Teaching Nurses to Build a Hospital
Without Walls:
Developing a Training Curriculum
for Telehomecare
Duncan Sanderson
1
and Lynda Atack
10842 Waverly; Montreal; Canada H3L 2W8
Abstract. "To what extent can people be taught to engage in Computer
Supported Cooperative Work (CSCW)?" is a question which has rarely been
discussed at meetings of CSCW researchers. The present study suggests that
qualitative research can contribute to the development of a curriculum for
preparing nurses to work with patients who live at a distance from themselves.
Building on the ethnographic research stream within CSCW, a qualitative study
was conducted of three different telehomecare (THC) programs in order to
identify work issues and difficulties which could be addressed in a training
course for telehomecare nurses.
1 Introduction
With increasing demand for hospital beds, tight funding frameworks, and scarce
human resources, convalescing and chronically ill people are increasingly receiving
medical care at home. Various types of home care programs are appearing, one of
which is telehomecare (THC), which is the use of computer and communication
technology in the delivery of nurse managed care to patients at home. With this
approach, sick patients at home transfer data or describe symptoms and health states
to nurses usually in a remote institution, who in turn provide information and
recommend certain actions to their remote clients. In many programs, there are three
main actors in the day-to-day operations, the nurse, the patient, and the
communication or computer technology. In general, the nurse can be considered to be
the conductor in this orchestrated activity.
Managers at a post-secondary educational institution in particular felt that there
would be an increased need for nurses who could provide telehomecare and for
managers who could plan and implement such programs. Accordingly they pursued
and obtained funding for the development of an online distance education program in
order to train and prepare an anticipated cohort of nurses who would be needed to
staff such programs. In this report, we will discuss the identification and analysis of
nursing practices which helped to shape the development of a curriculum for training
nurses to work in telehomecare programs. This paper departs from common analysis
Sanderson D. and Atack L. (2004).
Teaching Nurses to Build a Hospital Without Walls: Developing a Training Curriculum for Telehomecare.
In Proceedings of the 1st International Workshop on Computer Supported Activity Coordination, pages 41-50
DOI: 10.5220/0002672600410050
Copyright
c
SciTePress
of CSCW technology design practices, and instead concentrates on the design of a
training curriculum.
As part of this project, the authors conducted research into telehomecare in order to
facilitate curriculum development. The project manager and researchers felt that
intimate knowledge of the work practices of telehomecare nurses would set the
curriculum development on a solid footing. The focus of this paper is to document the
ways in which a qualitative study of the work activities in telehomecare influenced
the curriculum and to discuss certain aspects of the work environment and
collaborative work practices observed. The objective was not to influence the design
of technology, but rather to determine if some of the methods commonly used in
CSCW could be extended to the design of a course curriculum. Since the training was
intended to help prepare nurses who would be engaged in telehomecare, there was a
desire to render visible, in a detailed and frank way, the work that this entails [1], with
the hope that this would influence the curriculum and eventually help prepare nurses
for it.
Although qualitative and ethnographic studies of workplaces have been carried out
frequently in conjunction with computer system design and development, it appears
that the use of these approaches for curriculum design is relatively original. In the first
section, we will identify work within social studies of medical practice and CSCW on
which the current study builds. The subsequent section outlines the methods used to
gain some understanding of the work of the nurses. This is followed by a brief
analysis of key work practices which influenced the design of the curriculum.
Finally, we will provide a brief critique of the enterprise of preparing nurses for
telehomecare through a continuing education course.
1.1 Studies of Medical Work and Telehomecare
Social science studies of medical work are not new; a long line of sociologists and
anthropologists have analysed various aspects of medical work and institutions (for
example, [2], [3]). More recently, there has been a major thrust to understand the role
that paper records play in institutions in general [4], [5] and in the organization of
medical work in particular [6], [7]. There has also been an interest in understanding
why computer systems developed in one medical context, may not easily transfer to
another [8].
