Introduction
The objective of the nursing profession is to effectively care a patient that is why it is important for the professionals to adapt to the changes that arise. Such is the case of the digital age, in which new care modalities must be incorporated to provide follow-up to outpatients suffering from chronic degenerative diseases. One example for this is “the use of information and communications technology to deliver health services, expertise, and information over distance” (9), in such a way that the health status of the patient can be investigated from home providing guidance focused on their needs, their family and the environment that could be influencing their health status. In this sense, to develop this type of care, it is important to base the implementation of digital tools on the experiences of the use of telemedicine by nursing professionals, for which the research question was: What are the experiences of nurses in the use of digital tools in primary health care?
Methods
For this, the search for bibliographic information the PICO methodology was used, using several terms to be combined among them in the following way: (P)Nurse, Health Care worker, Caregiver; (I) Digital technology, M-Health E-Health, Tele-Health, Digital Health Care; (C) Primary care, Primary Health Care, First Level Health Care, Self-Management (O) Experience, Implement, Application, Use, using, Practice, Benefit. Subsequently, using the EBSCO database, 25 articles were linked to this question. Then, they were divided among the members of the team so they could read carefully each one of them. And according to reading whole articles, the results one by one, could be discarded or considered usefulness for our study was reconsidered. Finally, 16 articles, published, years 2016-2020, were identified that answered the research question.
Results
Based on coding process, positive and negative experiences using digital tools were discovered. Among the positive experiences two categories were revealed: 1) the improvement of work processes, which describes the experiences in how the use of certain digital tools helps to facilitate and order the information for virtual assistance to users and 2) nurses’ empowerment, which shows the experiences related to the motivation generated using digital tools, as well as the improvement in the relationship of nurses with the community. Negative experiences were: 3) difficulties in adapting to the use of digital tools when aiding, likewise some professionals expressed preferences for traditional care, and 4) difficulties in communication, work overload and little skill in the use and management of digital tools, were considered as technical problems.
Regarding the Improvement of work processes, there are also four subcategories considered: Efficiency of care practices, Time saving, Improved communication, Efficient data transfer.
Talking about the efficiency of care practices, when asked the HCP (Health Care Professionals) they considered that using the digital tools would change workflow (1), because the digitization of records improves work efficacy. Therefore, digital tools have transformed the delivery of care and has improved the availability of care (12), and care efficiency (6), likewise, the use and implementation of eHealth has been useful (6) and beneficial to the patients (13) in care units where the need for office and home visits are reduced (9). The HCP mentioned, errors are reduced when comparing medication orders with primary care physician’s orders (12). On the other hand, alerts produced by the unit are very helpful for identifying emerging health issues and useful for monitoring long-term trends (9). Another advantage, regarding efficiency, is that using new tools improves the coordination among the HCPs because they considered that it makes easy to identify missing persons to complete vaccinations, therefore digitalization made the procedure of vaccination easier and with the use of the app the weight of the children is required for control. It was helpful for monitoring child growth and showed vaccination schedule of each child but defaulter children by changing the colors of entry, which helped them contact mothers (2). Evidence illustrates that the HCPs are responsible for encouraging the patient to assimilate the health information in a deeper way considering the patient as a partner that helps them to assess a better outcome when they are well educated about their condition and behavior (6). Providers commonly suggested technology-based solutions involving the Electronic Health Record could improve the process (8). Nurses described their experience with telehealth to be positive (13) and agreed that telehealth Healthcare staff perceived that externality does not affect the consultations when using a software (15) and HCPs experience digital communication useful when combined with continuity care (15).
About time saving, the HCP considered that digitalization reduces work hours in minutes (2) and telemedicine saves time (10) because eHealth technology has provided well-timed information (6). Providers thought the direct patient contact via Secure Messaging reduced time spent in “phone tag” (8). Thus, HCP feels that with time they can handle digital queries better and faster (15). Therefore, the communication is improved because when asked the HCP about changes in projects, they would adapt to telehealth and consider communication with staff is enhanced (1) since using different apps helped answer questions from the community and allowed them to have the information at hand from your mobile phones (2). They also viewed communication as critical and beneficial to stay connected with the patient to tell their own stories and found it essential to send messages with positive expectations to get measurable outcomes and to communicate, therefore they found essential to build an empathic relationship before asynchronous eHealth coaching, nevertheless an initial face-to-face meeting before initiating digital coaching was necessary to establish a strong and compassionate relationship (3.)
Subsequently, the use of this interactive, web-based register enabled the provision of practical care (5) HCP claims more informed patients’ better health outcomes, therefore patient empowerment is enhanced through access to information and e-Health; consequently, they may have a holistic view and better understand their health situation (6). The HCP experience digital communication as useful (15) and identified the importance of eHealth in collaborative relationship with patients and the relationship among HCPs. Now, patients and other providers have moved to a collaborative teamwork even though they stated they are longing for access into different strategies how to communicate with patients. In that sense a range of approach between the HCP and patient is “alliance,” emphasizing patients’ choice and the relation of collaboration and teaching (6). With time HCP feel they can communicate easily with patients because they can fully express their concerns (15). Also, HCP report that some patients prefer to communicate online rather than face-to-face and consider a benefit of using an eHealth portal to promote recommended and communicate postsurgical regimens (7), because using software in a great tool to ask relevant questions (15). Finally, HCP who used Secure Messaging agreed that many patients’ questions were streamlined, and requests were addressed by the most appropriate member of the team (8).
