Nurse Educator
Vol. 40, No. 5, pp. 266-269
Nurse Educator
Telehealth Education in Nursing Curricula
Nagia S. Ali, PhD, RN & Kay Hodson Carlton, EdD, RN, ANEF, FAAN & Omar S. Ali, MSN, RN
Telehealth care is a fast-growing avenue of providing health care services at a distance. A descriptive study was conducted to
identify trends of telehealth education in 43 schools of nursing. Findings reflected inadequate integration of telehealth in
classroom content, simulation, and clinical experiences. Interviews with 4 nursing leaders of telehealth provided some
recommendations on how to integrate telehealth education in nursing curricula.
Keywords: nursing curricula; nursing education; telehealth; telehealth education
T
he enactment of the Affordable Care Act has resulted
in a growing number of people entering the health
care system.1 Telehealth provides health services
through the use of telecommunication technologies.2 In
addition, shortages of personnel and high workload in crit-
ical care units have increased the demand for telehealth ap-
plications to ensure safety for critically ill patients.3
Telehealth nursing application includes remote moni-
toring, patient education, and consultation.4 Telehealth nurs-
ing care is applied in any location where telecommunication
hardware and software such as videoconferencing, Internet,
or videophones are available. These locations could be a
physician’s office, hospital, specialty clinic, call center, and
home. Telehealth services do not replace traditional care but
supplement it for those who are unable to be physically
present with a health care provider.5,6
Review of Literature
The white paper7 about telehealth nursing set the founda-
tion of policies, procedures, and standards. The evidence-
based standards incorporate legal and ethical guidelines to
help minimize the nurse’s liability in telehealth practice. A
dimension of the practice standards is the Health Insurance
Portability and Accountability Act (HIPAA) regulations, which
would be followed by a telehealth nurse in the use of patient
data. A telehealth nurse should have skills in assessing, using
telecommunication technology, communicating with other
Authors Affiliations: Professors of Nursing (Drs Ali and Hodson Carlton),
School of Nursing, Ball State University Muncie; and Clinical Educator
(Mr Ali), Indiana University Health Methodist Hospital, Indianapolis.
The authors declare no conflicts of interest.
Correspondence: Dr Ali, School of Nursing, Ball State University, 2000 W
University Ave, Muncie, IN 47306 (nali@bsu.edu).
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s Web site (www.nurseeducatoronline.com).
Accepted for publication: December 19, 2014
Published ahead of print: February 13, 2015
DOI: 10.1097/NNE.0000000000000149
266 Volume 40 & Number 5 & September/October 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
health care providers, teaching patients and families, man-
aging data, and making appropriate decisions when the pa-
tient needs to be examined by a health care provider.
The Telehealth Nursing Special Interest Group recom-
mended principles of telehealth nursing be included in pre-
licensure and graduate nursing programs.4 These recommended
principles included definition of terms, benefits of telehealth,
differences between traditional and telehealth care, policies
and regulations, knowledge about information technology
and telecommunications, application of HIPAA to telehealth
nursing, interstate licensing, and ethical and legal issues of
telehealth.
Telehealth can be as effective as traditional nursing care.
