COMMUNICATION

TECHNOLOGY
(E-NURSING, TELE-MEDICINE 60
AND TELE-NURSING)

INTRODUCTION E-nursing has been defined

as the
learning and teaching tacilitated online
Nurses all around the world have risen to the through network technology.
challenge ofnew technology. Today, the nurses
-Garrison and Anderson, 2003
work in a variety of E-health programmes
such as tele-triage. They access online libraries E-nursing comprises all forms of
and databases of clinical practice guidelines electronically supported learning and
from computers in their work places. Nurse teaching. The information and commu-
in specialized areas of practice now interact nication system whether networked
with their peers in discussion groups over the learning or not, serves a spec1hc media
internet. Nurses are also involved in standards to implement the
nursing process.
development for the implementation of -Tavangarian D, 2004
electronic health records and many nurs1ng
I t is commonly referred to the inter-
educational programmes are now offered online.
Patient must be able to access information national use of networked information

best and communication technology in

on
practices from expert nurses or other
professionals. Many nurses practice in remote teaching and learning. Electronic
and isolated regions where
accessing needed learning is more than just training on
information and resources is difficult. computer: it has the potential to cover
both content and the administration
of learning
E-NURSING -Pollard and Hillary 2021
Definition of E-Nursing
Goals of E-Nursing
E-nursing involves the use of computers
or electronic devices in To improve nursing and the clients
some way to
provide training, education and learn- outcomes.

ing material. T o encounter challenge owing

-Derek Stockley, 2003 emergence of new technology.
 Communication Technology (E-Nursing, Telemedicine and Telenusing) 675

n u r s e s to benefit from Internet resources enhance the decision-

To enhance
all developments
in information, making prOCess. Theygive nurses access
timely, evidence-based and
communication and technology. to
them
expert
make
information, enabling to

Modalities of E-Nursing swifter, better-informed judgements

modalities ot
E-nursing are: on behalf of their patients. The result
The following Is sater patient care and better health
1. Individualized Self-Paced E-Learning
outcomes.
Online: When an individual nurse Nurses reap the
resources such as
Nursing Work Outs:
accesses learn1ng full benefits of technology into their
nursing database online through an
daily practice. Healthcare organiza-
internet. For example, a nurse student
tions are beginning to acknowledge
is searching for data on some nurse
the necessity of providing nurses withN
research on the nternet or a local
access to information, communication
network.

2. Individualized Self-Paced E-Learning and technology that supports nursing

such
Oline:When an individual nurse care; yet, the implementation of
learner is using nursing database or tools needs to be accelerated.

a computer-assisted learning pack-

(while not connected to
agesottline
the internet). A learner is using hard
drive, CD or DVD.
3. Group Based E-Learning Synchro-
nously: When groups of nurses are
working together at the same time
through the Internet. For example,
one- or two-way audio and video
conterenc1ng.
4.
Group-Based E-Learning Asynchro-
nously:When groups of nurses are
working over the Internet and they
exchange themselves with a time
delay. For example: online discussions
through e-mailing lists.
Theory of E-Learning
for adult learn-
Andragogy: It stands
ing. It is an art/science of teaching
adults. The adults can learn when they
feel need to learn. Their past experience
is of learning.
used as a
source Learners
must have as much autonomy as possible
and good learning climate minimizes
the anxiety.
Constructivism: It is a theory ot learn-
ing. The knowledge is constructed by
the learner based on mental activity.
The knowledge is constructed not
transmitted. It is a purposeful activity
that requires to build useful knowledge.

