National Estimates of Workplace Telehealth Use Among Emergency Nurses and All Registered Nurses in the United States

Abstract

Background:

The goal of this research was to quantify the baseline status of pre-pandemic workplace emergency nursing telehealth as a key consideration for ongoing telehealth growth and sustainable emergency nursing care model planning. The purpose of this research was to: 1) generate national estimates of pre-pandemic workplace telehealth use among emergency and other inpatient hospital nurses and 2) map the geographic distribution of pre-pandemic workplace emergency nurse telehealth use by state of nurse residence.

Methods:

We generated national estimates using data from the 2018 National Sample Survey of Registered Nurses. Data were analyzed using jackknife estimation procedures coherent with the complex sampling design selected as representative of the population and requiring analysis with survey weights.

Results:

Weighted estimates of the 161,865 emergency nurses, compared to 1,191,287 other inpatient nurses reveal more reported telehealth in the workplace setting (49% vs. 34%) and individual clinical practice telehealth use (36% vs. 15%) among emergency nurses. The geographic distribution of individual clinical practice emergency nurse telehealth use indicates greatest adoption per 10,000 state residents in Maine, Alaska, and Missouri with more states in the Midwest demonstrating emergency nurse adoption of telehealth into clinical practice per population than other USA regions.

Conclusion:

By quantifying pre-pandemic national telehealth utilization, the results provide corroborating evidence to the potential long-term adoptability and sustainability of telenursing in the emergency nursing specialty. The results also implicate the need to proactively define emergency nursing telehealth care model standards of practice, nurse competencies, and reimbursement.

BACKGROUND

The SARS-CoV-2 (COVID-19) pandemic presented the need to rapidly evolve the traditional in-person care model to decrease exposure. Emergent infection control considerations for clinicians and patients in higher-risk healthcare settings and worldwide shortages of personal protective equipment (PPE) gave rise to telehealth as a crucial component of emergency health care during the pandemic.^1–3 Telehealth, defined as a remote health care encounter between two clinicians or between a patient and a clinician, can be used for direct patient care at home, remote consults to specialists, and chat visits asynchronously.^4–9 During the pandemic, telehealth has been quickly leveraged to: 1) safely keep people at home; 2) disseminate information; 3) allow decisions around testing to be made; 4) coordinate testing when appropriate; and 4) risk stratify patients for evidence-based and resource efficient care.^10–12

While telehealth has existed for decades, its use in emergency departments had not been widespread over the last ten years; it grew significantly in 2020 requiring quick expansion and uptake.^10–12 Telehealth definitions, compared to telemedicine, are characterized as more all-encompassing, including medical encounters as well as the programs, processes and community objectives and will be used for this paper.¹³ Telehealth use in emergency departments includes on demand care for patients at home, tele-triage or evaluating ED patients remotely for orders and triage, on site consults for remote evaluation between patient and ED provider or specialist, and provider to provider consults between hub and spoke hospitals. Specifically, studies have demonstrated the feasibility, efficacy, and effectiveness for emergency interdisciplinary and medical care provided by telehealth for stroke,^{14, 15} cardiovascular,¹⁶ trauma,^16–19 burn,²⁰ and eye²¹ emergencies with an emphasis on decreasing rural access disparities²² and mortality.^14–16

The state of the science around telehealth specific to the ED setting is still emerging, hastened by the COVID-19 pandemic.^{23, 24} Prior to the pandemic, telehealth use in the emergency department has contributed to the reduction of ED workload burden and improved patient outcomes. This was seen in triage, assessment and treatment of lower acuity complaints, and in providing care to individuals in communities without immediate access to emergency care. For example, outpatient direct to consumer programs can be used to prioritize which patients can be evaluated virtually, and assist in determining the best location for care (e.g. emergency department or primary care setting).²⁵ In a matched cohort study evaluating efficiency and patient safety in the emergency department, screening via telehealth achieved the same level of efficiency as in-person screening.²⁶ A 2015 systematic review of telemedicine applications for emergency department use described its value in addressing health care needs and access for rural communities.²⁷ A 2018 report described a tele-triage program with the goal of optimizing ED efficiency and increasing patient satisfaction.²⁸ While a study on the same ED efficiency and patient satisfaction goals in 2019 showed that ED throughput is not affected despite improved time to provider and left without being seen.²⁹ A 2019 systematic review of use of telehealth in rural areas also supported the idea of program reducing unnecessary patient transfers and over triage (defined as misidentification of patients presenting with minor illnesses/injuries who on initial assessment appear to be critically ill), meanwhile allowing local emergency departments to support and manage patients without transfer.⁵ Reports from the COVID-19 pandemic have found willingness to use telehealth was high.²⁴ The benefits of interdisciplinary ED telehealth are balanced by its limitations: lack of information exchange, limited exam, lack of access to diagnostic testing, and unidentified unmet needs.⁵