Patients who have difficulty controlling their diabetes were
managed with continuous telehealth monitoring of their blood
glucose level, HbA1c, weight, and blood pressure.4 Telehealth
technology as a mode of educational delivery was well re-
ceived by nurses in a rural area and viewed as a cost-effective
method for continuing professional education and mentoring.8
Perceptions of critical care nurses about the use of telehealth
in critical care were examined in another study.9 The authors
found that critical care nurses believed telehealth increased
patients’ survival, but hindered privacy and did not prevent
medical errors. Most nurses preferred to have previously
worked with the telehealth physician to facilitate effective
use of the technology with the patient. The highest rated
attributes of tele-ICU nurses were effective listening, an abil-
ity to establish priorities of patients’ issues, skill in fostering
collaboration, and the effective use of tele-ICU application
tools.10
In a study of faculty needs for training in use of tech-
nologies, 77% of the sample never used telehealth applica-
tion, and 50% of the faculty perceived themselves to be
knowledgeable at the novice level.11 An earlier survey of
deans and directors of 266 baccalaureate and higher nursing
programs in the United States also revealed many gaps in
telehealth education at both undergraduate and graduate
levels. Less than one-third of the programs addressed tele-
health applications.12 In the future, virtual clinical experiences
Nurse Educator
that use telehealth technology may be commonplace in nurs-
ing education, allowing the students to gain confidence in
using the digital telehealth equipment.13 An earlier experien-
tial study was successful in integrating telehealth and telemon-
itoring content in nursing curricula through the development
and implementation of a telehealth course assignment in
5 campuses in a Midwestern institution.14
The literature review indicated the benefits of telehealth
applications to the individual, family, community, and health
care system. However, it is not clear how much telehealth
education is immersed in nursing curricula. Therefore, the
purpose of this study was to identify trends of telehealth
education in nursing curricula.
Research Questions
The questions were as follows: (1) What are deans and
directors’ perceptions of telehealth education? (2) What
telehealth content is included in nursing programs? (3) What
telehealth clinical and simulation learning experiences are
included in nursing programs? (4) What are the academic
institution and health care facility support to faculty in pro-
viding telehealth education? and (5) What are the barriers to
having telehealth education in nursing curricula?
Methods
Data were collected from deans and directors of schools of
nursing accredited by the Commission on Collegiate Nursing
Education (CCNE) that have baccalaureate, master’s, and
DNP programs published on the CCNE Web site in March
2014. The choice of including schools that have the 3 programs
was to identify the types of programs with telehealth edu-
cation in a school. There were 130 CCNE schools that met
this criterion: they constituted the sample and received the
survey electronically.
The study used a cross-sectional descriptive survey design.
The questionnaire ‘‘Telehealth in Nursing Curricula’’ devel-
oped by the researchers contained 15 questions. Of the 15
questions, 3 Likert scale items examined deans’ and directors’
perceptions of the importance of telehealth education. They
first asked participants to rank order the importance of
4 technology strategies, with 1 representing the highest and
4 the lowest. These 4 strategies were clinical simulation,
online education, telehealth, and flipping the classroom. The
second item was to rate ‘‘I believe telehealth should be part of
any nursing curriculum at any level—baccalaureate, master’s,
DNP’’ on a 5-point Likert scale ranging from 1 (strongly agree)
to 5 (strongly disagree). The third item asked participants
to rate their confidence that their faculty would integrate
telehealth education in nursing curricula on a 5-point Likert
scale that ranged from 1 (not very confident) to 5 (very
confident).
The remaining 12 questions were either closed- or open-
ended questions. Content and courses in curricula related
to telehealth were addressed through 4 questions. These
questions inquired about the presence of program(s) with a
telehealth component, content and courses, and their aware-
ness of the Telehealth Resource Center in their state. Two
questions targeted clinical and simulation learning experi-
ences related to telehealth. Five questions inquired about
the academic institution and health care facilities support in
providing telehealth education to faculty, the type of support,
Nurse Educator
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
the presence of a faculty development program, involvement
of other disciplines, and connections with other telehealth
care facilities. Barriers to implementing telehealth educations
were addressed in 1 question.
Face validity of the questionnaire was developed by
4 experts in telehealth and technology, 1 clinical informatics
nurse, 2 professional computer staff, and 1 professional tele-
communication technology staff. Suggestions of the experts
were used to refine the survey. The study was approved by
the university institutional review board. Of the 130 surveys
sent electronically, 43 were returned, with a 33% return rate.
Findings
Deans’ and Directors’ Perceptions of Telehealth
Table 1 shows the rank order of the 4 technology strategies.
