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. 2022 Nov 3;30(8):3996–4004. doi: 10.1111/jonm.13864

Identification of telehealth nursing approaches in the light of the COVID‐19 pandemic—A literature review

Petra Búřilová 1,2,3,4, Andrea Pokorná 1,3,4,✉, Jiří Búřil 5, Lucia Kantorová 1,2,3, Simona Slezaková 3, Zuzana Svobodová 3, Miloš Táborský 6
PMCID: PMC9874863  PMID: 36208135

Abstract

Aims

This study aimed to identify recommendations for quality nursing care provision, focusing on the possibilities of delivering telehealth nursing at the national level in the Czech Republic.

Background

The significant growth in the use of technology in health care has changed the environment for patient care and how health care is provided. The COVID‐19 pandemic has shown the requirement for telemedicine use in everyday clinical practice.

Evaluation

A literature review aims to find guidelines, recommendations, manuals, standards or consensus papers published in 2017–2022.

Key Issues

In total, 12 guidelines were identified. Based on a critical evaluation carried out by two experts, the World Health Organization guideline focused on digital interventions to strengthen the health system has been identified. This guideline was evaluated to be of the highest quality and in line with the Grading of Recommendations, Assessment, Development and Evaluations methodology.

Conclusion

The provision of telemedicine nursing interventions is currently limited at the national level and is not entirely accepted in reimbursement yet. The interprofessional collaboration will be initiated to make recommendations for specific patient groups.

Implications for Nursing Management

Selected guidelines can be recommended for national adoption to set up and support nursing interventions in telemedicine, including nursing management settings.

Keywords: COVID‐19, guidelines, nursing care, telehealth nursing, telemedicine, telemonitoring

1. INTRODUCTION

A significant increase in the technology used by health care providers has changed the care environment for the patients and health care provision at the national level in the Czech Republic. Telemedicine practices and/or the use of digital technologies in the health services providers, using routine and innovative forms of information and communication technologies to address and meet patient needs, have become an essential part of clinical practice (Brous, 2016). Telemedicine can be defined through telecommunications (mainly telemonitoring) and digital technologies as the facilitation of health and health‐related services, including medical and nursing care, providers and patient education, health information services and self‐care (Nagel et al., 2013). The quality and sustainability of telemedicine services must be implemented following legislation, general health insurance objectives, and support continuity and coordination of care (Hoffman, 2020; Taylor et al., 2015). The COVID‐19 pandemic demonstrated the need to use telemonitoring and telemedicine in everyday clinical practice. This includes the implementation of nursing interventions because COVID‐19 pandemic poses a threat mainly to nurses who would be the initial point of contact with the infected person (Hoffman, 2020; Kaplan, 2020).

Nursing care provided using telecommunications is referred to in foreign literature as telehealth nursing. People who receive such care can stay in their natural social environment, which reduces the need to travel and makes care more accessible. Telemedicine includes different devices, for example, mobile smartphones and web and digital platforms (Brewster et al., 2014). Telehealth meetings vary depending on the environment and the patient's needs.

Telemedicine is thus seen as a concept of health care transformation aimed at improved efficiency, quality of services and modernization, which involves many tools, including strategic planning and nursing management settings.

2. BACKGROUND

Guidelines have been defined as ‘systematically developed evidence‐based statements that assist providers, recipients and other stakeholders in making informed decisions about appropriate health interventions’ (World Health Organization [WHO], 2003). Guideline developers across the globe are increasingly endorsing the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach for guideline development, the most robust and transparent approach for developing recommendations (Schünemann et al., 2013). However, other systems exist and are used, based mainly on the evaluation of the research design of primary studies and various modifications to the GRADE approach.

The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument, a 23‐item tool organized into six quality domains, published by the AGREE Collaboration in 2010, is used to appraise the quality of guidelines and may also be used as a reporting checklist (Brouwers et al., 2010). It ascertains the measure of ‘confidence that the potential biases of guideline development have been addressed adequately and that the recommendations are both internally and externally valid, and are feasible for practice’ (Dans & Dans, 2010).