Types of E-Nursing Styles in E-Nursing

Smarter Decision Making: Its initia The following styles of e-nursing are:
tives such as electronic health records, Offline and Online Activities: Learn-
tele-health, databases, c-mail and
ing teaching activities takes place while
 676 A Comprehensive Textbook on Nursing Administration and Management
oftline. Evamples not connected to an
Internet learning activitics take place
while online cxamples are connected
to the Internet.
Synchronous and Asynchronous
Activities: Within Synchronous learn-
ing. learning and teaching takes place
at the same time (real time), Example,
listening to a live radio broadecast,
watching live television broadcast.
Telephone, video conferencing, chat,
online, seminar, skype conversation are
N used. Whereas asynchronous learning is
the teaching-learning activities taking
place with time delay (time shift).
Example; self-paced courses through
X
Internet or CD-ROM, video-tapped
classes or seminars, etc.
Different Multimedia Assets: When
the activities are carried out through
more than one media.
Different Didactical Interactions: The
different didactical approaches can be
used such as assignments, assessment,
pre-test, discussions, reading, presenting
information, watching a video, asking
questions, workshop, demonstrations
and participating in a simulation, etc.
Different Ways of Delivering Telc-medicine is the use of telecommunica-
Content: The various ways to deliver
the content are computer, PDA, TV,
mobile phones, iPod, etc. Every device
has its own characteristics, advantages
and disadvantages.
Self-Study and Collaborative
Learning: Icarning can be both ways:
individualized as wcll collaborative to
to
c-learning
Formal and Informal
Learning:
Formal lecarning is a
learning that
is planned with specified learning
objectives whereas informal learning
is unstructured or unplanned.
Advantages of E-Nursing
I t enhances innovative teaching.
I t promotes self-directed learning.
I t is convenient for the learner.
E-learning saves time and place for
learning.
I t promotes Internet use.
I t builds self-confidence among learners.
l t increases retention and application
of information.
Proof of completion and certification
is also automated.
Disadvantages of E-Nursing
Some forms of e-learning perceived
as isolating from the personal touch.
Nurses may not have the IT skills
needed to take advantages of e-learning.
I t decreases manual contribution.
TELE-MEDICINE
tion and information technologies in order to
provide clinical health care at a distance.
These technologies allow communication
between the patient and medical staff with
both convenience and the transmission
of
medical, imaging and health informatics
daa from one site to another. It is also useu
save lives in critical care and emergency
 Communication Technology
(E-Nursing, Telemedicine and Telenursing) 677
situations. It helps eliminate distance barriers
and can improve access to medical services that Tele-medicine is the use of
would often not be consistently available in information exchanged from medical
one site
to another via
distant rural communities. electronic communica-
tions
improve a patient's clinical
to

History of Tele-Medicine health status. Tele-medicine

includes
1906: ECG Transmission Einthoven,
a
growing variety of applications and
services using two-way video, email,
the Father of
electrocardiography.
1920: First ECG transmission over
smart
phones, wireless tools and
other forms of
telephone lines. telecommunications
1924: The first
technology.
exposition of Tele According to World Health Organi-
care "Radio News magazine from zation, tele-medicine is defined as,
April 1924. "The delivery of healthcare services,
1955: Tele-psychiatry The Nebraska where distance is a critical factor, by all
Psychiatric Institute first closed-circuit healthcare professionals using intorma-
TV. tion and communication
technologies
1959: University of Nebraska did for the exchange of valid information
first documented use of visual tele- for diagnosis, treatment and prevention
communication in health care. of disease and injuries, research and
1988: Under the first tele-medicine evaluation, and for continuing educa-
programme in December 1988, the site tion of healthcare providers, all in the
of massive earthquake in Armenia was interests of advancing the health of
linked to medical centres in the United individuals and their communities".
States for tele-medicine consultations. I t is transfer of medical data for:
1989: NASA introduced the first inter- Consultations
national tele-medicine programme. Diagnosis
The programme was extended to Russia Support for Clinical Case
to provide tele-medicine consultation to .Containing Medical Educations
Durn victims after a terrible train accident.
Concepts of Tele-nmedicine
Definition of Tele-Medicine A video image has a rate oft motion known as

Tele-medicine is defined as the use of the frame rate. This standard video like the
elecommunications, the delivery of one seen of the television has a frame rate of
frames second
healthcare expert sharing of medical 30 frames per
is
second. 30
the human
perdoes not
with persons who are at required, so eyes
Knowledge rate

distance locations. perceive any gaps in information. In video

 678 A Comprehensive Textbook on Nursing Administration and Management

there is limitation restriction Image X-Rays: which are still images

conferencing, or

information that be having a size of aroundIMB.

