An exploratory case study on Telenurses and patients experiences and perspectives about the use of telenursing services in rural New Zealand

An exploratory case study on Telenurses and patients experiences and perspectives about the use of telenursing services in rural New Zealand

Research Proposal

UC Doctoral confirmation

Doctor of Health Science (DHSc)

Vinu Kochupurackal Sasi

Faculty of Health

University of Canterbury

Christchurch, New Zealand

Introduction tele health context

Telemedicine is the delivery of health care services wherein the distance is a critical barrier by all healthcare providers through communication and information technologies to exchange purposeful data for treatment, diagnosis, and prevention of disease where distance is a critical barrier (World Health Organization [WHO], 2021). The terms telemedicine and telehealth are often used inter-changeable; however, some distinguish between them with telemedicine referring to clinical services whereas telehealth has a broader scope and can include remote non-clinical health services (Nelson, 2017). For this report, the broader interchangeable definition adopted by WHO will be used. So, what is telemedicine?

Disparities in healthcare access and delivery caused by transportation and health workforce shortages, negatively impact individuals living in rural areas and are especially prominent in older adults (Rural Health Information Hub, 2019). Telemedicine is viewed as being cost-effective and sustainable, enhancing both emergency and diagnostic health care in rural areas by expanding coverage of specialist cares and improving the quality of health outcomes (Palozzi et al., 2020). Batsis et al. (2019) noted that using a telemedicine system in routine practice could help to overcome barriers due to distance and access to care. Effective healthcare programmes and services implemented via telemedicine in rural areas include chronic care management interventions which can improve access to integrated care during primary visits, providing emergency consultations in real-time, home monitoring by assisting the patient to control their disease, long-term care for older patients with chronic health conditions, online therapy helps to link rural population with urban behavioural and mental health counselling services (Rural Health Information Hub, 2019). According to Hirko et al. (2020), telemedicine is increasingly being used to meet the health needs of individuals living in rural areas and was one method that was immediately used in reaction to the pandemic, but it has the potential to have far-reaching implications for rural health.

Despite its potential, telemedicine adoption before COVID-19 had s been weak and underwhelming. The COVID-19 pandemic and its accompanying social distancing measures, however, accelerated the adoption of telemedicine solutions in health systems around the world (Hirko et al., 2020). Telemedicine saved human resources and reduced patient interaction, lowering infection risks during COVID-19 (Chersich et al., 2020). Evidence from before COVID-19 suggests that when local options were accessible (e.g. hospitals, clinics), rural populations are less willing to use telehealth services (Rushet al., 2021). During the COVID-19 pandemic, telemedicine use increased in rural and distant locations, and this trend was seen across diverse levels of rurality, age groups, and chronic illnesses. For example, in Ontario, Canada, the rate of telemedicine visits among rural patients increased dramatically from 11 per 1000 visits in December 2019 to 147 per 1000 visits in June 2020 (Chu et al., 2021). Telemedicine consultations in New Zealand increased tenfold to 34,500 per week during the COVID-19 pandemic lockdowns though this figure has since declined (NZ Telehealth Forum and Resource Centre, 2020). Telemedicine usage in Australia was 18% in 2020 November and almost half of the respondents indicated that they would like to use telemedicine in the future given the background of the COVID-19 pandemic (Taylor et al., 2021). The pandemic has resulted in a large increase in the implementation and use of telemedicine services in the United States; accounting for 23.6% of interaction for March through June in 2020 compared to 0.3% for the same period in 2019 (Weiner et al., 2021). As a result of the quick adoption of telemedicine health services in rural areas in response to the COVID-19 epidemic, there is a lot of promise for reducing rural health disparities (Hirko et al., 2020). However, Weiner et al. (2021) noted that rates were lower in non-urban areas. Chu et al. (2021) also acknowledged the geographical disparity and concluded that Future studies should investigate the potential barriers to telemedicine use among rural patients and the impact of rural telemedicine on patient health care utilization and outcomes (p.1). If rural areas are to experience health care parity comparable to their city counterparts, rural populations must have the support they need to participate in telemedicine including the provision of sufficient digital infrastructure (Rushet al., 2021). It is also crucial to examine the engagement of rural populations with telemedicine and how satisfied they were with it during the COVID-19 pandemic, especially since some have predicted that telemedicine will become the new normal in health care delivery after the pandemic.

Telenursing

Advances in technology, research, education, and evaluation have led to changes in the delivery of healthcare services (Mataxen, 2019). In 2005, it was reported that although telemedicine had been used by physicians for many years prior, that its potential in advanced nursing practice was apparent in terms of economy, efficacy, access, and quality of care (Reed, 2005). Nurses providing telemedicine services are most commonly interested in the non-traditional forms of nursing (Mataxen, 2019). Telenursing requires active licensure, and does not need long continuous hours or physical shifts and allows nurses to work from home providing flexibility with scheduling, decreases in communicable diseases such as flu or cold and lower prevalence of work burnout (Mataxen, 2019). Telenursing provides health care, education, and counselling via a telephone or video call. A telenurse performs several responsibilities in telemedicine, such as assessment of symptoms, discussing changes in medication, giving valuable tips to manage chronic conditions, and ensuring follow-up appointments are provided (Fathi et al., 2017). In busy healthcare services, access to specialists is often difficult due to various reasons but having a nurse as a front-line worker helps to decrease daily patient burden while meeting patient requirements (Fathi et al., 2017). Research has shown that Nurse Practitioners from many different specialties have adopted the use of telemedicine to bridge gaps in healthcare delivery, using technology to coordinate and improve access to collaborative care for their patients (Henderson et al., 2014).