Further, the telehealth platform is a promising format in which to deliver nursing care, including patient history, adapted visual or sensor-assisted physical exams, patient counseling and education interventions, follow-up evaluation, and care coordination. In the outpatient setting, nurse-led models of care have been well-established for home monitoring to reduce the exacerbations of common chronic diseases like congestive heart failure³⁰ and provide care for older adults who are frail.³¹ The pandemic challenges have resulted in nurse-led innovations in telehealth use in the inpatient setting as well. For example, telehealth is emerging as an essential modality by which to engage remote family presence in the care of a patient physically receiving intervention and monitoring in the emergency department or hospital setting.^32–34 A substantial gap in the published science has been identified relative to telenursing care in disaster response.³⁵ By reducing physical job demands, risk for violence, and infectious disease exposures while potentially enabling more flexible scheduling options, telehealth may be a crucial priority option to enhance disaster surge demands for nursing workforce capacity by continuing to engage retired or injured nurses in emergency nursing care delivery.³⁶ Thus, while the use of telehealth by clinical site to clinical site as hub and spoke, ^4–9 and by emergency licensed independent providers²⁷ has been quantified, there remains a gap in the currently published science on the rate of telehealth utilization among inpatient nurses in general, and emergency nurses specifically.

Purpose

To address the gaps in the currently published science, the purpose of this research was to: 1) generate national estimates of pre-pandemic workplace telehealth use among emergency and other inpatient hospital nurses and 2) map the geographic distribution of pre-pandemic workplace emergency nurse telehealth use by state of nurse residence.

METHODS

We generated national estimates using data from the 2018 National Sample Survey of Registered Nurses.³⁷ We downloaded the dataset on January 19, 2021. As this was an epidemiologic analysis of a publicly available dataset, the study was not considered human subjects research and no human subjects ethical review or approval was required. Survey validity, reliability, sampling, and administration procedures are available on the US Department of Health and Human Services website. ³⁷ Population density estimates from 2018 by state were downloaded from the United States Census Bureau website.

Survey development.

As a secondary epidemiolocal analysis of an existing dataset, the authors of this research did not develop the original survey data collection tool.³⁷ The United States Census Bureau administered the survey on behalf of the Department of Health and Human Services. According to federal guidelines for statistical surveys established by the Office of Management and Budget, survey items are prepared using a standard process that includes cognitive interviewing for validity.³⁸

Participants.

Inclusion criteria for this analysis were registered nurses who reported that their primary nursing position on December 31, 2017 was in a hospital inpatient or emergency department setting and whose primary position included any patient care. Those who reported their primary nursing position was “Emergency Department, not Critical Access Hospital” were coded as emergency nurses. Those who reported working in a critical access hospital, inpatient unit, hospital ancillary unit, other hospital setting, inpatient mental health/substance abuse, or inpatient hospice unit were included as other inpatient unit nurses. We excluded nurses who had retired and advanced practice registered nurses from this analysis (certified registered nurse anesthetists, certified nurse specialists, nurse midwives, and nurse practitioners). We also excluded those who reported a primary nursing position in clinic/ambulatory settings, hospital nursing home unit, hospital administration, nursing home, rehabilitation or long-term care, correctional facility, or other types of settings (e.g., home health, occupational health, insurance company, dialysis center).

Variables.

We included demographic information collected on sex, race/ethnicity, age, marital status, highest educational attainment in nursing, years of experience in nursing, full time/part time, usual number of hours worked per week, and household income. Telehealth was quantified for this study using the items listed on Table 1.

Table 1.