Within the literature on telehomecare, several authors emphasize potential
benefits of such a program, such as more patient visits for a given budget, high patient
satisfaction (patients are happy not to be in or have to travel to the hospital) [9], less
hospital care [10], and less travel for homecare nurses. However, other authors
indicate that the anticipated economic benefits may not be very significant [11], that
numerous risks arise with this form of homecare [12], and some emphasize that
extensive planning and organizational preparation is necessary prior to program
implementation [13]. Medical personnel may also find the changes in work practices
difficult to accept or unattractive [14]. Thus, some authors suggest that behind the
often positive portrayal of telehomecare, lie a number of issues and difficulties with
which personnel will be confronted. Questions then arise as to what aspects should be
addressed in training programs, and how effective will this training be?
42
The authors noted above suggest a number of areas for further scrutiny: the
complex nature of the medical setting, activities which become routines and those
which are exceptions, the role of artefacts of all kinds in the work (paper documents,
computer systems), concerns about telehomecare, and administrative practices in
telehomecare programs. In our research, we were also interested in identifying that
which the medical personnel found to be difficult or troublesome, with a view to
alerting students to these issues and reporting others' approaches to solving the
problems experienced. It was anticipated that some difficulties could be overcome
relatively quickly (such as how to troubleshoot common technical problems), but that
others could remain troublesome even with experience.
1.2 Other Aspects of the Project Context
Various instructional design features were to be used in the training program delivery.
These included: an online delivery mode, web pages, streamed video to enhance
learners’ exposure to the knowledge and opinions of experts, instructor facilitation of
a discussion board to support a community of learning, and patient case studies to
stimulate discussion and problem solving.
Based on an estimation of program content and learners’ work and study
patterns, the THC course was developed as a 25 hour program and was to be provided
as a post-diploma continuing education program. The sponsoring educational
institution had developed a set of courses in telehealth, and although teaching staff
had knowledge of other types of telehealth programs, none had developed or worked
within a telehomecare program prior to the project.
2 The Methodology Used to Develop Knowledge of Telehomecare
Practices and Issues
Research activities were undertaken to develop an understanding of the work
practices and issues which could arise in the development of a telehomecare program.
One set was an extensive review of the THC literature, and the observation of THC
training at various sites. Another set was an in-depth case study of an existing
telehomecare program in Quebec, and observation of two other programs. The
context and methodology for the three case studies will be discussed below. As well,
current telehomecare nurses were also invited to comment on a draft outline of the
training curriculum and later on a protoype version of the on-line program (an
additional participatory approach).
The first THC program we studied had been in operation in Quebec for 3 years.
This program used a computer based monitoring technology, which had been
developed as a joint venture between the hospital and a company. The case study
entailed repeated interviews with two line-level nurses, a nurse program coordinator,
a main doctor associated with the program, and a senior manager. The interviews
explored the reasons for the creation of the program, its history, usual and unusual
tasks, what patients and staff learned during participation in the program, the
information which circulated, what personnel felt was useful to teach to others, and
43
interactions with others. During the interviews, the emphasis was on identifying
usual routines and patterns, along with perceived difficulties in the work.
Another part of this case study was five days of close observation of the work of
the nurses. This entailed paying attention to: the circulation and forms of information
[4], [15]; the way in which nurses monitored patient data; the nature of telephone
conversations with patients; the way in which patient records were created, updated,
and used; conversations between personnel; patient visits to see nurses at the hospital
and vice versa, and following nurses around the hospital.
There was some concern that a single case study could result in a training program
that was too oriented to a particular THC program, thus in order to broaden the base
of knowledge concerning learning needs in telehomecare, shorter studies were
undertaken of two other telehomecare programs. Both employed different
communication technology than the main field study site. One program, in a New
Brunswick hospital, was for post-cardiac surgery patients. The technology used in
this program (mainly a videophone with data transmission from peripheral devices)
had been developed in-house, from commercial components. The other program, in
Ontario, was in the developmental stage, and involved the participation of a
technology supplier, which provided off-the-shelf technology and acted as a
consultant to the program. The training provided by this technology provider, given
that they had the experience of several program start-ups, provided information in
terms of what this company believed was important for nurses to know.