Background of the researcher

Writing in progress

Significance of the research

The benefits of telehealth in terms of telenursing include, but are not limited to, efficient time use, improved and rapid access to services, and effective control over scheduling, supervision and improved collaboration between health professionals (Ministry of Health, 2017). The New Zealand Telehealth Forum includes consumers, clinicians, planning and funding managers, policymakers, information communication technology experts, and industry representatives. Their objective is to bring together resources and guidance that assists healthcare providers to perform and improve their telemedicine and telehealth services including telenursing (NZ Telehealth Forum and Resource Centre, 2021). This research will help inform such forums by providing evidence-based recommendations regarding the implementation and use of telenursing systems in rural areas by examining the experiences and perspectives of .Review of literature

A literature review is typically done as the first stage in any research project and is a written summary and collective evaluation of evidence on a specific study topic (Polit & Beck, 2015).In this review of the literature, which is different to the integrative review presented in following pages, the broader academic literature related to the use of rural telemedicine will be surveyed, including secondary and tertiary research and grey literature which does not meet the inclusion/exclusion criteria of an the integrative review. A thorough search of major nursing and allied health databases, including the Cumulative Index for Nursing and Allied Health Literature (CINAHL), Google Scholar, ProQuest and PubMed was conducted. Several major themes emerged: The impact of telemedicine on health outcomes in rural areas, the general factors affecting its use, along with country, discipline and demographic-specific factors affecting its use. These topics are reviewed below along with a section identifying the gaps in the existing literature.

The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities (p. 9, WHO, 2010)Telemedicine and rural healthcareDisparities in healthcare access and delivery caused by transportation and health workforce shortages, negatively impact individuals living in rural areas and are especially prominent in older adults (Rural Health Information Hub, 2019). Telemedicine is viewed as being cost-effective and sustainable, enhancing both emergency and diagnostic health care in rural areas by expanding coverage of specialist cares and improving the quality of health outcomes (Palozzi et al., 2020). Batsis et al. (2019) noted that using a telemedicine system in routine practice could help to overcome barriers due to distance and access to care. Effective healthcare programmes and services implemented via telemedicine in rural areas include chronic care management interventions which can improve access to integrated care during primary visits, providing emergency consultations in real-time, home monitoring by assisting the patient to control their disease, long-term care for older patients with chronic health conditions, online therapy helps to link rural population with urban behavioural and mental health counselling services (Rural Health Information Hub, 2019). According to Hirko et al. (2020), telemedicine is increasingly being used to meet the health needs of individuals living in rural areas and was one method that was immediately used in reaction to the pandemic, but it has the potential to have far-reaching implications for rural health.

Despite its potential, telemedicine adoption before COVID-19 has been weak and underwhelming. The COVID-19 pandemic and its accompanying social distancing measures, however, accelerated the adoption of telemedicine solutions in health systems around the world (Hirko et al., 2020). Telemedicine saved human resources and reduced patient interaction, lowering infection risks during COVID-19 (Chersich et al., 2020). Evidence from before COVID-19 suggests that when local options were accessible (e.g. hospitals, clinics), rural populations are less willing to use telehealth services (Rushet al., 2021). During the COVID-19 pandemic, telemedicine use increased in rural and distant locations, and this trend was seen across diverse levels of rurality, age groups, and chronic illnesses. For example, in Ontario, Canada, the rate of telemedicine visits among rural patients increased dramatically from 11 per 1000 visits in December 2019 to 147 per 1000 visits in June 2020 (Chu et al., 2021). Telemedicine consultations in New Zealand increased tenfold to 34,500 per week during the COVID-19 pandemic lockdowns though this figure has since declined (NZ Telehealth Forum & Resource Centre, 2020). Telemedicine usage in Australia was 18% in 2020 November and almost half of the respondents indicated that they would like to use telemedicine in the future given the background of the COVID-19 pandemic (Taylor et al., 2021). The pandemic has resulted in a large increase in the implementation and use of telemedicine services in the United States; accounting for 23.6% of interaction for March through June in 2020 compared to 0.3% for the same period in 2019 (Weiner et al., 2021). As a result of the quick adoption of telemedicine health services in rural areas in response to the COVID-19 epidemic, there is a lot of promise for reducing rural health disparities (Hirko et al., 2020). However, Weiner et al. (2021) noted that rates were lower in non-urban areas. Chu et al. (2021) also acknowledged the geographical disparity and concluded that Future studies should investigate the potential barriers to telemedicine use among rural patients and the impact of rural telemedicine on patient health care utilization and outcomes (p.1). If rural areas are to experience health care parity comparable to their city counterparts, rural populations must have the support they need to participate in telemedicine including the provision of sufficient digital infrastructure (Rushet al., 2021). It is also crucial to examine the engagement of rural populations with telemedicine and how satisfied they were with it during the COVID-19 pandemic, especially since some have predicted that telemedicine will become the new normal in health care delivery after the pandemic. Deciding the suitability and necessity of telehealth consultation

New Zealand telehealth policy recommends that the telehealth staff should assess the patient for suitability for telehealth consultation by using their professional judgement. However, no adequate parameters were mentioned for assessing a patient's suitability for telehealth consultations. The Australasian telehealth policy also has the same policy direction, which clearly states that the physician's decision making to determine whether the patient is suitable for telehealth consultation is based on the Clinical requirements in which the physician could assess the optimum model of care for the individual, shared care, and continuity of treatment and also the policy implies that it would be the physician's responsibility to identify the accessibility to the right technology and patient support as the information gathered during the clinical consultation will be significantly influenced by the quality of the technology at the remote site. Physicians can identify the patient's suitability based on their needs, travel capacity, and relationships with their family, employers, and cultures. Doctors should also take the patient's ability to cooperate into account. For individuals who have vision or hearing difficulties, a video consultation might not be appropriate (The Royal Australasian College of Physicians, 2013)

The telehealth policy in Canada by the College of Nurses of Ontario (2020) did not mention any specific criteria to identify the need and appropriateness for telehealth consultation. However, the telehealth policy in Canada states that the nurses hold accountability for decision making for telehealth consultations. Therefore tele-nurses can override the implemented protocols and policies if necessary for the best practice. The Australian telehealth policy by the Australian Nursing Federation (2013b) states that the suitability and eligibility of a person to take part in a Telehealth online video consultation depends on several different variables, including the ability of the patient to follow instructions, the ability of the patient to give informed consent, and the ability of the patient to use required technology, without assistance, if it is an unsupported consultation. Before the initial encounter, nurses and midwives must ascertain, to the best of their abilities and in accordance with their scope of practice, whether telehealth online video consultation is acceptable for each patient receiving treatment and their level of comfort with it. Before deciding if a person is eligible to participate in a Telehealth online video consultation, there are some things to take into account.

