Perceived Telehealth Behaviors by a Nurse Practitioner

Austin, M. (2021). Perceived Telehealth Behaviors by a Nurse Practitioner. Online Journal of Nursing Informatics (OJNI), 25(1).  https://www.himss.org/resources/online-journal-nursing-informatics

Abstract

Telehealth has been incorporated into healthcare delivery and its use is expanding. In the United States, it is predicted to be used by seven million patients in 2020 (US Department of Health and Human Services, 2018). For the purpose of providing the full benefit of Nurse Practitioner (NP) telehealth, NP’s must be proficient in the nuances that are required for a successful encounter. The delivery of telehealth patient care requires the NP to use prevailing NP professional behaviors in addition to specific telehealth professional behaviors known as telehealth etiquette. Telehealth etiquette is comprised of communication, equipment management, and the display of emotional intelligence (Haney, et al., 2015). It is imperative for NP’s to have the necessary skills for an effective NP-patient telehealth encounter. Healthcare accessibility that occurs with the use of telehealth is a focus in this study. Telehealth is one viable way to increase health care access. Remote telehealth delivery minimizes barriers for obtaining medical care. This increased health care access is especially significant to the rural and vulnerable population whose problems with health care access are exemplified due to limited resources (Bhatt & Bathija, 2018). Methods that were used to obtain data for this descriptive, qualitative study included individual, semi-structured interviews with NPs to explore the NP’s perceptions on telehealth and the required telehealth behaviors. Identification of the NP’s perceptions about telehealth behaviors will benefit telehealth delivery advancements.

Introduction

Telehealth is predicted to be used by seven million patients in 2020 (US Department of Health and Human Services, 2018). The purpose of this descriptive qualitative study is to evaluate nurse practitioners’ (NP’s) perception of telehealth and telehealth etiquette professional behaviors. The telehealth nurse practitioner-patient interaction differs from the in-person face to face interaction. The delivery of telehealth patient care requires the NP to use prevailing NP professional behaviors, in addition to specific telehealth professional behaviors, known as telehealth etiquette (Haney et al., 2015). Professional behavior implemented by a NP during a practitioner-patient interaction, consist of a varied set of components (Rutledge et al., 2017). These components include knowledge, communication, technical skills, reflection and values. Telecare etiquette is a specific set of skills inclusive of both technical and human factors for providing effective telehealth delivery. Both verbal and non-verbal communication are factors in telehealth etiquette. Since comprised of both verbal and non-verbal communication, telehealth etiquette requires the command of emotional intelligence (Haney et al., 2015). Technological components include connectivity, lighting, and equipment. Human factors in telehealth etiquette include virtually projecting empathy, and respect. To substitute for the lack of in person touch, empathy can be conveyed through body language of leaning in and eye contact. Telehealth etiquette behaviors include the appearance of the presenter which encompass additional professional components in telehealth etiquette including clothing color and style. Telehealth etiquette attire best practice suggest wearing clothes that would be worn during an in person visit but averting potential eye strain by avoiding visually distracting patterns. Clearing the visual environment of clutter is an effective telehealth etiquette intervention. Distractors include noise, nonfunctioning equipment, fidgeting behavior and improper lighting. Prior to initiating the telehealth encounter, the patient must be ensured that the environment is private and all present personnel should be introduced (Haney et al., 2015). This research will explore the nurse practitioner’s perception of telehealth etiquette behaviors in a telehealth, nurse practitioner encounter.

NP etiquette behaviors in telehealth delivery is an example of telepresence. The technical configuration is just as important as the provider’s dress as all merge in the behaviors involved in telehealth for the goals of an effective patient encounter. NP’s that are equipped with proper telehealth etiquette training will be better prepared to provide excellent telehealth patient delivery. A requirement for competent NP professional behavior is the NP’s knowledge and ability to recognize the behavior. Identification of the NP’s perceptions about telehealth etiquette behaviors will benefit telehealth delivery advancements, and establish the need for telehealth etiquette in-service training and inclusion in NP educational curriculum (Henry et al., 2018). NP’s must be proficient in telehealth etiquette nuances that are required for a successful encounter. The NP’s use of telehealth etiquette ensures the full benefit of NP telehealth (Haney et al., 2015).

