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Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Nursing and information and communication technology (ICT): A discussion of trends and future directions
Alison While *, Guy Dewsbury
Kings College London, Florence Nightingale School of Nursing and Midwifery, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom

A R T I C L E I N F O

A B S T R A C T

Article history: Received 17 May 2010 Received in revised form 2 February 2011 Accepted 25 February 2011 Keywords: Information and communication technology ICT Telehealth Telecare Telemonitoring Health portals

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 identied. 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.

What is already known about this topic?  ICT is increasingly part of health care delivery  Nurses are using ICT in various ways What this paper adds  This paper sets the context of future nursing practice within virtual and ICT delivered health care  It describes the current state of knowledge regarding nursing and ICT  It sets challenges for nursing to dene its relationship with ICT

1. Changing context of health care By 2020 the older population will outnumber the younger population (United Nations, 2004) and this

* Corresponding author. E-mail address: alison.while@kcl.ac.uk (A. While). 0020-7489/$ see front matter 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2011.02.020

combined with the increasing prevalence of chronic illness (World Health Organization, 2003) is creating a heavy demand on the nite resources in terms of both money and personnel (Kinsella and He, 2009). The use of information and communication technology (ICT) is one of a range of potential solutions to this health care challenge. ICT encompasses a range of technologies which enable the exchange of data through the telephone or internet (Fig. 1). The United States (US) National Broadband Plan (FCC, 2010) has identied a key role for ICT in improving health and health care through enhancing care delivery and coordination, and engagement with patients. To this end there are Federal incentives to providers who adopt electronic health records (EHR) both inside and outside hospitals with the use of EHR expected both to reduce the costs of care and improve quality and safety (Bates, 2010). Indeed, the US Medicare (American Telemedicine Association, 2010) reimburses for telehealth services which include non-face-to-face services that can be conducted either through live video conferencing or via store and forward telecommunication services. The United Kingdom (UK) Government has published similar ambitions (Department of Health, 2008).

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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ICT systems

Applications

Telephone internet Satellite television Mobile ICT

Landline Computer-based Television-based Mobile devices

Frequently used terms across ICT system applications Telephone triage, telecare, telehealth, telemonitoring, telemedicine, health portals, mHealth, Apps, personal digital assistants (PDAs), Smartphone.

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

ICT has the potential to modify the way in which people use health services both by increasing access to information and providing other forms of support remotely. Expectations are changing with people wanting to determine their own health needs through advice on the internet or other technological interfaces and faster more person-centred services from health care providers including nurses. Indeed, we may be witnessing a move from the face to face age of health care to the information age of health care. This discussion paper draws upon an extensive search of Pubmed and Medline for papers (n = 795) relating to ehealth, telehealth, telecare, mhealth and telenursing in addition to 63 books on health and technology to explore the developments relating to ICT in health care over time and the interface with nursing. Sources (n = 39 papers) were included where they added to the discussion; this was necessarily selective and it is acknowledged that a different search strategy may have yielded different sources such as those relating to nursing records. Forbes and Whiles (2009) conceptual framework was used to categorise nursing activity reported across the material. The evidence of the contribution of nursing within ICT developments 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 professional relationship was mediated through agencies such as hospitals and primary care services and person intensive relying on the face to face contact of health care professionals with patients. Fig. 2 illustrates changes over time with the replacement of wholly face to face contact by increasing use of ICT to deliver healthcare. However, the replacement of face to face contact by ICT has both potential advantages and disadvantages for health services which are set out in Fig. 3. As technology becomes increasingly clever, there will be a shift of staff from direct face to face contact to increasing non-face to face contact with remote sensors carried on the patient transmitting clinical information to a centre which will act as a hub for appropriate interventions (Lewin et al., 2010). Mobile health technologies are not new, but in the coming years, new technologies will be developed yielding smaller and more discrete devices capable of large dataset monitoring (Technology Strategy Board, 2010; Fong et al., 2011).

