International Journal of Nursing Studies 48 (2011) 1302–1310

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Nursing and information and communication technology (ICT):

A discussion of trends and future directions
Alison While *, Guy Dewsbury
King’s College London, Florence Nightingale School of Nursing and Midwifery, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: This paper traces the development of information and communication (ICT) within health
Received 17 May 2010 care and the emergence of telehealth as a key component of modern health care delivery as
Received in revised form 2 February 2011 health care moves from the ‘face to face age’ to the ‘information age’. The paper examines
Accepted 25 February 2011 the interface of ICT and nursing practice and highlights the limited evidence relating to the
nursing contribution within telehealth particularly beyond data input and output analysis
Keywords: for other health care personnel. Additionally, the absence of research relating to the impact
Information and communication of ICT upon nurses and their working lives is identified. The paper concludes that nurses
technology
need to engage more fully with ICT so that they contribute to shaping the care system and
ICT
emerge as leaders of the new care systems delivering future clinical activity.
Telehealth
Telecare
ß 2011 Elsevier Ltd. All rights reserved.
Telemonitoring
Health portals

What is already known about this topic?
 ICT is increasingly part of health care delivery
 Nurses are using ICT in various ways
What this paper adds
 This paper sets the context of future nursing practice
within virtual and ICT delivered health care
 It describes the current state of knowledge regarding
nursing and ICT
 It sets challenges for nursing to define its relationship
with ICT
1. Changing context of health care
By 2020 the older population will outnumber the
younger population (United Nations, 2004) and this
* Corresponding author.
E-mail address: alison.while@kcl.ac.uk (A. While).
combined with the increasing prevalence of chronic illness
(World Health Organization, 2003) is creating a heavy
demand on the finite resources in terms of both money and
personnel (Kinsella and He, 2009). The use of information
and communication technology (ICT) is one of a range of
potential solutions to this health care challenge. ICT
encompasses a range of technologies which enable the
exchange of data through the telephone or internet (Fig. 1).
The United States (US) National Broadband Plan (FCC,
2010) has identified a key role for ICT in improving health
and health care through enhancing care delivery and
coordination, and engagement with patients. To this end
there are Federal incentives to providers who adopt
electronic health records (EHR) both inside and outside
hospitals with the use of EHR expected both to reduce the
costs of care and improve quality and safety (Bates, 2010).
Indeed, the US Medicare (American Telemedicine Associa-
tion, 2010) reimburses for telehealth services which
include non-face-to-face services that can be conducted
either through live video conferencing or via store and
forward telecommunication services. The United Kingdom
(UK) Government has published similar ambitions
(Department of Health, 2008).

0020-7489/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2011.02.020
 A. While, G. Dewsbury / International Journal of Nursing Studies 48 (2011) 1302–1310
ICT systems Applications
Telephone Landline
internet Computer-based
Satellite television Television-based
Mobile ICT Mobile devices
Fig. 1. ICT systems, applications and frequently used terms.
ICT has the potential to modify the way in which people
use health services both by increasing access to informa-
tion and providing other forms of support remotely.
Expectations are changing with people wanting to
determine their own health needs through advice on the
internet or other technological interfaces and faster more
person-centred services from health care providers includ-
ing nurses. Indeed, we may be witnessing a move from the
‘‘face to face age of health care’’ to the ‘‘information age of
health care’’.
This discussion paper draws upon an extensive search
of Pubmed and Medline for papers (n = 795) relating to
ehealth, telehealth, telecare, mhealth and telenursing in
addition to 63 books on health and technology to explore
the developments relating to ICT in health care over time
and the interface with nursing. Sources (n = 39 papers)
were included where they added to the discussion; this
was necessarily selective and it is acknowledged that a
different search strategy may have yielded different
sources such as those relating to nursing records. Forbes
and While’s (2009) conceptual framework was used to
categorise nursing activity reported across the material.
The evidence of the contribution of nursing within ICT
developments and the potential impact of ICT upon nurses’
working lives are foci for the discussion.
2. ICT and change over time
Historically the patient and healthcare professional
relationship was mediated through agencies such as
hospitals and primary care services and person intensive
relying on the face to face contact of health care
professionals with patients. Fig. 2 illustrates changes over
time with the replacement of wholly face to face contact by
increasing use of ICT to deliver healthcare. However, the
replacement of face to face contact by ICT has both
potential advantages and disadvantages for health services
which are set out in Fig. 3.
