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Learning Activities
Nursing 4141: Nursing Practice 7

CHINS, Telenursing and Societal Health


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"Telenursing has been in existence for decades, using available technology to serve its purposes. For example, the telephone has long been used as a communication tool between nurses and health care consumers as well as other professionals. As new technology became available it was also adapted to educate consumers and peers, maintain professional contacts, and provide care for clients at other sites. As a result, nurses currently use telephones, faxes, computers and teleconferences in the practice of telenursing. Potential applications are varied, but common uses are telephone triage, follow-up calls, and checking biometric measurements. Interactive television or teleconferences enable home health nurses to make electronic house calls to clients in their homes; thus nurses can see more clients per day than would be possible via on-site visits."
- (Hebda, Czar & Mascara, 1998, p. 264)

Telehealth has become a topic of focus for many health care professionals across the globe, in answer to several issues. Proximity to health care, shorter hospitalizations, shortage of health care professionals, workloads, and the advent of sophisticated technologies all contribute to this phenomenon. Nurses are not the only professionals involved; there are now several branches of telehealth, including telemedicine, telepharmaceuticals, telepsychology, teleradiology, and so on. Virtually every member of the health care team can learn to provide care using technology and computers as the medium of assessment, diagnosis and care directives. Telehealth is not a replacement for in-person care, but it does fill a need for clients who wish contact with health care professionals yet either can not or do not want to have to go to an agency or clinic for treatment. Telehealth is having a positive impact on rural health care, where clients are scattered over large distances and may have trouble driving into more settled areas for health care.

Telenursing is the branch of telehealth that involves actual nursing and client interaction through the medium of information technology. Before the advent of computers, similar activity sometimes occurred using telephones (which still occurs, i.e. the BC NurseLine) or even two-way radio. “Telehealth is the provision of health care or health information using telecommunications technology to provide care or information over long or short distances. It may include consultation, assessment, diagnosis, treatment, transfer of health data, client education and professional development. Telehealth may use familiar technology such as telephone, e-mail, or personal digital assistants, or more complex technology such as remote control surgical instrumentation” (CRNBC, 2005, p. 1).

Telenursing first evolved to provide expert service to people living in remote areas, but it is becoming more common in urban regions as well. New technologies have added a visual component to the interactions that augments the historic audio exchange. Nurses can actually view healing wounds, can access physiological monitoring equipment to measure physical indicators such as vital signs and provide routine assessment and follow-up care without the client having to travel to the health care agency for an appointment. “Telehealth, considered the use of home-monitoring systems by nurses, may be designed to provide home healthcare nursing services to monitor chronic diseases, such as diabetes. A video monitoring system may be used in conjunction with the monitoring devices at both ends of the system, permitting video and voice interaction between nurse and patient and adding a personal touch” (Moody, 2005, p. 157).

It does seem logical that some clients would find value in telenursing services, especially if the alternative would require repetitive travel, expense, or isolation from home and significant others. However, nurses need to be aware of the less visible potential effects of providing nursing care “...on screen, instead of behind the screens” (Sandelowski, 2002, p. 64). Nurses need to question if the absence of physical presence and shared physical space detracts from caring and establishing reciprocity with clients. Telenursing “Nurses have an interest in determining how tele-technologies can be used to maximize health benefits and to enhance the felt presence of the nurse, but they also have an interest in understanding how these technologies can undermine the presence of the nurse. Tele-health practices not only call for nurses to reconceptualize presence, place, and bodies in nursing, but also to explore how these practices threaten to displace nursing” (p. 65). There is a danger that both nurses and clients can enter a sort of shadow land as they dissolve into the virtual interface. It is imperative for any nurse who engages in telenursing to be aware of this, and to ensure that network exchanges with their clients reflect dynamic, personable caring and attentiveness, even when the interactions occur via ICT mediums. In telenursing, it is the nurse who is responsible and accountable for ensuring that the client is never perceived as a “ ...hypertexted, hyperreal representation on screen in the form of a rhythm strip; black-and-white or colorized image; or numeric, graphic, digital, schematic, or other visual display” (p. 66).

It is theoretically possible, if the technology used is sophisticated enough to provide clear, crisp visuals, real-time relay, exceptional audio, and accurate physiological measurement, that an astute and technologically literate nurse could create a similar sense of caring, presence, and individualized attention with the client, using telenursing ICTs. Still, virtual environments for nursing care could challenge the nurse's ability to perceive the digitalized presentation of the client as an individual, and provide individualized care. “For nurses especially, they trouble the distinction between human being/body and information network, and between body work and information work. Yet they offer nurses an opportunity to move toward an informatics of the body and a more embodied informatics in nursing; that is, toward an orientation to nursing education, practice, and research that celebrates the body work of nursing and reunites it with the information work of nursing” (Sandelowski, 2002, p. 67).

While engaging with the virtual representation of a client, the nurse must strive to envision and experience the client's three dimensional body and being in order to accurately advise, assess, diagnose, and interact fully and dynamically. This perceiving must occur within the a virtual network environment, where both body-sense and body-awareness are combined with digital information. “Nurses must see body and information work as constituting each other, and the body as a source of knowledge and power for nursing. Because nurses occupy a distinctive place in the health care arena, they have a distinctive contribution to make to theorizing the body in the virtual environments of care now emerging” (Sandelowski, 2002, p. 68). Not only the body, but also the person's inner being must be acknowledged and somehow included.