The increased adoption of ICT will impact on the way in which services are provided and herald a change in nursing allowing the nurse relationship with patients to move from the face-to-face encounters of traditional nursing to an increasingly virtual nursing experience outside the hospital setting. Thus nursing which involves direct contact face-to-face interaction will evolve to include remote assessment of health need, information giving, diagnostics, support and monitoring of the patients condition.

3. Nursing practice and ICT The adoption of ICT within clinical practice may bring substantial benets through supplementing traditional nursing practice relating to assessment, health promotion, clinical interventions and service organisation (Fig. 4). Thus new technology may enable new services, for example, virtual health promotion sessions with one nurse working with a group of people simultaneously. Health portals will allow patients to store information as well as access information about their conditions in addition to receiving personalised health advice. Nurses will be able to conduct virtual visits over the internet and discuss a patient with other health and social care professionals through a secure connection in real time to enable better personalised care planning and care coordination. Mobile applications (mobile apps or portal devices) will increase in popularity and extend beyond the Apple Ipod and Iphone to other mobile devices enabling the download of appropriate applications to support people in managing

Fig. 2. ICT in healthcare delivery over time.

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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Advantages One nurse can interact with patients remotely. One nurse can manage a larger caseload through remote monitoring. Improved information sharing. Reduced cross-infection and other patient costs. Less travel time and other health care costs.

Disadvantages Dehumanization of healthcare delivery. Reduction of traditional services may not be acceptable to all. Challenge of controlling virtual information. Formulaic approach may constrain practice and inhibit professional judgment. Significant investment will be needed to ensure all practitioners are masters of ICT. Patient expectations may be unattainable / unmet. Reinforcement of the digital divide. Compatibility issues across different ICT systems. Failure of ICT at any time will undermine healthcare system.

Doctors and nurses can hold joint remote consultations with the patient and their family. Timely enhancements of patient self-care. Virtual titration of medication and virtual prescription changes. Efficient signposting to other services to maximize health resources.

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

their own health needs relating to specic conditions including mental health concerns. Apps are still in their infancy but it is likely that they will become the easiest way for patients to receive health related information and remote monitoring. Thus if a patients clinical data fall outside the recommended range then the app will suggest contacting a health professional or set up a contact with a named person automatically. The incorporation of ICT into nursing practice and patient care pathways will bring about changes in nursing work not only regarding nurse-patient relationships but also in the context of practice with greater demands placed upon nurses ICT and remote communication skills. However, patients need not be the only beneciaries of greater access to information because ICT provides the opportunity to increase nurses accessibility to evidence to inform practice in ways inconceivable a few years ago. 3.1. Health assessment The assessment process is a fundamental part of health mediation which ensures that health needs are identied early and appropriate interventions initiated. However, the evidence of the contribution of ICT to improvements in health assessment is limited both in its extent and its impact within the published literature, with examples of the use of various ICT applications being reported (Fig. 4). The UKs national telephone advice service, NHS Direct, handled 5,180,000 calls in England in its rst 3 years (19982001) but Munro et al. (2005) found that there was no change in overall demand for either emergency ambulance services or attendance at accident and emergency departments and there was no change in the usage of the four paediatric emergency departments in the study.