As technology becomes increasingly ‘‘clever’’, there will
be a shift of staff from direct face to face contact to
increasing non-face to face contact with remote sensors
carried on the patient transmitting clinical information to a
centre which will act as a hub for appropriate interventions
(Lewin et al., 2010). Mobile health technologies are not
new, but in the coming years, new technologies will be
developed yielding smaller and more discrete devices
capable of large dataset monitoring (Technology Strategy
Board, 2010; Fong et al., 2011).
1303
Frequently used
terms across ICT
system applications
Telephone triage,
telecare, telehealth,
telemonitoring,
telemedicine, health
portals, mHealth, Apps,
personal digital
assistants (PDAs),
Smartphone.
The increased adoption of ICT will impact on the way in
which services are provided and herald a change in nursing
allowing the nurse relationship with patients to move from
the face-to-face encounters of traditional nursing to an
increasingly virtual nursing experience outside the hospi-
tal setting. Thus nursing which involves direct contact
face-to-face interaction will evolve to include remote
assessment of health need, information giving, diagnostics,
support and monitoring of the patient’s condition.
3. Nursing practice and ICT
The adoption of ICT within clinical practice may bring
substantial benefits through supplementing traditional
nursing practice relating to assessment, health promotion,
clinical interventions and service organisation (Fig. 4).
Thus new technology may enable new services, for
example, virtual health promotion sessions with one nurse
working with a group of people simultaneously. Health
portals will allow patients to store information as well as
access information about their conditions in addition to
receiving personalised health advice. Nurses will be able to
conduct virtual visits over the internet and discuss a
patient with other health and social care professionals
through a secure connection in real time to enable better
personalised care planning and care coordination.
Mobile applications (mobile apps or portal devices) will
increase in popularity and extend beyond the Apple Ipod
and Iphone to other mobile devices enabling the download
of appropriate applications to support people in managing
Fig. 2. ICT in healthcare delivery over time.
1304 A. While, G. Dewsbury / International Journal of Nursing Studies 48 (2011) 1302–1310
Advantages
One nurse can interact with
patients remotely.
One nurse can manage a larger
caseload through remote
monitoring.
Improved information sharing.
Reduced cross-infection and
other patient ‘costs’.
Less travel time and other health
care costs.
Doctors and nurses can hold
joint remote consultations with
the patient and their family.
Timely enhancements of patient
self-care.
Virtual titration of medication and
virtual prescription changes.
Efficient signposting to other
services to maximize health
resources.
Fig. 3. Advantages and disadvantages of ICT in healthcare.
their own health needs relating to specific conditions
including mental health concerns. Apps are still in their
infancy but it is likely that they will become the easiest
way for patients to receive health related information and
remote monitoring. Thus if a patient’s clinical data fall
outside the recommended range then the app will suggest
contacting a health professional or set up a contact with a
named person automatically.
The incorporation of ICT into nursing practice and
patient care pathways will bring about changes in nursing
work not only regarding nurse-patient relationships but
also in the context of practice with greater demands placed
upon nurses’ ICT and remote communication skills.
However, patients need not be the only beneficiaries of
greater access to information because ICT provides the
opportunity to increase nurses’ accessibility to evidence to
inform practice in ways inconceivable a few years ago.
3.1. Health assessment
The assessment process is a fundamental part of health
mediation which ensures that health needs are identified
early and appropriate interventions initiated. However, the
evidence of the contribution of ICT to improvements in
health assessment is limited both in its extent and its
impact within the published literature, with examples of
the use of various ICT applications being reported (Fig. 4).
The UK’s national telephone advice service, NHS Direct,
handled 5,180,000 calls in England in its first 3 years
(1998–2001) but Munro et al. (2005) found that there was
no change in overall demand for either emergency
ambulance services or attendance at accident and emer-
gency departments and there was no change in the usage
of the four paediatric emergency departments in the study.
Disadvantages
Dehumanization of healthcare
delivery.
Reduction of “traditional”
services may not be acceptable
to all.
Challenge of controlling virtual
information.
Formulaic approach may
constrain practice and inhibit
professional judgment.
Significant investment will be
needed to ensure all
practitioners are “masters” of
ICT.