A final approach to the curriculum development was the consultation of
publications on telehomecare (some of which have been cited here), and documents
which suggested policies and procedures (in particular, [15], [16], [17]). The Kinsella
volumes were particularly oriented to the learning needs of nurses and managers, and
thus were a significant resource.
The three programs used various technologies which had been developed in
different ways. The question of how the technology was developed is not significant
in relation to the curriculum development (nurses would most likely be users of the
existing technology), and will not be discussed here. However, certain characteristics
of the technology were important in relation to the curriculum, and these will be
highlighted below.
3 Observations
First it would be useful to provide a little more background information on the nurses
in telehomecare programs and the technology that they use. Nurses who are hired for
these programs tend to be very experienced. Thus the nurses were quite familiar with
hospital and care procedures, and this in itself was probably a positive factor in what
appeared to be slow acceptance of such programs in the hospitals. Thus, it was likely
that nurses who would be hired in other telehomecare programs would also have
extensive experience, and that the curriculum developers could assume that the
participating nurses had pertinent knowledge about care of the target patient
populations, and hospital processes.
Another important background element is that there are two general modes of
telehomecare: interactive mediated visits (telephone or video conference) and
44
computer monitored care. In the sites we examined, the Ontario and New Brunswick
sites used videoconferencing to carry out the patient visits. This entailed relatively
little change in established care procedures, aside from the fact that a nurse could not
feel the patient or physically intervene (for example, to change dressings).
Assessment, instructions, and patient education took place interactively with the
patient. However, the Quebec program appeared to represent a greater departure
from traditional patient activities and nursing routines. In this case, patients sent in
data to the nurse's monitoring station according to reporting periods programmed by
the nurse. In a very direct sense, this program involved computer supported
cooperative activity. Assessment, instruction, and education was carried out
automatically through an Internet based interactive computer system, which
forwarded patient answers to the nursing stations. If the nurse received abnormal
data, then the nurse could telephone the patient to verify and probe into this data with
the patient. The question then arose as to how to train nurses in relation to these
significantly different ways of providing remote care.
To answer this question, the curriculum team first recognized that many of the
underlying issues that appear with telehomecare transcend any particular program.
We called these common issues, training topics. For example, patient selection
criteria are generally established and the patient has to be assessed for their
conformity (a preliminary way of "configuring" the patient so that only patients with
needs which can be met by the program enter it). Nurses also need to: seek and
obtain consent to participate, instruct patients in how to use the technology,
communicate clearly to patients, and be able to explain the rationale of the program to
other staff. As well, the organization which hosts a telehomecare program needs to
establish procedures such as home assessment, and have forms (or electronic patient
records) to track and review the care given. Thus several general topics were
identified which addressed certain types of knowledge and skills (see Table 1).
Table 1. Key training topics
Advantages and limitations of THC, program rationale
Patient selection and recruitment, patient flow, discharge
Patient information and consent
Patient instruction in technology
Home assessment
Types of THC technology
Organizational records
Documentation of care
After hours care
Technology operation and trouble shooting
Care protocols
However, although we had identified general topics, it was apparent that actual
work practices often varied from one program to another. The patient selection
criteria in one program was not necessarily the same as another. The way of
responding to patients after hours (nurses in most programs work primarily during the
day) varied from one program to another. Thus it became apparent that these
45
different practices needed to be addressed in the curriculum. More examples of
general topics and particular practices will be noted below.
An important curriculum topic was technology trouble shooting. If problems
appeared with the "technology," then this would drive the activities of the nurses. In
the Quebec program, nurses reported that approximately half of their telephone
conversations with patients were about data entry problems or other technology
related problems (this did not take up half of their time though). Nurses in the other
programs similarly had to develop technology problem solving skills, though these
were clearly different from one program to another. As reported elsewhere [18],
strategies and problem solving tips can be learned on the job and we did observe on
the job sharing of these among co-workers. In the New Brunswick program, there
was an actual one week apprenticeship period alloted for this. This observation in
relation to common problems with the technology had a direct impact on the training
curriculum, in that an entire section of the curriculum was devoted to informing
nurses about this aspect of their work, and proposing strategies for developing trouble
shooting skills.
