Telenursing use in mother and child community health centers: A qualitative study among public health nurses

Abstract

Objective

The use of telenursing has been increasing, but in mother and child community health centers in Israel, it is rarely in use. The study aimed to explore the existence and implementation of telenursing services and to analyze nurses’ perceptions, identifying factors that may promote or delay their use.

Design

A qualitative approach study using thematic analysis was conducted in the North, Tel-Aviv, and South regions of the Ministry of Health, and involved 19 nurses—7 in a management role, and 12 staff nurses.

Methods

Data collection employed semistructured interviews conducted in-person or over Zoom. The data were analyzed to identify themes, subthemes, and categories.

Results

Telenursing services exist mainly on a national level, including the nationwide Ministry of Health's call center and a service providing online parent enrichment lectures. Nurses viewed remote services as enriching family education, extending care beyond brief clinic visits through improved access, and creating opportunities for flexible work (including from home) and enhanced professional recognition. Yet, nurses addressed some challenges including fear that reduced face-to-face contact may erode trust with parents, decrease diagnostic accuracy, and marginalize nursing; they also reported added workload, digital-literacy gaps, and potential reductions in clinic utilization. System-level barriers included weak infrastructure, limited technical support, legal and procedural gaps, and needs for training, clear protocols, and ongoing monitoring. Finally, participants cautioned that telenursing may widen inequalities and foster distrust in vulnerable communities.

Conclusions

Telenursing can improve access, quality, and efficiency, but requires hybrid integration, strong infrastructure, training, and support.

Introduction

Technological advances provide options for the availability of and access to rich multidisciplinary knowledge in various areas of life, such as consumerism, economics, finance, government institutions, and health. Telehealth, the ability to provide remote healthcare services using digital tools (e.g., telemedicine, telenursing), has been experiencing significant growth around the world, motivated by technological and digital advances, changing the provision of healthcare services. ¹ However, the use of telenursing is still limited.^2,3 A 2025 US national RN survey found that 22% of nurses personally provided telehealth care and 43% worked in settings using telehealth. ⁴ In Israel, system-level data on telenursing use are limited; however, a 2024 time-motion study among family physicians reported that only 18% of encounters were conducted by telephone, <1% by video, and 36% via asynchronous online requests. ⁵

Telenursing means providing nursing services and transferring clinical information through communication technologies, eliminating the need for face-to-face contact or copresence of nurse and patient. ⁶ Telenursing was first documented in 1967, when Boston's Logan International Airport used specialized cameras and a television link to connect nurses and patients with physicians at Massachusetts General Hospital. Historically dominated by telephone-based triage and follow-up, telenursing has since expanded to synchronous video consultations, camera-enabled remote assessment, secure digital messaging, and integrated remote patient-monitoring platforms. ⁷ This development enables healthcare providers to offer a range of remote services, such as evaluating patients, counseling, and management of chronic diseases, thus improving both the range and efficiency of healthcare services provision. As part of the Fourth Industrial Revolution, telehealth shifts health from place-based encounters to connected care, modernizing diagnostic and treatment methods. ⁸ During the COVID-19 pandemic, the need for social distancing accelerated the adoption of telehealth services around the world, enabling the reduction of the exposure and infection risk of both patients and healthcare staff and improving the accessibility and availability of nursing services.^9,10 Telenursing also has additional benefits such as: reducing costs associated with providing face-to-face treatment and decreasing visits to urgent care centers.^10,11 Alongside telenursing's benefits, some factors hinder the use among nurses: factors related to characteristics of the nurses themselves, such as a lack of technical skills to use systems,^12,13 stress around the implementation of new systems that leads to increased workload and lack of time, ¹⁴ or nurses’ perception of the ability of patient populations (such as the elderly, low socioeconomic status, or low education) to receive online services, which may reduce nurses’ motivation. ¹⁵ According to an integrative review by Souza-Junior and colleagues, telenursing is an expanding field, with documented implementation across various countries and growing evidence supporting its benefits and effectiveness. ¹⁶

In Israel, the mother and child community health centers (MCCHC)—known as Tipat Halav, provide care according to national public health services guidelines. They operated even before the founding of the state. These centers operate nationwide, providing free consultation services and preventive care to babies, infants (from birth until six years of age), and families, and include immunizations, growth and developmental surveillance, anticipatory guidance, breastfeeding support, and screening for postpartum depression. ¹⁷ The primary care providers in the MCCHCs are public health nurses supported by pediatricians,^18,19 guided and supervised by the Israeli Ministry of Health.