Similar to New Zealand telehealth policy, Indian telehealth policy also describes that if an in-person consultation is required in the patient's best interest, the telehealth Practitioners should use their professional judgement to determine if a telemedicine consultation is appropriate in the current circumstance (Medical Council of India, 2020). However, no particular criteria were mentioned in the policy for the decision making to determine the appropriateness of teleconsultation apart from professional judgement. The telehealth policy of Dubai Health Authority (2021) states that the telehealth providing physician should take responsibility for deciding the telehealth suitability for a patient's health assessment, treatment, and follow-up via telehealth consultation.

General Factors Affecting Telemedicine Use in Rural AreasSeveral factors have been identified in the literature which influences the effective implementation of telemedicine in a rural area. Zachrison et al. (2020) identified that financial barriers, such as infrastructure needs and financial incentives for health professionals; cultural barriers, such as a preference for traditional methods of health care delivery; technologic barriers, such as a lack of confidence in equipment skills; and workforce barriers all affected the uptake of telemedicine. It has been noted that the top barriers to adopting telemedicine are technology-specific and include a lack of infrastructure and skills (Kruse et al., 2018) or socioeconomic means (Zhai, 2020). Zhai (2020) notes that Nearly 3.6 billion people (i.e., around half of the world population) still remain offline, while 97% of the world population lives within reach of a cellular signal (Para. 3). In the United States, according to the Broadband Deployment Report, 64.6 % of tribal locations and 69.3% of rural locations had access to high-speed broadband internet that meets the minimum standard defined by the Federal Communications Commission (Federal Communications Commission, 2018). The unin-availability of high-speed internet impacts the potential of individuals to participate in consultations through video-conferencing, transmit health information, and conduct an assessment of their health conditions at home. In addition, several remote and mobile health assessments of patients need the availability of smartphones. In addition, people living in rural areas are less likely to own smartphones and have less knowledge to use those applications than in other areas (Pew Research Centre, 2019). According to research conducted by Pew Research Centre in 2019, only 71% of the rural population were as found to have smartphones against 83% of an urban and suburban community. This requires rural telemedicine programmes to provide additional funds to buy devices for patients taking part in mobile healthcare facilities (Pew Research Centre, 2019).

Lack of reimbursement is another significant barrier in the adoption of telemedicine services (Lin et al., 2018; Weinstein et al., 2014). For instance, every state of America has varying rules and guidelines regarding the kind of telemedicine services that can be reimbursed by Medicaid (Rural Health Information Hub, 2021). According to the National Telehealth Policy Resource Centre studies conducted in 2018, the three primary telemedicine modalities, which are store-and-forward, live video, and remote patient monitoring, are reimbursed by only nine states. Furthermore, telemedicine services in rural areas may face difficulties in terms of sustainability. For instance, services may have problems with monitoring the revenue gained by telemedicine programmes. Rural Services with a lower number of patients may arise problems involving healthcare specialists to supply care when the requirement for telemedicine is not continuous (National Telehealth Policy Resource Centre, 2021).

Regulatory and legal barriers such as concerns about malpractice and professional standards have also limited the wider use of telemedicine (Gajarawala & Pelkowski, 2021; Zachrison et al., 2020). Aside from malpractice concerns, healthcare providers refuse to indulge in telemedicine due to liability concerns including informed consent, practice scopes and policies and liability reimbursement (Balestra, 2018). Moreover, providers must be licensed where they give care, have undertaken credentialing and privileging procedures at outside facilities, and avoid real or perceived conflicts of interest when delivering care and also the insurer determines whether or whether telemedicine is covered by a malpractice insurance policy, especially if interstate care is performed. Patient health information must be safeguarded in all telemedicine programmes (Fields, 2020). Concerns about telemedicine systems' privacy and security are another barrier to their widespread acceptance and use (Gajarawala & Pelkowski, 2021). Another concern to good telemedicine practice is data transfer accuracy. The validity and reliability of fine motor task measures are affected by Internet connectivity, according to a study looking into the accuracy of physical function measurements (American Telemedicine Association, 2018).

A systematic review by Saliba et al. (2012) concluded that regional networks can aid in the sharing of expertise and the development of novel approaches to overcoming hurdles to telemedicine service implementation and also, strong team leadership, training, flexible and locally responsive services given at low cost, using basic technologies, and within a clear legal and regulatory framework as all are critical factors in implementing cross-border telemedicine services successfully.Country and Discipline-specific Factors Affecting Telemedicine use in Rural AreasTelemedicine has the potential to increase access to health care for those living in rural and distant areas, but it has been delayed and fragmented in its adoption (Smith & Gray, 2009). Zhai (2020) highlights that 43% of households globally do not have internet access at home, and the majority of the offline population are mostly in Africa (71.8%) and Asia and the Pacific (51.6%). Nevertheless, on a small scale, introducing a mHealth application in primary health care in Ethiopia for routine collecting of maternal health data was viable and easy to handle the telemedicine implementation (Kifle et al., 2010; Medhanyie et al., 2015). Moreover, telemedicine has been adopted into various disciplines regardless of geographical borders. In 2017, across rural China, the overall prevalence of telemedicine application was 59%, and it was observed to boost the bed occupancy rate of primary health care clinics and telemedicine was observed to improve the number of yearly outpatient visits in western China and the bed occupancy rate in eastern China (Xu et al., 2020).