Telehealth contributes to the mandate of Healthy People 2020 prescribing that all people should be able to conveniently obtain health services for emergency care, primary care and mental health (Healthy People 2020). NP telehealth patient interactions require the NP’s use of professional behaviors; additional unique behaviors are required in the telehealth patient encounter. The rural and vulnerable (RV) population encounter similar health access problems as the general population, but the rural and vulnerable population encounter additional challenges. The list of challenges faced by the rural and vulnerable population include: Transportation, inadequate amount of medical facilities and providers, higher levels of chronic diseases, low health literacy, and stigmas related to health care. The low-density composition in rural populations is a cyclical problem leading to hospital closures affected by limited tax revenues from the small number of residents. Rural communities are also prone to a disproportionately large volume of geriatric residents that are prone to have mobility issues affecting the forced option of aging in place. The RV populations’ transportation issues are amplified by decreased finances and civic resources (Bhatt & Bathija2018). 40% of U.S rural roads are unsafe for travel. Incongruous to a smaller percentage of the U.S. population, 45% of U.S. highway fatalities occurred in rural areas (U.S. Department of Transportation, 2020).

A digital healthcare approach such as telehealth can diminish barriers to healthcare. Telehealth improves access to healthcare for the RV population with virtual care modalities, diminishing travel needs and expanding healthcare service options. Telehealth is a viable tool for RV access issues and has the added ability to provide virtual care including primary care with the additional capacity for broadening the range of services such as ophthalmology, radiology, cardiology, mental health and specialty services such as E-consults. Rural communities generate a decreased anonymity for its inhabitants. A lack of privacy can proliferate the stigma associated with health issues as with mental health in the rural community. Telehealth could provide a screen of anonymity in addition to increasing access to care (Rural Health Information Hub, 2019). Another benefit of telehealth to the RV community is financial. Healthcare costs are reduced when telecare delivery is implemented. Cost savings are evidenced through reduced use of emergency patient visits and hospital admissions (Bhatt & Bathija, 2018).  A large study involving rural communities demonstrated a yearly financial impact of $522.000 with telehealth implementation (Brooks et al., 2011). Increased telehealth etiquette knowledge can result in telehealth progress leading to improved healthcare access for the vulnerable and rural population. A goal of this descriptive research is to explore the research topic of nurse practitioners’ perceptions on telehealth etiquette and actual telehealth etiquette behaviors.

Problem

Rural and vulnerable populations lacking in civic resources, are especially impacted by healthcare barriers (American Hospital Association, 2019). Remote telehealth delivery minimizes barriers for obtaining medical care. This increased health care access is significant to the rural and vulnerable population whose problems with health care access are exemplified due to limited resources (Bhatt & Bathija, 2018). Combining the expertise of NPs with the use of telehealth can contribute to the eradication of health care inaccessibility. Telehealth lessens access impediments such as transportation difficulties, lack of providers in rural areas, and reduced resource options for the vulnerable population. Telehealth expands health care accessibility for patients by decreasing travel difficulties and problems specific to patients residing in rural locations. Telehealth, delivered by nurse practitioners (NP) can remove obstacles and increase health access by implementing digital health care modalities such as video interactions, remote appointments, and home monitoring (American Hospital Association, 2019).  There are multiple benefits with telehealth delivery to the RV population including 24-hour provider access, and options for treatments from specialists or clinicians that would be out of the geographical domain without the use of telehealth. Proper telehealth etiquette behaviors in the virtual visit are important for effective delivery in telehealth. The NP’s use of telehealth etiquette ensures the full benefit of NP telehealth. Human factors of telehealth etiquette are essential to healthcare access because their inclusion ensures a successful telehealth patient encounter delivery. (Haney et al., 2015). Increased telehealth etiquette knowledge can result in greater telehealth patient delivery leading to improved healthcare access for the vulnerable and rural population.

Disparities exist in health outcomes in the rural population. Research data demonstrates that rural communities obtained inferior quality medical services and a lower health outcome than metropolitan community residents. Telehealth can ease healthcare burdens of the RV through diminishing issues with access including medical costs, decreased provider availability and transportation (Agency for Healthcare Research and Quality, 2017). Telehealth can intervene as a tool to decrease healthcare inaccessibility and equitably align healthcare (Bhatt & Bathija, 2018).