Telehealth Variables from NSSRN Survey Items

Survey Section Header
“In the following questions, the term telehealth refers to communication technology, such as remote conferencing through phone and/or video, used to connect geographically dispersed practitioners.”
Variable Name	Question Identifier	Stem	Response Options
Telehealth in the Workplace Setting	B21	For the primary nursing position you held on December 31, 2017, did your workplace use telehealth?	•Yes •No->Skip questions below
Individual Clinical Practice Telehealth	B22	Did you personally use some form of telehealth in the primary nursing position you held on December 31, 2017?	•Yes •No->Skip questions below
Telehealth Type	B23	Which type(s) of telehealth did you use in the primary nursing position you held on December 31, 2017?	•Provider to Provider •RN to patient direct calls (e.g., care management/home monitoring) by phone and/or video •NP primary care e-visits* •Other

^*Not analyzed in this study focusing on emergency nursing use

Analysis.

Consistent with the analytic technique recommended by the survey developers in order to obtain nationally representative estimates, sample estimates were applied using the jackknife estimation procedure. The jackknife estimation procedure was recommended by the survey developers to obtain weighted population estimates. Briefly, the procedure allows for a more unbiased estimate of the standard error, significance, and confidence interval compared to traditional statistics. The procedure iteratively slices out one observation at a time to generate a pseudo value, thereby reducing undue influence of any one observation or outlier on the final numerical estimates. Weighted estimates are reported. We used Stata (Version 14.0, College Station, TX) software. Using R (Version 4.0.3) software, a choropleth map was generated to visualize the geographic distribution of emergency nurses who endorsed individual clinical practice telehealth use by state per capita of the general population. A choropleth map is a geographic map with areas shaded in various depth or color intensity to visualize data points by geographic characteristics.

RESULTS

Nearly 4 million registered nurses are represented in the original dataset (weighted N=3,957,661) which is a weighted national estimate derived from 50,273 respondents. The subpopulation included in this analysis represented 1.4 million nurses estimated from 859 emergency nurses (weighted N=161,865) and 7,359 other inpatient nurses (weighted N=1,191,287). Table 2 includes the national estimates of the demographics for emergency and other inpatient nurses.

Table 2.

National Estimates of the Demographic Characteristics of Emergency Nurses and Other Inpatient Nurses

		Emergency Nurses (N=161,865)		Other Inpatient Nurses (N=1,191,287)
	N	%	N	%
Sex
Male	35,594	21.99	134,973	11.33
Female	126,271	78.01	1,056,314	88.67
Ageᶧᶧ - mean [95% CI]	40.70	[39.84, 41.57]	42.59	[42.25, 42.94]
Race & Ethnicity
Hispanic	22,791	14.08	140,691	11.81
White Non-Hispanic	114,843	70.95	826,753	69.40
Black Non-Hispanic	10,732	6.63	88,989	7.47
Asian Non-Hispanic	6,021	3.72	85,654	7.19
American Indian	664	.41	2,740	.23
Pacific Islander	3108	1.92	7,267	.61
Other	1,489	.92	13,700	1.15
Multiple	2,218	1.37	25,613	2.15
Marital Status
Married	105,973	65.47	808,050	67.83
Widowed, Divorced, or Separated	22,645	13.99	160,228	13.45
Never Married	33,247	20.54	223,009	18.72
Highest Degree in Nursing
Diploma	2,784	1.72	50,931	4.23
Associates	58,709	36.27	379,306	31.84
Bachelors	89,576	55.34	707,148	59.36
Masters	10,635	6.57	52,774	4.43
Doctorate	162	.10	905	<.01
Years of Experience in Nursingᶧ – Mean [95% CI]	10.93	[10.10, 11.76]	12.97	[12.61,13.32]
Work Time
Full-time	135,837	83.92	955,889	80.24
Part-time	26,028	16.08	235,398	19.76
Usual Hours Per Week - Mean [95% CI]	37.16	[36.33,37.98]	36.48	[36.15,36.82]
Household Annual Income in USD
<=25,000	324	.20	3,693	.31
25,001–35,000	453	.28	6,076	.51
35,001–50,000	5,925	3.66	62,185	5.22
50,001–75,000	33,344	20.60	262,798	22.06
75,001–100,000	38,330	23.68	300,085	25.19
100,001–150,000	46,229	28.56	360,245	30.24
150,001–200,000	25,073	15.49	124,132	10.42
>200,000	12,188	7.53	72,073	6.05

Note: CI= Confidence Interval. USD=United States Dollar.

