Telehealth Competencies for Nursing Education and Practice: The Four P's of Telehealth.

BACKGROUND: Telehealth is a rapidly growing health care delivery modality with advanced practice nurses as key providers. This growth has occurred without critical consideration of provider training. Training requires the development of competencies situated within a framework. PROBLEM: Standardized telehealth competencies for advanced practice nursing are missing. The purpose of this article is to describe the development of telehealth competencies for education and practice. APPROACH: Using the Four P's of Telehealth framework (planning, preparing, providing, and performance evaluation), a modified Delphi technique was used to identify, develop, and evaluate telehealth competencies. OUTCOMES: Competencies were arranged around telehealth domains, expected activities, and outcomes. Effective use of the competencies to guide curriculum development, practice, and future research related to telehealth was identified. CONCLUSIONS: Providing education with competencies aligned to the Four P's Telehealth framework will provide learners with tools to assume leadership roles in all phases of telehealth implementation, delivery, and refinement.

Interdisciplinary Rounds on a Hospitalist Service: Impact on Palliative Care Measures, Quality, and Utilization Outcomes.

BACKGROUND: Despite growth in service availability, palliative care (PC) referrals are often underutilized or delayed, which may compromise patient outcomes. LOCAL PROBLEM: Underutilized or delayed PC referrals among hospitalized adults prompted this project aimed at improving PC measures, quality, and utilization outcomes. METHODS: Data extracted from the electronic medical record were used to identify needed improvements in PC. INTERVENTION: Interdisciplinary rounds (IDRs) were implemented on the hospitalist service in a nonintensive care setting. RESULTS: Following implementation, median time to PC referral decreased by 2 days. Length of stay (LOS), direct cost, and 30-day mortality also decreased. Postintervention patients were more likely to transition home compared with another facility. CONCLUSIONS: Results support IDRs as a mechanism to improve time to PC referral, decrease LOS, direct cost, and 30-day mortality among hospitalized adults. A more objective method of identifying patients with unmet PC needs may be warranted.

How to Prepare Interprofessional Teams in Two Weeks: An Innovative Education Program Nested in Telehealth.

PROBLEM: Preparing health professional students for interprofessional collaborative practice, especially at a distance where provider shortages prevail remains difficult. APPROACH: A two-week interprofessional education (IPE) immersion experience preparing students from 11 disciplines and four universities was implemented. Week-one, using online technology, students develop/present an interprofessional careplan for a complex patient. Students then meet face-to-face to conduct group interviews with two standardized patient dyads. Week-two, students develop a website for use of the patient dyads. Websites are presented to faculty and fellow students via an online virtual meeting space. OUTCOMES: To date, 594 students have participated demonstrating capacity to: 1.effectively engage in interprofessional care, 2. utilize Telehealth to impact care and break down barriers of isolation, and 3. implement skills to advance healthcare. CONCLUSION: IPE combined with Telehealth technology provides future providers with knowledge and skills for interprofessional care regardless of geographic barriers. Next Step: Integrate more technology using mobile devices and enhance the evaluation process.

Telehealth and eHealth in nurse practitioner training: current perspectives.

Telehealth is becoming a vital process for providing access to cost-effective quality care to patients at a distance. As such, it is important for nurse practitioners, often the primary providers for rural and disadvantaged populations, to develop the knowledge, skills, and attitudes needed to utilize telehealth technologies in practice. In reviewing the literature, very little information was found on programs that addressed nurse practitioner training in telehealth. This article provides an overview of both the topics and the techniques that have been utilized for training nurse practitioners and nurse practitioner students in the delivery of care utilizing telehealth. Specifically, this article focuses on topics including 1) defining telehealth, 2) telehealth etiquette, 3) interprofessional collaboration, 4) regulations, 5) reimbursement, 6) security/Health Insurance Portability and Accountability Act (HIPAA), 7) ethical practice in telehealth, and 8) satisfaction of patients and providers. A multimodal approach based on a review of the literature is presented for providing the training: 1) didactics, 2) simulations including standardized patient encounters, 3) practice immersions, and 4) telehealth projects. Studies found that training using the multimodal approach allowed the students to develop comfort, knowledge, and skills needed to embrace the utilization of telehealth in health care.