Nursing, as a profession is a dynamic evolving process.  Telehealth is also an evolving process in the delivery of health care. Impediments to healthcare access such as a lack of transportation are diminished with the use of telehealth. The improvements in health care accessibility with telehealth delivery is supported by studies in the literature. Examples of telehealth’s influence is seen in the instance of patients with access obstacles, facilitating specialty care for patients in rural hospitals, and reducing healthcare costs. The patient’s positive perception of NP telehealth encounters is also supported in the literature (Bhatt & Bathija, 2018). It is imperative for NPs to have both technical and non-technical telehealth skills, to deliver an effective NP-patient encounter (Barbosa & Silva, 2017). This descriptive, qualitative research will explore the nurse practitioner’s perceptions and ability to identify telehealth etiquette behaviors.

Purpose and Background

The purpose of this descriptive study is to evaluate nurse practitioners’ perception of telehealth and telehealth etiquette professional behaviors. Enhancing the expertise of NP’s in the delivery of telehealth will contribute to the eradication of health care inaccessibility. This research data may be useful for improving NP telehealth and delineating the need for telehealth etiquette in the NP educational curriculum (Rutledge et al., 2017). A continued trend in the U.S. population illustrates an upsurge of rural communities with decreasing populations, indicating a continuation of the challenges embedded in the RV communities (Johnson & Lichter, 2019).  A primary determinant of medical management is health care accessibility.  Integrating the proficient NP with telehealth will help reduce healthcare inaccessibility. Telehealth delivers both direct and indirect improvements, such as, medical expense savings, healthcare access patient satisfaction and enhanced patient outcomes. Appropriate access to health care is a necessity for the advancement of good health. Some common healthcare impediments are lack of available appointments, clinician shortages, inadequate transportation, and rural geographical challenges.

Telehealth expands health care accessibility for patients by decreasing travel difficulties and problems specific to patients residing in rural locations. Telehealth delivered by NPs broadens tangible health access for the RV population. Body language is an integral part of a NP-patient encounter. In a telehealth interaction, visualization of the clinician can be limited, reduced by the scope of the visual projection. Therefore, the communication and presentation factors of tone, facial expression, and choice of words, are imperative components in a NP-patient telehealth encounter (Haney et al., 2015). Correct encounter behaviors are important for effective telehealth delivery and etiquette behaviors are essential. A NP’s perception of the professional behaviors in telehealth etiquette is a demonstration of knowledge that indicates the ability to also perform the appropriate behavior (Haney et al., 2015). Data that demonstrates the efficacy of evidenced-based practices, contributes to intervention and implementation that can narrow the disparity in the treatment gap, for rural Americans which can save lives (Bhatt & Bathija, 2018).

Theoretical Framework

The nursing process discipline theory, first presented in 1961, is a model constructed by Ida Jean Orlando from her own research (Petiprin, 2016). The main foundation of the theory, which is also called the deliberative nursing process theory, depicts an opinion that nursing’s goal is to decipher and meet the patient’s immediate requirements (Petiprin, 2016). A central concept in this theory, the function of professional nursing, epitomizes the NP’s role in the delivery of telehealth. Incorporating the nursing process to manage the patient’s immediate reaction is also a foundational component of the deliberative nursing process theory.  The dimension modeled in Orlando’s theory illustrating that a patient’s outward display, may not be the actual cause of the symptom, is a dimension that is applicable to the telehealth NP-patient encounter. Accordingly, an assumption in Orlando’s theory is that nursing’s core function is to use perception to discern the patient’s needs. This theory provides a framework to fulfill the patients immediate need during the telehealth encounter. A nursing goal of working together with the patient to determine the patient’s needs is both a nursing goal and a communication method. Cooperative communication methods used by NPs during the telehealth NP-patient encounter, is also the communication model assumption in the deliberative nursing theory. Orlando’s theory is an applicable tool to improve and organize NP behaviors (Petiprin, 2016). 