3. AIM

The literature review aims to identify recommendations from international clinical practice guidelines (CPGs) for providing high‐quality nursing care, focusing on the identification of possibilities for delivering telehealth nursing at the national level in the Czech Republic.

4. METHODS

4.1. Objective

The review aims to provide a comprehensive list of recent (issued in the last 5 years) CPGs on telemedicine, assess their quality using the AGREE II tool and identify the highest quality guideline(s) and specific recommendations that can be applied and implemented in nursing. Based on the analysis of the recommendations, the role of nursing care in accordance with the nurses' competencies is also identified.

4.1.1. Eligibility criteria

The following a priori‐developed inclusion and exclusion criteria were applied (Table 1).

TABLE 1.

Criteria defined for inclusion in the review

Inclusion criteria Exclusion criteria
Guidelines containing recommendations and methods of their development using the GRADE approach:

  • provide a detailed description of methods,

  • use the GRADE approach,

  • contain the GRADE Evidence tables (Summary of Findings) and evidence‐to‐decision framework, and

  • based on a systematic search of evidence with direct links between recommendations and evidence

 Documents that self‐proclaim as guidelines in which it is not clear which parts of the text are recommendations or how any of the provided statements were developed
Guideline's scope covers telemedicine or telehealth Guidelines older than 5 years
Papers containing only good practice statements
Guidelines published in the period 2017–2021 in any language and geographical location
Guidelines with unavailable full text
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Abbreviation: GRADE, Grading of Recommendations, Assessment, Development and Evaluations.

4.2. Search strategy

The search aimed to find guidelines, recommendations, manuals, standards or consensus papers published in any language from 2017 to 2022. The time period was chosen in view of the potential impact of the pandemic and the need to develop guidelines focused on telemedicine. There were no geographical or language limitations. We searched the guideline databases and repositories (such as the Guidelines International Network library, BIGG international database of GRADE guidelines and ECRI Guidelines Trust) and websites of guideline developers (e.g., National Institute for Clinical Evidence, WHO and Haute Autorité de Santé) using the following keywords: telemedicine OR tele‐medicine OR telehealth OR tele‐health OR telecare OR tele‐care OR telehealthcare OR tele‐healthcare OR telenursing OR tele‐nursing OR teleconsultation* OR tele‐consultation* OR ehealth OR e‐health OR mhealth OR m‐health OR ehealthcare OR e‐healthcare OR mhealthcare OR m‐healthcare OR mobile OR telephone OR telephone‐based OR virtual OR digital OR remote OR distant OR distance OR online OR video OR digitis* OR digitiz* OR electronic* OR phone and their equivalents in other languages. The full list of searched sources is provided in the supporting information. Moreover, we conducted the search in the database MEDLINE (Medical Literature Analysis and Retrieval System Online) (Ovid) using the Canadian Agency for Drugs and Technologies in Health broad guideline filter (All Clinical Trials—MEDLINE, Embase, PsycInfo, 2022), which has the highest sensitivity in comparison to other identified guideline filters, according to Lunny et al. (2020). The search strategy is available in the supporting information.

4.3. Guideline selection

In the first phase, titles/abstracts of identified records were screened by two independent reviewers for assessment against the inclusion criteria for the review. The full texts of potentially relevant reports were retrieved, uploaded to a shared folder and checked by two independent reviewers. Full‐text reports that did not meet the inclusion criteria were excluded. The reasons for their exclusion and the process of guideline selection are described in Figure 1. Any disagreements were resolved in consultation with a third reviewer if needed.

FIGURE 1.

FIGURE 1

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Flow diagram of guideline selection

4.4. Data extraction

The basic characteristics (title, scope, year of publication, author/organization, language, method of development and information needed for assessing eligibility) of the included, as well as the excluded, guidelines were extracted independently by two reviewers to make sure the data were accurate. We also extracted all recommendations with their depicted strength and certainty of the eligible guideline(s) evidence.