The New Zealand telehealth report says that telemedicine adoption has increased significantly across all district health boards (DHBs), according to the 2019 survey (NZ Telehealth Forum & Resource Centre-Telehealth, 2019). Many more clinical services are utilising telehealth technology that is primarily video-based and the number of DHBs using patient consultations has increased from sixteen in 2014 to nineteen in 2019 (NZ Telehealth Forum & Resource Centre-Telehealth, 2019). A case study from the West Coast, a rural area of New Zealand says that the video consultation helped people from the remote area to get health care by connecting them to the general practitioner via video consultation without travelling hundreds of kilometres (NZ Telehealth Forum & Resource Centre, 2015). Mobile "robot" videoconferencing devices were used in a telepaediatric service in Queensland, Australia that began in 2000. Patients and professionals have found it to be cost-effective and well-received. In Queensland, Australia, telegeriatric services were established in 2005, primarily using videoconferencing. Telegeriatrics has proven to be an excellent option for frail older people in rural settings (Smith & Gray, 2009). The lack of reliable internet connectivity in other parts of the Northern Territory (NT) in Australia limits the expansion of telehealth. Despite mounting evidence of telehealth benefits, there is still a lack of adoption in the primary health care sector in the NT (Clair & Murtagh, 2019).Wade and Stocks (2017) believe that there is enough evidence to continue forwards with telemedicine deployment for acute cardiac, acute stroke, and cardiac rehabilitation services on a bigger scale in New Zealand and Australia (Wade & Stocks, 2017). Demographic and People-specific Factors Affecting Telemedicine use in Rural AreasSeveral demographic and people-specific factors have been identified as affecting equitable access to telemedicine. Research has shown that telemedicine may not be accessible to individuals with disabilities, such as vision and hearing impairments, and older adults (Hargittai et al., 2019; Park et al., 2018). However, Chu et al. (2020) state that, compared to standard care, the nurse-trained, family member-delivered rehabilitation telemedicine programmes enhanced physical recovery without increasing caregiver stress in rural disabled stroke patients (Chu et al., 2020). Lopez et al. (2021) found that because of unfamiliarity with technology, impairment, and a lack of social supports to assist, 32% of older individuals would be unable to use virtual consultations. Switching to phone consultations could close the gap for an additional 16% of older persons, although factors such as dementia and hearing impairment remained obstacles (Lopez et al., 2021).

Many individuals encounter barriers to telemedicine due to their socioeconomic status (Dorsey & Topol, 2020; Lopez et al., 2021). The elder population's use of the internet varies significantly based on age, income, and educational level (Hargittai et al., 2019). Due to technological hurdles and costs, the use of telemedicine as an alternative to in-person follow-up visits has several restrictions (Ayad, 2021). Despite an increase in telemedicine visits, during the COVID-19 pandemic, there was a significant decrease in overall in-person visit volume to the hospitals and clinics that exceeded what telemedicine attempted to replace (Lopez et al., 2021). Also, the older persons were not prepared to use video visits on the spur of the moment, and that many were left behind in the hasty and poorly organised transition to virtual care (Lopez et al., 2021).

While income may be a significant barrier to many of low socioeconomic status due to the cost of internet access and the appropriate technology, telemedicine for diabetic retinopathy has the potential to save a lot of money, especially for low-income people and patients who live in rural areas with high transportation costs (Avidor et al., 2020).

Telenursing during the COVID-19 pandemic

Nurses have given a variety of hospital, social, and home services since the beginning of the pandemic. Telenursing has been argued to allow a closer and more effective contact between nurse and patient due to the limitations around actual presence in the hospital amidst pandemic crisis. This is because patients have been able to speak with their nurses more easily in this situation and hence, telenursing allows the nurse to devote more time to the patients during the COVID-19 pandemic (Kord et al, 2021). Non-contact nursing has been used via telenursing in elderly living facilities, nursing homes, and long-term management institutions to improve residents' access to healthcare services since the COVID-19 pandemic. As a result, telenursing has been widely used for people who live in areas with restricted access to healthcare services (Heo et al,2021).

Moreover, while telenursing is thought to improve nurses' efficacy in managing emotions and social situations, it is also thought to be effective in assisting and managing the complex medical conditions, improving health functional status and quality of life and reducing the need for support care (Komariah et al,2021). For example, during the COVID-19 pandemic, professional guidance on treating and preventing pressure injuries in bed ridden patients is extremely valuable. Telenursing can help minimise the care giver burden by teaching them how to visually examine, clean, monitor, and risk assess bed ridden patients skin to prevent pressure injury (Mamom & Daovisan ,2022).Telemedicine adoption in New Zealand During the first COVID-19 pandemic 'lockdown' in Aotearoa/New Zealand (MarchMay 2020, when strict 'stay at home' measures were implemented), general practitioners were instructed to use telephone and video consultations (telehealth) instead of in-person visits whenever possible (Imlach et al, 2021a).The following services were reported the most frequently by the 18 District Health Boards; community and outpatient mental health, oncology, occupational therapy, acute mental health and speech language pathology( NZ telehealth forum and resource centre ,2019).

According to the report, 17 District Health Boards completed around 3,300 telehealth consultations per week in the pre-Covid-19 month of November 2019 to January 2020, a figure that jumped to 34,500 per week in April (A Hinz special report into Telehealth at New Zealand District Health Boards and the impact of COVID-19). Despite the disruptive lockdown, which resulted in an unanticipated and quick introduction of telehealth services in general practice, the vast majority of patients had pleasant experiences with telehealth because telehealth was convenient, and it allowed people to safely obtain health care without having to choose between the risk of contracting COVID-19 and the necessity to see a doctor (Imlach et al, 2021a).

Only hard-copy prescriptions signed by a clinician were legal prior to shut down in New Zealand under the Medicines Act 1981; these prescriptions were taken to a pharmacy by an individual or delivered by fax or post. General practises that use the secure New Zealand ePrescription Service (NZePS), which contains an enduring waiver for signature-less prescriptions, were the lone exception. During lockdown, the number of general practises using the NZePS expanded from roughly 300 at the end of 2019 to 800 by April 2020, from a total of around 1000 (Imlach et al, 2021b). In terms of demographics, the demand for telehealth helpline support from younger individuals grew the fastest. Male demand grew faster than female demand and the demand from Mori has been steadily declining, while demand from other ethnic groups has increased. Because of lower infection rates, COVID-19-related death, and bereavement at the time, the extent of the demand rises was smaller in Aotearoa/New Zealand (Pavlova et al,2022).

Experiences, perspectives and social factors of rural population about telehealth uptake.