The importance of telehealth services became evident during pandemics, wars, or social distancing periods in Israel^20–22 demonstrating their potential to transform components of the traditional service model. Telenursing in Israel in general and particularly in MCCHCs is still in its infancy, the extent of usage and quality of these services is unknown, and it is not clear what the attitudes of healthcare staff are toward using telenursing. Therefore, in this study, we seek to answer the following research questions:

1. Which telenursing services exist in MCCHC, and how are they implemented and performed?

2. What factors promote or hinder MCCHC nurses’ use of telenursing?

Methods

Study design

This study employs a phenomenological qualitative research approach, using a field-anchored theoretical approach and a methodology of thematic analysis. ²³ The focus of the investigation was on exploring the existing telenursing services in MCCHCs and understanding participants’ attitudes and perceptions, classifying topics from the data collected. We used the PICo framework (Population, phenomenon of Interest, Context). The population is MCCHC nurses; the phenomenon of interest is perceptions of integrating telenursing; the context is MCCHC in Israel. The researchers used the COREQ guidelines.

Research location and participants

Participants were 19 MCCHC nurses who belong to the Ministry of Health, in three districts of the country: North, Tel-Aviv, and South. The participants were either in a management role (n = 7) or in a staff–nurse role (n = 12). Inclusion criteria: one-year work experience as an MCCHC nurse. There were no exclusion criteria. We used a combined purposeful sampling method, ²⁴ focusing on nurses who have various roles and work with diverse populations. The management nurses were nurses in a local, district, or national management position which enables extended points of view. The management nurses were chosen as politically important for the study. The staff nurses were recruited using the snowball method ²⁴ from clinics in various areas and with diverse populations (i.e., Ultraorthodox, Bedouin, Arabs, Jews; low, middle, and high socioeconomic levels of the clinic population; and living either in rural or urban settlements). This approach ensured a wide range of experiences and insights for the nurses.

Recruitment and data collection

Data collection was conducted both in-person and online via Zoom using semistructured interviews during 2022. The interviewer was ZA, a female during her Master degree in nursing sciences and community nurse. The study was conducted as part of the interviewer's thesis in the Nursing Department, Ben-Gurion University of the Negev. The interviewer was trained to conduct the interviewed in two courses about qualitative research. The interviewer had no prior acquaintance with the study participants, except for one. The regional nurses were contacted by email by the researcher OK. The staff nurses were contacted through WhatsApp messages or emails. The participants were informed about the purpose of the study and the fact that it was a nursing degree thesis. The researchers attempted to arrange a meeting with the regional nurse for the Tel Aviv district, but this was unsuccessful. Data collection continued until data saturation was achieved. The mean interview duration was 46.8 min (ranging between 29.0 and 69.0 min).

Instrument

The semistructured interview tool (see Supplementary file 1) was developed specifically by the researchers for the current study, using dedicated interview guides for the managerial-level and the staff-level nurses. To achieve credibility, the content was checked and approved by an expert researcher (OK), and tested in a pilot study with one nurse, and since there was no need for changes, its data were included in the analysis. The tool included 23 open-ended questions intended to uncover the existing telenursing services in MCCHCs and to understand the nurses’ attitudes and perceptions regarding telenursing services. The interview covered topics of nurses’ perceptions of telenursing in general, their experiences and attitudes regarding existing services offered in their clinics, and the key challenges, aspirations, and objectives related to future telenursing services in MCCHCs. Adjustments were made to the interview tool for management nurses to align with their areas of responsibility. Table 1 presents the topics covered in the interview and an example of a question.

Table 1.

Interview tool topics and questions.

Topic	Question
Conceptualization	How do you define telenursing from your perspective? How do you think telenursing integrates into the MCCHC where you work?
Existing Telenursing	What services are provided remotely? To what extent is the use of online services at the nurse's discretion? Beyond the existing services, do you think there is a need to add additional online services?
Importance and Effectiveness	What is the importance of telenursing in general and specifically in MCCHCs? How do you see telenursing contributing to nursing work? How, in your view, does telenursing benefit patients? What difficulties are associated with using telenursing? Describe the challenges you face in using telenursing. Has the implementation of telenursing in MCCHCs made the work of nurses more efficient? How? Do you think telenursing currently impacts the quality of care? How?
Implementation Process	What could accelerate or encourage the implementation of telenursing in your clinic? What hinders or harms the process of implementing telenursing in your clinic?
Adaptation During COVID-19	During the COVID-19 pandemic, especially in the early lockdowns, did the nursing staff provide telenursing services? If yes, describe what it included and how it was implemented. Describe how the nurses coped with the transition to telenursing services. Was the clinic staff prepared for the transition to telenursing services? What was the level of responsiveness to telenursing services during this period? How did it affect the nurses’ willingness to continue these services?
Vision for the future	Focusing on your clinic, how do you envision the future of telenursing in MCCHCs? In what way do you think telenursing might impact the quality of care? What would you hope or expect to see in 5–10 years?