on the amount of can

transmitted through digital lines. Basically, Video Movie: Ultrasound/patient's

four types of data are used in tele-medicine: visualization, movie images have a
size of 10 MB or more; the patient can
Text for Patient Notes: Generally
be seen by a doctor at a remote
place
file of less than 10 KB.
having a using cameras.
Audio: electronic stethoscope, with a
hle size of around 10 KB.
TABLE 60.1: Modalities of Data Transmission in Tele-medicine

System Data Speed Advantages/Disadvantages

Economical Ubiquitous Slow, not Suitable for
Public Service Telephone Network (PSTN) 56 kbps
High Resolution
Integrated Service Digital Network (ISDN) 128 kbps Cheap and Flexible Cheap

Service Digital Network ISDN 2 mbps Fast High Quality, Expensive and Patchy
Availability
Satellite 2 mbps High Quality and Remote Access Expensive
X
Wireless <2 mbps Convenience, Free Movement, New Technology
and Limited Standards
Leased Lines 64 kbps to Reliable
50 mbps
A Synchronous Transfer Mode (ATM) Asyn- 155 mbps High Band Width, Expensive, maybe Superseded
chronous Digital Subscriber Line (ADSL)

2. Remote Monitoring: It is also known

Types of Tele-medicine
as selt-monitoring/testing. lt enables
Tele-medicine can be broken into three main monitor a
medical professionals to
categories as follows: techno-
patient remotely using various
1. Store and Forward: It involves logical devices. It manages chronic
specihc conditions, such
as
acquiring medical data (medical images, diseases or

bio-signals) and then transmiting this heart disease, diabetes mellitus or asthma
data to the doctor or medical specialist Ttgives greater satistaction to patienis.
Interactive
at a convenient time for assessment 3. Interactive Services:
offine. It does not require both the tele-medicine services provide real-time
parties at the same time. Medical interactions berween patient and
the
specialities like dermatology, pathology provider. lt includes phone conver
and
etc. are conducive to this kind. Most Sations, onl1ne communication
as
beneficial for population living in isolated home visits. Many activities such
Communities and remote regions. history review, physical examination
 Communication Technology (E-Nursing, Telemedicine and
Telenursing) 679

sychiatric
sychia evaluations and ophthal- Tele-Education
mology assessments can be conducted Th
The use of tele-medicine
comparably to those done in traditional it much better than
technologies makes
face-to-face visits. In "clinician-inter- just surfing websites forP

information. Doctors can attend clinical meet-

active", tele-medicine services may be
ings at remote places and also participate and
less costly than in-person clinical visits.
present in them. Some projects such as
cases
health net project of Africa use both Internet
Tele-Medicine Applications
and satellite communications for doctors
Emergency Health Care in remote areas.If this is dealt with using
Video Consulting tele-medicine, the approach is real time; the
Telecardiology referring doctor knows how the specialist is
Telepathology dealing with theand can thus further
patient
his knowledge. Tele-consultation, video
Teledermatology
Teleophthalmology conferencing on surgery, online clinical audit
Teleoncology and continuing medical education are just some
Telepsychiatry of the education applications of tele-education. X

Teledentistry
Tele-Monitoring
Distance Leaning
Medical education and the transter Tele-monitoring is the remote monitoring
status can be
of medical data. of patient data. The patient's
monitored, wherever he/she is, whether in
an

Medical care delivery, diagnosis, consul-

at a distance. aircraft or in a remote village as long he has
tation and treatment
The data includes, blood
homes or retirement centres. a telephone access.

Nursing ECG, spirometry,

ultrasound,
Home monitoring for patients. pressure, pulse,
data. These can be
in the aftermath of disasters. CT scan and other radiology
Health care lines or through
transmitted using telephone
devices.
of appropriate
wireless with the
use
Tele-consultation
himself Advantages of Tele-Medicine
Adoctor ofa paramedic or even a patient with a
L
remote area can have a consultation Utilization: The first benefit
Resource
to 1. of
pecialist. This requires certain procedures
utilization
tele-medicine is proper
needs to be of population
rollowed; the person initiating resources. In India,
doctor