The transition from traditional health service delivery methods to digital health services can be challenging if the approach is not socially acceptable. This study found (Section 4.2.4) that the telemedicine consumers were generally ready to adopt the change if the technology was available, whereas the telemedicine providers were seemingly reluctant to change the method of practice. In line with this, a study by Zachrison et al. (2020) indicated that the preference for the traditional way of delivering health care services had an impact on the uptake of telemedicine in a rural area. Unfamiliarity was another factor for the adoption of telemedicine or both telemedicine consumers and provider and Zachrison et al. (2020) stated that lack of confidence or familiarity for using telemedicine equipment hinders telemedicine adoption. Another study by Choukou and his colleagues, (2021) indicated that successful adoption of telehealth technology among rural people will depend on keeping the patient's acceptability and culture in mind, as well as providing healthcare services by telehealth-trained healthcare professionals (Choukou et al., 2021). Cultural competency and safety in the mobile and telehealth setting has been signalled as an issue that needs further research (Dawson, et al., 2020; Hilty et al., 2021)

Convenience is greatly influencing telemedicine implementation in rural areas. This study found that rural telemedicine consultations are more convenient due to less travel distance and time. Telehealth (2017) states that convenience is one of the main advantages of telemedicine for the remote population to access health care by decreasing travel. Another factor affecting the implementation of telemedicine is the income and education level of the consumers in rural areas. Lack of reimbursement or inconsistent reimbursement policies hinders telemedicine adoption in remote areas (Butzner & Cuffee, 2021). Unfortunately, broadband access has become a contemporary social determinant of health and the digital divide in terms of geography, socioeconomic status, education and usage skills need to be addressed for telemedicine/telehealth to be widely accepted, implemented and accessible in rural areas (Benda et al., 2020).

Experiences and perspectives of nurses about telenursing use in rural areas.

Rygg et al., (2021) emphasized that by using telenursing technology, nurses can spend less time traveling for home visits in rural locations and promote accessible, frequent, and patient-safe follow-up. However, this study highlights that the necessity of evaluating the suitability of telenursing technology use in diverse scenarios on an individual basis. Whereas Tran et al.,2004 found that the Telenurses were satisfied using the telenursing technology to render the nursing services to the rural people and the Telenurses felt that rapport between the Telenurses and the people from the rural location played a vital role for the uptake of telenursing services in rural area. This notion has been supported by another study conducted in New Zealand by DoolanNoble et al, (2021) states that, nurses in rural areas of New Zealand managed their service challenges in rural area such as isolation and resource constraints, by having a good relationship with their local rural community. Another study by Mara RodrguezOrtega et al, (2024) found that rural nurses were supported in their rural nursing practice by introducing telenursing counselling tools for aiding their decision-making capacity and these tools promoted the safety of nursing professionals by aiding in decision-making, as well as the rural populations they serve by utilizing a multidisciplinary approach to their procedures. Similarly, Ameen et al, (2005), Bhatia et al, (2019) and Trondsen et al, (2014) emphasised that the telenursing support educational sessions helped rural nurses to enhance their confidence and improved the clinical practice in the underserved areas. However, contrastingly another study by Richards, (2004) found that the rural nurses were not satisfied with the implementation of telenursing services because the utilisation of telemedicine services is less than the doctors at rural areas due to lack of training and increase work load and the rural nurses expressed concerns about how teleconsulting would affect patient privacy and the consultation process itself despite user friendly telenursing technology and its clinical usefulness.

Australasian -Telehealth and telenursing practice guidelines and policies

The task of creating standards and guidelines for telehealth began in July 2012 and was finished in March 2013. The Australian Government Department of Health and Ageing supported, and the Australian Nursing Federation coordinated the initiative to create Telehealth standards and guidelines for nurses and midwives (The Royal Australasian College of Physicians, 2013)

If a telehealth consultation is the best consultation for each patient, doctors who offer these services should make that decision. The patient must be capable of participating in the telehealth consultation and any unofficial caregivers they may have. Services would often not be offered across state lines unless there have been referrals from nearby interstate towns. Physicians should ensure that patients are aware of the process before starting a telehealth session. To ensure the patient is well-informed, doctors may need to communicate with the patient's end health worker. The specialist must make sure that the patient has received sufficient information on the telehealth consultation in situations where there is no healthcare professional at the patient's end (The Royal Australasian College of Physicians, 2013)

Patients' consent to engage in the telehealth consultation should be confirmed by doctors. Consent should be sought in the same manner as in a face-to-face session when the patient is incompetent or incapable of giving it. It may be necessary for the doctor or patient end practitioner to arrange for a family member or friend with the necessary legal standing to provide consent (The Royal Australasian College of Physicians, 2013)

A healthcare professional from the referring healthcare organisation shouldpresent with the patient throughout some or all of the video consultations with the specialist in assisted consultations. The referring healthcare professional should verify the patient's identity with the specialist or healthcare facility, as well as the identity and qualifications of the remote specialist. The patient's confidentiality and privacy should always be respected throughout telemedicine sessions. If a teleconsultation is being recorded, privacy and confidentiality must be protected while the recording is stored securely (The Royal Australasian College of Physicians, 2013)

The telehealth information and communications technology should be appropriate for the consultation's clinical goal. Mainly, the telehealth technology should be compatible with that utilised by the patient's end-user healthcare provider. Physicians should make sure they have a backup plan that is appropriate to the consequences of failure in the event of equipment or connectivity failure. For non-urgent consultations, rescheduling or completing the consultation by telephone may be sufficient. Doctors may think about establishing an uninterruptible power supply and a second source of connectivity if telehealth is likely to give urgent medical aid. Urgent consultations are to be considered, and they should only take place while a patient-end practitioner is available who is qualified to perform CPR and decide on patient transfer, if necessary (The Royal Australasian College of Physicians, 2013)

Telehealth policies and regulatory frameworks in the New Zealand context

According to international standards, New Zealand's health sector extensively uses advanced information and communication technologies. This is partially because of several government initiatives to encourage the advancement and application of technology in the provision of healthcare (Arun Sam Singh, 2022). In addition, the Medical Council of New Zealand has established certain telehealth policies, especially regarding e-prescription practice and the requirement for face-to-face consultation before writing any scripts, whether in person or via teleconference (Medical Council of New Zealand, 2020). Suppose a telehealth practitioner is based overseas and offering services from abroad. In that case, that telehealth practitioner must be registered in New Zealand under the regulatory framework under which health practitioners are expected to operate. The Privacy Commissioner has the authority to forbid the transfer of personal data outside of New Zealand under the Privacy Act. (Telehealth around the world: A global guide, 2020). The Privacy Commissioner of New Zealand established a telecommunication information privacy code in 2003 in accordance with the privacy act 1993, which states that information should be gathered for a legitimate purpose related to an agency function or activity, and its acquisition is required to fulfil that goal (NZ telehealth forum and resource centre, 2003). However, it does not directly mention or covers telehealth practice in New Zealand.