4.5. Quality assessment

One senior nursing expert (with more than 20 years of professional clinical experience) and one junior nursing expert (with more than 10 years of clinical experience) working as clinical practice methodologist assessed the methodological quality of the eligible guidelines with the AGREE II tool—a 23‐item tool organized into six quality domains (Brouwers et al., 2010). Only guidelines that pass all eligibility criteria were assessed for quality using the AGREE II tool.

4.6. Analysis

We chose the best guideline(s) based on AGREE II tool criteria according to junior and senior expert screening and assessment. Both methodologists are experienced in assessing the quality (or certainty) of evidence and strength of recommendations and are members of the core team of the Masaryk University GRADE Centre and nursing experts with an academic background. The team of authors selected recommendations for the implementation of telemedicine at a national level with potential use in the nursing field.

4.7. Presentation of results

The basic characteristics of the included and excluded guidelines were extracted and are provided in a tabular and narrative form below: the guideline title, publication year, author/organization, language, focus, the grading method and the provision of the GRADE Summary of Findings tables. We also provide the results of a quality assessment of the eligibility guidelines and a list of recommendations that are considered applicable to nursing.

5. RESULTS

Based on the search results, 7216 records were identified from the databases/repositories and 41 records from websites of guideline developers (Figure 1). Finally, 12 guidelines were assessed for eligibility according to the criteria provided in Table 1. The MEDLINE database identified 28 resources that would be suitable for further use. Still, they were found during the previous search as a part of the 12 evaluated guidelines for full‐text screening, and thus, they were excluded as duplication. After the full‐text screening of 12 guidelines, 11 were excluded (Table 2). One guideline passed the eligibility criteria and was included in the final analyses (Table 3).

TABLE 2.

Summary—Specification of excluded guidelines

Guideline title Publication year Grading method GRADE tables Institutions, state Guideline language Guideline focus
The COVID‐19 pandemic and eating disorders in children, adolescents, and emerging adults: Virtual care recommendations from the Canadian consensus panel during COVID‐19 and beyond (Couturier et al., 2021) 2021 Consensus recommendations by GRADE No McMaster University (Canada) English Eating disorders in children, adolescents and emerging adults
Revisiting health information technology ethical, legal, and social issues and evaluation: Telehealth/telemedicine and COVID‐19 (Kaplan, 2020) 2020 Other than GRADE No Professional society (USA) English Quality of care, access, consent and privacy
DoD COVID‐19 practice management guide: Clinical management of COVID‐19. Version 4.0 (Matos et al., 2020) 2020 Other than GRADE No Department of Defense (USA) English COVID‐19
Behaviour change: Digital and mobile health interventions—NICE guideline (NICE, 2020) 2020 Other than GRADE No NICE (UK) English A healthy lifestyle
Canadian adult obesity clinical practice guidelines: Emerging technologies and virtual medicine in obesity management (Tytus et al., 2020) 2020 Other than GRADE No Canadian Association of Bariatric Physicians and Surgeons, and Obesity Canada (Canada) English Obesity
Réponses rapides dans le cadre du COVID‐19—Téléconsultation et télésoin (Haute Autorité de Santé, 2020) 2020 Other than GRADE No Haute Autorité de Santé (France) English COVID‐19
Guideline of the Brazilian Society of Cardiology on telemedicine in cardiology—2019 (Lopes et al., 2019) 2019 Other than GRADE No Brazilian Society of Cardiology (Brazil) English General without specifications
Therapist‐supported internet therapy for mental disorders—A health technology assessment (Elvsaas et al., 2018) 2018 GRADE No Norwegian Institute of Public Health (Norway) English Mental disorders
Efectividad clínica y coste‐efectividad de la telemonitorización no‐invasiva en pacientes con insuficiencia cardiaca (Informe n°: Osteba E‐17‐11) (Aguado et al., 2017) 2017 GRADE modification No Ministry of Health, Social Services and Equality (Spain) Spanish Cardiology
Canadian stroke best practice recommendations: Telestroke best practice guidelines update 2017 (Blacquiere et al., 2017) 2017 Other than GRADE No Heart and Stroke Foundation of Canada (Canada) English Stroke
American Telemedicine Association practice guidelines for telemental health with children and adolescents (Myers et al., 2017) 2017 Other than GRADE No American Telemedicine Association (USA) English Children and adolescents
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Abbreviations: GRADE, Grading of Recommendations, Assessment, Development and Evaluations; NICE, National Institute for Health and Care Excellence.