About the efficient data transfer, HCP reported that they can enter information in a single mobile device thereby the use of mHealth gives greater efficiency in the registration of information because they were able to comparatively record the vaccination of children (2) as a result of using the technology participants improved the quality of documentation. Therefore, the use of interactive, web-based registers enabled documentation to be systematized (5) and access to patients’ information helps HCP to understand what patients refer to during consultations (4). HCP mostly uses eHealth resources of information than other technologies (6). All professionals get more patients’ information from online sources (7) and they were surprised about the rich and vast information (7) it means to have enough balanced information, not too much not too little and compared with regular phone calls HCPs find automated patient interview more feasible (15). Regarding that, the physicians said it was helpful when notes on patients’ use of tele homecare units were made in their charts; they found that data from the tele homecare units helped them assess patients’ stability (14). On the other hand, patients informed about their health situation through eHealth are more clinically useful because the technology has provided precise and accessible information (6).
About Nurses’ empowerment, it included motivation, improvement of capabilities and the improved community perception.
Regarding motivation, the healthcare practitioners felt curious and excited about using digital technologies, and with time they felt positive about it (15). Nurses were aware that remote support is more practical for some patients (4) and found the telehealth units are very useful (9). The replacement of registers by a mobile phone (2) and the implementation of digital platforms (15) brought excitement into their work (2, 15). HCP were enthusiastic about the potential of digital technologies to improve medication reconciliation (8) and most expressed wishing to stay digital (15).
In case of improvement of capabilities, it is one of the aspects that nurses pointed out as a positive change in their practice when using technology (5) because they identified innovation and enhancement in the learning process. The HCP also showed perseverance in dealing with technological problems and became more skilled in solving them (10). As a result, there’s an improved community perception because the HCP shared that the use and introduction of apps had a positive effect in building up their image in the community, for the community trusted and showed them respect. The HCP were pleased about the possibility of getting recognized for their hard work. (2).
In general, Nursing relationship challenges included lack of time, workload increase and communication difficulties.
Essentially for the HCP, lack of time meant that they find challenging to view patient’s information due to their limited time in primary health, therefore they had to book time out in their schedule to provide support which proved to be a good solution (4). They were also worried about how the management of digital information can lead them into unmanageable responsibilities and therefore influence their time (6). They reported organizational challenges such as time constraints when to do their work and the time required for handling the postings was significant (7). Consequently, HCP agreed that updating the records and the triaging process was taking much longer than they had expected (13).
Regarding the increase in work load, the HCP were worried about how the management of digital information could create unrealistic expectation for patient in terms of assignment (6), how digitization increased their job (12), and time; consequently, nurses did manage to fit telehealth in their day-to-day work, even with their busy timetables (13). The professional expected more flexibility when performing their work, but they had to prioritize normal work routines (7). On the other hand, at the beginning healthcare practitioners felt that it could be a lot to handle (15) considering that there’s an organizational challenge due to busy working hours (7).
About the communication difficulties, the lack of feedback from the patient indicated a need to approach things differently from what the HCP were used to in face to face-coaching sessions, and often paused this process, making them wonder what is going on (3), they reported an organizational challenge related to communicating in writing with patients online (7), by the way they feel that communication via text leads to loss of communication (15).
Concerning to Digital adaptation challenges, it included preference for traditional practice, uncertainty, lack of decision–making power, resistance to change and lack of training.
Indeed, preference for traditional showed that HCP are not used to communicate with patients online (4) and think that personal contact should not be replaced (14) because they feel a face-to-face approach is more effective and find it challenging not to give advice to patients as they were used to and resulting from having less preference providing remote support. So, there is a preference for face-to-face methods (10), not consider remote support as real support (4) because their typical tools to elicit feedback were not applicable. In fact, some participants were even reserved about emailing patients (6). In other words, it means a resistance to change due to some HCP did not provide support via email to their patients (4) and chose not to suggest the use of eHealth (14). They also reported organizational challenges such as lack of incentives as underpinning for their work (7).
According to HCP, the use of digital tools created a nurses’ uncertainty because more structured forms of communication should be investigated (7). In fact, there is no certainty whether the use of telemedicine has increased the level of competence, because the HCP is also not sure if, for instance, the completion of wound care training has increased the level of competence, and if their competences improved with the use of telemedicine (5). Some nurses believed that telehealth did have its place, but should be clearly defined (14), others believe they cannot cope with eHealth (14) or expressed skepticism to the usefulness of digital technologies (15), likewise nurses suggest that videocalls create too much of distance (14), and did not think that the implementation of telehealth should be a priority for local National Health Services (13). HCP suggest that a lower frequency use of tech does not necessarily mean a less positive perception (4), the effective use of available tools cannot be guaranteed (6) and they experience uncertainty in the implementation of digital platform (15).
