Background

Modern information and communication technologies have rapidly changed the way we purchase merchandise, organize travel arrangements, communicate and search for information around the world. These advances in technology have also influenced health care whereby there is an expectation that technology will assist clinicians to work smarter and more efficiently to deliver services. The term "telehealth" is used to broadly describe the use of technology in health care, and various definitions exist encompassing a range of technologies. For the purpose of this review, telehealth is defined as "the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities".1^(p.9) Telehealth technologies include videoconferencing that relies on infrastructure and equipment such as the internet, computers and videoconferencing systems. These technologies are the focus of this review. The use of the telephone or other technologies that monitor patients is out of scope for this review.

Telehealth in the form of videoconferencing is intended to improve health outcomes for patients and provide clinical support by overcoming geographical barriers and connecting patients and clinicians who are not in the same physical location. The preferred model is for a patient to be supported by a healthcare clinician in their local area (often a rural or remote site) with a healthcare practitioner providing clinical guidance at a distant location (often an urban site).2,3 A clinical consultation uses videoconferencing to enable all parties to see and hear each other in real time. This model has several advantages:

* If a physical examination is required during the video consultation, the local clinician attending at the patient's end may be able to perform this.

* The local clinician is available to clarify any information for both the patient and the distant clinician.

* The local clinician can ensure documentation of the outcomes or recommendations of the consultation in the patient's local medical records.

* Continuity of care for the patient is facilitated when healthcare professionals at both local and distant locations can frequently collaborate to manage health care with the patient.3

In this way, videoconferencing can be used to provide clinical consultations for the management of a wide range of health issues. Assessment and diagnosis can be made, interventions can be implemented and supervised, care planning facilitated, treatment follow-up and review can all be undertaken, and the patient is able to receive high-quality care in their location of choice.2,4 This reduces the cost to the healthcare system by reducing the need for travel for both patients and healthcare specialists. It can also reduce the negative impact of travel on families and demonstrates patient-centered care and respect for cultural safety.

Videoconferencing can also be used in professional practice to provide education, training and support to rural and remote practitioners thereby increasing their capacity to confidently and capably manage patients in their local area.5 It can enable clinicians working in isolation to access clinical supervision, peer support and case review more readily.

Videoconferencing is a valuable tool that can facilitate the delivery of high-quality care and improve health outcomes for patients who otherwise would be disadvantaged in their ability to access care. Evidence describes benefits as improved patient outcomes, increased access to services, reduced waiting times, reduced travel, efficient use of resources, and provision of education and support.6 Despite these advantages, videoconferencing remains widely underutilized. Barriers and enablers to the integration of telehealth services into routine practice are well described.7-11 Factors such as clinician acceptance, organizational readiness, economics and policy directives can all hinder integration,11 whereas education and training, and administrative and technical support are factors associated with the successful implementation of telehealth services.12,13

Within nursing and midwifery practice telehealth is still considered "novel"; only a small proportion of nurses and midwives actually use telehealth in routine practice.14 For example a survey undertaken in 2012 in the United Kingdom of 1158 nurses found only 6% had used videoconferencing whereas over 80% did not think that telehealth would change nursing practice.15 In 2011, the global health workforce was estimated to comprise around 10 million nurses, 5.8 million physicians and 6.6 million "other" health workers.16 As nurses and midwives make up the largest proportion of the healthcare workforce around the world, their influence in the way health services are delivered is significant. Most nurses work in hospital settings with a smaller proportion working in primary care and community settings including patient's homes. With the rising costs of health care and the global shortages of the health workforce, there is an increasing emphasis on outpatient or ambulatory and home-based care, and a need to minimize hospital-based care wherever possible.17 To meet the demands of changing healthcare systems, nurses and midwives must be prepared to keep pace with the expansion of technologies and the opportunities for improving efficiencies of services wherever possible. These changes are likely to include videoconference technologies. Understanding the experiences of nurses and midwives, including their perceptions of the appropriateness and meaningfulness of videoconferencing may help further understanding of the benefits, limitations, barriers and enablers of videoconferencing. This information may aid with integration of such technology into routine practice. Nurses empowered to utilize videoconferencing may make major contributions to the provision of health care in the future.

Around the world, policy makers and nursing organizations have recognized the need to empower nurses to incorporate videoconferencing into their practice. In the United Kingdom, widespread education has been recommended by the Royal College of Nurses to equip nurses with skills to deliver care via telehealth.15 In the United States, the National Organization of Nurse Practitioners has incorporated telehealth objectives into their core competencies for nurse practitioners.18 Australia's Nursing and Midwifery Federation has developed telehealth professional practice standards and guidelines written specifically for nurses and midwives.19,20 Although objectives, guidelines and standards are important for ensuring best practice, understanding nurse and midwife perceptions and experiences in relation to videoconferencing can provide useful information for practitioners and policy makers, particularly those who want to integrate videoconferencing into their health systems.