^ᶧTruncated at 78 years.

^ᶧᶧTruncated at 50 years.

Table 3 depicts telehealth use by percent of emergency nurses compared to other nurses. Nearly half (49.31%) of emergency nurses reported telehealth was utilized in their workplaces at the end of 2017, while only one-third (33.54%) of other inpatient nurses reported telehealth was utilized in their work environment. Over twice the proportion of emergency nurses (36.35%) reported using telehealth in their own clinical practice than other inpatient nurses (15.40%). While the direct nurse to patient percentages of telehealth use were similar (both 5–6%), 27% of emergency nurses participated in provider-to-provider telehealth while only roughly 10% of other inpatient nurses individually, in clinical practice, used the telehealth platform for provider-to-provider consultation and care.

Table 3.

Telehealth Use

Telehealth Variables	Emergency Nurses (N=161,865)		Other Inpatient Nurses (N=1,191,287)
	N	%	N	%
Telehealth in the Workplace Setting	79,816	49.31	399,558	33.54
Individual Clinical Practice Telehealth	58,835	36.35	183,458	15.40
Telehealth Type
Provider to Provider	43,105	26.63	115,317	9.68
Nurse to Patient	9,210	5.69	65,521	5.50

The geographic distribution of individual clinical practice telehealth use by emergency nurses per state capita is depicted on Figure 1. The highest use rates were in Maine (7.36 per 10,000), Missouri (5.42 per 10,000), and Alaska (5.02 per 10,000). The lowest rates were observed in Connecticut (0.94 per 10,000), Maryland (1.34 per 10,000) and Georgia (1.37 per 10,000).

Figure 1.

Emergency Nurse Individual Clinical Practice Telehealth Use per 10,000 state population

Figure note: Results for North and South Dakota (West North Central Other); Montana and Wyoming (Mountain Other); Rhode Island and Vermont (New England Other) were combined from bi-state, rather than single state, data and averaged across the two states. Nurses were analyzed by their state of residence, which may not represent the state in which they were actively working.

DISCUSSION

We conducted a secondary data analysis of pre-pandemic telehealth use to better understand and contextualize the rapid growth of telehealth use during the COVID-19 pandemic. To our knowledge, this is the first study to generate national estimates of emergency nurse telehealth use and other inpatient nurse telehealth use at the national United States level. While the COVID-19 pandemic has necessitated exponentially increased use of telehealth modalities to reduce infectious disease exposures, we quantified pre-pandemic utilization estimates which provide baseline knowledge that contributes to the advancement of telehealth adaptation and growth.

The main findings of our results indicate that at the end of 2017, half of emergency nurses already reported telehealth use in their work environments with over one third of emergency nurses utilizing telehealth in their own clinical practice. Our baseline figures indicate that telehealth in emergency care prior to the COVID-19 pandemic was common and will only continue to grow. As it expands, there is a large need for better care collaboration which includes a variety of care team members including nurses. In provider-to-provider services, nurses can provide direct care, support interdisciplinary care and care coordination. Advanced practice providers have already been utilized in tele triage for direct patient care and screening for e-visits. Despite these use cases, emergency telenursing may have been vastly underutilized, likely due to the low engagement of telehealth prior to the pandemic, reimbursement models, and need for specific roles and care models during the pandemic. The future of emergency telenursing requires an intentional plan that includes defining and advocating for the unique value that nursing provides in emergency telecare, education and training that reflects the new telehealth scope, and reimbursement and implementation processes that enable successful caregiving practices.

In our study, telehealth use among emergency nurses was much higher than among other inpatient nurses, where only one-third reported telehealth in their work environment and only half of these reporting integrating the modality into their own personal clinical practice. This widespread experience and adoption in the specialty pre-pandemic provides an important implication for prioritizing the ongoing growth of telehealth in emergency nursing as a solution to pandemic and pandemic recovery related challenges. For example, the occupational exposures of the pandemic place emergency nurses at high risk for burnout.³⁹ The different job demands and task variety inherent to integrating telehealth care delivery may eliminate several root causes of burnout in future crises. These improvements include: adding telehealth shifts into in-person care shift mix, more flexible hours and scheduling, different types of patient interactions and better career development. Telehealth also allows for more interaction with specialists and can extend both the scope and practice for nursing staff. These hypothetical advantages require further research evidence, but much newer research shows that having mixed shifts and access improves some burnout symptoms.^{39, 40} Some nursing staff may find the change and feeling of distance to patients as a disadvantage; however, with training geared at webside manner (a term referring to bedside manner in the telehealth setting) and virtual care empathy, some of this can be alleviated. Telehealth care delivery shifts will continue to take a change in how data and information will be exchanged between patient and clinicians.