Patient expectations may be
unattainable / unmet.
Reinforcement of the “digital”
divide.
Compatibility issues across
different ICT systems.
Failure of ICT at any time will
undermine healthcare system.
However, they noted a significant reduction in the calls to
out-of-hours general practice which suggested some
workload diversion away from general practice. Similarly
North and Varkey’s (2008) review of telephone triage calls
(27,979 symptom assessments for mainly female callers
[71%] received by the Ask Mayo Clinic, US July 2006–June
2007) noted that 16% of callers (n = 4469) had intended to
seek help from emergency services if they had not accessed
the triage service suggesting some diversion of activity
away from emergency services.
However, an analysis of the large UK General Household
Survey dataset (n = 20,421) has revealed a consistent socio-
economic bias regarding the use of telephone advice
compared to accident and emergency services with those
in lower socio-economic groups, older people, those with
long term illnesses and from minority ethnic groups being
less likely to use telephone services (Shah and Cook, 2008).
This suggests that affluent households are more likely to
benefit from the provision of telephone advice services
emphasising the importance of adequate health facilities
for less affluent households. Indeed, this socio-economic
bias appears to extend to internet usage with Gracia and
Herrero’s (2009) national survey of internet use and self-
rated health among older people (n = 709) in Spain finding
that internet users had better self-rated health than non-
users (p = 0.002), although with weighting for social class
the significance of the results disappeared.
In contrast the evidence relating to assessment in the
form of chronic illness monitoring is more positive with
consistent evidence of positive clinical outcomes, some-
times quite limited, consequent upon tele-monitoring
especially in relation to advanced heart failure from a
range of countries where small trials have been conducted
(Antonicelli et al., 2008; Biddiss et al., 2009; Scherr et al.,
 A. While, G. Dewsbury / International Journal of Nursing Studies 48 (2011) 1302–1310
Assessment
Remote signposng including
contact with health care
professionals or other agencies
Telephone triage
Telemonitoring
Internet self-assessment
Portable mHealth
Mobile apps for clinical
monitoring
Clinical Intervenon
Remote consultaons (may
include MDT)
Remote traon of therapy
including prescripons where
needed
Remote psychological therapies
eg movaonal interviewing,
CBT
Remote carer support
Fig. 4. ICT and potential applications to nursing practice.
2009; Maric et al., 2010). However, none of these trials
properly accounted for the ‘non-key interventions’ which
may also be important to patients in a number of ways
including: promoting confidence in the quality of care;
alleviating social isolation; and improving the relationship
between health care providers and the patient. Currell
et al.’s (2000) systematic review involving seven trials of
telemedicine versus face to face care also questioned the
benefits of telemedicine despite its acceptance by patients
and particularly noted the absence of formal economic
analysis and evidence of safety.
Importantly all the available evidence relating to health
assessment and the use of ICT fails to articulate the nursing
contribution with any clarity. Indeed, nurses were
reported as either delivering or were part of the delivered
health care assessment but few details emerge relating to
the nursing activity undertaken.
3.2. Health promotion
Health promotion, which includes health education,
health protection and preventative work, forms a key
component of health care practice and will be increasingly
important if global health demands are to be controlled
through preventative action. All forms of ICT may augment
the nursing contribution to health promotion by extending
contact beyond traditional face to face practice, however,
the literature to date only reports the use of the telephone
and computer based interventions with studies of perso-
nalised e-health, podcasts and webcasts not yet published
(see Fig. 4).
Fry and Neff’s (2009) systematic review of limited
contact interventions targeting weight loss, physical
activity, and/or diet included 19 studies (1988–2008) with
combined sample size of 15,655. Studies were included if a
1305
Health promoon
Telephone, text, email
intervenon / prompts
Health portals delivering
personalized health promoon
Webcasts and podcasts
intervenons
Service organisaon
Electronic health records /
electronic paent records
(EHR/EPR)
Care pathway management
Care system governance
(audits etc)
Professional clinical networks
(discussion boards etc.)
e- CPD for professionals.
periodic prompts were used as an intervention or a
component of an intervention, a behavioural or biological
outcome measure was used, and an ongoing health
promotion behaviour was targeted. Eleven studies
reported positive findings regarding the use of periodic
prompts with benefits relating to diet, weight loss and
exercise behaviours and nine studies showed enhanced
effectiveness when prompts were frequent and personal
contact with a counsellor (sometimes a nurse) was
included. However, Fry and Neff identified the need for
additional research on limited contact interventions
targeting health behaviours such as weight loss, physical
activity, and/or diet to test prompt types and frequencies,
specific intervention components and prompt character-
istics. Additionally data are needed regarding the short
term and longer term effectiveness of limited contact
health promotion interventions.