However, they noted a signicant reduction in the calls to out-of-hours general practice which suggested some workload diversion away from general practice. Similarly North and Varkeys (2008) review of telephone triage calls (27,979 symptom assessments for mainly female callers [71%] received by the Ask Mayo Clinic, US July 2006June 2007) noted that 16% of callers (n = 4469) had intended to seek help from emergency services if they had not accessed the triage service suggesting some diversion of activity away from emergency services. However, an analysis of the large UK General Household Survey dataset (n = 20,421) has revealed a consistent socioeconomic bias regarding the use of telephone advice compared to accident and emergency services with those in lower socio-economic groups, older people, those with long term illnesses and from minority ethnic groups being less likely to use telephone services (Shah and Cook, 2008). This suggests that afuent households are more likely to benet from the provision of telephone advice services emphasising the importance of adequate health facilities for less afuent households. Indeed, this socio-economic bias appears to extend to internet usage with Gracia and Herreros (2009) national survey of internet use and selfrated health among older people (n = 709) in Spain nding that internet users had better self-rated health than nonusers (p = 0.002), although with weighting for social class the signicance of the results disappeared. In contrast the evidence relating to assessment in the form of chronic illness monitoring is more positive with consistent evidence of positive clinical outcomes, sometimes quite limited, consequent upon tele-monitoring especially in relation to advanced heart failure from a range of countries where small trials have been conducted (Antonicelli et al., 2008; Biddiss et al., 2009; Scherr et al.,

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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Assessment Remote signpos ng including contact with health care professionals or other agencies Telephone triage Telemonitoring Internet self-assessment Portable mHealth Mobile apps for clinical monitoring Clinical Interven on Remote consulta ons (may include MDT) Remote tra on of therapy including prescrip ons where needed Remote psychological therapies eg mo va onal interviewing, CBT Remote carer support

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

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

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

2009; Maric et al., 2010). However, none of these trials properly accounted for the non-key interventions which may also be important to patients in a number of ways including: promoting condence in the quality of care; alleviating social isolation; and improving the relationship between health care providers and the patient. Currell et al.s (2000) systematic review involving seven trials of telemedicine versus face to face care also questioned the benets of telemedicine despite its acceptance by patients and particularly noted the absence of formal economic analysis and evidence of safety. Importantly all the available evidence relating to health assessment and the use of ICT fails to articulate the nursing contribution with any clarity. Indeed, nurses were reported as either delivering or were part of the delivered health care assessment but few details emerge relating to the nursing activity undertaken. 3.2. Health promotion Health promotion, which includes health education, health protection and preventative work, forms a key component of health care practice and will be increasingly important if global health demands are to be controlled through preventative action. All forms of ICT may augment the nursing contribution to health promotion by extending contact beyond traditional face to face practice, however, the literature to date only reports the use of the telephone and computer based interventions with studies of personalised e-health, podcasts and webcasts not yet published (see Fig. 4). Fry and Neffs (2009) systematic review of limited contact interventions targeting weight loss, physical activity, and/or diet included 19 studies (19882008) with combined sample size of 15,655. Studies were included if a

periodic prompts were used as an intervention or a component of an intervention, a behavioural or biological outcome measure was used, and an ongoing health promotion behaviour was targeted. Eleven studies reported positive ndings regarding the use of periodic prompts with benets relating to diet, weight loss and exercise behaviours and nine studies showed enhanced effectiveness when prompts were frequent and personal contact with a counsellor (sometimes a nurse) was included. However, Fry and Neff identied the need for additional research on limited contact interventions targeting health behaviours such as weight loss, physical activity, and/or diet to test prompt types and frequencies, specic intervention components and prompt characteristics. Additionally data are needed regarding the short term and longer term effectiveness of limited contact health promotion interventions. The importance of access to the internet and email were highlighted by Bot et al. (2009) who carried out an emailbased 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 email intervention with the educational level of the women also affecting their active engagement in the process (p < 0.001). This digital divide has been noted by others in relation to internet access across both social-economic and age groups (An et al., 2007; Verdegem and Verhoest, 2009; Weaver et al., 2009) Additionally a US quasi-experiment (Pak et al., 2009) of online health information seeking for different aged participants (n = 50, 1823 years; n = 50, 6080 years) found differences in the seeking behaviours of participants from the different age groups. The older people reported using computers for less time (p = 0.002) and less often (p = 0.001) whereas the younger adults had greater spatial