Online education was ranked highest by most, followed by
clinical simulation, then telehealth, and lastly flipping the
classroom. Participants’ narrative comments about their chosen
rank order included the importance of online education, es-
pecially for master’s and DNP students but also for students
on campus, the belief in proficiency in online education as a
base and foundation for success, and online education as a
vehicle to accommodate the busy lifestyles of current learners.
With the second rank, clinical simulation was perceived as a
key to quality and safety. The strategy was also perceived as
critical because clinical placements are difficult to obtain, and
simulation helps students gain experience in critical thinking,
decision making, teamwork, and communication skills out-
side the clinical setting.
There was an 88.2% agreement (strongly agree and
agree combined) to the statement about telehealth being a
part of any nursing curriculum at any level—undergraduate,
master’s, and DNP. Some participants’ narrative comments
indicated that all students should have some experience with
telehealth. However, other participants believed telehealth
should not be in the undergraduate curriculum but rather
included at the master’s and DNP program levels, mainly in
the nurse practitioner track.
Almost 57% of deans and director were confident (very
confident and confident combined) that their faculty will
integrate telehealth education in nursing curricula. Partici-
pants reported that incorporating telehealth is a challenge
with other curriculum demands and overworked faculty. In
addition, there is already so much content in the curriculum.
Telehealth Content
Twenty-two deans and directors (71%) reported having tele-
health content in their programs. Examples of content in-
cluded definition of terms, evidence-based telehealth practice,
Table 1. Rank Order of 4 Technological
Strategies by Deans and Directorsa
Strategy Rank Order, na (%) Mean (SD)
Online education 15 (45.5) 1.94 (1.06)
Clinical simulation 14 (42.4) 1.88 (.96)
Telehealth 2 (6.3) 3.16 (.95)
Flipping the classroom 2 (6.3) 3.03 (.90)
a
n = 33. Mean scores from 1 (high) to 4 (low).
Volume 40 & Number 5 & September/October 2015 267
telehealth policies, telehealth standards, and ethical guidelines
(Table, Supplemental Digital Content 1, http://links.lww.com/
NE/A213). Less than half of participants (45.2%) reported
awareness of the Telehealth Resource Center for their state.
More than half of the sample (61.3%) reported having an
informatics course that included a telehealth component, and
only 9.7% reported having a separate elective course about
telehealth. Other courses with components in telehealth were
acute care, adult health, community health nursing, nursing
capstone, leadership, and assessment.
Telehealth Clinical and Simulation Learning
Experiences
Forty-two percent of participants reported having a telehealth
learning experience through the use of a remote telehealth
unit. Participants’ comments about the unit included devel-
oping students’ skills in remote examination, partnerships
with community facilities and schools, remote assessment of
patients in nursing homes in rural areas, and monitoring of
home health patients. Other types of clinical and simulation
experiences were reported (Table 2).
Faculty Support in Telehealth Education
Fifty-two percent of participants reported having academic
institutional support, whereas only 24% received health care
facility support. Examples of support included pedagogical,
administrative, and technical (Table, Supplemental Digital
Content 2, http://links.lww.com/NE/A214). Narrative com-
ments about the support included attending telehealth ed-
ucation to obtain certification in telehealth presentation,
training of all faculty involved in telehealth in the use of the
equipment, and providing faculty with opportunities to
present their research findings about telehealth at national
meetings. Forty-five percent of participating schools were
partners with other disciplines in telehealth education, and
48% were partners with health care facilities that provide
telehealth services.
Table 2. Telehealth Clinical and Simulation
Experiences
Type of Experience Percent of Responsesa
Telehealth tools (ie, real-time video or audio
for nurse-patient encounter)
Patient education
Remote patient monitoring devices
(ie, machines that monitor heart functions
such as pulse, blood pressure, etc)
Distance education
Store-and-forward telehealth transmission
(ie, digital images, video, audio, clinical data)
Real-time or interactive telehealth communication
link between involved parties
Grand rounds
Administrative uses, eg, meetings
Research
Telephony (ie, telephone interfaced to computer
for health data, disease prevention, and
health promotion)
a
More than 1 option was chosen.