The geographic distribution of individual clinical practice nurse telehealth use in our study indicated greatest clinician adoption per 10,000 state residents in Maine, Alaska, and Missouri. More states in the Midwestern region demonstrated higher adoption of telehealth than Western, Northeastern Corridor, Middle Atlantic, or Southern states. While telehealth use increased substantially as a result of the COVID-19 pandemic in the United States, disparities in its uptake exist due to connectivity, access to devices and services that are being offered in these regions.⁴¹ Notably, while telehealth had initially been reimbursed in rural areas allowing for increased use, one study of telehealth use during the COVID-19 pandemic reported urban residents as more likely to use these modalities over rural participants.⁴² Within urban areas, not all groups of residents used these programs equally. Ongoing and priority efforts are required at the individual practice, organization, region, state, and national levels to ensure telehealth adoption and availability are utilized to decrease access disparities, rather than exacerbate a digital access divide.

While many benefits of telehealth exist, concerns and potential shortfalls are well documented. Misguided reliance on emergency telehealth could increase already existing racial, socioeconomic, geographic disparities especially for populations that lack device and internet access and technological literacy.^{32, 34} Lastly, while temporary provisions have been made during the COVID-19 pandemic to allow for the use of technological platforms that might not be HIPAA compliant, there’s a continued need to evaluate and address concerns regarding issues specific to patient privacy.^{33, 34} Emergency nursing leaders are in a crucial place to leverage their clear position as pre-pandemic early adopters of site-to-site telehealth adoption, as seen in the results of our present study with disaster pandemic telehealth use. The specialty expertise inherent with being early adopters of site-to-site may be leveraged to inform disaster recovery and post-pandemic care models for direct to patient nursing care requiring inpatient nursing expertise and skill levels. Although, much of the current telehealth growth was supported by special disaster waivers for reimbursement and privacy,^{33, 34} proactive planning for sustained emergency telenursing models is timely and important in order to leverage crucial opportunities to improve access, efficiency, and balance emergency workforce job demands with novel care delivery opportunities.

Emergency Patient Outcomes and Nurse Sensitive Telenursing Indicators

While decades of research have established the feasibility, efficacy, and effectiveness of interdisciplinary and medical emergency telehealth, telehealth patient outcomes that are most impacted by nursing care, or emergency nursing care have yet to be clearly defined and delineated. Theoretical development, informatics, and outcomes research specific to nursing is needed in this area. Between 2011 and 2013, Mueller and colleagues evaluated tele-emergency services in the upper Midwest between rural low-volume hospitals and an urban “hub” emergency department.²² The study results included improved quality of care, improved care coordination, expansion of the care team and resources during critical events. ²² Previous research has shown other important outcomes with use of tele-emergency/teleconsultation. These include: confirmation and alteration of patient diagnosis and treatment, better care management, guidance in preparing patients for transfer, reduction in unnecessary patient transfers, and recommendations for transfer to local care vs. specialist care.^{5, 14–22} For example, by examining high resolution images, ophthalmologists were able to recommend where to transfer patients – to local facility vs. specialist care.²¹ Similarly, by viewing images, burn specialists were able to recommend what type of facility patients should transfer.²⁰ Additionally, several studies have illustrated the use of real-time telehealth consultation with specialists in stabilizing serious trauma patients before transferring to a trauma center.^16–19 Furthermore, for patients with stroke or acute myocardial infarction, teleconsultation has improved adherence to clinical protocols and reduced mortality.^14–16 As our results demonstrate pre-pandemic update of emergency nursing telehealth, additional scholarship is needed to elucidate best-practice emergency telenursing activities, patient outcomes and nurse-sensitive measures of telehealth feasibility, efficacy, and effectiveness.