The medical council of New Zealands (MCNZ) definition of "the practice of medicine" would include providing medical services via communication technology. Hence the qualified medical practitioners who practice "domestic" telemedicine within New Zealand must comply with the requirements of the Health Practitioners Competence Assurance Act 2003 (HPCA Act) and the professional standards established by the medical council of New Zealand (Hedley & Findlay, 2015). A position statement on the use of telemedicine for 2016 was endorsed by the New Zealand Medical Council, and the Nursing Council of New Zealand's Code of Conduct for Nurses contains guidelines and standards for professional behavior. All healthcare methods, including telehealth, must adhere to these guidelines and criteria. (NZ telehealth forum and resource centre, 2019). It is not as unlikely as it may appear that New Zealand will use international telemedicine. In New Zealand hospitals, there are numerous instances of the usage of international telemedicine, and since 2010, the MCNZ has had a unique purpose and scope of practice for international teleradiology (Hedley & Findlay, 2015).

Theoretical frame work

Writing in progress

Research topic

An exploratory case study on Telenurses and patients experiences and perspectives about the use of telenursing services in rural New Zealand

Research Question

What are the experiences and perspectives of Telenurses and patients about the use of telenursing services in rural New Zealand?

Research Objectives

To explore the perspectives and experiences of Telenurses about the use of telenursing in Rural New Zealand

To explore the perspectives and experiences of Telenursing patients or consumers about the use of telenursing in Rural New Zealand

To examine the preparedness of Telenurses for the effective use and implementation of telenursing services to the rural population.

Methodology and methods

Research methodology and appropriateness

Understanding the experiences and the perspectives of Telenurses and the consumers of telenursing, regarding the telenursing service and practice in rural area is the purpose of this study. This part would cover the rationale of the researcher for choosing a qualitative research approach, as well as the reasons why the case study design and a qualitative method are best suited for addressing the research objectives. Studies in the social sciences, sciences, and many other fields revolve around the crucial subject of research design. The choice of design is perhaps the most crucial one a researcher takes, after deciding on the research topic and developing questions (Abutabenjeh & Jaradat 2018). An appropriate research design is necessary for any research project to be completed successfully. This is a strategy that a researcher adopts prior to the start of data collecting in order to legitimately accomplish the research goal of and translating a research problem into data for analysis in order to provide pertinent answers to research questions at the lowest possible cost is the fundamental component of research design (Asenahabi.,2019). According to Creswell (2009) the general strategy for connecting the conceptual research questions to the relevant and attainable empirical research is known as research design and it is an investigation that offers precise guidance for research processes. The type of analysis required to produce the desired results is always determined by the research design and it outlines the kinds of data that are needed, the procedures for collecting and analysing the data, and how the data will address the research objectives (Asenahabi.,2019).Researchers employ quantitative methodologies when examining certain situations that have numerical expressions (Lakshman, et al., 2000). However qualitative approaches seek to offer descriptive explanations of the phenomena, while quantitative approaches rely on counting instances and volumes (Gelo et al., 2008). Rural Telenurses and telenursing consumers experiences and perspectives about the telenursing services in the practice context will be the focus of this study.In the qualitative study, the researcher's primary focus will be on understanding the perspectives of the participants and their experiences (Meadows, 2003). The use of quantitative methods was inappropriate because they imply that humans learn from an objectivist epistemology, in which scientists create general laws explaining social behaviour by statistically analysing data that they take to be a fixed reality (Yilmaz, 2013). Whereas qualitative researchers highlight the significance and meaning of peoples' lived experiences and quantitative researchers use numerical data to describe events (Yilmaz, 2013). This study focusing to explore the experiences and perspectives of Rural Telenurses and telenursing consumers and hence a quantitative approach that takes data out of context will not be appropriate for this study.To comprehend, ascertain, and characterize people's attitudes, behaviours, beliefs, experiences, and interactions with non-numerical data, researchers employ qualitative methodologies (Pathak et al., 2013). The views of staff were crucial to this study. Researcher might examine trends or themes using qualitative methodologies to learn how Telenurses experiences and perspectives about their telenursing services to the rural population in New Zealand and why they decided to continue their role and scope of practice as Telenurses (Merriam, 2009). When research topics pose issues that are difficult to solve using conventional methods, researchers turn to qualitative methods (Frankel & Devers, 2000). A qualitative research design would be appropriate research design to explore the perceptions, perspectives and experiences (Creswell.,2007). The decision to choose the appropriate methodology for this study is completely based on the research question. Qualitative research aims to reveal the experiences that groups have on a daily basis and the significance they place on the actions they take (Merriam & Tisdell, 2015). This study aims to explore the perceptions and the experiences of Telenurses about the telenursing practice and services in rural New Zealand. Hence the choice of qualitative inquiry aligns with the research question of this study as it aims to explore the lived experiences of Telenurses about telenursing use and its services in rural New Zealand. The ability to capture the "essence of the experience for individuals incorporating 'what' they have experienced and 'how' they have experienced it" (Creswell, 2012, p. 79) is a key justification for selecting qualitative research to explore the experiences and perception of Telenurses about telenursing services in rural New Zealand. I expect that the interviews would provide some insight into perspectives, experiences, and ideas whereas that would be difficult to capture in a questionnaire.When doing qualitative research to study human experiences and perspectives, researchers may use many designs such as grounded theory, ethnography, phenomenology and case study (Percy et al., 2015). In this study, a case study methodology would be most effective to explore the Telenurses interpretation about their telenursing practice and service experiences. Telenursing services like real -time telenursing consultations would be an example of how the case study technique enables the researcher to "retain the holistic and meaningful characteristics of contemporary real-life events" (Yin, 2009). By addressing "how" and "why" questions, a case study approach enabled the researchers to investigate individuals and facilitate the breakdown and subsequent reconstruction of phenomena (Baxter & Jack, 2008). With the use of the exploratory single case study approach, the researcher would certainly be able to create a social unit's story, look for trends and themes, and discover fresh information about Telenurses experiences and perceptions about rural telenursing services (Yin, 2009).