importantly the complete

to
rained and in comparison
more
s ratio is 1:15000 these
PrOCess needs to be documented for the patient nations, and
1:500 in developed
equally.
t h e doctor's record. Tele-consultationa
distributed
are not
doctors lives
so involves a family doctor seeking helpO cent
Indian population
80 per
specialist in an emergency
 and Management
680 A Comprehensive Textbook on Nursing Administration

in rural and semi-urban arecas. Tele- 5. Medical Education and

Research
medicine can help in cost-effective Tele-medicine is also useful in
medical
utilization of mcagre resources and education. When medical
students are
at the same time can decrease paticnt posted in rural area,
they be linked
can

workload few referral centres.

on a
2. Early Intervention: One of the most
eftective means of providing medical
intervention is by early detection and
treatment. There are factors that inhibit
the continuity of care. Issues such as
geographic location, incdement weather,
socio-economic barriers, patient's
apathy are significant factors that delay
and even prevent the speciality care. By
providing these primary cure sites with
the ability to quickly access speciality
consultation services are provided.
Patients are able to reap the benefits of
early intervention while the healthcare
system maintains quality service and
clinical efficiency.
3. Avoids
Unnecessary Transporta-
tion: Local health providers discuss
cases of a patient on the phone with a
specialist if the specialist is not getting
clear After
a
picture. a few
he will be able to send the patient but
ifby video conferencing he has a clear
picture of the patient, un-necessary
referral and patient transport can be
definitely avoided.
4.
Community Based Care: Community
based care is another big
advantage of
tele-medicine. People like to receive high
quality care in their local community.
This reduces travel time and related
stressesassociated with
many referrals.
to medical college for
grand rounds
and they can also do case presen tation
to teachers in medical
colleges. In
India, Indira Gandhi National Open
University (IGNOU) carries out regular
monthly sessions of teaching of its
diploma in maternal and child health
(PGDMCH) students. Physicians
living in different parts of the world
also use tele-medicine in collaborative
research; they can also share dataor
can discuss current trends.
Limitations to Spread of
Tele-medicine
Physician/Patient Acceptance
Reasonable Cost
Accessibility
Reliability
Funding/Reimbursement Issues
Lack ofTrained Manpower
questions, Legal and Ethical
Privacy and Security Concerns
Rural Tele-medicine Network
Indian Scenario of Tele-medicine
Now with the availability of Internet connection
in most cities of India, interest in tele-medicine
is increasing day by day but still major draw-
a
back in India is that communication network
ue
is not suitable for most tele-medicine applCa
tions. ISDN lines are not available in most or
the places in India, which is basic requirement
 Communication Technology (E-Nursing.
Telemedicine and
deo conferencing. Video
Telenursing) 681
conferencing
technology will be limited to some big cities
and ele-medicine technology that will be used
and te
TELE-NURSING
most of
the parts of India will be store and According to
American
in
forward technology. It willlike sending
be Association, "Tele-nursing is Nurses
subset a
of tele-health in which the focus is
radiological images, patients records, sounds
radiol a
nursing practice via
through e-mail or modem and getting opinion telecommunication
Tele-nursing refers to the
af experts. Many medical centres in India use of tele-
Communications and intormation
are now successtully running tele-medicine
projects using video conferencing. India is an
technology for providing
nursing
services in health care whenever a
ideal place to use this technology as 80 per
large physical distance exists berween
cent population in India lives in villages
patient and nurse or between any
where treatment is provided by unqualified numbers of nurses.
medical practitioners. Tele-nursing is defined as the practice
of nursing using protocols
Evolution of Tele-Medicine through
telecommunication technology.
in India
Arkansas Staff Board of Nursing
The Indian Space Research Organiza-
tion (ISRO). Applications of Tele-Nursing
SGPGIMS in Lucknow (Sanjay Tele-nursing application is home care. For
immobilized or live
andhi Postgraduate Institute of example, patients who are citizens
Medical Sciences). in remote or difficult to reach places,
chronic
oMG (Sri Ramachandra Medical who have chronic ailments, such as

disease. diabetes,
College) in Chennai. obstructive pulmonary
Medical congestive heart disease or disabiliry, such
AMS in Kochi (All India diseases (Parkinson's
neural degenerative
Science). as
Alzheimers disease,
ALS) et., may stay
Hrudayalaya in Bangalore. disease,
Narayana home and be
"visited" and
assisted regularhy

The Apollo Hospital Group. at

nurse via
Internet,
videoconterencing.