Factors That Influence Women to Disclose Sexual Assault History to Health Care Providers.

OBJECTIVE: To examine women's experiences with sexual assault screening by health care professionals and identify factors that influence women to disclose their sexual assault history to providers. DESIGN: Cross-sectional descriptive survey with correlational analysis. SETTING: On-line survey distributed nationally. PARTICIPANTS: One hundred forty-three women. METHODS: Participants were recruited through social media; the authors e-mailed organizations across the nation and asked them to share links to a Facebook page connected to the survey. Descriptive statistics, Spearman's rho, and contingency tables were calculated, and qualitative content analysis was performed by thematic analysis. RESULTS: Most (n = 103, 72.5%) participants reported that they felt comfortable with being asked about sexual assault, but only 41 (28.7%) participants were screened for sexual assault by health care professionals. Positive attitude and increased comfort level with screening were associated with increased intention to disclose past assault (p < .05). A total of 113 (82.5%) women reported intentions to disclose sexual assault to a provider if asked, whereas only 35 (24.6%) women would voluntarily disclose. Women identified prevention of medical and physical consequences as main facilitators to disclosure, and provider attitude and demeanor as the main barriers. Sixty-nine (48.9%) participants were victims of sexual assault. Women with a history of sexual assault were no more likely than women not victimized to have been screened for sexual assault. CONCLUSION: Study findings suggest that women are often not screened for sexual assault despite being receptive to inquiry. Health care professionals often do not identify those who have been sexually assaulted because they do not ask. Thus, many victims do not receive needed sexual assault resources and support.

The Noncompete Clause and the Nurse Anesthetist: An Assessment of Knowledge, Perception, and Experience.

Economic pressures and the challenge to maintain competitive advantage have resulted in many healthcare entities requiring their practitioners to contractually enter into noncompete clauses (NCCs). Many student registered nurse anesthetists (SRNAs) and Certified Registered Nurse Anesthetists (CRNAs) are unaware of NCCs in employee contracts. An anonymous, web-based questionnaire regarding NCCs was distributed to SRNAs and CRNAs nationwide. Of 242 practicing CRNAs who responded, 147 (60.7%) were employed without a noncompete clause and 22 (9.1%) were unaware whether they had such a provision in their employment contracts. The knowledge level of the nurse anesthetist respondents was low (average score of 55.3%). There was a significant difference in knowledge level between independently practicing CRNAs and group-practice CRNAs (P = .007) as well as practicing CRNAs vs SRNAs (n = 8, P = .006). Independent CRNAs had more experience with declining positions, changing positions, and loss of employment due to NCCs. More CRNAs believed the NCC is not applicable to practice, and no evidence existed to show a relationship between geographic location and having an NCC. Business-minded CRNAs with a practical knowledge of keyterms, concepts, and legal implications of NCCs are in a better position to bargain and negotiate against objectionable provisions.

Barriers in asthma care for pediatric patients in primary care.

INTRODUCTION: There are many barriers to treating children with asthma. Barriers limit access with subsequent disturbances in quality outcomes. This study explored the difference in quality outcomes, utilization outcomes, parental knowledge, and barriers to care between children who had controlled versus uncontrolled asthma. METHOD: Data were analyzed between two intact groups of caregivers of children with asthma. Caregivers in both groups completed the Asthma Knowledge Test and the Asthma Barrier Questionnaire. RESULTS: Caregivers (n = 62) were primarily mothers (85.5%). Children with uncontrolled asthma missed 33.3% more days of school. The caregivers of the children with controlled asthma answered more questions on the Asthma Knowledge Test correctly and had a lower score on the Asthma Barrier Questionnaire. DISCUSSION: Asthma control is essential. By identifying barriers to care, health care providers can build an action care plan to individualize each patient's needs.

Telehealth: preparing advanced practice nurses to address healthcare needs in rural and underserved populations.