The importance of access to the internet and email were
highlighted by Bot et al. (2009) who carried out an email-
based health intervention for pregnant women
(n = 14,154) in the Netherlands and found that only 8%
of the pregnant women could be reached though the email
intervention with the educational level of the women also
affecting their active engagement in the process
(p < 0.001). This digital divide has been noted by others
in relation to internet access across both social-economic
and age groups (An et al., 2007; Verdegem and Verhoest,
2009; Weaver et al., 2009)
Additionally a US quasi-experiment (Pak et al., 2009) of
online health information seeking for different aged
participants (n = 50, 18–23 years; n = 50, 60–80 years)
found differences in the seeking behaviours of participants
from the different age groups. The older people reported
using computers for less time (p = 0.002) and less often
(p = 0.001) whereas the younger adults had greater spatial
1306 A. While, G. Dewsbury / International Journal of Nursing Studies 48 (2011) 1302–1310
visualisation and orientation abilities (p < 0.001) and a
larger memory span (p = 0.001). Further, in the information
search tasks the older adults performed worse than the
younger adults (p = <0.001). Pak et al. concluded that there
is a need to design health information sites taking into
consideration the age related changes in cognition and
online information seeking behaviours.
Computer programmes are another approach to health
education but Slootmaker et al.’s (2009) RCT of a physical
activity based software-based intervention in Holland
found no significant intervention effect with a large
proportion (39%; n = 14) of the intervention group
(n = 51) reporting that the advice was not appealing. This
highlights how information delivery on its own may not
bring about behaviour change and that stimulating
behaviour change requires careful consideration of both
information delivery as well as other factors (Prochaska
and DiClemente, 1983). Indeed, Lee et al.’s (2008) survey of
59,202 Koreans aged 25 years and over found that, while
social participation significantly decreased with age, the
influence of social participation on health status increased
with age. This study highlighted the importance of social
participation for health in all age groups, notwithstanding
that the effect of social participation differs by age and
gender.
However, Tse et al. (2008) evaluation of a 4 week e-
health programme for older people designed to improve
their use and access to health-related information in the
form of physical exercise videography from a Hong Kong
government-sponsored website demonstrated the poten-
tial of e-health. The participants’ mastery of basic
computer operating skills increased significantly
(p < 0.05) and they were able to access health information
via the internet and had gained health-related knowledge
by the week 4 post-test (p < 0.05). Tse et al. concluded that
a technology-based e-health programme was an effective
way to provide health education to older people although
the short follow-up of this study provides no evidence
regarding the sustained use of the internet for health
information nor its long term acceptability to older people.
Thus the available evidence suggests that it may be
premature to embrace the internet for health promotion
for the whole population both due to differential access
and use of the internet but also because it will reduce social
participation which appears particularly important to
women and older people. Additionally the trustworthiness
of health information websites is not uniformly high.
Meadows-Oliver and Banasiak’s (2010) evaluation of 68
websites using eight core educational concepts developed
by the National Heart, Blood, and Lung Institute (NHLBI)
found that only 6 websites (8.8%) had accurate and
complete information regarding asthma according to
NHBLI recommendations. This means that nurses must
be conscious of the limitations of internet sites purporting
to have expert knowledge and which may undermine
patient education.
However, there is a need for more evidence regarding
the effectiveness of this approach to health promotion and
the key characteristics of the most successful initiatives
together with the respective roles of qualified and
unqualified nurses. In particular, the reported initiatives
shed no light on the potential contribution of nursing to
health promotion using ICT.
3.3. Supporting those with long term conditions
The range of ICT applications within health care are
most evident in the field of long term conditions and
chronic disease management (see Fig. 4) with all examples
of ICT being reported. Rosser et al. (2009) systematically
reviewed 45 studies testing the use of technology to
promote behaviour change in chronic illness. The areas
reviewed were: (1) methods employed to adapt traditional
therapy from a face-to-face medium to a computer-
assisted platform; (2) targets of behaviour change; and
(3) level of human (e.g. therapist) involvement. More than
half (53%) of the studies featured interventions that were
web-based and 10 of these included an additional
technology (e.g. telephone, web-based discussion group).