Data analysis

To ensure comprehensive data analysis, the interviews were recorded and transcribed verbatim and were analyzed using MAXQDA22 software. Data analysis was conducted according to Braun and Clarke's thematic analysis in psychology guidelines ²³ following six phases. In the first phase, familiarizing data, the transcripts were read several times by the authors to obtain a good sense of the whole. In the second phase, the interviewer generated initial codes, systematically coding meaningful features across the entire data set. Data saturation was achieved after 10 staff-level interviews. Two additional interviews were conducted to ensure that no new topics arose. On the managerial level, interviews were conducted with key position holders. The transcripts were not sent to the participants, as this was not considered relevant. To enhance confirmability, meaning units were extracted from the text and labeled with codes independently by three authors (OGC, RA, and ZA). In the third phase, various codes were compared against each other and stored into categories. The fourth phase included review of the categories by our study group and compared with the original text to reach agreement regarding the way the data were labeled and sorted under categories and themes. The fifth phase involved ongoing analysis to refine each theme and the overarching narrative, resulting in clear definitions and names for all themes. The final phase involved selecting illustrative extracts, completing the analysis, and linking findings to the research question and literature to produce the report. Verbatim quotes were selected to illustrate each theme, capturing both common and divergent perspectives. Quotes were chosen to provide clear, vivid evidence for the analytic claims while ensuring representation across participants. Transferability was established by clearly describing the research design, as well as the data collection and analysis processes. Overall, the quality of data was ensured through credibility, transferability, dependability, confirmability, and reflexivity in all stages of the research, from data collection to analysis and dissemination of results.

Ethical issues

All methods were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki ²⁵ and its later amendments or comparable ethical standards. The Institutional Human Subjects Research Committee of Ben-Gurion University of the Negev approved the study protocol and the study materials (Approval No. 08-2022). The aims, methods, and potential risks and benefits of the project were explained to all participants, and assurances were provided regarding the anonymity and confidentiality of their information and audio files. Participation was voluntarily, with no incentives provided. Informed consent was obtained from all participants. They were informed of their right to withdraw from the study at any stage or at any later time. All hard copy and electronic research documents were stored securely, either in a locked cabinet or on a protected server, with access restricted solely to the research team. The documents will be retained for no longer than seven years, after which they will be permanently destroyed.

The study was conducted in accordance with the principles of scientific integrity, ensuring honesty, objectivity, and responsibility throughout data collection, analysis, and dissemination of the findings.

Results

Characterization of participants

All of the study's participants were women. Among the participants, 15 nurses were Jewish (79%), two were Muslims (10.5%), and two were Druze (10.5%). All the nurses had academic degrees. Five out of 12 staff nurses and 6 out of 7 management nurses had master's degrees (26.3% and 31.6%, respectively).

The average age of the sample's nurses was 48.9 years (SD 11.9), with the average age of the staff nurses lower in comparison with the management nurses (43.9 SD 11.9 and 56.7 SD 8.11, respectively). The professional seniority as nurses was an average of 24.6 years (SD 12.2), and the seniority as MCCHC nurses or public health nurses was 19 years on average (SD 10.6). Table 2 shows the participants’ sociodemographic features.

Table 2.

Study participants (N = 19).