A preliminary search was undertaken for existing studies and reviews regarding nurses' and midwives' perceptions and experiences of telehealth, including videoconferencing. A Joanna Briggs Institute (JBI) protocol for a qualitative systematic review on nurse professionals' experience of the facilitators and barriers to the use of telehealth applications was published in 2012.21 The proposed review by Koivunen and Saranto21 will focus on electronic forms of communication and online services (such as email) from nurses' perspectives. Our review will focus more specifically on the experiences and perceptions of videoconferencing as this is recognized as one of the most important ways to increase access to services.22 There are also systematic reviews that evaluate specific telehealth applications such as that published by Chipps and Brysiewicz2 on the experience of videoconferencing for telepsychiatry for health professionals and adult patients, and Tan and Lai23 examining telemedicine for the support of parents of high-risk newborn infants. Other examples of systematic reviews on telehealth have focused on cost-effectiveness,24 clinical effectiveness25,26 and patient satisfaction.27 To our knowledge no review has been undertaken to systematically collate and appraise the qualitative evidence regarding nurses' and midwives' experiences and perceptions of using videoconferencing. Given that the demand for new technologies such as videoconferencing is likely to increase, it is important to understand how best to encourage nurses and midwives to adopt this in their practice. Understanding experiences and perceptions will provide useful information for developing interventions to integrate videoconferencing into mainstream healthcare services.

The aim of this review is to identify, appraise and synthesize the existing qualitative evidence of nurses' and midwives' experiences of videoconferencing.

Inclusion criteria

Types of participants

This review will consider all qualitative studies that include professional nurses and midwives (i.e. those with formal tertiary qualifications), including those who are registered to practice as a nurse and/or midwife, such as clinical nurses, nurse practitioners, practice nurses, community nurses, nurse specialists, clinical midwives, clinical midwifery specialists and independent private practicing midwives.

Phenomena of interest

The review will explore nurses' and midwives' accounts of the factors that influence use of videoconferencing, and their perceptions and experiences of the appropriateness and meaningfulness of the use of videoconferencing in the delivery of health care. The review will focus on the use of videoconferencing to facilitate clinical practice, defined as activities directly related to patient/client care; and professional practice, including education and training, maintaining competencies or networking and peer support.

Types of studies

This review will include studies that have used qualitative methods to collect and analyse data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, critical inquiry, action research and feminist research. Qualitative components of mixed methods studies may also be included in this review.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial broad search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. A second, more focused search using all identified keywords and index terms will then be undertaken across all included databases.

Third, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. No time restriction will be placed on the years of search to elicit changes in the accounts of perceptions and experiences over time. Authors or primary studies will be contacted for further information if required.

The databases to be searched will include:

* CINAHL

* Embase

* ScienceDirect

* MEDLINE

* PsycINFO

* Sociological Abstracts

* Web of Science

The search for unpublished studies will include:

* British Library

* Conference Proceedings

* Institute for Health & Social Care Research (IHSCR)

* National Library of Australia

* National Information Center on Health Services Research and Health Care Technology

* NIH REPORT

* New York Academy of Medicine Grey Literature Report

* Open Grey

* ProQuest Dissertations and Theses Database

Initial keywords to be used will include: "nurs^*" or "nurs^* personnel" or "registered nurs^*" or "homecare nurs^*" or community nurs^* "midwife^*" or "midwives" "clinical midwi^*", "community midwi^*".

AND

"telehealth" or "telemedicine" or "telenursing" or "videoconferenc^*" or "telecare" or "telecommunication" or "online" or "remote consult^*" or "communication technology" or "tele-education".

AND

"qualitative" or "action research" or "content analysis" or "conversation^* analy^*" or "discourse analy^*" or "discursive analy^*" or "discursive psycholog^*" or "ethnograp^*" or "ethnomethodolog^*" or "symbolic interaction^*" or "grounded theor^*" or "hermeneutic^*" or "narrative^*" or "phenomeno^*" or "thematic analysis" or "mixed-method^*" or "critical".

Assessment of methodological quality

Two reviewers will independently assess the qualitative articles selected for retrieval using the JBI Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I) to establish the nature and appropriateness of the methodological approach and methods prior to inclusion. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Data extraction

Qualitative data will be extracted from articles included in the review using the standardized data extraction tool from JBI-QARI (Appendix II) by one reviewer. The second reviewer will complete data extraction for 10% of articles and results will be compared to ensure errors during data extraction are minimized. The data extracted will include specific details about videoconferencing used by nurses and midwives, including study methods and outcomes of significance to the review question and specific objectives. These outcomes will include data related to perceptions of the feasibility, appropriateness and meaningfulness of videoconferencing. Data related to feasibility may include infrastructure, staffing, training and competencies required. Data related to appropriateness may include transferability, cultural appropriateness, and adaptability. Data related to meaningfulness may include positive and negative experiences.

Data synthesis

Qualitative research findings will, wherever possible, be pooled using JBI-QARI. Categories will include findings that relate to perceptions of feasibility, appropriateness and meaningfulness of videoconferencing. Aggregation or synthesis of findings will be undertaken to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.

Acknowledgements

The authors would like to thank the following people for their assistance. Professor Anne Chang and Ms Mary-Anne Ramis, from the Centre for Evidence-based Healthy Ageing (CEBHA) at QUT, provided training and support relating to this review. Ms Ramis also offered helpful comments on the draft of this protocol.

Appendix I: JBI-QARI appraisal instrument

Appendix II: JBI-QARI data extraction instrument

References