The main dimension in the deliberative nursing theory is identifying patients’ needs through assessment of both the patient’s verbal and non-verbal behaviors. The theory’s foundation can be integrated into telehealth delivery, as the use of etiquette behavior including verbal and nonverbal communication are necessary components for effective telehealth delivery. Orlando posited her theoretical foundation on her research conclusions; ascertaining that meeting the primary patient needs is the essential purpose of the nursing profession (Petiprin, 2016). Orlando’s observational research culminated in a theory specifically for the purpose of interacting between the nurse and patient, integrating the nurse’s perception and validation to enhance patient outcomes.  The development of Orlando’s theory establishes conditions for patients to be addressed specifically, encouraging patient input (Petiprin, 2016). 

Significance of the Study

Telehealth, predicted to be used by seven million patients in 2020, (US Department of Health and Human Services, 2018) is an expanding medical technology. Telehealth, delivered by nurse practitioners can remove obstacles and increase health access by implementing health care modalities such as video interactions, remote appointments, and home monitoring (American Hospital Association, 2019). Elements that contribute to the progress of telehealth are also improvements for patient health care access. The ability to identify professional behavior is positively associated with the knowledge and capability to apply the behavior (Bashir & Bastola, 2018). Identification of the NP’s perceptions about telehealth behaviors will benefit telehealth delivery advancements, illuminating the need for telehealth etiquette in-service training and inclusion in the NP educational curriculum (Henry et al, 2018). The NP’s use of telehealth etiquette ensures the full patient benefit of NP telehealth (Haney et al., 2015).

LITERATURE REVIEW

Gap in the Literature

There is a gap in the literature pertaining to nurse practitioner (NP) telehealth behaviors. There are research articles with data that supports the benefits of telehealth for improved patient outcomes, increasing patient’s access to healthcare and articles that indicate patient satisfaction with telehealth. To provide effective telehealth care, NPs will incorporate the nuances in behavior that are specific for telehealth. The delivery of telehealth patient care requires the NP to use prevailing NP professional behaviors in addition to specific telehealth etiquette behaviors, yet there is a dearth of studies in the literature on these behaviors and nursing telehealth delivery. An effective telehealth encounter requires that the NP incorporate specific telehealth behaviors applicable to the clinical situation. (Haney et al., 2015). Further research that contributes to professional behaviors for successful telehealth delivery such as the identification of the NP’s knowledge about telehealth behaviors, will benefit telehealth delivery advancements, and illuminate specific educational content needs for telehealth etiquette in-service training and telehealth etiquette inclusion in NP educational curriculum (Henry et al., 2018). Research on NP telehealth behaviors can contribute to finding the best practices for NP’s to deliver optimal telehealth, contributing to eliminating inaccessibility in healthcare.

Henry and colleagues (2018) completed a systematic literature review and qualitative interview study. The purpose was to identify experienced nurse practitioners’ and educators’ thoughts on interpersonal telehealth skills. In addition to the systemic reviews of the nine studies, data was obtained from semi-structured interviews with participants who met the inclusion criteria of having a minimum of 3.5 years of telehealth experience. There was a total of six participants from several regional telehealth centers. Thematic analysis was used for data analysis of the transcribed audio/video recorded interviews. Interview data was categorized into six themes construed from the systematic review data. Results from the systematic literature review indicated a gap in the literature on telehealth human factor behaviors. Participants identified clinician buy-in and technological proficiency as essential for effective telehealth delivery.
A qualitative study of home health professional’s perceptions of telehealth completed by Guise and Wiig (2017), explored the perceptions of healthcare professionals on telehealth training. The author aims to explore the lack of data in the literature and, identify specific training needs for telehealth delivery. One of the study’s research question was: How is telecare training and the need for telecare training perceived by healthcare professionals in the home healthcare services? The sample size consisted of a cross section of 26 telehealth home health professionals who worked at four different home healthcare agencies. Data was obtained from six focus group interviews with the 26 participants and was collected over a span of five months from the 90-minute semi-structured focus group interviews. Participants included 11 nurses along with other health professionals from four different home health services. A systematic text condensation was used for data analysis of the transcribed focus group interviews. The common theme abstracted from the interview corroborates the assertion that telehealth requires specific training to master specific behavior skills in addition to the technical required learning elements. The study data indicated the perceptions from healthcare professionals is that telehealth practitioners need telehealth training to learn both the technical as well as human behaviors that are required for telehealth delivery. Data from the study was categorized into five major themes based on study results. Training matter should be specific to the unique requirements in telehealth delivery is the theme that is most relevant to perceptions of nurse practitioners on health care delivery. The study’s results align with the premise that telecare delivery entails the need to integrate the specific skill set of telecare with traditional professional roles.
Polinsnski et al, (2016) conducted a cross sectional design study on patient’s preference and satisfaction with the telehealth delivered care at a CVS health clinic. The study’s aim was to assess quality improvement and patient satisfaction. The factors that the study focused on were patient’s satisfaction with the telehealth nurse’s behaviors and the physical and external quality required for telehealth delivery such as sound, lighting, and transmission quality. The sample inclusion criteria were patients that attended a health session at the CVS health clinic. The survey instrument was used to obtain the study data. After attending the medical appointment with the nurse practitioner, participants were given a 12-page survey with questions pertaining to their experience with the practitioner.  Survey data results from 1744 patient participants showed that 94 percent of the participants affirmed being very satisfied with the telehealth encounter. The results showed that patients expressed a greater satisfaction with a telehealth visit than with the traditional in-person visit.