Variable	Staff nurses (n = 12)	Management (n = 7)
	n (%)	n (%)
Gender—female	12 (63.2)	7 (36.8)
Religion
Jew	8 (42.1)	7 (36.9)
Muslim	2 (10.5)
Druze	2 (10.5)
Education level
BA	7 (36.8)	1 (5.3)
MA	5 (26.3)	6 (31.6)
Age (mean, SD)	43.9, 11.9	56.7, 8.1
Seniority as a nurse (mean, SD)	19.7, 11.5	33.3, 8.6
Seniority in MCCHC (mean, SD)	14.7, 9.7	26.6, 7.9

Telenursing services in MCCHCs in Israel

Telenursing services related to mother and child health exist at the local clinic level and the national level. At the national level, there is a free online group meetings platform for parents under the guidance of the nurses of the MCCHC, called “Tiponet” (Virtual parents’ meetings with MCCHC nurses). This service was set up in collaboration with the Goshen and Lotem nonprofits to offer the parents of babies and infants from birth up to six years of age with group enrichment lectures given by MCCHC nurses who have trained for this purpose. The topics of lectures are determined in advance, and the lectures are given in Hebrew and Arabic. Among the topics are child development, nutrition, sleep, and positive parenting. This service was established as an initiative of nurses during the COVID-19 pandemic as a substitute for group meetings at the MCCHCs, which were canceled due to social distancing, and it has continued to operate after all the restrictions were removed, thanks to its great success. In addition, Tipat Halav's call center is a hotline that enables consult about topics such as healthcare for infants and children. The call center is staffed by MCCHC nurses, breastfeeding consultants, sleep consultants, and clinical dieticians, who provide parents support and answer questions on various topics, including developmental, crying, side effects following vaccinations, sleep issues, breastfeeding, and nutrition. It is not a 24-hour service. Call center operation hours: Sunday through Thursday, 16:00 to 21:00 and Friday and holiday eves, 8:00 to 13:00 (Contact a Family Health Center at *5400 | Ministry of Health).

At the local level, the clinics, typically, the service provided on-site focuses on addressing parents’ questions. Parents can call the clinic during operating hours, and the nurses respond and provide advice. Often, this service is limited to the clinic's official working hours. If a call cannot be answered immediately, parents may leave a message, and the nurses aim to return the call as soon as possible. The nurses also use proactive follow-up by contacting parents in situations requiring special attention, such as the birth of a premature baby, or close monitoring of growth or development. This service is not standardized or official and depends on the clinic and its local policies. Table 3 summarizes the telenursing services operated by MCCHC. A staff nurse described how phone-based telenursing is delivered during routine clinic operations:

“We provide phone call support after patient reception hours. We also do outreach, which is something unique to our clinic. For example, we call parents when there are children whose vaccinations are delayed, or if we receive a notification about a premature baby. We contact the mother to check on the baby's condition.”

Table 3.

Telenursing services in MCCHCs in Israel.

Level of service	Service name / description	Scope & target population	Providers	Languages	Topics covered	Operational details
National	“Tiponet”—Virtual Parents’ Meetings with MCCHC Nurses	Education for parents of babies and children (0–6 years)	MCCHC nurses trained for group guidance; collaboration with nonprofits	Hebrew, Arabic	Child development, nutrition, sleep, positive parenting, and other enrichment topics	Online group lectures; topics set in advance; initiated during COVID-19; continues post-pandemic due to high demand and interest
National	Tipat Halav Call Center	Parents seeking advice on infant/child health outside clinic hours	MCCHC nurses, breastfeeding consultants, sleep consultants, clinical dieticians	Hebrew (main); availability in other languages not specified	Development, crying, vaccination side effects, sleep, breastfeeding, nutrition	Hotline service; not 24/7; staffed Sun–Thu 16:00–21:00, Fri & holiday eves 8:00–13:00
Local	Clinic-Based Telephone Support	Parents served by local MCCHC clinics	Local MCCHC nurses	Based on clinic staff (typically Hebrew, Arabic where relevant)	General parental concerns; proactive follow-up for special cases (e.g., premature birth, growth monitoring)	During clinic operating hours; not standardized, depends on local policies

Factors promoting and hindering MCCHC nurses’ use of telenursing

We identified several perspectives, some of which have a more positive voice, encouraging the use of telenursing as part of care, while others have a more negative voice, delaying the introduction of these methods. These perceptions are gathered into five themes: (1) Quality of service; (2) Quality of care; (3) Aspects regarding the nurses’ work; (4) Managerial and systematic aspects; and (5) Aspects of patient population. The themes and categories are summarized in Figure 1.

Figure 1.

Study themes and categories.

