles, students must develop a quality improvement plan for modifying a clinical practice information system to improve efficiency and related patient outcomes. Lastly, using principles of educational theory, students explore an area of interest for health consumers. This culminating assignment results in the evaluation of specific patient healthcare information derived from internet websites, mobile phone/tablet applications, and various sources of technology, such as wearable technology, mobile computer, and telehealth applications. All sources are evaluated by the students for accuracy, timeliness, and linguistic appropriateness and cultural sensitivity, all of which may influence healthcare outcomes. Technological advances in nursing practice are changing nurse education programs. All of these examples demonstrate some relevant ways that students can gain skill in using telehealth technologies. However, technological advancements are never static and will constantly evolve, as will nursing practice, in all three of King’s interacting systems (Lane-Tillerson, 2007). What is now the current state of technology will be obsolete in the near future; nurse education programs will need to keep pace.
Summary and Conclusions King’s systems-based approach along with multiple collaborations in the personal, interpersonal, and social systems provides the strongest framework to develop educational innovations to meet the goals of nurse educators to stay current in the ever-changing world of telehealth. The school described here is taking steps to provide opportunities to engage in telehealth practice, but more questions will evolve as the technology continues to advance. The discipline of nursing continues to expand and evolve in ways that still have not yet been imagined, especially as it relates to telehealth technology. One concern always seems to linger; how can faculty best teach nurses at all levels of practice to find comfort or harmony with technology while providing the best care possible. Another question is how technology is influencing the perceptions, communications, interactions, and transactions between nurse and clients in both positive and negative ways to attain mutual goals. While technology is an increasing essential element of healthcare, it should not replace the unique nurse-patient relationship. From an educational perspective, faculty also must ensure that they provide opportunities for student nurses to blend the art of nursing with the science of technology.
Acknowledgments The author guarantees that neither all or part of this manuscript has been published elsewhere in its present form, in another publication, or under a different title by either these authors or other authors. It is also acknowledged that this manuscript is not currently under review by any other publication.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this review.
Funding A portion of this project was funded by the Regional Economic Development Council of the Southern Tier Telemedicine and Mobile Healthcare Technology Fund (Southern Tier Telemedicine and Mobile Health Research, Development and Training Center, funded $1,666,163).
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