Technology was generally used as the platform for therapy
delivery, ranging from basic information provision and
advice to progressive modules providing interactive
assessment, skills training, self-monitoring and mobile
therapy delivery. In eight studies an on-line message board
discussion as a means of social support formed part of the
intervention. Most of the interventions (73%) were not
fully automated with some therapist (frequently a nurse)
involvement which ranged across supervision, assistance
and instruction. In many cases the technology-based
therapy was used as an addition to face-to face therapy
and/or as a component of a larger intervention. Rosser et al.
concluded that technology based self-management sys-
tems could provide a practical method for both monitoring
chronic illness health status as well as delivering
therapeutic interventions to promote desired health
behaviours and, indeed, this appears to be echoed in more
recently published studies.
There are an increasing number of trials reporting
benefits including improved treatment adherence, dis-
ease knowledge and reduced hospital admissions arising
from the use of telemonitoring in various forms
especially related to heart failure (Dansky and Vasey,
2009; Bowles et al., 2009; Dang et al., 2009; Wakefield
et al., 2009) although not all published trials have
reported significant differences (Wootton et al., 2009).
This variable effect of telephone interventions was noted
in Stolic et al. (2010) review of 24 papers where seven
studies demonstrated statistically significant differences
in all outcomes measured while eight studies demon-
strated some positive effects and nine studies reported
no effect. Interestingly the studies which reported
positive effects had stronger designs, however, the exact
contribution of the nurse within the various nurse-led
telephone interventions for those with heart disease was
not analysed.
Additionally frequent text messaging has been found to
be helpful in supporting weight loss in overweight adults
(p = 0.02) over 16 weeks (Patrick et al., 2009). At the end of
the study 22 of 24 (92%) intervention participants reported
that they would recommend the intervention for weight
control to friends and family confirming the acceptability
of this intervention within the study group.
 A. While, G. Dewsbury / International Journal of Nursing Studies 48 (2011) 1302–1310
In contrast a small UK RCT (Wu et al., 2010a) of a
telephone booster intervention for overweight adults with
type 2 diabetes comprising a weekly reinforcement of
clinic advice for lifestyle modification to support weight
loss found no intervention effect. However, the telephone
intervention was acceptable to the intervention group who
reported that the weekly telephone calls met their need for
on-going support. This result is similar to that reported in a
systematic review with a meta-analysis of seven RCTs
which found that overall telephone follow-up on its own
has a limited impact on glycaemic control for Type 2
diabetes (Wu et al., 2010b). Telephone interventions
incorporating a more ‘intelligent’ approach which varied
the intensity of the follow-up based on patient need
appeared to deliver better outcomes suggesting that there
may be some benefit in developing telehealth that
incorporates this type of approach. Another UK RCT
(Istepanian et al., 2009) testing mobile health technology
(Bluetooth wireless link) in diabetes management found
no differences in the HbA1c outcomes between the
intervention and control groups in part reflecting the high
attrition from the intervention group as a result of
technical problems. Of note in a sub-group analysis there
was a trend of the telemonitoring group having a lower
HbA1c (7.76%) than those in the control group (8.40%)
(p = 0.06).
While the majority of the literature reports single site
trials and other study designs, Cady et al. (2009) reported a
record review of hospital resource utilisation by children
with special needs (n = 43; July 1996–December 2006) care
managed by the U Special Kids Programme based in
Minnesota, US. Unplanned hospitalisations decreased
significantly from 74 in the first year to 35 in the second
year (p < 0.007) with the rate of unplanned admissions
stabilising in subsequent years. In contrast, planned
hospitalisation was relatively constant over the five-year
period. This suggests that telephone-based care coordina-
tion and case management offers a promising approach for
supporting children with multiple, complex health condi-
tions.