Quality of service

Nurses view the introduction of telenursing as an essential component in improving the quality of healthcare services, by improving access and adapting to the modern digital world. Healthcare services that are more convenient and accessible are crucial to achieving population adherence, especially for those experiencing mobility difficulties or when there is a national crisis of any kind (for example social distancing or war). As a management nurse said:

“As someone who provides such important healthcare, I must ensure accessibility, the ease of consuming this service for anyone who wants it… it doesn't matter who they are and where they live”

The quality of service, as perceived by the nurses, is also a reflection of the integration of advanced technologies. Utilizing innovative methods aligned with modern technological advancements makes the services more current and relevant for young mothers. It allows them to access services in a manner consistent with how they typically engage with other aspects of their daily lives.

“It's amazing that you have the option to receive services while sitting on your couch at home in pajamas. In my opinion, this is an incredible service. It's something that truly benefits the population, and with the advancement of technology, it's something people need—it's indispensable.”

Quality of care

Nurses referred to the impact of the quality of care provided online versus in-person service. On the one hand, a prominent concern raised repeatedly by the nurses is the potential for reduced quality in certain aspects of care. The nurses were particularly worried about the limitations of the remote interactions, which could detract from the care, with an emphasis on precise diagnosis of situations that require thorough assessments, such as physical examinations to locate developmental issues among children or signs of postpartum depression among mothers.

“The personal meeting has its added value of more contact, more closeness, more… feeling, seeing, body language, etc. We also need the real [in-person] meeting.”

“I think sometimes we might miss a diagnosis when we don’t see the woman, don’t hear her, and might find ourselves in a situation where a diagnosis is overlooked”

At the same time, they addressed the ability to provide holistic, comprehensive care to patients using telenursing services, for example, by including visual means that show the patients in their natural surroundings, or an online visit to complement the visit to the clinic and the ability to provide enrichment training for parents beyond the time allotted in the clinic.

“It's like doing half a home visit for each of the patients, because the moment I see the patients in their natural surroundings, for example, if I see the patient in the living room, I can see the whole environment, and that's not always something I can see when they are coming here [to the clinic].”

Furthermore, some nurses believe that failing to adopt remote-access services affects how parents ultimately receive health-related advice, potentially leading to nonevidence-based guidance and adverse health outcomes. Many mothers find it difficult to leave the house and visit the clinic with a young child just for a consultation. Consequently, they often rely on social media for answers. Implementing remote services could help minimize dependence on unverified or nonprofessional information sources.

“It's [telenursing] a service that is really welcome if it's online. Even when you're at home and the weather is bad and you can really [stay] at home. You want to know, and you can receive guidance from a professional team and no, no, not from the internet, not Facebook, and not… Like online professionals, and that's welcome.”

Aspects of nurses’ work

The nurses share that in their opinion, including telenursing services in the clinic will have a significant impact on the personal aspects of the nurses’ work, an impact on their schedules, workload, and professional roles. Nurses believe that telenursing services offer flexibility, efficiency, and variety in the work processes, thus enabling them to optimize their time, maximize the time nurses spend answering the present human resources shortage, and relieve the burden on clinic hours. One nurse stated:

“I have a friend who sometimes does this [meeting] over the phone. She creates the draft of the card and conducts an initial interview over the phone. Then, when the patient arrives, she doesn’t need to spend a full hour with them; she can dedicate just half an hour. It doesn’t really shorten her time, because she still has to interview them on the phone, so she needs to allocate time for that as well. However, she does it at a time that's convenient for her and for the patient. So, when they have free time [at the clinic], she calls [the patients] and checks if they can talk. It's more flexible than, for example, scheduling you for Wednesday at 10:00 AM, where that's the time I set aside for you, and you have to come then.”

Moreover, nurses believe that the regular integration of telenursing into MCCHCs will elevate both the nurses’ roles and the clinics’ prestige. They feel that MCCHC nurses should focus more on professional tasks rather than administrative ones, which could enhance the effectiveness of patient care and strengthen the nurses’ standing in the eyes of their patients.

“I think it's a great idea. I believe we should always think about how we can progress, even in our service, as this also enhances the service. Sometimes, we hear fewer good things about it [MCCHC] for some reason, or the role doesn’t have as much prestige. So yes, I think the more progress we make, the more it will elevate us as nurses and provide better support to parents. I definitely think it makes things more efficient. However, this is not my job, sorry, I’m not a secretary to do this and find appointments. It takes up a lot of time… it's not our role. My role is to provide answers to questions and issues [that relate to mother and baby's care]. So yes, I do think it's important, and I also believe it raises the prestige of the role.”

