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rsing and information and communication technology (ICT):discussion of trends and future directions

son While *, Guy Dewsbury

’s College London, Florence Nightingale School of Nursing and Midwifery, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom

What is already known about this topic?

T is increasingly part of health care deliveryurses are using ICT in various ways

What this paper adds

his paper sets the context of future nursing practiceithin virtual and ICT delivered health caredescribes the current state of knowledge regarding

ursing and ICTsets challenges for nursing to define its relationshipith ICT

hanging context of health care

By 2020 the older population will outnumber thenger population (United Nations, 2004) and this

combined with the increasing prevalence of chronic illness(World Health Organization, 2003) is creating a heavydemand on the finite resources in terms of both money andpersonnel (Kinsella and He, 2009). The use of informationand communication technology (ICT) is one of a range ofpotential solutions to this health care challenge. ICTencompasses a range of technologies which enable theexchange of data through the telephone or internet (Fig. 1).

The United States (US) National Broadband Plan (FCC,2010) has identified a key role for ICT in improving healthand health care through enhancing care delivery andcoordination, and engagement with patients. To this endthere are Federal incentives to providers who adoptelectronic health records (EHR) both inside and outsidehospitals with the use of EHR expected both to reduce thecosts of care and improve quality and safety (Bates, 2010).Indeed, the US Medicare (American Telemedicine Associa-tion, 2010) reimburses for telehealth services whichinclude non-face-to-face services that can be conductedeither through live video conferencing or via store andforward telecommunication services. The United Kingdom(UK) Government has published similar ambitions(Department of Health, 2008).

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A B S T R A C T

This paper traces the development of information and communication (ICT) within health

care and the emergence of telehealth as a key component of modern health care delivery as

health care moves from the ‘face to face age’ to the ‘information age’. The paper examines

the interface of ICT and nursing practice and highlights the limited evidence relating to the

nursing contribution within telehealth particularly beyond data input and output analysis

for other health care personnel. Additionally, the absence of research relating to the impact

of ICT upon nurses and their working lives is identified. The paper concludes that nurses

need to engage more fully with ICT so that they contribute to shaping the care system and

emerge as leaders of the new care systems delivering future clinical activity.

� 2011 Elsevier Ltd. All rights reserved.

Corresponding author.

E-mail address: [email protected] (A. While).

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

ease cite this article in press as: While, A., Dewsbury, G., Nursing and information and communication technology (ICT):discussion of trends and future directions. Int. J. Nurs. Stud. (2011), doi:10.1016/j.ijnurstu.2011.02.020

0-7489/$ – see front matter � 2011 Elsevier Ltd. All rights reserved.

10.1016/j.ijnurstu.2011.02.020

http://dx.doi.org/10.1016/j.ijnurstu.2011.02.020

mailto:[email protected]


http://www.sciencedirect.com/science/journal/00207489


A. While, G. Dewsbury / International Journal of Nursing Studies xxx (2011) xxx–xxx2

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ICT has the potential to modify the way in which peopleuse health services both by increasing access to informa-tion and providing other forms of support remotely.Expectations are changing with people wanting todetermine their own health needs through advice on theinternet or other technological interfaces and faster moreperson-centred services from health care providers includ-ing nurses. Indeed, we may be witnessing a move from the‘‘face to face age of health care’’ to the ‘‘information age ofhealth care’’.

This discussion paper draws upon an extensive searchof Pubmed and Medline for papers (n = 795) relating toehealth, telehealth, telecare, mhealth and telenursing inaddition to 63 books on health and technology to explorethe developments relating to ICT in health care over timeand the interface with nursing. Sources (n = 39 papers)were included where they added to the discussion; thiswas necessarily selective and it is acknowledged that adifferent search strategy may have yielded differentsources such as those relating to nursing records. Forbesand While’s (2009) conceptual framework was used tocategorise nursing activity reported across the material.The evidence of the contribution of nursing within ICTdevelopments and the potential impact of ICT upon nurses’working lives are foci for the discussion.

2. ICT and change over time

Historically the patient and healthcare professionalrelationship was mediated through agencies such ashospitals and primary care services and person intensiverelying on the face to face contact of health careprofessionals with patients. Fig. 2 illustrates changes overtime with the replacement of wholly face to face contact byincreasing use of ICT to deliver healthcare. However, thereplacement of face to face contact by ICT has bothpotential advantages and disadvantages for health serviceswhich are set out in Fig. 3.