The user perspective regarding the adoption of new
modes of contact has attracted limited interest so that
Grayston et al.’s (2010) interview study of primary care
patients in Edinburgh (n = 200) is particularly useful as it
compares new technologies with traditional methods of
giving blood test results. A clear preference for traditional
methods (telephone contact, face to face contact) was
expressed with email being favoured by 53.3% of those
having email access. SMS was not generally favoured with
older patients being significantly less favourable (p < 0.01)
and similarly use of an internet webpage was not generally
favoured with females being significantly less favourable
towards a webpage compared to male patients (p < 0.01).
Information security was a concern relating to the three
new technologies highlighting a major user issue which
may inhibit the adoption of new technologies.
While there is some evidence regarding the effective-
ness of ICT in supporting people with long term conditions,
there is little attempt to distinguish between the different
types of ICT (telephone versus internet based) and the key
characteristics of the most successful initiatives and for
1307
whom they are best suited. The cost of teleheath is
substantial and therefore understanding where it is most
effective will be important. Further there is generally a lack
of clarity regarding ‘dosage’ and frequency of the various
interventions and the respective roles of nurses. It is also
noteworthy that publication bias may result in under-
reporting of no differences depriving health systems of the
full evidence on which to invest wisely.
4. Nurses’ working lives and ICT
Stevenson et al. (2010) reviewed five studies of nurses’
experiences of using electronic patient records derived
from a database search of published papers written in
English or Swedish 2000–2009. The five small studies
conducted in Australia, United States and England (two
quantitative and three qualitative) found that nurses were
generally dissatisfied with the electronic patient record
because they did not support nursing practice through
their failure to provide a good overview of the patient and
lack of availability which undermined patient safety.
Nurses reported that the records did not support
individualisation of care and had a tendency to control
the way that the nurse worked through the imposition of
protocols. The nurses also reported that the actual
computer systems were cumbersome, illogical, slow,
complicated and unreliable at times. They suggested that
nurses must become involved in the future design and
development of the electronic patient record echoing the
call by Forbes and While (2009) for nurses to become more
involved in all levels of ICT design to avoid subordination
within the care system.
More recently a large survey (De Veer and Franke, 2010)
of Dutch nurses (n = 685) had more positive findings with
nurses associating electronic patient records with
improved care but negative attitudes were recorded
regarding the consequences for the cost effectiveness of
care and work circumstances highlighting the challenge
for electronic patient record implementation. However, an
ongoing issue regarding the nursing workforce is their
computer literacy with evidence that some nurses are
reluctant users of computers (Timmons, 2003; Verdegem
and Verhoest, 2009) with the lack of skills training
compounding the problem (Murphy et al., 2004,). Indeed,
this reluctance to engage with ICT needs sensitive
management because there is evidence that the experience
of the benefits of using ICT and electronic patient records
increases their acceptability (De Veer and Franke, 2010)
and therefore their likely successful implementation.
Indeed, the introduction of electronic health records
and electronic health information exchange is not without
its challenges as illustrated by Goroll et al.’s (2009)
implementation report of the Massachusetts eHealth
Collaborative (MAeHC) comprising a diverse set of
competitively selected communities of nearly 500 physi-
cians serving over 500,000 patients. The challenges
included compatibility with existing systems, function-
ality, data security and cost which they managed through
careful contracting and phased implementation following
an invitation process to practices. They noted that the
implementation had high transactional costs comprising
1308 A. While, G. Dewsbury / International Journal of Nursing Studies 48 (2011) 1302–1310
many hours of donated time by ‘highly skilled profes-
sionals’ some of whom were presumably nurses. The UK
experience of implementing ICT into the National Health
Service has been equally troubled (Hendy et al., 2005,
2007) although paper based systems have many weak-
nesses which may be forgotten through the haze of
nostalgia.
A benefit of ICT is its ability to increase accessibility to
information sources. Doran et al. (2010) using a long-
itudinal survey assessed access to information resources
for nurses (n = 488) in 29 acute care hospitals, long-term
care providers, home care nursing providers and primary
care programmes in Ontario, Canada. Only personal digital
assistant (PDA) users reported a significant improvement
over time in the perceived quality of care delivered
(p = 0.001) and job satisfaction (p < 0.001), especially
among those working in long-term care settings
(p = 0.01). However, both PDA and tablet computer users
reported high satisfaction with their devices although
there were differences in the reported ease of using the
different information resource packages reflecting the
greater information available on the screen of a tablet
computer (p = 0.05) and the faster information delivery to a
PDA (p = 0.05). The study nurses reported a significant
improvement in research awareness and accessibility over
time (p = 0.05) leading Doran et al. to recommend mobile
information technologies as a means of reducing the
barriers to research utilisation. Indeed, mobile ICT devices
may be an important enabler of evidence-based nursing
practice.