On the other hand, nurses expressed concern about the increased workload and multiple tasks that will be added with the implementation of telenursing. Also, a major anxiety raised by nurses is the disparity in digital literacy. While the younger nurses and those familiar with technologies will be able to adapt rapidly to online services, more senior and older nurses might have difficulties with the transition. Nurses noted that this disparity could lead to inconsistency in the provision of remote services and impact on the overall quality of care.

“People [nurses] who are usually willing to do this are those who can and are willing to work extra hours, typically beyond regular working hours. As for my day, for example, as it is today, I don't see how I can add another online service and more hours…”

“…Many nurses struggle with the computer, with Zoom. I myself am not yet 100% comfortable with it. We don’t do it often; it's not something we do on a daily basis. So yes, it's possible, and you can learn everything, but [education is] necessary. There are nurses who are intimidated by it. The whole idea of approaching the computer and using Zoom is intimidating. Personally, I’m not a big fan of Zoom either. I don’t like being on the computer or the phone. I have no problem with face-to-face meetings, but I’m less fond of this media thing. But I get over it and do it, as they say. I think many other nurses don’t like it as much. They feel less comfortable with it and don’t feel as in control. Maybe younger nurses, because it's something they’ve done and the computer has been their tool since the moment they were born, more or less. There are older nurses who are intimidated by it…”

Nurses are also concerned about the day when women will no longer visit the clinics, as they will be able to receive all the care they need remotely. At that point, the authorities may decide to close these clinics (A topic that has been addressed several times over the past decade by the Israeli government). As one nurse said:

“…Once I provide all the services [in the clinic], they come to me more. If only part of the services will be available here, and they only come for vaccinations, they can go to the health clinic [HMOs], get their vaccinations there, and go home. It's a shame to give up on MCCHCs… I love my job, and I love the children. It's a shame to give up on it.”

Managerial and systemic aspects

The nurses raised disparities and difficulties affecting the assimilation of telenursing services. These challenges include faults in the infrastructure due to very old buildings, lack of training programs, the absence of legal regulation, organized procedures and protocols, and the need for strong, continuous technical support to operate the online services smoothly. Nurses reported significant gaps in the infrastructure, such as many MCCHCs that lack internet connection and even basic cellular reception, which complicates the maintenance and promotion of assimilating telenursing services.

“…our infrastructure in the north doesn't yet enable…a physical technological infrastructure. We don't have yet, in the northern region we have clinics even without reception… there are clinics in more central places that have technology [internet], and there are places where it's really primitive… If we go in that direction … we have to know that it's based on good infrastructure. Our clinics are not yet in a condition where they can enable this.”

Furthermore, there is a critical need for clear procedures and legal regulation to ensure the effective inclusion of telenursing services into the routine, and this does not exist yet. The absence of such frameworks constitutes a danger in terms of the accuracy of information and legal responsibility. The safety of both nurses and patients should be ensured in law, as nurses stressed:

“When I give you guidance or you give me guidance and it's personal, how do you document this in the file? You see, there are issues that are still completely open legally… There is the nurse's responsibility to the woman…We have to receive the whole protective envelope from a legal standpoint…”.

Beyond the legal considerations, there is a need for ongoing technical support to ensure the smooth operation of remote services. Nurses are unwilling to take on this responsibility themselves.

“There should be a [technical] professional available to address questions and solve problems—someone specifically designated for this role. In other words, it shouldn’t be me—the nurse that is currently running [clinical] things, who has to handle this. Having such a professional could really encourage the use of online activities. There needs to be a clear point of contact, a place we can call, that is readily accessible to me. When there's an issue, we should receive immediate assistance or support because currently, this doesn’t exist.”

Another disparity raised by nurses is the lack of control and monitoring of existing services at the national level, such as the “Voice of Health” call center and the “Tiponet” online lectures. Nurses expressed frustration about the lack of sufficient data regarding the use and effectiveness of these services. This lack of overall supervision detracts from the ability to evaluate the effectiveness of these services, improve them, and accurately develop telenursing platforms that would answer the population's needs.

“"I think there isn't enough advertising, which might lead to low participation. I keep hearing that the response rate is relatively low now, and I think it's a matter of marketing and advertising… we pass it [information about the upcoming lectures] to the nurses, including sessions tailored for the ultra-Orthodox or Arab sectors, provided in Arabic. The nurses can print it out and hang it at the clinic. However, proper digitization would involve sending text messages to patients or having a large screen at the clinics running ads about upcoming events… They show us surveys at the end of the year, and [“Tiponet” has] been working and living and breathing for a long time already, and it's proven itself, but I think that if it had more advertising, more validity, more nurses who lectured there, it would be a lot more significant.”