N e w Delhi, and
PGIMER by a
It can be assisted in care with
videophone, etc.
Graduate Institute of Medical home patients atter
Ost at
care

Education Rescarch) Chandigarh. help of tele-nursing

wound dressing,
ostomies,

with
surgeries
Egovernance projectwith 110,000 multi- handicapped ete.

purpose Internet kiosks in villages.

 682 AComprehensive Textbook on Nursing Administration and Management

In normal home health care, one nurse is tele-nursing need to be under the
able to visit up to 5-7 patients per day. Using vision of reg1stered nurse or super-
tele-nursing, one nurse can visit 12-16 patients Nurses and midwIves
midwife
in the same amount of time. practising tele.
nursing are personally responsible for
A common application of tele-nursing is ensuring that their nursing and or
also used by call centres operated by managed midwifery skills and expertise remain
care
organizations, which are stafted by registered current for their
practice.
nurses who act as case Nurses and midwives should
managers or pertorm inform
patient triage, information and counselling as consumers of the tele-health
process
a means of regulating patient access and flow including other persons/professionals
and decrease the use of emergency rooms. Tele- who may be participations or
nursing can also involve other activities such as
presence
is the tele-health consultations and urban
patient education, nursing tele-consultations, consent betore proceeding.
examination of results of medical tests and Nurses are midwives in tele-nursing
exams, assistance to physicians in the imple- who have a duty to provide privacy
mentation of medical treatment protocols. and confidentiality in all interactions.
Nurse and midwives practicing in tele
Legal, Ethical and Regulatory Issues
nursing be aware of both the evidence
Tele-nursing is fraught with legal, ethical and base for the practice and the areas of
regulatory issues, as it happens with tele-health practice in need of research.
as awhole. In many countries, interstate and Nurses and midwives
intercountry practice of tele-nursing is forbidden
practising tele
nursing should engage in evaluation of
(the attending nurse must have a license both in their practice in relations to issue of
her state/ country of residence and in the state/
quality safety and patient outcomes.
country where the patient receiving tele-care is
located). Legal issues such as accountability and Advantages of Tele-Nursing
malpractice etc. are also still largely unsolved t helped to improve the qual1ty or
and difficult to address. In addition, there
health services.
are many considerations related to
patient I t enables nurses to consult with on
nhdentiality and safety of clinical data. another, thus acquiring knowledge
in

how to improve their services.

Guidelines for Tele-Nursing fvital
Tele-nursing serves as a source of
Nurses and midwives practicing in tele- information for nurses.
nursing shall be registered nurses or The nurses can use remo
cameras

midwives. Enrolled nurses involved by to examine the wound and g

 Communication Technology (E-Nursing, Telemedicine and Telenursing) 683
the appropriate the
scommendations
on
opportunity assist those who are
course o f t r e a t m e n t .
unable to access health care services.
nurses
can make a regular follow Using clinical protocols or guidelines
The the paticnt recovers to
to
e n s u r e
that systematically assess the patient's
up possible. needs and symptoms.
as
quickly
as
and time for Prioritizing the urgency ofthe patient's
Telenurs1ng saves money
nurses and patients
since they needs.
hoth the
have to
travel. Collaborating and developingga plan or
do not care with the patient and supportive,

of Nurse in Tele-Nursing disciplines which may include recom-

Role mendation for cure, call back educations.
Tele-health
nurses monitor patients
with chronic diseases.
Evaluation outcomes.
nurses to overcome
Tele-nursing allows
distance and gives then
the barriers of

SUMMARY education and heaith

revolutionizing
tele communication
and technologies that are even a patient
deals with of a paramedic or
This chapter
the provision of nursing services. A doctor in India are now
services globally, including specialist. Many medical centres
fimself in remote area can
have a consultation with a
using video-conferencing.
Successfully running tele-medicine projects

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