As technology becomes increasingly ‘‘clever’’, there willbe a shift of staff from direct face to face contact toincreasing non-face to face contact with remote sensorscarried on the patient transmitting clinical information to acentre which will act as a hub for appropriate interventions(Lewin et al., 2010). Mobile health technologies are notnew, but in the coming years, new technologies will bedeveloped yielding smaller and more discrete devicescapable of large dataset monitoring (Technology Strategy

The increased adoption of ICT will impact on the way inwhich services are provided and herald a change in nursingallowing the nurse relationship with patients to move fromthe face-to-face encounters of traditional nursing to anincreasingly virtual nursing experience outside the hospi-tal setting. Thus nursing which involves direct contactface-to-face interaction will evolve to include remoteassessment of health need, information giving, diagnostics,support and monitoring of the patient’s condition.

3. Nursing practice and ICT

The adoption of ICT within clinical practice may bringsubstantial benefits through supplementing traditionalnursing practice relating to assessment, health promotion,clinical interventions and service organisation (Fig. 4).

Thus new technology may enable new services, forexample, virtual health promotion sessions with one nurseworking with a group of people simultaneously. Healthportals will allow patients to store information as well asaccess information about their conditions in addition toreceiving personalised health advice. Nurses will be able toconduct virtual visits over the internet and discuss apatient with other health and social care professionalsthrough a secure connection in real time to enable betterpersonalised care planning and care coordination.

Mobile applications (mobile apps or portal devices) willincrease in popularity and extend beyond the Apple Ipodand Iphone to other mobile devices enabling the downloadof appropriate applications to support people in managing

ICT systems Applications Frequently used terms across ICT system applications

Telephone Landline Telephone triage, telecare, telehealth, telemonitoring, telemedicine, health portals, mHealth, Apps, personal digital assistants (PDAs), Smartphone.

internet Computer-based

Satellite television Television-based

Mobile ICT Mobile devices

Fig. 1. ICT systems, applications and frequently used terms.

Fig. 2. ICT in healthcare delivery over time.
Board, 2010; Fong et al., 2011).
Please cite this article in press as: While, A., Dewsbury, G., Nursing and information and communication technology (ICT):A discussion of trends and future directions. Int. J. Nurs. Stud. (2011), doi:10.1016/j.ijnurstu.2011.02.020


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A. While, G. Dewsbury / International Journal of Nursing Studies xxx (2011) xxx–xxx 3

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ir own health needs relating to specific conditionsluding mental health concerns. Apps are still in theirncy but it is likely that they will become the easiest

y for patients to receive health related information andote monitoring. Thus if a patient’s clinical data fall

side the recommended range then the app will suggesttacting a health professional or set up a contact with aed person automatically.

The incorporation of ICT into nursing practice andient care pathways will bring about changes in nursingrk not only regarding nurse-patient relationships but

in the context of practice with greater demands placedn nurses’ ICT and remote communication skills.ever, patients need not be the only beneficiaries of

ater access to information because ICT provides theortunity to increase nurses’ accessibility to evidence torm practice in ways inconceivable a few years ago.

Health assessment

The assessment process is a fundamental part of healthdiation which ensures that health needs are identifiedly and appropriate interventions initiated. However, thedence of the contribution of ICT to improvements inlth assessment is limited both in its extent and itsact within the published literature, with examples ofuse of various ICT applications being reported (Fig. 4).

The UK’s national telephone advice service, NHS Direct,dled 5,180,000 calls in England in its first 3 years98–2001) but Munro et al. (2005) found that there waschange in overall demand for either emergency

bulance services or attendance at accident and emer-cy departments and there was no change in the usagehe four paediatric emergency departments in the study.

However, they noted a significant reduction in the calls toout-of-hours general practice which suggested someworkload diversion away from general practice. SimilarlyNorth and Varkey’s (2008) review of telephone triage calls(27,979 symptom assessments for mainly female callers[71%] received by the Ask Mayo Clinic, US July 2006–June2007) noted that 16% of callers (n = 4469) had intended toseek help from emergency services if they had not accessedthe triage service suggesting some diversion of activityaway from emergency services.