TABLE 3.

Summary—Specification of guidelines included in the final evaluation

Guideline title Publication year Grading method GRADE tables Institutions, state Guideline language Guideline focus
Recommendations on digital interventions for health system strengthening: WHO guideline (WHO, 2019) 2019 GRADE Yes WHO (international) English General without specifications
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Abbreviations: GRADE, Grading of Recommendations, Assessment, Development and Evaluations; WHO, World Health Organization.

Of the twelve guidelines identified, three were in 2017, one in 2018, two in 2019, five in 2020 and one in 2021. Eleven were issued in English and one in Spanish, for which we were able to identify a version in English. The issuing organizations were as follows: the WHO; the Department of Defense (DoD) and the American Telemedicine Association (USA); the National Institute for Health and Care Excellence (NICE, UK); the Ministry of Health, Social Services and Equality (Spain); Haute Autorité de Santé (France); the Heart and Stroke Foundation of Canada, the Canadian Association of Bariatric Physicians and Surgeons, and Obesity Canada (Canada); and the Brazilian Society of Cardiology (Brazil). One guideline used the GRADE approach for developing recommendations, whereas the others used either GRADE modification or non‐GRADE methods. Only one of the guidelines provided the GRADE Summary of Findings tables with the rating of the certainty of the evidence for each outcome. Two guidelines were general in their scope, applicable to any field in medicine, whereas the rest focused on specific clinical fields or data security aspects in providing telemedicine.

Based on the critical assessment by two independent reviewers (junior and senior nursing experts and methodologists; see above) using the AGREE II tool, the recommendations from the WHO (2019) guideline were identified as fulfilling the eligibility criteria. This guideline had the highest score across the six domains and was developed according to the GRADE methodology (Schünemann et al., 2013) and was chosen as the basis for this review.

We extracted recommendations from the chosen highest quality eligible guideline that can be used and adapted to telehealth nursing at the national level in the Czech Republic (Table 4). The selected recommendations are suitable for setting health policy, implementing changes in the nursing management and the education system in telemedicine at the national level in the Czech Republic, especially concerning the competencies of non‐medical health care workers.

TABLE 4.

Recommendations adaptable for telehealth nursing

Recommendation

WHO recommends using client‐to‐provider telemedicine to complement, rather than replace, the delivery of health services and in settings where patient safety, privacy, traceability, accountability and security can be monitored.

In this context, monitoring includes establishing standard operating procedures that describe protocols for ensuring patient consent, data protection and storage and verifying provider licensing and credentials.

WHO recommends digital targeted client communication for health issues regarding sexual, reproductive, maternal, newborn and child health under the condition that potential concerns about sensitive content and data privacy can be addressed.
WHO recommends using digital decision support accessible via mobile devices for community and facility‐based health workers in the context of tasks that are already defined within the scope of practice for the health worker.
WHO recommends digital tracking of clients' health status and services, combined with decision support under these conditions:

  • in settings where the health system can support the implementation of these intervention components in an integrated manner and

  • for tasks that are already defined as within the scope of practice for the health worker.

WHO recommends the use of digital tracking combined with decision support and targeted client communication under these conditions:

  • where the health system can support the implementation of these intervention components in an integrated manner,

  • for tasks that are already defined as within the scope of practice for the health worker and

  • where potential concerns about data privacy and transmitting sensitive content to clients can be addressed.
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Abbreviation: WHO, World Health Organization.