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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visualisation and orientation abilities (p < 0.001) and a larger memory span (p = 0.001). Further, in the information search tasks the older adults performed worse than the younger adults (p = <0.001). Pak et al. concluded that there is a need to design health information sites taking into consideration the age related changes in cognition and online information seeking behaviours. Computer programmes are another approach to health education but Slootmaker et al.s (2009) RCT of a physical activity based software-based intervention in Holland found no signicant intervention effect with a large proportion (39%; n = 14) of the intervention group (n = 51) reporting that the advice was not appealing. This highlights how information delivery on its own may not bring about behaviour change and that stimulating behaviour change requires careful consideration of both information delivery as well as other factors (Prochaska and DiClemente, 1983). Indeed, Lee et al.s (2008) survey of 59,202 Koreans aged 25 years and over found that, while social participation signicantly decreased with age, the inuence of social participation on health status increased with age. This study highlighted the importance of social participation for health in all age groups, notwithstanding that the effect of social participation differs by age and gender. However, Tse et al. (2008) evaluation of a 4 week ehealth programme for older people designed to improve their use and access to health-related information in the form of physical exercise videography from a Hong Kong government-sponsored website demonstrated the potential of e-health. The participants mastery of basic computer operating skills increased signicantly (p < 0.05) and they were able to access health information via the internet and had gained health-related knowledge by the week 4 post-test (p < 0.05). Tse et al. concluded that a technology-based e-health programme was an effective way to provide health education to older people although the short follow-up of this study provides no evidence regarding the sustained use of the internet for health information nor its long term acceptability to older people. Thus the available evidence suggests that it may be premature to embrace the internet for health promotion for the whole population both due to differential access and use of the internet but also because it will reduce social participation which appears particularly important to women and older people. Additionally the trustworthiness of health information websites is not uniformly high. Meadows-Oliver and Banasiaks (2010) evaluation of 68 websites using eight core educational concepts developed by the National Heart, Blood, and Lung Institute (NHLBI) found that only 6 websites (8.8%) had accurate and complete information regarding asthma according to NHBLI recommendations. This means that nurses must be conscious of the limitations of internet sites purporting to have expert knowledge and which may undermine patient education. However, there is a need for more evidence regarding the effectiveness of this approach to health promotion and the key characteristics of the most successful initiatives together with the respective roles of qualied and unqualied nurses. In particular, the reported initiatives

shed no light on the potential contribution of nursing to health promotion using ICT. 3.3. Supporting those with long term conditions The range of ICT applications within health care are most evident in the eld of long term conditions and chronic disease management (see Fig. 4) with all examples of ICT being reported. Rosser et al. (2009) systematically reviewed 45 studies testing the use of technology to promote behaviour change in chronic illness. The areas reviewed were: (1) methods employed to adapt traditional therapy from a face-to-face medium to a computerassisted platform; (2) targets of behaviour change; and (3) level of human (e.g. therapist) involvement. More than half (53%) of the studies featured interventions that were web-based and 10 of these included an additional technology (e.g. telephone, web-based discussion group). Technology was generally used as the platform for therapy delivery, ranging from basic information provision and advice to progressive modules providing interactive assessment, skills training, self-monitoring and mobile therapy delivery. In eight studies an on-line message board discussion as a means of social support formed part of the intervention. Most of the interventions (73%) were not fully automated with some therapist (frequently a nurse) involvement which ranged across supervision, assistance and instruction. In many cases the technology-based therapy was used as an addition to face-to face therapy and/or as a component of a larger intervention. Rosser et al. concluded that technology based self-management systems could provide a practical method for both monitoring chronic illness health status as well as delivering therapeutic interventions to promote desired health behaviours and, indeed, this appears to be echoed in more recently published studies. There are an increasing number of trials reporting benets including improved treatment adherence, disease knowledge and reduced hospital admissions arising from the use of telemonitoring in various forms especially related to heart failure (Dansky and Vasey, 2009; Bowles et al., 2009; Dang et al., 2009; Wakeeld et al., 2009) although not all published trials have reported signicant differences (Wootton et al., 2009). This variable effect of telephone interventions was noted in Stolic et al. (2010) review of 24 papers where seven studies demonstrated statistically signicant differences in all outcomes measured while eight studies demonstrated some positive effects and nine studies reported no effect. Interestingly the studies which reported positive effects had stronger designs, however, the exact contribution of the nurse within the various nurse-led telephone interventions for those with heart disease was not analysed. Additionally frequent text messaging has been found to be helpful in supporting weight loss in overweight adults (p = 0.02) over 16 weeks (Patrick et al., 2009). At the end of the study 22 of 24 (92%) intervention participants reported that they would recommend the intervention for weight control to friends and family conrming the acceptability of this intervention within the study group.