Another key topic that was identified was patient recruitment and patient flow. In
an emergency department, patients may literally stumble into the emergency
department "program" of care. Nurses do not generally go out of their way to look for
patients. Not so in the case of telehomecare. In Quebec, nurses actively checked a
paper list of patients admitted to the hospital, and identified those that they thought
would soon be suitable candidates for the program. After that, they would leave a
form with the attending physician, and ask if the physician accepted to assign the
patient to the program. If asked about this, the nurse would explain the program to
the physician. If the physician accepted, then the nurse would visit the patient and ask
him or her if they consented to participate. In other words, in order for the computer
supported cooperative activity to begin, another actor, physicians, had to "cooperate"
with the nurse, endorse the philosophy and practices of the program, and agree to
continue to provide care. In short, telehomecare created a new and significant task for
the nurse, which was patient recruitment. This is also an example of the way in which
one of our curriculum topics, nurses' knowledge of the telehomecare program and
their ability to explain its rationale, was intimately linked to another topic, that of
patient recruitment.
Once in the program, then another new task was training the patient in the use of
the technology. In the New Brunswick program, the patient stay was relatively short
(about a week), resulting in high patient turnover. In this program, patient training in
the technology became a necessary but repetitive and sometimes unpleasant task for
the nurses. This observation also resulted in learning activities in the curriculum to
help nurses teach patients about using the technology.
Another topic became the development and/or use of care protocols. A protocol
represents an attempt to both standardize and make routine the care activities for
patients with a given illness. For example, patients with diabetes would be asked a set
of questions related to that particular illness. In the Ontario program, no new protocol
procedures were introduced, and nurses continued to use whatever protocols they may
have used previously for their traditional home care activities. In the New Brunswick
program, a computerized questionnaire was used by the nurses which suggested
particular questions to ask, and answers which could be ticked off. A senior nurse
with considerable experience had developed this protocol using specialized software.
46
Work in this program, at least for this senior nurse, had taken on an added dimension
of learning about new software and the formalization of knowledge and practices
[19].
The development and use of patient protocols was even more significant in the
Quebec program, which used the computerized monitoring program. Patients would
sign on to the web phone based system, and be led through a series of screens which
would ask questions about their symptoms and accept text or numeric data. Much of
the time of the program coordinator (a nurse) had been taken up with the
development, computer entry, validation, and teaching of protocols to other nurses.
In this work, a general protocol was developed first, which could take weeks to
produce, and entailed analysis of medical articles, inquiries about national and
regional best practices, and validation by a physician. Once the protocol was
represented on paper, it had to be translated into software, through a protocol editor
(which took a few days to learn). In short, the nurses created a sort of computer
program for each patient by using the protocol editor. The automated protocol
"coordinated" patient activity, since patients had to fill in the screens three or four
times daily. It also acted as question asker, instructor (the patient was reminded to do
certain activities and the reasons for this), motivator, and note taker. However,
although the software assumed certain nurse activities, the price for this was that
nurses had to learn how to develop and computerize the protocols, and spend time
developing the protocols and customizing them to patients. Some general information
about care protocols was included in the curriculum, but because of the complexity of
this activity and its use in only one program, the curriculum did not teach nurses how
to develop such automated protocols.
Another important observation was the significant differences in patient care
philosophy between the two program modes (interactive vs. monitoring). In the
interactive mode (ie videoconference), nurses continue to inquire orally about patient
symptoms, direct care, and to remind patients of required action. In the Quebec
program, there was a distinctive philosophy of shifting responsibility for patient care
from the nurse to the patient. The personnel in this program had a pronounced
attitude of involving patients directly in their home care. For example, patients
became responsible for taking their blood pressure correctly (whereas there were
automatically inflated blood pressure cuffs in other programs), patients had to enter
their own data (weight, medication, etc.) into the computer system so that they would
know what this was, and a conscious decision had been made to not use peripheral
devices which automatically transmit data to the nursing station. Nurses were aware
that patients could enter false data, but felt the patient was responsible for this. In
terms of the new nurse - technology - patient relationship, part of traditional nurse
responsabilities (i.e. taking blood pressure, asking about symptoms and recording
them) had been shifted to the patient. This example helps to illustrate the surprising
turn that "cooperative" work took within this program. This program variation was a
difficult topic area for the curriculum designers to incorporate into the training
curriculum, and one which ultimately was not addressed directly.