Healthcare is being confronted with questions on how to deliver quality, affordable, and timely care to patients, especially those in rural areas, in systems already burdened by the lack of providers. Advanced Practice Registered Nurses (APRNs) have been challenged to lead this movement in providing care to these populations through the use of technologies, specifically telehealth. Unfortunately, APRNs have limited exposure to telehealth during their educational experience, thereby limiting their understanding and comfort with telehealth. To address this problem, a telehealth program was developed at a large university that prepares Doctor of Nursing Practice (DNP) APRN students. The telehealth program, embedded into the DNP curriculum, consisted of a simulation workshop, practice immersion, and written project. This program was well received by students, making them aware of the benefits and barriers to the implementation of telehealth as a care delivery modality. Telehealth was embraced as students implemented the program in their own practices.

Predictors of self-efficacy for sleep in primary care.

AIMS AND OBJECTIVES: To identify factors impacting self-efficacy for sleep. Specifically, the aims were to examine associations between self-efficacy for sleep and (1) socio-demographic variables and (2) potential predictors including sleep severity, depression, dysfunctional beliefs about sleep, quality of life/health status and insomnia treatment acceptability for behavioural treatment. BACKGROUND: Between 50 and 70 million Americans experience insomnia. Costs of treatment, absenteeism and reduced productivity exceed 42 billion dollars annually. Medication for insomnia can result in impaired memory, fatigue, injuries, reduced health, medication habituation, difficulties in work and relationships and enhanced healthcare usage. Studies have suggested that behavioural management can be beneficial; however, factors contributing to success with behavioural management are unclear. DESIGN: This quantitative correlational study used inventory-based measures. METHODS: The Self-Efficacy for Sleep Scale, Insomnia Treatment Acceptability Scale, SF-8™ Health Survey, Center for Epidemiological Studies Depression Scale and Dysfunctional Beliefs about Sleep Scale were completed by 236 individuals with significant insomnia as measured by Insomnia Severity Index scores of 8 or higher. RESULTS: A significant association was found between sleep self-efficacy and race (p < 0·01). All predicator variables except one were found to be significantly correlated with the self-efficacy for sleep (p < 0·01). CONCLUSIONS: For behavioural self-management strategies to be effective for treating insomnia, these reported predictors may need to be assessed and managed. RELEVANCE TO CLINICAL PRACTICE: These findings suggest that nurses may want to assess insomnia severity, health status, level of depression and beliefs about sleep prior to beginning or when encountering barriers to the successful utilisation of behavioural approaches to manage sleep. If a patient is found to possess these limiting factors, the nurse may want to address these issues through medication, education and/or other behavioural approaches. Once addressed, the patient may find behavioural management for insomnia to be quite successful.

Herbal supplements in primary care: patient perceptions, motivations, and effects on use.

Relationships between primary care patients' herbal use and influencing factors were examined. Most felt that herbals were safer than prescription medications and preferred their use. There were significant relationships between perceived herbal safety and efficacy and other motivational factors with use. Supplement cost and demographics were less predictive of use.

Effectiveness of nurse practitioner coordinated team group visits for type 2 diabetes in medically underserved Appalachia.

PURPOSE: To study the effectiveness of multidisciplinary nurse practitioner coordinated team (NPCT) group visits in medically underserved Appalachia on the health, knowledge, and self-efficacy of patients with type 2 diabetes (DM). The study also identified perceived barriers to participating in the diabetes programs. DATA SOURCES: A researcher-developed tool was used to assess demographic data, clinical data, and barriers to care. The participants completed the Diabetes Knowledge Tests and the Diabetes Empowerment Scales. Two groups were assessed. One group participated in the diabetes intervention, and the other received usual care. Both groups completed the instruments prior to the intervention and after the intervention was completed. CONCLUSIONS: The group that participated in the intervention had better clinical outcomes (blood glucose and A1Cs), greater knowledge, and better self-efficacy following the intervention than the usual care groups. This suggests that the intervention was important in improving outcomes of patients with type 2 DM. Barriers to care included fuel, time, family, work, and transportation. Barriers need to be addressed in order to have more patients participate in such programs. IMPLICATIONS FOR PRACTICE: NPCT group visits may represent an effective means of integrating diabetes self-management education and medical management in a family practice clinic in medically underserved areas.

Telehealth stroke education for rural elderly Virginians.