268 Volume 40 & Number 5 & September/October 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Table 3. Barriers to Integrating Telehealth in
Nursing Curricula
Responsesa
Barriers n (%)
Lack of telehealth training for faculty 10 (77)
Full curriculum with no room for telehealth content 9 (69)
Lack of knowledge and skills of faculty about telehealth 9 (69)
Inadequate time to learn telehealth delivery 9 (69)
Cost of telecommunication technology equipment 8 (62)
Complexity of use of telehealth technology hardware 3 (23)
Lack of demographic or geographic market for telehealth 2 (15)
nurses in respondent’s vicinity
a
More than 1 option was chosen.
Barriers to Integrating Telehealth
Identifiable barriers included lack of telehealth training for
faculty, inadequate time to learn telehealth delivery, full cur-
riculum, and cost of telecommunication technology equip-
ment (Table 3).
Phone Interview Findings
Four participants agreed to phone interviews. Interview ques-
tions were about initiation of telehealth in nursing curricula,
role of the nurse in telehealth practice, and advice on tele-
health integration. All 4 faculty participants reported that
initial telehealth integration began with funding from a Health
Resources and Services Administration grant. The grant was
either specific to telehealth education or to other purposes
that contained telehealth components. In addition, donors’
monies were often used to purchase telehealth devices. Inte-
gration of telehealth started by incorporating telehealth in a
hospital affiliated with the school of nursing, simulating tele-
health experiences, developing a separate telehealth course,
or using a telehealth remote presence robot. There was an
agreement that telehealth education is ‘‘still a hit and miss’’
experience because not everyone is getting it.
Another aspect mentioned during the interviews was
about developing partnerships in telehealth education. Part-
nerships with other disciplines and health care facilities that
use telehealth should be sought initially in the local area.
100 The partners’ needs and learning objectives should be iden-
tified before telehealth application occurs. Deans and di-
75 rectors interviewed also indicated that students should be
63 taught ‘‘telehealth etiquette’’ and should be comfortable in
the new environment with the telecommunication tools and
with their assessment skills when the patient is not in the
63 room. All 4 participants indicated that 1 or more champions
63 should take the lead to start examining the curriculum and
identifying where telehealth could be integrated.
63
Discussion
50
38 The purpose of this study was to explore what schools of
38 nursing are teaching about telehealth, support and strategies
38 for telehealth integration and use, and the barriers to the
implementation of telehealth. Online education and simu-
lation were perceived as priorities by most participants.
Online education is a basic technological avenue to teaching
and learning for many students, but telehealth is a techno-
logical strategy that will improve nursing practice and make
Nurse Educator
health care delivery accessible to people outside the acute
care setting. Although more than half of participants agreed
that telehealth is part of nursing curricula, less than half were
unsure or not confident that their faculty will integrate tele-
health education. Faculty participants have not yet perceived
that preparing future nurses should include education about
the emerging telehealth technology.
The fast spread of telehealth services in different avenues
of health care systems, disciplines, and across the country
requires that schools of nursing start to integrate telehealth
components in the curricula across all academic programs.
Currently, the traditional face-to-face nursing practice en-
counters need to be supplemented with virtual and electronic
practice connections. Students need to learn how to be com-
fortable in this new virtual environment, and this should
happen initially in nursing programs. Essential V Informatics
and Healthcare Technologies of Master’s Education in nurs-
ing addresses technologies in general, but not telehealth
specifically.