For this reason, the HCP considered that they didn’t have participation about joining the telehealth service which means lack of decision-making power, and their views of the telehealth service were not considered (13). Under those circumstances lack of training is an issue because nurses highlighted lack of formal e-health training in nursing job training programs (12) therefore they needed to be trained to make a better use of eHealth (1). They also believed that more input and training would enhance and ensure the success of telehealth (13). In fact, HCP wished to integrate the platform into practice so they can maintain digitalized and they are longing for access into different strategies of using eHealth preventing burden or abuse. As a result, the HCP declared their needs are not supplied with the resources they have (6), and they believed that the local health services could do a lot to support the success of the service (13). After all, nurses believe they need more knowledge on eHealth (14).
In addition, Technical challenges included need for support personnel, inoperable technology, lack of technical skills andlimited access to information.
Regarding the need for support personnel, nurses felt it was important to have backup personnel if something goes wrong (12), and they believed that training support staff to assist with medication reconciliation could improve the process (8). Nurses highlighted the shortage of staff working on telehealth and suggested that having an administrator to deal with non-significant triggers would overcome the overload issue (13).
Likewise inoperable technology was a challenge because HCP expressed incompatibility of computer systems are time-consuming; nurse’s computer systems were not integrated with each other, they had to enter multiple data systems to get a complete picture of patient (12). They also expressed that before using the app they got tired of using many registers (2), and they were not satisfied with the resources available to run the service (13), therefore, technical problems discourage them (10). As a result, the HCP feel overwhelmed because of the inefficiencies of the electronic health records (6). Nurses consider user-friendliness of tools to be important to show patients to avoid fragmented information (14). Physicians were concerned about the medicolegal liability associated with receiving time-sensitive data (9) and HCP reported that remote support can be difficult if patients are not available by phone (4), in fact, they identified the multi-step process for Secure Messaging registration as a challenge to widespread patient adoption of SM, and complaint about the need for separate log-in-to the Secure Messaging service. Finally, they complained about the slow network speeds (8).
Equally important, lack of technical skill was puzzling for the HCP in order they found that the system was complicated (10) and they noted that a lengthy opt-in process and requirements are barriers to increase SM use among patients. They also identified less technically savvy elderly patients for Secure Messaging registration as a challenge to widespread the adoption of SM. HCPs also expressed frustration with their inability to easily access Secure Messaging (8), the system was sometimes a bit cumbersome and difficult to handle (11). Finally, HCP feared that if computer errors would occur, they could not solve the technical problem, therefore that situation may affect patients’ health (10,11). Under those circumstances, practitioners got frustrated when not being able to see information given to patients and outgoing emails do not confirm whether HPC mails are read (4) because of limited access to information. They also reported difficulty in clearly displaying reconciled medications in electronic health records (8). Thus, the HPC recognize the patients’ concerns and needs about systems are wider than they can assist (6).
Afterward, the conclusions developed from the analysis of each of the established categories can be identified.
Conclusion
The experiences of the use of digital technologies for some Healthcare Professionals (HCP) have improved the efficiency of delivered healthcare regarding the treatment of chronical diseases, vaccination processes, and reduced time for office and home visits (2). When using the digital apps, the patients are impowered in their selfcare considering that some of them prefer the on-line coaching sessions (6). In effect, access to patients’ information helps HCPs to understand what patients refer to during consultations. Regarding motivation, HCPs feel felt curious and excited about using digital technologies and implementing digital platform because that remote support is more practical. On the contrary, for some other HCPs the use of technologies has challenged them increasing the work time and loan time to support patients digitally for example in the triaging process (13). So that, they reported communication problems because of the uncompleted information provided by the patient. Indeed, some HCPs preferred the traditional nursing practice, face-to-face, because remote support is considered inefficient due to the lack of personal contact (4) In effect, nurses considered the multiple stages in the process makes it difficult to achieve and sometimes the patients don’t have free access to the digital tools. They are also concerned about the inefficiencies of the electronic health records because a computer error may occur and could affect the patient’s health. Therefore, it’s observed a resistance of changing the traditional way to deliver healthcare to the use of digital tools. This literature review will provide an overview of the implementation of digital tools to enhance the work of nursing, benefiting the prevention of chronic noncommunicable diseases, promoting self-care in the patient. These results can be used when designing the main output of the SmartNurse project, the SmartNurse methodology.
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Esta revisión de literatura permitirá tener un panorama sobre la implementación de herramientas digitales potenciando el trabajo de la enfermería, beneficiando la prevención de enfermedades crónicas no trasmisibles, fomentando el auto cuido en el paciente haciendo uso de la modernidad tanto en los estudiantes como en los profesionales de la salud.