Telehealth in Disaster Settings

Our results provide pre-pandemic baseline estimates before a rapid uptake and evolution in response to the large-scale disaster care of the COVID-19 pandemic. Telehealth in disaster settings has evolved from its use by the military or non-governmental organizations in austere and conflict-affected areas. A clear advantage of telehealth during a disaster is the ability for affected communities to rapidly access healthcare using out-of-state providers (when providers are licensed to provide care in the patient’s state, participate in interstate compacts, or state licensing requirements are relaxed under emergency executive orders),⁴³ while also minimizing the logistical and safety issues.^{44, 45} However, limitations in telehealth in disaster settings in the past have included lack of infrastructure such as limited or non-functioning cellular service and restrictions on healthcare provision across state lines.^{43, 46} Early in the COVID-19 pandemic, the Centers for Medicare and Medicaid Services expanded telehealth services under an 1135 waiver--allowing for Medicare to pay for office, hospital, and other visits completed via telehealth, as well as allowing flexibility in reducing or waiving the cost-sharing requirement for telehealth visits paid by federal healthcare programs.⁴⁷ Substantial changes in telehealth coverage spurred by the events of 2020 will likely continue into the future, as policy around telehealth evolves.⁴⁸ Healthcare will likely see a rapid increase in innovations in telehealth as a result of the pandemic. Launched during the COVID-19 pandemic, the Department of Defense in conjunction with the Veteran’s Health Administration is developing the National Emergency Tele Critical Care Network (NETCCN), a cloud-based health information system designed to provide virtual critical care during disasters and other public health emergencies.⁴⁹ In the post-disaster recovery phase, it is reasonable to anticipate major advances in telehealth reimbursement, privacy, and nurse education or competency rules and regulations.⁵⁰ The crisis places the emergency nursing specialty in a crucial position and inflection point to proactively define sustainable and effective emergency nursing care models in the disaster recovery and post-pandemic phase.⁵¹

Future Research on Family Presence

The 2018 National Sample Survey of Registered Nurses did not include family presence specifically as a type of telehealth (Table 1). The provision of patient and family centered care in the emergency department is a vital to ensuring high quality care experience, and failure to incorporate family presence into emergency care can lead to a multitude of adverse consequences.⁵² The advancement of emergency telehealth has the potential to dramatically shift how patient and family centered care is delivered, but there is a paucity of evidence to address potential barriers and a lack of guidance related to provider and family education, resource acquisition, and policies and procedures specific to the virtual integration of family presence in emergency care.^32–34 In the emergency department, family presence has traditionally relied on physical presence by allowing caregivers at the bedside, practicing regular structured in person communication, and engaging multidisciplinary support during an emergency encounter, but as telehealth continues to expand, challenges remain to support family presence in the absence of in person interactions.³³

Family satisfaction with emergency telehealth is due in part to flexibility in timing, decreased costs associated with travel, increased access to social support, better ability to tailor care delivery to patient and family needs, reduced wait times and fewer interactions with sick people.^{30, 53, 54} Telehealth also offers opportunities to involve additional family caregivers who may not be physically present at the time of acute illness or injury.^{34, 53} In addition, increased utilization of telehealth may mitigate existing barriers that have plagued full adoption of family presence in emergency care. For example, issues with crowding and high acuity negatively impact clinicians’ ability to provide respectful, sensitive care, but improved triage and care efficiencies with telehealth may reduce workload burden and lead to less rushed, higher quality, and more invested care interactions. Additionally, the lack of previous existing relationship between the patient, family and ED clinician can inhibit the ability to quickly establish a connected care partnership. Telehealth can create more personalized interactions by allowing clinicians to connect to patients and families on a personal level from their homes. Lastly, emergency telehealth may help facilitate communication and care coordination by simultaneously engaging language interpreters and consulting physicians in a telehealth session.⁵²

Limitations

Consistent with any study that rely of self-reported measures, the results should be interpreted to represent the perceptions of nurses nationally in the United States and may not accurately quantify the actual telehealth device and platform available in organizations across the country. The sampling design and weights used are best-practice methods to generate a nationally representative sample, though response and representation bias are possible. The geographic distribution depicts nurse’s state of residence, which may not represent their state(s) of practice. This is a limitation particularly for travel and short-term contract nurses or those who participate in inter-state compacts and deliver care in several states during the same clinical shift. We excluded nurses who did not deliver direct patient care, which may have limited the perceptions of an organization’s telehealth use from an executive or manager’s perspective or from places like poison control centers located adjacent to or within emergency departments. As telehealth platforms and activities expand to include additional video and sensor capabilities, the conceptual meaning of what does or does not constitute telehealth may also change, creating a measurement error in how participants interpret and respond to the survey items for nursing activities such as telephone voice-only tele triage or pre-visit patient consultation.