However, an analysis of the large UK General HouseholdSurvey dataset (n = 20,421) has revealed a consistent socio-economic bias regarding the use of telephone advicecompared to accident and emergency services with thosein lower socio-economic groups, older people, those withlong term illnesses and from minority ethnic groups beingless likely to use telephone services (Shah and Cook, 2008).This suggests that affluent households are more likely tobenefit from the provision of telephone advice servicesemphasising the importance of adequate health facilitiesfor less affluent households. Indeed, this socio-economicbias appears to extend to internet usage with Gracia andHerrero’s (2009) national survey of internet use and self-rated health among older people (n = 709) in Spain findingthat internet users had better self-rated health than non-users (p = 0.002), although with weighting for social classthe significance of the results disappeared.

In contrast the evidence relating to assessment in theform of chronic illness monitoring is more positive withconsistent evidence of positive clinical outcomes, some-times quite limited, consequent upon tele-monitoringespecially in relation to advanced heart failure from arange of countries where small trials have been conducted(Antonicelli et al., 2008; Biddiss et al., 2009; Scherr et al.,

Advantages Disadvantages

One nurse can interact with patients remotely.

Dehumanization of healthcare delivery.

One nurse can manage a larger caseload through remote monitoring.

Reduction of “traditional” services may not be acceptable to all.

Improved information sharing. Challenge of controlling virtual information.

Reduced cross-infection and other patient ‘costs’.

Formulaic approach mayconstrain practice and inhibitprofessional judgment.

Less travel time and other health care costs.

Significant investment will be needed to ensure all practitioners are “masters” of ICT.

Doctors and nurses can hold joint remote consultations with the patient and their family.

Patient expectations may beunattainable / unmet.

Timely enhancements of patient self-care.

Reinforcement of the “digital” divide.

Virtual titration of medication and virtual prescription changes.

Compatibility issues across different ICT systems.

Efficient signposting to other services to maximize health resources.

Failure of ICT at any time will undermine healthcare system.

Fig. 3. Advantages and disadvantages of ICT in healthcare.




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2009; Maric et al., 2010). However, none of these trialsproperly accounted for the ‘non-key interventions’ whichmay also be important to patients in a number of waysincluding: promoting confidence in the quality of care;alleviating social isolation; and improving the relationshipbetween health care providers and the patient. Currellet al.’s (2000) systematic review involving seven trials oftelemedicine versus face to face care also questioned thebenefits of telemedicine despite its acceptance by patientsand particularly noted the absence of formal economicanalysis and evidence of safety.

Importantly all the available evidence relating to healthassessment and the use of ICT fails to articulate the nursingcontribution with any clarity. Indeed, nurses werereported as either delivering or were part of the deliveredhealth care assessment but few details emerge relating tothe nursing activity undertaken.

3.2. Health promotion

Health promotion, which includes health education,health protection and preventative work, forms a keycomponent of health care practice and will be increasinglyimportant if global health demands are to be controlledthrough preventative action. All forms of ICT may augmentthe nursing contribution to health promotion by extendingcontact beyond traditional face to face practice, however,the literature to date only reports the use of the telephoneand computer based interventions with studies of perso-nalised e-health, podcasts and webcasts not yet published(see Fig. 4).

Fry and Neff’s (2009) systematic review of limitedcontact interventions targeting weight loss, physicalactivity, and/or diet included 19 studies (1988–2008) withcombined sample size of 15,655. Studies were included if a

periodic prompts were used as an intervention or acomponent of an intervention, a behavioural or biologicaloutcome measure was used, and an ongoing healthpromotion behaviour was targeted. Eleven studiesreported positive findings regarding the use of periodicprompts with benefits relating to diet, weight loss andexercise behaviours and nine studies showed enhancedeffectiveness when prompts were frequent and personalcontact with a counsellor (sometimes a nurse) wasincluded. However, Fry and Neff identified the need foradditional research on limited contact interventionstargeting health behaviours such as weight loss, physicalactivity, and/or diet to test prompt types and frequencies,specific intervention components and prompt character-istics. Additionally data are needed regarding the shortterm and longer term effectiveness of limited contacthealth promotion interventions.