Gustin et al., (2019). conducted a group research design with a pre-test and post-test to evaluate the effectiveness of a telehealth etiquette training program for a graduate nursing curriculum. The study’s research question was: Will a two-week in-service improve students’ knowledge base on telehealth etiquette? Students’ knowledge about telehealth etiquette and the human elements requirements for an effective telehealth encounter was tested two weeks before the program and at the end of the program. In addition to the pre-test and post-test standardized multiple choice questions, a series of open-ended questions were presented at the end of the program to measure the impact of the telehealth etiquette class. Participants consisted of 100 university graduate and undergraduate students. Data collected from student knowledge of the telehealth etiquette was evaluated with a survey tool of 11 questions on telehealth etiquette knowledge. Data from the pre-test and post-test indicated the ability of students to gain telehealth etiquette knowledge in a brief time period. The pre-test and post-test telehealth etiquette results corroborate previous studies results that the unique elements involved with telehealth etiquette are not intuitive and specific instructions are necessary.

Application to Healthcare Access

A primary determinant of medical management is healthcare accessibility.  Appropriate access to health care is a necessity for the advancement of good health. Some common healthcare impediments are lack of available appointments, clinician shortages, inadequate transportation, and rural geographic challenges. Studies in the literature support the benefits of telehealth for reducing issues of inaccessible healthcare. Telehealth expands health care accessibility for patients by decreasing travel difficulties and problems specific to patients residing in rural locations. Telehealth, delivered by nurse practitioners (NP) can remove obstacles and increase health access by implementing digital health care modalities such as video interactions, remote appointments, and home monitoring (American Hospital Association, 2019).  Increased telehealth etiquette knowledge can result in telehealth progress leading to improved healthcare access for the vulnerable and rural population. NPs must be proficient in telehealth etiquette nuances that are required for a successful encounter. The NP’s use of telehealth etiquette ensures the full benefit of NP telehealth (Haney et al., 2015). The article by Bhatt & Bathija, (2018), presented evidence that there is a crucial need for effective telehealth delivery related to the healthcare demand from rural residents and the vulnerable population, defined in the article as populations with severely limited resources. Identification of the NP’s perceptions about telehealth behaviors will benefit telehealth delivery advancements, illuminating the need for telehealth etiquette in-service training and telehealth etiquette inclusion in NP educational curriculum (Henry et al, 2018). Combining the expertise of NPs with the use of telehealth will contribute to the eradication of health care inaccessibility. This data may be useful in improving NP telehealth and delineating the need for telehealth etiquette in NP educational curriculum (Bhatt & Bathija, 2018).

METHODOLOGY

The delivery of telehealth patient care requires the NP to use prevailing NP professional behaviors in addition to specific telehealth professional behaviors known as telehealth etiquette. Telehealth etiquette is comprised of verbal and non-verbal communication, equipment management, and the display of emotional intelligence (Haney et al., 2015).   For the purpose of providing the full benefit of NP telehealth, NPs must be proficient in the nuances that are required for a successful encounter. Consequently, it is imperative for NPs to have both technical and non-technical skills that are necessary for an effective NP-patient patient telehealth encounter.