IMPLICATION FOR EMERGENCY CLINICAL CARE

Our results and discussion can be used to raise awareness among emergency nurses about integrating various forms of telehealth into individual practice, as a potential replacement for several traditional in-person care activities (like patient education), site-to-site access to higher levels of care or specialization, and family presence platform. We demonstrate that emergency nurses were pre-pandemic early adopters and leaders among inpatient nurses for site-to-site telehealth care delivery, positioning the specialty as potential leaders for all post-disaster telenursing models of care that require inpatient nursing skills. Inpatient and emergency nurse leaders are also in a crucial position to develop novel and telehealth adapted nursing care models that integrate telehealth platforms in order to enhance remote family presence, shift physical care processes to remote care platforms when feasible, and integrate remote monitoring, patient education, and patient history taking. Interdisciplinary collaboration is essential in developing this leadership and telehealth innovation for inpatient care. It is noteworthy that while a larger percentage of emergency nurses utilized provider-to-provider telehealth compared to other inpatient nurses prior to the pandemic, only between 5–6% of all hospital nurses utilized direct to patient healthcare in their individual practices. Thus, emergency nurses were early adopters of telehealth in general, but telehealth use in providing direct patient care was substantially limited pre-pandemic and sustainable growth will require thoughtful and structured change management in the absence of extensive pre-pandemic direct telehealth care experience.

The job demands of the pandemic resulted in increased telehealth in order to reduce unnecessary infection exposure and divert nonurgent patients from the hospital setting as disaster surge resource conservation. While much of the published literature indicates the need to shift emergency nursing care to the telehealth platform whenever possible, this telehealth function was largely actually performed or assumed by licensed independent providers^{55, 56} responsive to financial structures, rapid care models and competency development, and reimbursement models and waivers that prioritize licensed independent provider provision of telehealth direct to patient care.⁴⁷ Without intentional and aggregate advocacy through organizations like the Emergency Nurses Association, we risk missing an opportunity to optimize emergency nursing telehealth and revert to pre-pandemic care models. Priority engagement of nurse executive, emergency managers, advanced practice care providers, nurse educators, bedside nurses, and interdisciplinary colleagues is essential in this moment in time to proactively define the next generation of nurse competency, care models, and reimbursement practices.

Anticipating the future as telehealth models evolve, emergency nurses are in a crucial role to evaluate the quality and usability of telehealth service provider vendors and technology in their practice settings, while influencing the organization’s purchasing decisions to support high quality and affordable care. As a specialty, emergency nurses are poised in an essential position in this pandemic recovery era to redefine not only telehealth nursing models, but the role of the stretcher-side nurse in telehealth with well-defined practice competencies and educational requirements.⁵⁷ As emergency telehealth evolves to incorporate home based emergency care, there will be a larger scope of practice using this technology, and telenursing will become crucial to care coordination and team based practice. Caution and sensitivity to patient privacy are paramount as telehealth models exponentially evolve, with an ongoing priority need to evaluate and address both HIPAA compliance and proactively prevent and mitigate issues specific to protecting patient privacy.^{33, 34} Further, to develop sustainable growth in emergency telehealth care models, additional roles may need to be created to help clinicians, families, and patients need navigate and troubleshoot technology.³³ Educational content specific to patient centered care and family presence must be added to both professional education curricula as well as tailored to patients and families.^{34, 52, 58} Establishment of immediate, individualized assessments of patient and family dynamics, available resources, needs, and care goals is critical to successfully implementing emergency telehealth.⁵²

CONCLUSION

Emergency telenursing has expanded due to the pandemic. We suggest that including nursing in future policy, education and processes will expand how well care collaboration will be for patients. The input of emergency nursing leaders is essential to continue to define reimbursement for the valuable services the specialty’s workforce can provide over telehealth. As technology use increases, nurses will continue to be key members of the clinical care team and need to not only be included, but also lead the aspects of interdisciplinary decision-making process that defines nursing practice in the future of healthcare.