The importance of access to the internet and email werehighlighted by Bot et al. (2009) who carried out an email-based health intervention for pregnant women(n = 14,154) in the Netherlands and found that only 8%of the pregnant women could be reached though the emailintervention with the educational level of the women alsoaffecting their active engagement in the process(p< 0.001). This digital divide has been noted by othersin relation to internet access across both social-economicand age groups (An et al., 2007; Verdegem and Verhoest,2009; Weaver et al., 2009)

Additionally a US quasi-experiment (Pak et al., 2009) ofonline health information seeking for different agedparticipants (n = 50, 18–23 years; n = 50, 60–80 years)found differences in the seeking behaviours of participantsfrom the different age groups. The older people reportedusing computers for less time (p = 0.002) and less often(p = 0.001) whereas the younger adults had greater spatial

Assessment

Remote signpos�ng includingcontact with health care professionals or other agenciesTelephone triageTelemonitoringInternet self-assessmentPortable mHealth Mobile apps for clinicalmonitoring

Health promo�on

Telephone, text, email interven�on / prompts Health portals delivering personalized health promo�onWebcasts and podcasts interven�ons

Clinical Interven�on

Remote consulta�ons (mayinclude MDT) Remote �tra�on of therapy including prescrip�ons where neededRemote psychological therapies eg mo�va�onal interviewing, CBTRemote carer support

Service organisa�on

Electronic health records / electronic pa�ent records (EHR/EPR)Care pathway managementCare system governance (audits etc)Professional clinical networks (discussion boards etc.)e- CPD for professionals.

Fig. 4. ICT and potential applications to nursing practice.



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alisation and orientation abilities (p< 0.001) and aer memory span (p = 0.001). Further, in the information

rch tasks the older adults performed worse than thenger adults (p =<0.001). Pak et al. concluded that thereneed to design health information sites taking into

sideration the age related changes in cognition andine information seeking behaviours.Computer programmes are another approach to healthcation but Slootmaker et al.’s (2009) RCT of a physical

ivity based software-based intervention in Hollandnd no significant intervention effect with a largeportion (39%; n = 14) of the intervention group51) reporting that the advice was not appealing. This

hlights how information delivery on its own may notg about behaviour change and that stimulatingaviour change requires careful consideration of bothrmation delivery as well as other factors (ProchaskaDiClemente, 1983). Indeed, Lee et al.’s (2008) survey of

202 Koreans aged 25 years and over found that, whileial participation significantly decreased with age, theuence of social participation on health status increasedh age. This study highlighted the importance of socialticipation for health in all age groups, notwithstandingt the effect of social participation differs by age andder.However, Tse et al. (2008) evaluation of a 4 week e-lth programme for older people designed to improveir use and access to health-related information in the

of physical exercise videography from a Hong Kongernment-sponsored website demonstrated the poten-

of e-health. The participants’ mastery of basicputer operating skills increased significantly0.05) and they were able to access health information

the internet and had gained health-related knowledgethe week 4 post-test (p< 0.05). Tse et al. concluded thatchnology-based e-health programme was an effective

y to provide health education to older people althoughshort follow-up of this study provides no evidence

arding the sustained use of the internet for healthrmation nor its long term acceptability to older people.

Thus the available evidence suggests that it may bemature to embrace the internet for health promotionthe whole population both due to differential accessuse of the internet but also because it will reduce social

ticipation which appears particularly important tomen and older people. Additionally the trustworthinesshealth information websites is not uniformly high.adows-Oliver and Banasiak’s (2010) evaluation of 68bsites using eight core educational concepts developedthe National Heart, Blood, and Lung Institute (NHLBI)nd that only 6 websites (8.8%) had accurate andplete information regarding asthma according to

BLI recommendations. This means that nurses mustconscious of the limitations of internet sites purportinghave expert knowledge and which may undermineient education.However, there is a need for more evidence regardingeffectiveness of this approach to health promotion andkey characteristics of the most successful initiatives

ether with the respective roles of qualified andualified nurses. In particular, the reported initiatives

shed no light on the potential contribution of nursing tohealth promotion using ICT.