OBJECTIVE: Stroke is a prevalent condition found in elderly, rural populations. However, stroke education, which can be effective in addressing the risks, is often difficult to provide in these remote regions. The objective of this study is to evaluate the effectiveness of delivering stroke education to elderly individuals through telehealth versus in-person stroke prevention education methods. MATERIALS AND METHODS: A quasi-experimental nonequivalent control group design was used in this study. A convenience sample of 11 elderly adults (36% men, 64% women) with a mean age of 70 was selected from an Appalachian Program for All Inclusive Care for the Elderly (day care) facility. Subjects completed preintervention surveys, received a 20-min group in-person or telehealth delivered education session, and then completed the postintervention surveys. RESULTS: Satisfaction with delivery method and post-education knowledge was equivalent between the two groups. Knowledge increased in both groups after the educational programs. Likelihood of reducing risk factors showed no differences pre-posttest. However, there were significant improvements in the pre-post likelihood scores of the telehealth group in contrast to the in-person group. CONCLUSIONS: This project provided a rural, high-risk population access to telehealth stroke education, thus enabling these individuals to receive education at a distance from experts in the field. The telehealth program was found to be equivalent to in-person stroke education in regards to satisfaction, knowledge, and likelihood of making changes to decrease vascular risk factors. The study demonstrated feasibility in providing effective stroke education through telehealth, thus suggesting an often overlooked route for providing patient education at a distance.

Validation of the Insomnia Treatment Acceptability Scale (ITAS) in primary care.

Patients with insomnia respond best to cognitive-behavioral treatments (CBT) if they find the approach acceptable. One tool, the Insomnia Treatment Acceptability Scale (ITAS), has been used to identify such patients, however, its reliability and validity has not been well established especially in primary care. The purpose of this study was to assess the reliability and validity of the ITAS in a primary care setting. A cross-sectional survey was conducted with 236 primary care patients, aged 18 and above, with clinically significant insomnia (Insomnia Severity Index ≥8). Descriptive and summary statistics, Cronbach's alpha, Principal Axis Factor analysis with Promax rotation, and comparison of ITAS subscale scores with self-reported treatment preferences (Chi-Square) are included. Factor analysis identified two factor solutions for the ITAS subscales. The ITAS was shown to be a reliable and valid tool that can be used to facilitate psychological practice and research on interdisciplinary behavioral-medical care.

Acceptability of behavioral treatments for insomnia.

BACKGROUND: Behavioral treatments for insomnia are safe and efficacious but may not be embraced by patients in primary care. Understanding factors associated with acceptability can enhance successful use of these modalities. The objective of this study was to identify demographic and clinical/psychosocial correlates of behavioral insomnia treatment acceptability. METHODS: This nonexperimental, inventory-based, cross-sectional study enrolled patients from a hospital-sponsored primary care clinic and 2 urban academic family practices. Participants (n = 236) were 18 years of age or older who had clinically significant insomnia (Insomnia Severity Index score ≥ 8) and were recruited consecutively at these sites. A study coordinator obtained informed consent then distributed survey materials. Participants received a $10 honorarium. The main outcome measure was the Acceptability Insomnia Treatment Acceptability Scale-Behavioral subscale (ITAS-B). RESULTS: Only acceptability of medications (r = 0.259) and dysfunctional beliefs (r = 0.234) scores had significant bivariate correlations with ITAS-B scores (P < .001). Medication acceptability, dysfunctional beliefs, and self-efficacy accounted for 12.45% of ITAS-B variance in linear regression. CONCLUSIONS: Screening for dysfunctional beliefs about sleep may identify patients with interest in behavioral approaches. Improving self-efficacy for sleep may improve acceptance of behavioral insomnia therapies. Interest in behavioral and medication treatments are not mutually exclusive. However, the modest variance reported here suggests other factors impact acceptance of behavioral treatments.

Educating advanced practice nurses in using social media in rural health care.