MethodsParticipantsA minimum of X telenurses and patients to a maximun of Y will be recruited. If more express interest that Y, then the participants will be chosen in the order their interest was received. Pseudonyms will be used for all participants and their geographical area will be recorded as rural. Inclusion Criteria

Registered Nurses who are working as a full time Telenurses in rural areas of New Zealand

Full time Telenurses who are providing telenursing services to the rural population of New Zealand, even though they are located in Urban areas.

People residing in rural areas of New Zealand who received telenursing services or consultations.

Telenurses who haves undergone formal training to handle telenursing technology and equipment.

Exclusion criteria

Telenurses who are not providing telenursing services to the rural population of New Zealand.

Patients residing in urban areas of New Zealand, even if they received telenursing services or consultations.

Telenurses who has not taken formal training to handle telenursing technology and equipment.

Sampling

There are two components to traditional sampling techniques. To create a sampling frame a list of the participants in the population to be studied a complete set of data sources must first be identified. Secondly, from this sampling frame, a particular sample of data is gathered. Since snowball sampling does not rely on a sampling frame, it violates both requirements. When a sampling frame cannot be created, snowball sampling is frequently used (Kirchherr & Charles.,2018). Cooke and & Jones (2017) states that it is common for researchers to be unable to create a sampling frame while studying a population that is hard to reach.

One of the most widely used sampling techniques in qualitative research is snowball sampling, which places a strong emphasis on networking and referral. Typically, the researchers begin their work with a limited group of initial contacts, or "seeds," who meet the research criteria and are extended an invitation to participate in the study. After that, the agreeable participants are asked to suggest other connections who meet the study's eligibility requirements and who might also be willing participants. These contacts then suggest further contacts who might be interested in participating, and so on. Therefore, researchers use their social networks to create the first connections, and then sampling momentum grows from these connections, catching an ever-longer chain of participants. Once a specified sample size or saturation point is reached, sampling often comes to an end (Parker et al.,2019)

The research question of this study aims to explore the perceptions of the telenursing uses in rural area of New Zealand, which would be difficult to reach the rural population directly who had telenursing exposure in rural New Zealand, hence snowballing sampling would be the most appropriate sampling technique for this study. To justify the selection of sampling technique, I would exemplify a study conducted by Parker (2012). For her dissertation research on experiences and views of Britishness, nationalism, and citizenship, Parker (2012) used a snowball sample approach when interviewing St Helenians. While spending time in this British Overseas Territory, she created the initial sample using contacts she already had with a few St. Helenians as well as new contacts she made through other interactions.Data Collection

Open-ended, semi-structured voice-recorded interviews without video will be used to gather the data, and the questions will be tailored to the study topic. The systematic method of speaking with and listening to the participant will be employed in the interviews. If an interview not conducted in person, participants might still conduct it over the phone or using Skype. The interview measures and recording during the interviews supported the framework for data collection (Creswell, 2003; Leedy & Ormrod, 2010). Other methods to collect the data would be from the official records and field observations, kept as a researcher reflective journal. Official records include previous employer surveys, feedback forms from the Telenurses and the consumers. More data can be collected by observing the real time telenursing consultations which would enable the researcher to identify more themes in person.Prior to collecting the data, the researcher would apply for approval from the university of Canterburys ethical committee. Once the approval obtained from the university ethical committee, the first source of data would come from the semi-structured interview of Telenurses to explore their experiences and perspectives of telenursing services in rural New Zealand and the second set of data source would come from the semi-structured interview of telenursing consumers who reside in rural areas of New Zealand to explore their experiences and perspectives of telenursing services in rural New Zealand.

Gathering the Telenurses and their rural patients thoughts, views, and personal experiences is the aim of the interviews (Merriam, 1998). The researcher listens to the data collected to detect emergent themes during the data collecting process and then will be labelled or coded the data in order to reflect and identify the themes (Leedy & Ormrod, 2010). Using data collection and appropriate types of methodology, the framework for data collection, transcription, coding, and analysis was constructed (Creswell, 2013; Leedy & Ormrod, 2010).Open-ended and semi-structured questions will be employed for the qualitative data collection method and protocols for this study. The information needed to identify and differentiate between themes and the standard information presented will be obtained from data gathered throughout the interview procedure. After the interviews are finished, the data obtained will become the main source of data for this research.The semi-structured interview procedure is designed to give participants the chance to share their thoughts and feelings regarding their experiences and perceptions about the telenursing services in rural New Zealand. (Creswell, 2013; Leedy & Ormrod, 2010; Stake, 1995; Yin, 2013). By obtaining detailed information about the perceptions and experiences of the Telenurses and telenursing consumers from the rural areas, this setting would achieve the study's goal. In addition, as compared to a detached setting of mailed surveys or questionnaires collecting quantitative data, the environment would offer the chance to speak with participants face-to-face and spend time asking follow-up questions as needed (Merriam, 1998; Stake, 1995) and the collected data will be transcribed into codes and a copy of transcribed interview data will be ehandd over to the participants to read and assure the accuracy of the collected data content and the transcription.

Data analysis

The analysis of the collected data will be a mixture of doing with either NVivo transcribe software and or Braun and Clarkes (2006) thematic analysis. The transcripts will be cross checked by the researcher and respondents in order to confirm the accuracy of the data by member checking. The NVivo qualitative data analysis program might?? be used to import the transcripts and assist in the coding, grouping, and theme development processes (Yin, 2014).

Braun and Clarkes (2006) step-by-step approach for thematic analysis is was used as follows:

Familiarisation with the data: this phase involved active reading of the transcribed data to locate the key findings for later stages.

Generating initial codes: Braun and Clarke, (2006) described coding as recognizing elements in the actual data related to the research question. Elements of the data could be words, phrases or quotes used by the participants during the semi structured interview. After reviewing the initial codes, categories will be made based on the commonalities in the codes.