3.3. Supporting those with long term conditions

The range of ICT applications within health care aremost evident in the field of long term conditions andchronic disease management (see Fig. 4) with all examplesof ICT being reported. Rosser et al. (2009) systematicallyreviewed 45 studies testing the use of technology topromote behaviour change in chronic illness. The areasreviewed were: (1) methods employed to adapt traditionaltherapy from a face-to-face medium to a computer-assisted platform; (2) targets of behaviour change; and(3) level of human (e.g. therapist) involvement. More thanhalf (53%) of the studies featured interventions that wereweb-based and 10 of these included an additionaltechnology (e.g. telephone, web-based discussion group).Technology was generally used as the platform for therapydelivery, ranging from basic information provision andadvice to progressive modules providing interactiveassessment, skills training, self-monitoring and mobiletherapy delivery. In eight studies an on-line message boarddiscussion as a means of social support formed part of theintervention. Most of the interventions (73%) were notfully automated with some therapist (frequently a nurse)involvement which ranged across supervision, assistanceand instruction. In many cases the technology-basedtherapy was used as an addition to face-to face therapyand/or as a component of a larger intervention. Rosser et al.concluded that technology based self-management sys-tems could provide a practical method for both monitoringchronic illness health status as well as deliveringtherapeutic interventions to promote desired healthbehaviours and, indeed, this appears to be echoed in morerecently published studies.

There are an increasing number of trials reportingbenefits including improved treatment adherence, dis-ease knowledge and reduced hospital admissions arisingfrom the use of telemonitoring in various formsespecially related to heart failure (Dansky and Vasey,2009; Bowles et al., 2009; Dang et al., 2009; Wakefieldet al., 2009) although not all published trials havereported significant differences (Wootton et al., 2009).This variable effect of telephone interventions was notedin Stolic et al. (2010) review of 24 papers where sevenstudies demonstrated statistically significant differencesin all outcomes measured while eight studies demon-strated some positive effects and nine studies reportedno effect. Interestingly the studies which reportedpositive effects had stronger designs, however, the exactcontribution of the nurse within the various nurse-ledtelephone interventions for those with heart disease wasnot analysed.

Additionally frequent text messaging has been found tobe helpful in supporting weight loss in overweight adults(p = 0.02) over 16 weeks (Patrick et al., 2009). At the end ofthe study 22 of 24 (92%) intervention participants reportedthat they would recommend the intervention for weightcontrol to friends and family confirming the acceptabilityof this intervention within the study group.




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In contrast a small UK RCT (Wu et al., 2010a) of atelephone booster intervention for overweight adults withtype 2 diabetes comprising a weekly reinforcement ofclinic advice for lifestyle modification to support weightloss found no intervention effect. However, the telephoneintervention was acceptable to the intervention group whoreported that the weekly telephone calls met their need foron-going support. This result is similar to that reported in asystematic review with a meta-analysis of seven RCTswhich found that overall telephone follow-up on its ownhas a limited impact on glycaemic control for Type 2diabetes (Wu et al., 2010b). Telephone interventionsincorporating a more ‘intelligent’ approach which variedthe intensity of the follow-up based on patient needappeared to deliver better outcomes suggesting that theremay be some benefit in developing telehealth thatincorporates this type of approach. Another UK RCT(Istepanian et al., 2009) testing mobile health technology(Bluetooth wireless link) in diabetes management foundno differences in the HbA1c outcomes between theintervention and control groups in part reflecting the highattrition from the intervention group as a result oftechnical problems. Of note in a sub-group analysis therewas a trend of the telemonitoring group having a lowerHbA1c (7.76%) than those in the control group (8.40%)(p = 0.06).

While the majority of the literature reports single sitetrials and other study designs, Cady et al. (2009) reported arecord review of hospital resource utilisation by childrenwith special needs (n = 43; July 1996–December 2006) caremanaged by the U Special Kids Programme based inMinnesota, US. Unplanned hospitalisations decreasedsignificantly from 74 in the first year to 35 in the secondyear (p< 0.007) with the rate of unplanned admissionsstabilising in subsequent years. In contrast, plannedhospitalisation was relatively constant over the five-yearperiod. This suggests that telephone-based care coordina-tion and case management offers a promising approach forsupporting children with multiple, complex health condi-tions.