Health care in the United States is facing a crisis in providing access to quality care for those in underserved and rural regions. Advanced practice nurses are at the forefront of addressing such issues, through modalities such as health care technology. Many nursing education programs are seeking strategies for better educating students on technology utilization. Health care technology includes electronic health records, telemedicine, and clinical decision support systems. However, little focus has been placed on the role of social media in health care. This paper describes an educational workshop using standardized patients and hands-on experiences to introduce advanced practice nurses in a Doctor of Nursing Practice program to the role of social media in addressing issues inherent in the delivery of rural health care. The students explore innovative approaches for utilizing social media for patient and caregiver support as well as identify online resources that assist providers in a rural setting.

Psychosocial correlates of insomnia severity in primary care.

PURPOSE: Insomnia is a substantive primary care issue that leads to adverse outcomes. These can be improved by addressing factors that accentuate insomnia severity. Accordingly, this study identifies correlates of insomnia severity and determines whether these relationships vary with sociodemographic attributes. METHODS: This correlational cross-sectional study was conducted in a hospital-sponsored primary care clinic and 2 urban, academic family practice centers. Participants consisted of 236 patients 18 years old or older with clinically significant insomnia (Insomnia Severity Index scores of 7 or more). Surveys instruments included the Insomnia Severity Index, SF-8 (Medical Outcomes Study SF-8 global health status measure), CES-D (Center for Epidemiologic Studies-Depression Scale), DBAS (Dysfunctional Beliefs about Sleep scale), SE-S (Self-Efficacy for Sleep Scale), and a researcher-designed demographic survey. Analytic techniques included descriptive statistics to characterize the study sample, Pearson or Spearman Correlation Coefficients to examine individual associations with insomnia severity, and step-wise linear regression to identify net predictors. RESULTS: Insomnia severity was significantly correlated with health status, depression, self-efficacy, and dysfunctional beliefs (P < .001) but not with sociodemographic attributes. Linear regression demonstrated insomnia severity was best predicted by low self-efficacy and high depression scores. DISCUSSION: These findings indicate that clinicians treating insomnia should not only manage comorbid depression but also facilitate self-efficacy for sleep-inducing behavioral change.

Integrative simulation: a novel approach to educating culturally competent nurses.

Nursing education faces many challenges as a result of the population's increased cultural diversification. Of primary importance is the need to prepare culturally competent nurses to provide care in both urban and remote rural areas. This paper presents a HRSA funded program that utilises simulations to provide culturally diverse learning opportunities for both university-based and distance learning students. Cases are developed using focus groups and individual interviews. The information is used with standardised patients to develop vignettes that are loaded into a web-based virtual hospital where students conduct interviews with culturally diverse patients. The information obtained during the interview is then used to provide hands-on care to a high performance simulator (simulated mannequin). The encounters are videotaped for use in debriefing sessions with the students, for educational programs in the classroom, and for video-streaming to web-based distance students. Students in the debriefing sessions and classroom participate in a review of the videotape using the Personal Response System to respond to question. Through the culturally enhanced integrated simulation, students have an opportunity to address clinical situations and the impact of culture in a relatively safe non-threatening environment where the impact of their biases can be explored.

Vulnerable Goth teens: the role of schools in this psychosocial high-risk culture.

BACKGROUND: In recent years, a number of tragedies have been linked to the Goth culture. Most alarming have been the acts of violence, suicide, and self-harm found among teens. Teachers, parents, administrators, and fellow students are at a loss on how to relate to such students. They are unsure what role they might play in addressing some of the psychosocial issues they encounter. The purposes of this article are to describe characteristics of Goth teens, identify psychosocial risks for these teens, and describe roles school personnel can play. METHODS: This article provides a review of the Goth culture, risk factors for Goth teens, and methods school personnel can use in identifying and addressing the psychosocial needs of this group. RESULTS: The Goth culture attracts teens who are depressed, feel persecuted, have a distrust of society, or have suffered past abuse. They then surround themselves with people, music, Web sites, and activities that foster angry or depressed feelings. They have a higher prevalence of depression, self-harm, suicide, and violence than non-Goth teens. CONCLUSIONS: School personnel are in a position to make a difference. By preparing themselves with knowledge, skills, materials, and referral sources, they can serve as liaisons. They have a specific role in advocating for the health and safety of students, identifying students who are at risk, disseminating new knowledge, and providing guidance in the management of the troubled teens.