In addition, nurses noted that while calls to the “Voice of Health” call center are documented, and they receive notifications about the call and its summary and can add it to the patient's record, there is no documentation when parents participate in “Tiponet” lectures, even though parents are required to enter identification details when joining the lecture. As a result, these national services are not integrated into routine visits and do not alleviate the workload of clinic nurses.

“I would like to know [if a women use a national service]. For example, if someone calls *5400 [the number of “Voice of Health” call center], I can see who is calling, but with ‘Tiponet’ I don’t know.”

Aspect of patient population

Nurses recognize the potential advantages, stressing the need to keep young parents up-to-date and the convenience that digital services can offer to those who are interested and capable:

“I think that the lectures, the parents’ ability to choose for themselves to join the lectures on Zoom, which is accessible, which is at home for mothers who are looking for something to do, it's good.”

However, they expressed significant concerns regarding the population's willingness and ability to adapt to these technologies. These concerns result from differing education levels, cultural differences, and technological access. For example, disparities in technological access are particularly evident among minority groups, such as the Ultra-Orthodox Jewish and the Bedouin communities, who already show low adherence to routine follow-ups. These groups face fundamental challenges, including limited access to smart devices, internet connectivity, or technical skills. Nurses expressed apprehension that transitioning to remote services could exacerbate these inequalities further.

“With them [Gur Hassidic community] the difficulty is more technological, because in this respect they don't have this ability, and they won't introduce it… So, I don't know if we can introduce this technology into this world at all… On the other hand, in the Bedouin population we have communication difficulties, which are already difficult in-person and online it becomes even more complicated. You understand, those who live in the Bedouin areas hardly have reception. Sometimes I can't get them on the phone, so something on a computer? I'm not sure this can be introduced.”

“The technical aspect might be the main obstacle… the technical part. If you specifically want to reach those mothers in remote areas who are isolated, it's difficult. The very mothers you want to reach, the ones alone at home, it won’t be easy.”

In addition, differences in openness to others, whether stemming from personal or cultural factors, may also pose challenges to the implementation of telenursing services, as one nurse noted:

“Not everyone will agree to do it, partly because not everyone necessarily has the required technological equipment, like a camera. Also, some won’t approve of it because they don’t want to expose their natural environment or allow me to see what's in their home—similar to how some refuse home visits. It's the same idea.”

Nurses worry that digital services might further harm trust and reduce involvement, especially among communities where in-person interactions with nurses have a significant social value:

“I think it's also related to the deep respect they have for the MCCHC nurse. In the general public, people don’t talk about an MCCHC nurse in the same way they talk about an ICU nurse, as if she's not at the top of the “hierarchy.” However, among Bedouin women and even men, there is a great deal of respect and importance attributed to the MCCHC nurse.”

Nurses emphasized the importance of mothers meeting each other while waiting for the nurse at the clinic, particularly in areas where mothers are isolated and lack a supportive or nurturing environment. They highlighted the potential negative impact that reducing in-person meetings could have in such situations.

“… Bedouin women are often so lonely that the meeting at the clinic enables meeting other women in the waiting room, which they don't have routinely, it becomes, the clinic becomes a sort of community center, an opportunity to talk to other women, to friends, to make friends. So, interpersonal meetings have become a goal in itself. It's beyond our goals, and the goal of the women too…”.

Discussion

The findings highlight that telenursing is perceived by MCCHC nurses as a critical advancement in improving the quality of healthcare services. By enhancing accessibility and adapting to the modern digital landscape, telemedicine and telenursing addresses barriers faced by diverse populations, particularly during crises such as pandemics, wars, or social distancing periods.^20,21,26 Nurses emphasized how the convenience and accessibility of remote healthcare encourage population adherence, especially for individuals with mobility challenges. For instance, the ability to provide care regardless of geographic location was seen as a significant strength. This aligns with global trends advocating for more patient-centered care models that prioritize convenience and equity. ²⁷

Telehealth enables patients to connect with healthcare providers conveniently, for example, from their homes. ²⁸ Additionally, the integration of advanced technologies makes healthcare services more relevant to younger, tech-savvy populations, aligning healthcare delivery with how these individuals interact with other aspects of daily life. ²⁹ However, these advancements raise important questions about digital inequality, as not all patients may have access or the skills required to use telehealth services effectively. Addressing digital health equity is crucial to ensure the equitable benefits of telenursing. ¹⁴