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In contrast a small UK RCT (Wu et al., 2010a) of a telephone booster intervention for overweight adults with type 2 diabetes comprising a weekly reinforcement of clinic advice for lifestyle modication to support weight loss found no intervention effect. However, the telephone intervention was acceptable to the intervention group who reported that the weekly telephone calls met their need for on-going support. This result is similar to that reported in a systematic review with a meta-analysis of seven RCTs which found that overall telephone follow-up on its own has a limited impact on glycaemic control for Type 2 diabetes (Wu et al., 2010b). Telephone interventions incorporating a more intelligent approach which varied the intensity of the follow-up based on patient need appeared to deliver better outcomes suggesting that there may be some benet in developing telehealth that incorporates this type of approach. Another UK RCT (Istepanian et al., 2009) testing mobile health technology (Bluetooth wireless link) in diabetes management found no differences in the HbA1c outcomes between the intervention and control groups in part reecting the high attrition from the intervention group as a result of technical problems. Of note in a sub-group analysis there was a trend of the telemonitoring group having a lower HbA1c (7.76%) than those in the control group (8.40%) (p = 0.06). While the majority of the literature reports single site trials and other study designs, Cady et al. (2009) reported a record review of hospital resource utilisation by children with special needs (n = 43; July 1996December 2006) care managed by the U Special Kids Programme based in Minnesota, US. Unplanned hospitalisations decreased signicantly from 74 in the rst year to 35 in the second year (p < 0.007) with the rate of unplanned admissions stabilising in subsequent years. In contrast, planned hospitalisation was relatively constant over the ve-year period. This suggests that telephone-based care coordination and case management offers a promising approach for supporting children with multiple, complex health conditions. The user perspective regarding the adoption of new modes of contact has attracted limited interest so that Grayston et al.s (2010) interview study of primary care patients in Edinburgh (n = 200) is particularly useful as it compares new technologies with traditional methods of giving blood test results. A clear preference for traditional methods (telephone contact, face to face contact) was expressed with email being favoured by 53.3% of those having email access. SMS was not generally favoured with older patients being signicantly less favourable (p < 0.01) and similarly use of an internet webpage was not generally favoured with females being signicantly less favourable towards a webpage compared to male patients (p < 0.01). Information security was a concern relating to the three new technologies highlighting a major user issue which may inhibit the adoption of new technologies. While there is some evidence regarding the effectiveness of ICT in supporting people with long term conditions, there is little attempt to distinguish between the different types of ICT (telephone versus internet based) and the key characteristics of the most successful initiatives and for