Finally, to build on an expression used by [20], it is interesting to note that some
of the nurses in the New Brunswick program indicated that in some ways they had
been too successful at eliminating the walls of the hospital, and that it had become a
little too easy for patients to enter into the nurse's home space. They noted that
patients could page them after hours, at home when the nurse was asleep, and woke
47
the nurse up just to say they had difficulty getting to sleep! The late night telework
situation of the nurses was invisible to the patients. In a way, the hospital and
bedroom walls which separated the nurse's work space from their residence had
actually disappeared. The curriculum simply alerted the nurse students to this
possibility.
4 Conclusion
A qualitative research approach was taken in order to identify issues, difficulties,
routines, and exceptional work which nurses carry out in telehomecare programs.
Building on the concepts and methods developed by others (particularly [1] [4] [15]
[17], we were attentive to the flow of information and the artefacts active in this
process, the definitions that individuals and organizations gave of their work, and the
importance of making visible routine and problematic aspects of their work. This
analysis revealed several topics suitable for a training program which could be of use
to nurses wishing to work in telehomecare (Table 1). Several of these key topic areas
were presented and discussed above.
The particular technology used can also impact certain aspects of the interaction
between nurse and patient. The two programs which used videoconferencing required
patients to be available at a pre-arranged time, once a day. This is not the same kind
of patient - nurse interaction as occurs when a patient sends in data three times a day.
In the Quebec program, days or weeks could go by without a telephone call to or visit
with the patient. The nurses who used the video conference technology also
appeared to have less discretion in relation to the way he or she structured the
working day. As well the choice of technology (made by managers) impacts on
patients in that it may prevent certain patients from receiving telehomecare. The
monitoring technology used by the Quebec program did not have a function for
capturing images (although theoretically possible, this would have required much
development to integrate image capture into the existing technology), and so patients
with wound care were excluded from it (whereas wound monitoring, which was
enabled by the camera, was a key aspect of the post-cardiac surgery program in New
Brunswick).
A dilemma emerged in our efforts to develop the curriculum for telehomecare
nurses. The qualitative analysis reported here contributed to the identification of this
dilemma, and in a way this could be considered to be a sign of the success of the
analysis. As noted throughout the text the dilemma was how to create a common
curriculum for nurses who would work in telehomecare programs when these
programs could be quite ideosyncratic. Moreover, the college providing the
instruction was allied with a particular THC program, with its own inter-
organizational referral system, videoconference technology, and private nursing
services provider. Understandably, the college wanted to instruct nurses who would
be working in that program. The solution that we adopted was to alert students to
certain general issues (such as patient recruitment, training patients in technology), to
outline the range of practices that we had observed, and to provide information
specific to the program associated with the college.
48
It is worthwhile to remind the reader that the eventual contribution of the
curriculum to the preparation of nurses is unknown at this time. In this regard, it is
useful to point out that two of the three programs noted here were started with
relatively little nurse training (in the third program nurses received only two days of
training from the technology provider before starting to work in the program). If
nurses can begin to participate in a program after relatively little training, to what
extent will nurses and managers believe that the college training outlined here is
needed? At this point nurses' and managers' perceptions of the usefulness of such
training is still largely unknown, although there has been some positive appreciation
of the prototype on-line training.
Nevertheless, we believe that the implementation of THC is likely to be facilitated
if nurses know in advance the kinds of issues that are likely to arise and if they are
prepared with knowledge of possible approaches to solving these. Although the
question, "To what extent can people be taught to engage in CSCW?", remains
unanswered, the present report suggests that a first step in answering this question is
to develop such a training program. The qualitative research reported here contributed
to the development of a curriculum for preparing nurses to work with patients who
live at a distance from their place of work. Subsequent to this, and after nurses
participate in the course, further evaluation may then indicate the extent to which the
course actually prepares nurses to work in telehomecare programs.