Implementation of telenursing in MCCHC

We found that telenursing in MCCHCs was infrequent and largely confined to local, phone-based contacts, with national-level activity limited to educational Zoom sessions. This pattern aligns with prior literature indicating that, despite postpandemic expansion, telehealth coverage and the supporting evidence for mothers and young children remain uneven, constraining its overall impact on postpartum maternal and child health. In particular, Howland and colleagues called for clearer use-cases and barrier removal, underscoring that current services are not yet sufficient at scale. ¹⁵ Moreover, many maternal–child telehealth programs still focus primarily on education or counseling (e.g., telelactation), ³⁰ even though more advanced clinical tools are feasible, ³¹ pointing to persistent gaps in both reach and clinical scope and the need for broader integration into routine care.

Factors promoting and hindering telenursing

The impact of telenursing on the quality of care presents a more complex picture. Nurses expressed concerns about the limitations of remote interactions, highlighting the irreplaceable value of in-person meetings. On the other hand, they acknowledged that telenursing offers unique opportunities for holistic and comprehensive care. Telenursing allows providers to detect complications earlier, facilitating prompt interventions that enhance patient outcomes and optimize provider efficiency. ²⁸ Studies show that children may experience elevated levels of social and separation fear in unfamiliar environments, triggering maladaptive behavioral responses. ³² Virtual consultations provide an advantage by giving a window into patients’ natural environment, allowing more convenience and accurate observations compared to clinical settings. ³³ Furthermore, telenursing complements in-person visits by enabling extended follow-ups and enrichment programs that empower clients with professional guidance. ³⁴ This can reduce reliance on potentially harmful, nonprofessional information from social media, thereby improving health outcomes. ³⁵ While the hybrid approach combining in-person and remote care appears to address some of these concerns, its successful implementation requires strategic planning and investment in advanced telehealth tools and training for nurses.

Nurses have assumed a leadership role in delivering healthcare services to rural communities. ³⁶ The nurses in our study believe that implementing telenursing in healthcare settings that serve geographic and social periphery populations presents several challenges, primarily due to infrastructural, socioeconomic, and cultural barriers. Previous studies showed that limited internet access and inadequate broadband infrastructure significantly hinder the use of digital health tools in rural and underserved areas.^37,38 In addition, technologies designed without considering local cultural contexts face resistance. ³⁸

Telemedicine empowers nurses and equips nurses with the tools to monitor patients, provide education, collect data, conduct follow-ups, and deliver multidisciplinary care. ³⁹ In this regard, it is important to understand and reflect on the role nurses have played in integrating these technologies, especially telenursing, into the profession and to consider their potential impact on the future of the Nursing profession. ⁴⁰ Being the largest workforce in the healthcare system, nurses should lead this technological change. Improving organizational backing to strengthen the role of nurses as agents of change in implementing telehealth services, and adding telenursing to the training of future nurses, would help create a safer and more adaptable workforce.

Conclusions

This study explored the existence and implementation of telenursing in Israeli MCCHCs and analyzed nurses’ perceptions of its use. Findings show that while telenursing can improve accessibility, convenience, and efficiency of maternal and child health services, it also raises concerns about diagnostic accuracy, personal connection, and equity among vulnerable populations. For nurses, telenursing not only offers flexibility and professional advancement but also increases workload and highlights gaps in digital literacy. At the system level, barriers such as poor infrastructure, lack of training, unclear procedures, and insufficient technical support limit its integration.

A hybrid model that combines in-person and remote services may offer the most effective framework, preserving the benefits of direct encounters while leveraging digital tools to extend reach. Successful implementation requires strategic investment in infrastructure, continuous training, organizational support, and policies that promote equitable access for all communities. These steps are expected to strengthen the nursing workforce, enhance job satisfaction, and advance maternal and child health in the community.

Three major limitations should be considered: First, the participants were a small sample of nurses, though efforts were made to recruit nurses from different roles (management and staff nurses) and different populations under their responsibility. Second, participants were recruited from MCCHCs of the Ministry of Health and not from HMO-owned clinics, which constitute about 30% of the MCCHCs in Israel. Last, the study reflects only the nurses’ point of view, as this was the aim of the research. Thus, including patients’ perspectives in future studies could provide a more comprehensive understanding.