whom they are best suited. The cost of teleheath is substantial and therefore understanding where it is most effective will be important. Further there is generally a lack of clarity regarding dosage and frequency of the various interventions and the respective roles of nurses. It is also noteworthy that publication bias may result in underreporting of no differences depriving health systems of the full evidence on which to invest wisely. 4. Nurses working lives and ICT Stevenson et al. (2010) reviewed ve studies of nurses experiences of using electronic patient records derived from a database search of published papers written in English or Swedish 20002009. The ve small studies conducted in Australia, United States and England (two quantitative and three qualitative) found that nurses were generally dissatised with the electronic patient record because they did not support nursing practice through their failure to provide a good overview of the patient and lack of availability which undermined patient safety. Nurses reported that the records did not support individualisation of care and had a tendency to control the way that the nurse worked through the imposition of protocols. The nurses also reported that the actual computer systems were cumbersome, illogical, slow, complicated and unreliable at times. They suggested that nurses must become involved in the future design and development of the electronic patient record echoing the call by Forbes and While (2009) for nurses to become more involved in all levels of ICT design to avoid subordination within the care system. More recently a large survey (De Veer and Franke, 2010) of Dutch nurses (n = 685) had more positive ndings with nurses associating electronic patient records with improved care but negative attitudes were recorded regarding the consequences for the cost effectiveness of care and work circumstances highlighting the challenge for electronic patient record implementation. However, an ongoing issue regarding the nursing workforce is their computer literacy with evidence that some nurses are reluctant users of computers (Timmons, 2003; Verdegem and Verhoest, 2009) with the lack of skills training compounding the problem (Murphy et al., 2004,). Indeed, this reluctance to engage with ICT needs sensitive management because there is evidence that the experience of the benets of using ICT and electronic patient records increases their acceptability (De Veer and Franke, 2010) and therefore their likely successful implementation. Indeed, the introduction of electronic health records and electronic health information exchange is not without its challenges as illustrated by Goroll et al.s (2009) implementation report of the Massachusetts eHealth Collaborative (MAeHC) comprising a diverse set of competitively selected communities of nearly 500 physicians serving over 500,000 patients. The challenges included compatibility with existing systems, functionality, data security and cost which they managed through careful contracting and phased implementation following an invitation process to practices. They noted that the implementation had high transactional costs comprising

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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many hours of donated time by highly skilled professionals some of whom were presumably nurses. The UK experience of implementing ICT into the National Health Service has been equally troubled (Hendy et al., 2005, 2007) although paper based systems have many weaknesses which may be forgotten through the haze of nostalgia. A benet of ICT is its ability to increase accessibility to information sources. Doran et al. (2010) using a longitudinal survey assessed access to information resources for nurses (n = 488) in 29 acute care hospitals, long-term care providers, home care nursing providers and primary care programmes in Ontario, Canada. Only personal digital assistant (PDA) users reported a signicant improvement over time in the perceived quality of care delivered (p = 0.001) and job satisfaction (p < 0.001), especially among those working in long-term care settings (p = 0.01). However, both PDA and tablet computer users reported high satisfaction with their devices although there were differences in the reported ease of using the different information resource packages reecting the greater information available on the screen of a tablet computer (p = 0.05) and the faster information delivery to a PDA (p = 0.05). The study nurses reported a signicant improvement in research awareness and accessibility over time (p = 0.05) leading Doran et al. to recommend mobile information technologies as a means of reducing the barriers to research utilisation. Indeed, mobile ICT devices may be an important enabler of evidence-based nursing practice. A telephone call centre is a different working environment from clinical care settings. Mueller et al. (2008) and Snelgrove (2009) have reported the experience of nurses working within UK NHS Direct call centres (Mueller et al., 2008 [2 call centres; 17 semi-structured interviews];