Project Design/Data Collection

This is a qualitative, descriptive study to explore perceptions of NP on telehealth and the phenomenon of telehealth behaviors. Data on the nurse practitioner’s perception of telehealth was collected during individual semi-structured interview. This interview process consisted of the use of web-based Zoom software. Interviews spanned approximately 30 minutes with free-flowing dialogue of 10 questions recorded in Zoom. Participant demographics collected were age, gender, years of nursing experience, and nursing specialty if there is one. The recordings from the video-audio interviews were transcribed and thematic analysis was used to reach data saturation. Data was categorized using content analysis of themes. Questions were designed specifically for a qualitative study, to promote dialogue. The interview questions used in the study pertained to the NP’s perception of telehealth delivery and telehealth etiquette behaviors.
Study inclusion: licensed nurse practitioner, minimum age 18, minimum telehealth experience 1 year, exclusion: less than 1 year of telehealth work experience. Study data was collected by video/audio recorded interviews using web-based Zoom software. Content analysis and deduction was used to categorize the identified themes from the coded transcription data (Henry et al., 2018.

Sample

The subjects were obtained from colleagues that are NPs using the snowball sampling method (Bengtsson, 2016). Nine nurse practitioners were interviewed for this study. Recruitment procedures ensured voluntary participation. Telehealth etiquette is a skill set of professional behaviors specific to a telehealth encounter to enable a successful patient interaction. Correct encounter behaviors are important for effective telehealth delivery and etiquette behaviors are essential. The NP’s perception of the professional behaviors in telehealth etiquette is a demonstration of knowledge that indicates the ability to also perform the appropriate behavior (Haney, Kott & Fowler, 2015). There is little evidence on the NP’s perception of professional behavior in telehealth.  There is no data in the literature on the NP’S perceptions of telehealth etiquette behaviors.

Protection of Human Subjects

Precautions to Minimize Risks were implemented for the protection of subject confidentiality and to avoid data breech.  Professional security standards were adhered to.  Study data including web-based Zoom interview audio-video recordings, transcriptions, demographic data and signed consents were stored electronically on password protected Google drive. To prevent data breech, access was limited to the researcher and PI. Paper documents were contained in a confidential folder inside a locked cabinet with access available only to the researcher. Shared, study data was presented in aggregate form with no participant identifying information. Patient personal information obtained for the study will be deleted from the computer after one year. All research information has been managed adhering to standards that protect confidentiality and prevent data breach. Study subjects were assigned an identification number for analysis in lieu of personal identifying information for privacy and anonymity. This code was stored on the researcher’s secured computer. Data was also collected and stored electronically on the researcher’s secured password protected computer. Only the researcher and PI have access to this data. All research information has been managed adhering to standards that protect confidentiality and prevent data breach.

ANALYSIS

This study’s exploration of NP’s perception on telehealth behaviors merged into a diverse set of themes and categories arising from interview responses that correlate with the study’s focus.  Themes and categories were identified by related codes. Content analysis entails data evaluation and structuring with a coded label. This technique was used to explore themes generated from the NP interview responses. Data analyzed through content analysis makes objective inferences from the data collection. After methodically classifying content and characteristics, content analysis of the NP interview data produced objective inferences that was categorized and compiled into themes. Completion of the content analysis process developed five categories procured from similar concepts and identified in the NP interview responses (Bengtsson, 2016).

Behaviors

This qualitative study’s exploration is focused on the NP perceptions of behaviors known as telehealth etiquette. The premise of the study is that the specific skill set required in telehealth etiquette is necessary for providing effective telehealth delivery. The category of behaviors is represented in the interviews with a frequency of responses related to skills, voice, tone, empathy, eye contact, attire, equipment, and connectivity (Haney et al., 2015).

Theme: Telecare etiquette requires a specific set of skills inclusive of both technology and human factors for providing effective telehealth delivery. NP1’s comment reflecting specific skills of telehealth etiquette:

“We have to work at using eye contact and tone, something to convey meaning that may not be as obvious as in the face to face visit”. Telehealth is also inclusive of technological behaviors stated in NP’s response “Part of our communication skill is making sure connectivity is secure.”