5.1. Patient and public involvement

No patients were involved in this review.

6. DISCUSSION

The chosen recommendations defined in suitable WHO (2019) guidelines (see Table 4) serve as frameworks for the delivery of evidence‐based health services that have been identified for telemedicine settings internationally. The impact of the COVID‐19 pandemic on the availability of health services at the national level in the Czech Republic has caused a risk of worsening manifestations of chronic diseases, delayed diagnosis of acute conditions and reduced quality of care in the rural regions. Adopting 2019 WHO recommendations at the national level would be a basis for developing innovative telemedicine nursing interventions that will help maintain quality of care even during the COVID‐19 pandemic. The literature review is expanded in the discussion to include specific nursing interventions consistent with legislative requirements at the national level in the Czech Republic, which will help establish interdisciplinary collaboration. The WHO recommendations provide a framework for setting up electronic health records or other digital forms of health records for patients to monitor their health status. The recommendations also support training for health workers on the condition that they complement, not replace, traditional methods of providing continuing medical and nurses' education and in‐service training. Nursing interventions within telemonitoring should contribute to the early identification of patient status deterioration and the need for face‐to‐face contact with a physician.

Telehealth nursing is currently used abroad as an extension of the outpatient care of many health care providers and some hospitals. For example, some health insurers offer telehealth nursing services as part of on‐site wellness programmes, where patients meet regularly through video conferences to discuss their overall health, treatment of chronic health problems and advice on wellness nursing diagnoses (Koivunen & Saranto, 2018). It is common clinical practice at the national level to communicate the results of laboratory tests by telephone to find out the effect of the medication and possible education of patients and relatives or lay carers on how to manage symptoms or minor health problems at home (Solli et al., 2015). In setting up the competencies of general nurses in telenursing, consideration could be given to providing instructions for the treatment of chronic conditions (under the legislatively identified competencies), for example, (i) care for patients with hard‐to‐heal (chronic) wounds (pressure ulcers, treatment of minor burns or injuries at home), (ii) the use mobile devices for telemonitoring to measure vital signs (e.g., blood pressure, oxygen levels, blood sugar levels, of heart rate and respiration) and (iii) possible use of remote nursing for preoperative and postoperative care (Taylor et al., 2015).

Patient‐specific considerations should be balanced in conjunction with health care workers' safety and with the goal of providing high‐quality care according to the specific disease and patient needs and our family. Several protocols for a telemedicine‐based model of care for patients with current heart failure and stroke have been introduced to address the COVID‐19 pandemic (Cheshire et al., 2021; Hiddemann et al., 2021). The models presented evolve into everyday practice based on developing knowledge within the health care system and society about the COVID‐19 pandemic. A critical activity to support during the epidemic is point‐of‐care risk assessment. Every nurse and frontline nursing staff perform a point‐of‐care risk assessment in contact with every patient to determine their level of risk and how to protect themselves. While assessing and controlling personal risk, nurses rely on individual nurses' professional judgement (i.e., knowledge, skills, reasoning and education) (Qureshi et al., 2020). With telemedicine, nurses can support the protection of their communities from this and many other infectious agents that pose a threat.

Obtaining detailed medical histories and health information from patients and family members is often essential (Barbosa & Silva, 2017). However, many health care providers have appropriately restricted visits or instituted no‐visit policies, making this information unavailable in routine and regular contact. Families should be contacted by telephone to discuss the patient's medical history, condition, treatment options and discharge planning with family members and caregivers. It is also necessary to educate the patient and family members about COVID‐19 transmission tests to diagnose the disease, its course, possible complications and ways to protect themselves and their families from SARS‐CoV‐2 (Schmit et al., 2020). The telemedicine models of care established to date for patients with heart failure and stroke can be used in everyday practice and were used in a modified form in some regions of the Czech Republic during the COVID‐19 pandemic but rather as isolated local projects. The future aims to establish national plans for telemonitoring and telenursing in the Czech Republic. In the preparation of specific recommendations for patient groups, the concept of patient–family linkage will be set up so that the risk of infection is minimized in the long term. In contrast, the patient has sufficient contact with the family.