Snelgrove, 2009 [3 call centres; 92 nurse questionnaires (RR 83%); 2 focus groups]) and highlighted the tensions which arise for nurses regarding meeting call targets, adherence to decision protocols with limited room for autonomy and the absence of patient visibility which challenge the traditional nursing identity in terms a holistic approach to patient care. Mueller et al. (2008) identied a dichotomy between delivering efciency and a professional patient focus as the call centre service attempts to adopt some of the commercial call centre norms within its delivery. These ndings were echoed in Purc-Stephenson and Thrashers (2010) review of 16 studies relating to tele-nurses working in primary care derived from a systematic search of four literature databases of published papers 19802008. They identied ve major concerns experienced by nurses which include: the impact of protocols and algorithms upon autonomy; the comfort of the physical workspace; and stress caused by heavy workloads, assessing the credibility of callers and the challenge created by language difculties and hostile callers. The reviewed studies described how nurses attempted to adopt a holistic approach to assessment using their nursing skills to develop a rapport and listen to what was unsaid in building a clinical picture drawing upon clinical expertise to determine the urgency of health needs and the appropriate advice. The electronic health record will require all nurses to demonstrate computer literacy of varying sophistication depending upon the electronic health record functionality in the different health care organisations. Additionally, different job roles will demand differential use of ICT reecting both role autonomy and the practice setting (Fig. 5). Regardless, the emergence of ICT as a key component of modern health care will inevitably impact upon nurses and their working lives although to date there

Fig. 5. ICT use in nursing practice.

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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8 A. While, G. Dewsbury / International Journal of Nursing Studies xxx (2011) xxxxxx An, J.-Y., Hayman, L.L., Panniers, T., Carty, B., 2007. Theory development in nursing and healthcare informatics: a model explaining and predicting information and communication technology acceptance by healthcare consumers. Advances in Nursing Science 30 (3), E37E49. Antonicelli, R., Testarmata, P., Spazzafumo, L., Gagliardi, C., Valentini, M., Olivieri, F., Prati, G., 2008. Impact of telemonitoring at home on the management of elderly patients with congestive heart failure. Journal of Telemedicine and Telecare 14 (6), 300305. Bates, D., 2010. Getting in step: electronic health records and their tele in care coordination. Journal of General Internal Medicine 25 (1), 174176. Biddiss, E., Brownsell, S., Hawley, M.S., 2009. Predicting need for intervention in individuals with congestive heart failure using a homebased telecare system. Journal of Telemedicine and Telecare 15 (5), 226231. Bot, M., Milder, I.E.J., Bemelmans, J.E., 2009. Nationwide implementation of hello world: a Dutch email-based health promotion program for pregnant women. Journal of Medical Internet Research 11 (3), e24. Bowles, K.H., Holland, D.E., Horowitz, D.A., 2009. Comparison of in-person home care, home care with telephone contact and home care with telemonitoring for disease management. Journal of Telemedicine and Telecare 15 (7), 344350. Cady, R, Finkelstein, S., Kelly, A., 2009. A telehealth nursing intervention reduces hospitalization in children with complex health conditions. Journal of Telemedicine and Telecare 15 (6), 317320. Currell, R., Urquhart, C., Wainwright, P., Lewis, R., 2000. Telemedicine versus face to face patient care: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews Issue 2. Art. no.: CD002098. doi:10.1002/14651858.CD002098. Dang, S., Dimmick, S., Kelkar, G., 2009. Evaluating the evidence base for the use of home telehealth remote monitoring in elderly with heart failure. Telemedicine and e-Health 15 (8), 783796. Dansky, K., Vasey, J., 2009. Managing heart failure patients after formal homecare. Telemedicine and e-Health 15 (10), 983991. De Veer, A.J.E., Franke, A.L., 2010. Attitudes of nursing staff towards electronic patient records: a questionnaire survey. International Journal of Nursing Studies 47 (7), 846854. DoH (Department of Health), 2008. High Quality Care For All: NHS Next Stage Review Final Report. TSO (The Stationery Ofce), Norwich, UK. Doran, D.M., Haynes, R.B., Kushniruk, A., Straus, S., Grimshaw, J., Hall, L.M., Dubrowski, A., Di Pietro, T., Newman, K., Almost, J., Nguyen, H., Carryer, J., Jedras, D., 2010. Supporting evidence-based practice for nurses through information technologies. Worldviews Evidence Based Nursing 7 (1), 415. FCC, 2010. Connecting America: The National Broadband Plan. Federal Communications Commission, Washington DC, USA. Fong, B., Fong, A.C.M., Li, C.K., 2011. Telemedicine Technologies: Information Technologies in Medicine and Telehealth. John Wiley & Sons Ltd., Chichester, UK. Forbes, A., While, A., 2009. The nursing contribution of chronic disease management: a discussion paper. International Journal of Nursing Studies 46 (1), 120131. Fry, J.P., Neff, R.A., 2009. Periodic prompts and reminders in health promotion and health intervention behaviour interventions: systematic review. Journal of Medical Internet Research 11 (2), e16. Goroll, A.H., Simon, S.R., Tripathi, M., Ascenzo, C., Bates, D., 2009. Community-wide implementation of health information technology: the Massachusetts eHealth collaborative Experience. Journal of American Medical Information Association 16 (1), 132139. Gracia, E., Herrero, J., 2009. Internet use and self-rated health among older people: a national survey. Journal of Medical Internet Research 11 (4), e49. Grayston, J., Fairhurst, K., McKinstry, 2010. Using new technologies to deliver test results in primary care: structured interview study of patients views. Primary Health Care Research and Development 11 (2), 142154. Hendy, J., Fulop, N., Reeves, B., Hutchings, A., Collin, S., 2007. Implementing the NHS information technology programme: qualitative study of progress in acute trusts. British Medical Journal doi:10.1136/ bmj.39195.598461.551. Hendy, J., Reeves, B., Fulop, N., et al., 2005. The National Programme for Information Technology: challenges to implementation. British Medical Journal doi:10.1136/bmj331.7512.331. Istepanian, R.S.H., Zitouni, K., Harry, D., Moutosammy, N., Sungoor, A., Tang, B., Earle, K.A., 2009. Evaluation of a mobile phone telemonitoring system for glycaemic control in patients with diabetes. Journal of Telemedicine and Telecare 15, 125128. Lee, H.Y., Janga, S.-N., Leeb, S., Chob, S., Park, E.-O., 2008. The relationship between social participation and self-rated health by sex and age: a