Searching of themes: In this phase, the generated codes will be analysed and organised into themes, and all relevant data was collected based on the themes to address the research question.

Reviewing themes: In this phase, the themes identified in the previous stage were rechecked at the level of coded data extracts and then at the complete set of data to ensure the availability of adequate data to support.

Defining and naming themes: At this point, each theme will be examined thoroughly to identify and determine the aspects of the data that each theme captures from the data. Furthermore, the theme titles will refine and consider the preferred names for each theme in the final report.

Producing the report: In this phase, the final analysis of the collected extracts will be completed to address the research question before producing the final report of the findings.

Confidentiality and informed consent

Each approach will be followed with the informed consent and confidentiality requirements established by the Institutional Review Board. A description of the study's objectives, methods, and results will be given to the participants. Every participant will be kept safe the entire time the study is being conducted. To prevent any ethical concerns, each participant will get an informed consent form together with a cover letter outlining the purpose of the study. In order to maintain confidentiality, participant names also will be removed from data that is gathered and the same will be maintained following the interview. For three years after the study's completion, all data, including voice recording devices, will be kept secure and kept in a safe and the data stored laptop will be secured with password which only the researcher will be aware of. All study must follow the ethical guidelines of informed consent, which guarantees participants confidentiality (Creswell, 2003; Leedy & Ormrod, 2010). The benefits of the study, the fact that participation is voluntary and that withdrawal is possible at any time for any reason, and the guarantee that all information obtained will be kept private and destroyed in the event that participation is withdrawn from the study will all be included in the informed consent. o maintain confidentiality, anonymous identities will be used in place of real names. The code number will be allocated to each participant during the interview and to store the date to ensure confidentiality. Upon participant withdrawal from the study, all written material would be destroyed and all voice recordings would be erased. The participants also will know why they are being studied, how they are selected, how data will be collected, their rights and procedures regarding withdrawal, and whom to contact with any questions or concerns regarding the researcher or research process.

Issues of trustworthiness

According to Hadi and Closs (2016), exhibiting rigor in qualitative research is crucial for verifying the accuracy of the study's conclusions and refuting common criticisms of this type of research. The reliability of the outcomes is supported by taking the right actions. I explain how this research study will handle the trustworthiness in terms of credibility, transferability, dependability, confirmability, and ethical considerations in the following subheadings.

Credibility

The foundation of excellent qualitative research is the credibility of the findings (Birt et al., 2016). Credibility confirms that a research study captures the genuine essence of participant experiences and measures the things it set out to measure (Maher et al., 2018). A researcher can utilize certain approaches outlined by Lincoln & Guba (1986) to gain credibility. These comprise choices made on data sources both before and during the study, as well as research activities. Long-term participant engagement, ongoing observation, triangulation of data sources, and member checks are the criteria for determining trustworthiness (Lincoln & Guba, 1986, Birt et al, 2016, Yin 2013). Spending time with the participants, hearing about their experiences and perceptions, and gaining a thorough grasp of the phenomenon of how the Telenurses and their patients experienced telenursing services in rural areas and what are their perceptions upon the same would strengthen the study's credibility. As the investigator expands upon the experience and insights acquired from the participants via knowledge and comprehension, the more precise andValidity of the research findings will be (Creswell, 2013).

In order to make sure I accurately capture each telenurses and patients experiences and perceptions response, member checks involved validating the transcripts of the interviews and having each participant analyse the data (Smith & McGannon, 2018). This also would facilitate to validate my interpretations of the collected data (Hadi & Closs, 2016). By enabling rural telenurses and patients to verify and validate results, member checking would help to lessen researcher bias (Birt et al., 2016). In order to guarantee that rural telenurses and patients real experiences and perceptions were appropriately recorded and described, member verification certainly will carry out for this research project.

Transferability

The term "transferability" describes how well study results can be applied to different situations and environments (Noble & Smith, 2015). A study's transferability is determined by providing thorough explanations and theoretical examples that show how its components can be extensively applied to a wide range of individuals, groups, and environments (Suter, 2012). Factual descriptions from this study will be shared by describing how the telenursing stakeholders which includes tele nurses, patients who underwent telenursing consultations and the telenursing providers would describe their experiences with telenursing use in rural New Zealand. McDowell, (2020) emphasising that giving that much data makes it possible for researchers in the future to model their work after this particular study and come up with findings that are comparable. This implies that a reader of the study might be able to transfer which is, see how the findings might be applied to their own situation or one in which they might be findings may resonate with others in a similar context (Lincoln & Guba, 1986).

Dependability

In qualitative studies, dependability is the capacity of a study to generate findings that would be consistent if it were conducted again with different participants in the same setting McDowell, (2020).An audit trail will be included, the study protocol will be described, and the data collection procedure will cover in full, in order to guarantee the dependability of this research (Forero et al., 2018). In qualitative research dependability can be explained thorough methodological explanations that make it possible for other people to carry out the investigation again (Lincoln & Guba, 1986; Shenton, 2004). In addition, once the research is over, an audit trail of the decisions made during the study can be reviewed by others (Mayan, 2009). This study will comprise an audit trail that will include meticulous procedural descriptions about how the study carried out (Lincoln & Guba, 1982). A decision that needs to be justified is the selection of the data collection strategy based on the study question and design (Thorson-Mador.,2023). In this instance, semi structured interviews will be conducted to collect data as this would align with the research questions, which will ask the participants to describe their experiences and perceptions as well as how they felt about the telenursing use in a rural setting.

Te Tiriti O Waitangi

As a researcher within the New Zealand context there is a need to consider the roles and responsibilities of the researcher as a partner in Te Tiriti o Waitangi and to ensure appropriate consultation with Tangata Whenua is undertaken. I anticipate that there would be the Telenurses who rendering services to the New Zealand rural population and the patients from the rural areas of New Zealand as study participants from Mori community. During the research process, as a researcher I will ensure the protection and observance of Mori individual and group rights. and I will strongly protect Mori data, culture, concepts, values, customs, traditions, and language, as well as individual and communal rights, during the research process. Moreover. I will obtain the approval from the ethical committee of university of canterbury before executing the actual research.

Time line

BudgetLimitations of the study

Conclusion

Appendices

References