The user perspective regarding the adoption of newmodes of contact has attracted limited interest so thatGrayston et al.’s (2010) interview study of primary carepatients in Edinburgh (n = 200) is particularly useful as itcompares new technologies with traditional methods ofgiving blood test results. A clear preference for traditionalmethods (telephone contact, face to face contact) wasexpressed with email being favoured by 53.3% of thosehaving email access. SMS was not generally favoured witholder patients being significantly less favourable (p< 0.01)and similarly use of an internet webpage was not generallyfavoured with females being significantly less favourabletowards a webpage compared to male patients (p< 0.01).Information security was a concern relating to the threenew technologies highlighting a major user issue whichmay inhibit the adoption of new technologies.

While there is some evidence regarding the effective-ness of ICT in supporting people with long term conditions,there is little attempt to distinguish between the differenttypes of ICT (telephone versus internet based) and the keycharacteristics of the most successful initiatives and for

whom they are best suited. The cost of teleheath issubstantial and therefore understanding where it is mosteffective will be important. Further there is generally a lackof clarity regarding ‘dosage’ and frequency of the variousinterventions and the respective roles of nurses. It is alsonoteworthy that publication bias may result in under-reporting of no differences depriving health systems of thefull evidence on which to invest wisely.

4. Nurses’ working lives and ICT

Stevenson et al. (2010) reviewed five studies of nurses’experiences of using electronic patient records derivedfrom a database search of published papers written inEnglish or Swedish 2000–2009. The five small studiesconducted in Australia, United States and England (twoquantitative and three qualitative) found that nurses weregenerally dissatisfied with the electronic patient recordbecause they did not support nursing practice throughtheir failure to provide a good overview of the patient andlack of availability which undermined patient safety.Nurses reported that the records did not supportindividualisation of care and had a tendency to controlthe way that the nurse worked through the imposition ofprotocols. The nurses also reported that the actualcomputer systems were cumbersome, illogical, slow,complicated and unreliable at times. They suggested thatnurses must become involved in the future design anddevelopment of the electronic patient record echoing thecall by Forbes and While (2009) for nurses to become moreinvolved in all levels of ICT design to avoid subordinationwithin the care system.

More recently a large survey (De Veer and Franke, 2010)of Dutch nurses (n = 685) had more positive findings withnurses associating electronic patient records withimproved care but negative attitudes were recordedregarding the consequences for the cost effectiveness ofcare and work circumstances highlighting the challengefor electronic patient record implementation. However, anongoing issue regarding the nursing workforce is theircomputer literacy with evidence that some nurses arereluctant users of computers (Timmons, 2003; Verdegemand Verhoest, 2009) with the lack of skills trainingcompounding the problem (Murphy et al., 2004,). Indeed,this reluctance to engage with ICT needs sensitivemanagement because there is evidence that the experienceof the benefits of using ICT and electronic patient recordsincreases their acceptability (De Veer and Franke, 2010)and therefore their likely successful implementation.

Indeed, the introduction of electronic health recordsand electronic health information exchange is not withoutits challenges as illustrated by Goroll et al.’s (2009)implementation report of the Massachusetts eHealthCollaborative (MAeHC) comprising a diverse set ofcompetitively selected communities of nearly 500 physi-cians serving over 500,000 patients. The challengesincluded compatibility with existing systems, function-ality, data security and cost which they managed throughcareful contracting and phased implementation followingan invitation process to practices. They noted that theimplementation had high transactional costs comprising



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ny hours of donated time by ‘highly skilled profes-als’ some of whom were presumably nurses. The UKerience of implementing ICT into the National Healthvice has been equally troubled (Hendy et al., 2005,7) although paper based systems have many weak-ses which may be forgotten through the haze oftalgia.A benefit of ICT is its ability to increase accessibility tormation sources. Doran et al. (2010) using a long-inal survey assessed access to information resourcesnurses (n = 488) in 29 acute care hospitals, long-term

e providers, home care nursing providers and primarye programmes in Ontario, Canada. Only personal digitalistant (PDA) users reported a significant improvementr time in the perceived quality of care delivered0.001) and job satisfaction (p< 0.001), especially

ong those working in long-term care settings0.01). However, both PDA and tablet computer users

orted high satisfaction with their devices althoughre were differences in the reported ease of using theerent information resource packages reflecting theater information available on the screen of a tablet

puter (p = 0.05) and the faster information delivery to a(p = 0.05). The study nurses reported a significant

rovement in research awareness and accessibility overe (p = 0.05) leading Doran et al. to recommend mobilermation technologies as a means of reducing the

riers to research utilisation. Indeed, mobile ICT devicesy be an important enabler of evidence-based nursingctice.A telephone call centre is a different working environ-nt from clinical care settings. Mueller et al. (2008) andlgrove (2009) have reported the experience of nursesrking within UK NHS Direct call centres (Mueller et al.,8 [2 call centres; 17 semi-structured interviews];