A telephone call centre is a different working environ-
ment from clinical care settings. Mueller et al. (2008) and
Snelgrove (2009) have reported the experience of nurses
working within UK NHS Direct call centres (Mueller et al.,
2008 [2 call centres; 17 semi-structured interviews];
Fig. 5. ICT use in nursing practice.
Snelgrove, 2009 [3 call centres; 92 nurse questionnaires
(RR 83%); 2 focus groups]) and highlighted the tensions
which arise for nurses regarding meeting call targets,
adherence to decision protocols with limited room for
autonomy and the absence of patient visibility which
challenge the traditional nursing identity in terms a
holistic approach to patient care. Mueller et al. (2008)
identified a dichotomy between delivering efficiency and a
professional patient focus as the call centre service
attempts to adopt some of the commercial call centre
norms within its delivery. These findings were echoed in
Purc-Stephenson and Thrasher’s (2010) review of 16
studies relating to tele-nurses working in primary care
derived from a systematic search of four literature
databases of published papers 1980–2008. They identified
five major concerns experienced by nurses which include:
the impact of protocols and algorithms upon autonomy;
the comfort of the physical workspace; and stress caused
by heavy workloads, assessing the credibility of callers and
the challenge created by language difficulties and hostile
callers. The reviewed studies described how nurses
attempted to adopt a holistic approach to assessment
using their nursing skills to develop a rapport and listen to
what was unsaid in building a clinical picture drawing
upon clinical expertise to determine the urgency of health
needs and the appropriate advice.
The electronic health record will require all nurses to
demonstrate computer literacy of varying sophistication
depending upon the electronic health record functionality
in the different health care organisations. Additionally,
different job roles will demand differential use of ICT
reflecting both role autonomy and the practice setting
(Fig. 5). Regardless, the emergence of ICT as a key
component of modern health care will inevitably impact
upon nurses and their working lives although to date there
 A. While, G. Dewsbury / International Journal of Nursing Studies 48 (2011) 1302–1310
is limited research focusing upon this topic area. There is a
need to further understand the demands of telephone triage
work as well as the characteristics of the ‘ideal’ electronic
patient record from a nursing perspective. In addition
studies are needed which test ICT as a vehicle for enabling
evidence-based practice and high quality patient care.
5. Conclusion
The growth of virtual healthcare is inevitable and
provides the vehicle for significant changes in health care
delivery especially for people in remote locations. It allows
people to access health care and advice directly from their
home or other places such as shops or their workplace and
it may enable the personalisation of health care with
people taking control over their own health and health
records. However, it is also the harbinger of health care on
demand in which people will expect access to health
related information and services 24 h a day, 7 days a week,
52 weeks a year in much the same way that there is access
to other services through the telephone and internet.
To date the evidence reports nurses as either delivering
or being part of health care interventions but there is little
detail relating to nursing activity, dosage or frequency of the
interventions, and the respective roles of nurses. Further, the
evidence of the effect of these interventions is mixed despite
the high cost of many of the interventions and the potential
under-reporting of no difference. In addition, the impact of
ICT upon nursing practice and nurses’ lives and the
acceptability of the ‘‘information age of health care’’ to
both patients and their carers require further exploration.
Indeed, the lack of research exploring the impact of ICT upon
nursing practice and nurses’ working lives needs urgent
attention if it is to inform the ongoing development of
nursing practice and future employment practices relating
to nurses as they move into new roles.
In the meantime the nursing workforce needs to engage
fully with ICT so that nurses do not have a merely passive
relationship with technology feeding the system with data
for others to interpret or acting as an output analyst in
meeting health needs (Forbes and While, 2009). Nurses
need to become the ICT system managers and designers in
addition to clinical data collectors and data analysts so that
they contribute to system management and system design
thereby shaping the care system and defining the
structural components that define the care system or they
will remain subordinate within the new systems deliver-
ing clinical activity (Forbes and While, 2009).
Conflict of interest
None declared.
Funding
None.
Ethical approval
None.
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