The descriptive findings reflected inadequate integra-
tion of telehealth in nursing curricula, simulation, and clin-
ical experiences. The phone interview findings indicated
that telehealth integration can be accomplished in different
ways and would yield positive outcomes, similar to what has
happened in simulation. Barriers to integrating telehealth in
nursing curricula can be resolved. Conversations with faculty
members who have coordinated or championed telehealth
education in their schools confirm that telehealth can be
successfully implemented. Nurse educators do not need a
mandate to integrate telehealth in curricula: they can start now.
Limitations
This study has several limitations. First, the response rate was
only one-third, yielding a small sample size. Nonrespondents
may not have had telehealth in their program, or the tele-
health components may be inadequately reflected in their
curricula. The small sample size limits the generalization of
the study findings to other schools. Second, the technolog-
ical terms used in the questionnaire may have deterred
potential participants to complete the survey. Third, the in-
terpretation of telehealth as a less important technological
strategy may have contributed to inadequate completion of
the questionnaire.
Conclusion
To prepare students to practice telehealth care, nurse edu-
cators should integrate telehealth content and skills across
all academic program levels. Integration does not need to
Nurse Educator
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
involve a massive curriculum revision. Faculty can examine
their curricula and identify where telehealth concepts can be
incorporated, explore institutional resources related to tele-
health, consider linking with other disciplines and clinical
agencies that are already implementing telehealth, and talk
with faculty who have already implemented telehealth care
in their nursing programs.
References
1. US Department of Health and Human Services. The Affordable
Care Act. 2011. http://www.hhs.gov/healthcare/rights/law/index.html.
Published October 2011. Accessed May 2014.
2. 2013 American Telemedicine Association. Examples of research
outcomes: telemedicine’s impact on healthcare cost and quality.
http://www.americantelemed.org. Published April 2013. Accessed
March 2014.
3. Yeo W, Ahrens SL, Wright T. A new era in the ICU: the case for
telemedicine. Crit Care Nurs Q. 2012;35(4):316-321.
4. 2011 Telehealth Nursing Special Interest Group. Telehealth nursing
fact sheet. http://www.americantelemed.org/telehealthnursing.
Published April 2011. Accessed March 2014.
5. McGonigle D, Mastrian K. Nursing Informatics and the Founda-
tion of Knowledge. 3rd ed. Burlington, MA: Jones & Bartlett, LLC;
2015.
6. Kamei T. Information and communication technology for home
care in the future. Japan J Nurs Sci. 2013;10(2):154-161.
7. Telehealth Nursing Special Interest Group. Telehealth nursing: a
white paper developed and accepted by the telehealth special
interest group. 2008. http://www.americantelemed.org/telehealth
nursing. Published April 17, 2008. Accessed March 2014.
8. Sevean P, Dampier S, Spadoni M, Strickland S, Pilatzke S. Bridging
the distance: educating nurses for telehealth practice. J Contin
Educ Nurs. 2008;39(9):413-418.
9. Mullen-Fortino M, DiMartino J, Entrikin L, Mulliner S, Hanson W,
Kahn JM. Beside nurses’ perceptions of intensive care unit tele-
medicine. Am J Crit Care. 2012;21(1):24-31.
10. Goran S. A new view: tele-intensive care unit competencies. Crit
Care Nurs. 2011;31(5):17-29.
11. Nguyen DN, Zierler B, Nguyen HQ. A survey of nursing faculty
needs for training in use of new technologies for education and
practice. J Nurs Educ. 2011;50(4):181-189.
12. McNeil BJ, Elfrink VL, Bickford CJ, et al. Nursing information
technology knowledge, skills, and preparation of student nurses,
nursing faculty, and clinicians: a US survey. J Nurs Educ. 2003;
42(8):341-349.
13. Grady J. The virtual clinical practicum: an innovative telehealth
model for clinical nursing education. Nurs Educ Perspect. 2011;
32(3):189-194.
14. Gallagher-Lepak S, Scheibel P, Gibson C. Integrating telehealth
in nursing curricula: can you hear me now? Online J Nurs Inform.
2011;13(2):1-16.
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