Acknowledgements
The research reported here was funded by CANARIE. The authors would like to
thank Robert Luke, Project Director, for his important contribution to this project.
Our sincere thanks is also extended to the health care personnel who participated in
interviews and allowed us to observe their training and work.
References
1. Suchman, L.: Making Work Visible. Communications of the ACM (1995)
38 (5) 57-65.
2. Strauss, A, Fagerhaugh, S., Suczek, B. and Wiener, C.: Social Organization
of Medical Work. Chicago: University of Chicago (1985).
3. Garfinkel, H.: "Good" organizational reasons for "bad" clinic records, in H.
Garfinkel, Studies in Ethnomethodology, Prentice Hall, Englewood Cliffs
(1967) 186-207.
4. Harper, R.H.R.:. The Organisation in Ethnography: A Discussion of
Ethnographic Fieldwork Programs in CSCW. CSCW (2000) 9 239-264.
5. Trigg, R.H., Blomberg, J. and Suchman, L.: Moving document collections
online: The evolution of a shared repository. Proceedings of the European
Conference on Computer-Supported Cooperative Work ECSCW'99, Kluwer,
Copenhagen, Dordrecht, (1999) 331-350.
49
6. Berg, M.: Medical Work and the Computer-Based Patient Record: A
Sociological Perspective. Methods Of Information in Medicine, (1998) 37:
294-301.
7. Harper, R., O'Hara, K., Sellen, A., and Duthie, D.: Toward the Paperless
Hospital? British Journal of Anaesthesia, (1997) 78, 762-767.
8. Forsythe, D.: New Bottles, Old Wine: Hidden Cultural Assumptions in a
Computerized Explanation System for Migraine Sufferers. Medical
Anthropology Quarterly (1996) 10 (4): 551-574.
9. Maiolo, M., Mohamed, E., Fiorani, C., de Lorenzo, A.: Home
telemonitoring for patients with severe respiratory illness: the Italian
experience. Journal of Telemedicine and Telecare, (2003) 9 (2) 67 -71.
10. Riegel, B.; Carlson, B.; Kopp, Z: LePetri,B; Glaser, D.; Unger, A.: Effect of
a Standardized Nurse Case Management Telephone Intervention on Resource
Use in Patients with Chronic Heart Failure. Archives of Internal Medicine,
(2002) 162 (6) 705-712.
11. Shepperd, S., Iliffe, S..: Hospital at home versus in-patient hospital care.
(Cochrane Review), The Cochrane Library, (2003) Issue 4.
12. Roback, K., Herzog, A.: Home informatics in healthcare: Assessment
guidelines to keep up quality of care and avoid adverse effects. Technology
and Health Care (2003) 11 (3) 195 - 206 .
13. NIFTE.: National Initiative for Telehealth Framework Framework of
Guidelines. Ottawa. (2003) www.cst-sct.org.
14. Steding, P.: Telehealth Users Step Up to the Microphone. Success in Home
Care. (2001) November/December, 14-21.
15. Berg, M.: Accumulating and Coordinating: Occasions for Information
Technologies in Medical Work. CSCW (1999) 8: 373-401.
16. Kinsella, A.: Home telehealth: process, policy, and procedures. Kensington,
MD, Information for Tomorrow, (2003).
17. Kinsella, A.: Home healthcare: Wired and ready for telemedicine. The
nurses' and nursing students' edition. Kinsington, MD, Information for
Tomorrow, (2003).
18. Orr, J.: Ethnography and Organizational Learning: In pursuit of learning at
work. In S. Bagnara, C. Zucchermaglio, and S. Stucky, (eds.):
Organizational Learning and Technological Change. New York, Springer-
Verlag, (1995).
19. Berg, M.: On Distribution, Drift and the Electronic Medical Record: Some
Tools for a Sociology of the Formal. In Proceedings of ECSCW'97, Hughes,
J, Prinz, W., Rodden, T., and Schmidt, K. (Eds.), Kluwer, (1997) 141-156.
20. Wilson, L., Gill R., Sharp, I., et al.: Building the Hospital Without Walls -- a
CSIRO home telecare initiative. Telemedicine Journal (2000) 6: 275-281.
50