is limited research focusing upon this topic area. There is a need to further understand the demands of telephone triage work as well as the characteristics of the ideal electronic patient record from a nursing perspective. In addition studies are needed which test ICT as a vehicle for enabling evidence-based practice and high quality patient care. 5. Conclusion The growth of virtual healthcare is inevitable and provides the vehicle for signicant changes in health care delivery especially for people in remote locations. It allows people to access health care and advice directly from their home or other places such as shops or their workplace and it may enable the personalisation of health care with people taking control over their own health and health records. However, it is also the harbinger of health care on demand in which people will expect access to health related information and services 24 h a day, 7 days a week, 52 weeks a year in much the same way that there is access to other services through the telephone and internet. To date the evidence reports nurses as either delivering or being part of health care interventions but there is little detail relating to nursing activity, dosage or frequency of the interventions, and the respective roles of nurses. Further, the evidence of the effect of these interventions is mixed despite the high cost of many of the interventions and the potential under-reporting of no difference. In addition, the impact of ICT upon nursing practice and nurses lives and the acceptability of the information age of health care to both patients and their carers require further exploration. Indeed, the lack of research exploring the impact of ICT upon nursing practice and nurses working lives needs urgent attention if it is to inform the ongoing development of nursing practice and future employment practices relating to nurses as they move into new roles. In the meantime the nursing workforce needs to engage fully with ICT so that nurses do not have a merely passive relationship with technology feeding the system with data for others to interpret or acting as an output analyst in meeting health needs (Forbes and While, 2009). Nurses need to become the ICT system managers and designers in addition to clinical data collectors and data analysts so that they contribute to system management and system design thereby shaping the care system and dening the structural components that dene the care system or they will remain subordinate within the new systems delivering clinical activity (Forbes and While, 2009). Conict of interest None declared. Funding None. Ethical approval None. References
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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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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