Snelgrove, 2009 [3 call centres; 92 nurse questionnaires(RR 83%); 2 focus groups]) and highlighted the tensionswhich arise for nurses regarding meeting call targets,adherence to decision protocols with limited room forautonomy and the absence of patient visibility whichchallenge the traditional nursing identity in terms aholistic approach to patient care. Mueller et al. (2008)identified a dichotomy between delivering efficiency and aprofessional patient focus as the call centre serviceattempts to adopt some of the commercial call centrenorms within its delivery. These findings were echoed inPurc-Stephenson and Thrasher’s (2010) review of 16studies relating to tele-nurses working in primary carederived from a systematic search of four literaturedatabases of published papers 1980–2008. They identifiedfive major concerns experienced by nurses which include:the impact of protocols and algorithms upon autonomy;the comfort of the physical workspace; and stress causedby heavy workloads, assessing the credibility of callers andthe challenge created by language difficulties and hostilecallers. The reviewed studies described how nursesattempted to adopt a holistic approach to assessmentusing their nursing skills to develop a rapport and listen towhat was unsaid in building a clinical picture drawingupon clinical expertise to determine the urgency of healthneeds and the appropriate advice.

The electronic health record will require all nurses todemonstrate computer literacy of varying sophisticationdepending upon the electronic health record functionalityin the different health care organisations. Additionally,different job roles will demand differential use of ICTreflecting both role autonomy and the practice setting(Fig. 5). Regardless, the emergence of ICT as a keycomponent of modern health care will inevitably impactupon nurses and their working lives although to date there

Fig. 5. ICT use in nursing practice.




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is limited research focusing upon this topic area. There is aneed to further understand the demands of telephone triagework as well as the characteristics of the ‘ideal’ electronicpatient record from a nursing perspective. In additionstudies are needed which test ICT as a vehicle for enablingevidence-based practice and high quality patient care.

5. Conclusion

The growth of virtual healthcare is inevitable andprovides the vehicle for significant changes in health caredelivery especially for people in remote locations. It allowspeople to access health care and advice directly from theirhome or other places such as shops or their workplace andit may enable the personalisation of health care withpeople taking control over their own health and healthrecords. However, it is also the harbinger of health care ondemand in which people will expect access to healthrelated information and services 24 h a day, 7 days a week,52 weeks a year in much the same way that there is accessto other services through the telephone and internet.

To date the evidence reports nurses as either deliveringor being part of health care interventions but there is littledetail relating to nursing activity, dosage or frequency of theinterventions, and the respective roles of nurses. Further, theevidence of the effect of these interventions is mixed despitethe high cost of many of the interventions and the potentialunder-reporting of no difference. In addition, the impact ofICT upon nursing practice and nurses’ lives and theacceptability of the ‘‘information age of health care’’ toboth patients and their carers require further exploration.Indeed, the lack of research exploring the impact of ICT uponnursing practice and nurses’ working lives needs urgentattention if it is to inform the ongoing development ofnursing practice and future employment practices relatingto nurses as they move into new roles.

In the meantime the nursing workforce needs to engagefully with ICT so that nurses do not have a merely passiverelationship with technology feeding the system with datafor others to interpret or acting as an output analyst inmeeting health needs (Forbes and While, 2009). Nursesneed to become the ICT system managers and designers inaddition to clinical data collectors and data analysts so thatthey contribute to system management and system designthereby shaping the care system and defining thestructural components that define the care system or theywill remain subordinate within the new systems deliver-ing clinical activity (Forbes and While, 2009).

Conflict of interest

None declared.

Funding

None.

Ethical approval

None.

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