What are the psychological and emotional effects of being examined and assessed via a video camera? Is the sense of intimacy and privacy common in caring client-nurse interchanges lost in the virtual translation? These are questions that nurses must consider before engaging in telenursing network interactions and activities. The ideal scenario would be that nurses and ICT designers could work together to create more sophisticated ICTs that could meet the needs of the clients better. “Although they seem far removed from each other, both media designers and nurses share a common interest in presence: in how to create it, how to use it effectively, and how it works to generate its effects. At the heart of all efforts to enhance media is the creation of the illusion that technologically mediated experiences, such as tele-health encounters and virtual reality, are not mediated at all; that is, to create the perception of presence. The design intentions behind distance technologies are to overcome the effects of distance and electronic mediation; that is, to simulate lifelike and full-bodied encounters in proximate space that close the distance between people and allow users to feel as if they were,...reaching out to touch someone” (Sandelowski, 2002, p. 65).

Community Health Information Network Systems (CHINS) are another approach to using technology to bolster societal health that relies on sophisticated computer systems. A well-integrated CHIN seamlessly conveys information, client records, treatment initiatives, test results, nursing notes, and other health documentation to a variety of health care professionals across the community-acute care health setting. “A CHIN can be defined as an organization that offers electronic connections that enable all providers, payers, and purchasers of care to exchange financial, clinical, and administrative information in a defined geographic location. In other words, a CHIN is a public wide-area network, linking various participants in a community of care,” (Hebda, Czar & Mascara, 1998, p. 201).

Ends in View

This learning activity is intended to give the learner the opportunity to:

1. Explore the current and future applications of telenursing both locally and globally through the lens of change.

2. Recognize the advantages and challenges inherent in the practice of telenursing.

3. Explore the impact telenursing can have on societal health.

4. Understand the components and rationale for CHINS within a community, and the changes that the transition would entail.

5. Comprehend the processes involved to provide quality health care and the role that CHINS have in these processes.

6. Recognize their own learning needs to become proficient in practicing telenursing and using a CHINS to document client care.

In Preparation

1. READ: Peters, D. (2008). Reducing hospitalizations through the implementation of a telehealth program. Home Health Care Management and Practice, 21(1), 39-43.

2. EXPLORE: the website of the Office for the Advancement of Telehealth at http://telehealth.hrsa.gov/

3. VIEW: the Powerpoint by Dancey, A. (2004). The Community Health Information Network. CANARIE Workshop Showing Results – Sharing Knowledge, Toronto, Ontario.

4. READ: Lowenstein, A. (2003). Vision for the future of nursing. Editorial. ICUS Nursing Web Journal, 16, October-December, 1-2.

5. READ: Marsh, L. (2007) Innovations in Theory Development for the Nursing Discipline. pp. 112-118 (Chapter 9) in Browning, G. et al (eds), Innovations in Theory Development for the Nursing Discipline, Volume 1.

6. EXPLORE AND REFLECT: on how eHealth can help nursing as you visit - the Centre for Global eHealth Innovation website.

VIEW VIDEOS7. VIEW VIDEOS: View the embedded brief videos featuring benefits and processes of using Telenursing, E-health, CHINs.

In Practice

1. Describe how telenursing could facilitate quality health care for the following clients (apply change theory principles in your answer - use the Worksheet to record your answers):

a) Mrs. Brown, a 78 year old widow who lives in a country home alone, forty kilometers from the nearest town.

b) Mr. Jones, 35 discharged from a local acute care hospital twenty four hours after abdominal surgery.

c) A pregnancy support group located in a small Northern B.C. settlement.

2. Create a conceptual map reflecting both the advantages and the challenges of telenursing. Include change issues and the theory reflected in the readings.

3. Using a graphics program, make a pictoral model of a CHINS, including as many health care professionals, services and agencies as you can think of.

In Reflection

1. Telenursing and the use of CHINS are predicted to be the norm in the future. How will you prepare yourself to be an active participant in these movements? Will you feel comfortable providing nursing care this way? Why?

2. How can nurses be involved in the design and configuration of CHINS in their nursing community? What advantage is there for becoming involved in this process?


Dancey, A. (2004). The Community Health Information Network. CANARIE Workshop Showing Results – Sharing Knowledge, Toronto, Ontario.

Doyle, E. (1995). New computer networks offer a revolution at your fingertips. ACP - ASIM Observer, June.

Hebda, T., Czar, P. & Mascara, C. (1998). Handbook of informatics for nurses and health care professionals. Menlo Park, CA: Addison-Wesley.

Marsh, L. (2007) Innovations in Theory Development for the Nursing Discipline. pp. 112-118 (Chapter 9) in Browning, G. et al (eds), Innovations in Theory Development for the Nursing Discipline, Volume 1.

Office for the Advancement of Telehealth at http://telehealth.hrsa.gov/

Registered Nurses Association of Nova Scotia. (2000). Guidelines for Telenursing Practice. Halifax, NS: Author.


Nursing Informatics Integration for the BSN in Nursing Program at Kwantlen Polytechnic University
Design & Content by © June Kaminski, RN MSN PhD(c) - 1999 - 2011
All rights reserved. No reproduction without written permission