Health care providers follow national guidelines for the nursing management of COVID‐19 patients. These guidelines may change quickly, though, in response to new information from researchers or as the result of patient caseloads. Nursing professionals correspond to more than half of the health workforce worldwide, being crucial in implementing public health policies and programmes (Ali et al., 2015). General nurses have a critical role in the COVID‐19 prevention and response, not only by providing direct assistance to patients and communities but also by implementing health promotion and prevention strategies (Hoffman, 2020). Setting specific recommendations for telemedicine in nursing can lead to improved long‐term effects of treatment of chronic diseases, reducing the requirement for personal visits to the office or hospitals. In addition, limiting unnecessary contact with other people who may be ill is particularly important for those with weakened immune systems, such as the elderly and people with disabilities, and for those who care for them, as in the case of the COVID‐19 pandemic, i.e., outside (Hiddemann et al., 2021). Remote nursing is also beneficial for patients who live in rural areas and usually have inadequate access to health care than those who live in larger cities with better access to health care providers.

7. CONCLUSION

General nurses are an essential part of health care systems worldwide, and it has never been more apparent than it is now during the COVID‐19 pandemic. Clinical best practices should serve as a basis for developing innovative telemedicine nursing interventions (telehealth nursing) to help maintain the quality of care during the COVID‐19 pandemic. Currently, the limited availability of health services can cause most patients to worsen chronic diseases, or they can later be diagnosed in acute conditions, which reduces the quality of care provided.

The COVID‐19 pandemic has encouraged the development of telemedicine use, and the WHO guidelines provide an opportunity to set up telemedicine services at a national level in the Czech Republic. Based on the presented overview, a summary of specific nursing interventions within the framework of interdisciplinary cooperation for particular patient groups will be prepared, including educational programmes that will lead to a change in nursing management at the national level in the Czech Republic. It is stressed that the implementation of telemonitoring and telenursing strategies will bring about a change in human resource management in nursing. We foresee the possibility of less direct control of the specific nursing staff and caregivers by line management and, on the other hand, a necessary higher level of accountability for the implemented interventions.

8. IMPLICATIONS FOR NURSING MANAGEMENT

The proposal for CPGs will be prepared for the approval of the Ministry of Health of the Czech Republic. Those CPGs will comprehensively summarize the prevention and diagnostic–therapeutic procedures for telemedicine with a declaration of a high level of evidence as a part of a national project for trustworthy CPG development in the Czech Republic. We assume that the formation of the CPG will lead to the initiation focused on reimbursement for telehealth in nursing and recognition of the need for and importance of telehealth in nursing.

ETHICAL APPROVAL

No ethical approval was required for this integrative review.

CONFLICTS OF INTEREST

The authors declare that there is no conflict of interest with respect to the research, authorship and/or publication of this article.

Supporting information

Supporting Information S1

Click here for additional data file. (31.2KB, docx)

ACKNOWLEDGEMENTS

This paper was written at Masaryk University as part of the project ‘Comprehensive approach to disorders of the skin and mucous membrane integrity’, Number MUNI/A/1341/2021, supported by the special purpose support for specific university research provided by the Ministry of Education and Science in 2021 and Czech Health Research Council, Czech Republic, Project Clinical Practice Guidelines, number: CZ.03.2.63/0.0/0.0/15_039/008221.

Búřilová, P. , Pokorná, A. , Búřil, J. , Kantorová, L. , Slezaková, S. , Svobodová, Z. , & Táborský, M. (2022). Identification of telehealth nursing approaches in the light of the COVID‐19 pandemic—A literature review. Journal of Nursing Management, 30(8), 3996–4004. 10.1111/jonm.13864

Funding information This research received no specific grant from any funding agency in the public, commercial or not‐for‐profit sector.

DATA AVAILABILITY STATEMENT

The data that supports the findings of this study are available in the supporting information of this article.

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