Communication

NPs that are equipped with proper telehealth etiquette training will be better prepared to provide excellent telehealth patient delivery. A communication category, an essential telehealth etiquette component was identified based on the thematic categorization of the NP’s responses. Similarities in NP responses include interaction, engage, nonverbal, signs, tone, express, convey (Haney et al., 2015).

Theme: Effective NP telehealth requires telehealth etiquette knowledge. NP3’s response is an example of the importance of communication behaviors in telehealth.
“Nonverbal communication behavior is very important with telehealth. nonverbal communication helps express empathy and caring which leads to trust and compliance with your patients that leads to patient satisfaction.”

Alignment

A relationship between nurse practitioners’ perceptions on telehealth etiquette and actual telehealth etiquette behaviors is an explorative element of the study. Examples of responses to the study interview question on telehealth etiquette performed by the NP indicate that the NP’s perceptions of telehealth etiquette behaviors are actual telehealth etiquette behaviors.

Theme: A requirement in attaining competent NP professional behavior is the NP’s knowledge and ability to recognize the behavior (Henry et al., 2018).

NP4: “So providing positive feedback, asking the right question, keeping the patients engaged, make them feel that they're being listened to and making them feel that they are appreciated. Provide a friendly environment: being polite, smiling”.

NP5: “Maintaining eye contact. A lot of times we look up towards the little light instead of looking down, towards the patient so that we look engaged. Develop trust or develop rapport by introducing ourselves, you know, explaining how, you know, the ritual modality works, ensuring, you know, their privacy, making them feel at ease, and of course, you know, conveying that you're knowledgeable and have the skills to do the job”.

 Plan

There is continual demand for NP telehealth. NP telehealth has been proven to improve the health care gap that exists when there is reduced health care access, yet, there is limited telehealth etiquette preparation included in NP educational curriculum (Henry et al., 2018). Although NP education was not a question on the questionnaire, in discussing preparation and organizational support for telehealth delivery, all of the interviewees disclosed that they did not receive sufficient telehealth education during their NP education. Concerning specific preparation for a telehealth encounter, the consensus based on content analysis consisted of telehealth etiquette behaviors like preparing before the visit with a patient pre-visit introduction, ensuring connectivity and equipment operations.

Theme: Identification of the NP’s perceptions about telehealth etiquette will benefit telehealth delivery and reveal the need for telehealth etiquette in-service training and telehealth etiquette inclusion in NP educational curriculum. The following response by NP6 is representative of many of the participants responses:

“It truly comes down to the simple things like where's your webcam, positioned so that the patient can see you well, making sure that the patient can hear you on the other end and that your pictures are clear, making sure there's nothing distracting in the background like you have your blinds closed behind you. If you don't think of those things and the patient can't see you because of the window behind you, they're not even going to be paying attention to what you're trying to talk to them about”.

Challenge

The consensus from the NP interview data of challenges to telehealth delivery, was related to performing the patient examination, especially the heart and lung assessments without the use of touch. Patients that have difficulties interfacing with digital technology were also a reported telehealth delivery difficulty.
Theme: Physical touch assessment is preferred by NP for patient exams.

CONCLUSION

The ability to identify professional behavior is positively associated with the knowledge and capability to apply the behavior (Bashir & Bastola, 2018). Identification of the NP’s perceptions about telehealth behaviors will benefit telehealth delivery advancements, illuminating the need for telehealth etiquette in-service training and inclusion in NP educational curriculum (Henry et al, 2018). The majority of the study’s NP’s interview responses were in accord with the theme that telehealth behaviors are unique and are necessary for an effective patient encounter. Response generated themes highlighted that etiquette behaviors are a professional skill that needs to be included into the nursing education and professional competencies.  Prevailing themes generated from participant responses indicated a consensus on the importance of establishing trust before and during a patient interaction.

Increased telehealth etiquette knowledge can result in telehealth progress leading to improved healthcare access for vulnerable and rural populations. Combining the expertise of NPs with the use of telehealth can contribute to the eradication of health care inaccessibility. Data that demonstrates the efficacy of evidenced-based practices contributes to intervention and implementation that can narrow the disparity in the treatment gap for the RV population. This study data contributes to filling a void in the research gap on NP perceptions of telehealth etiquette behaviors. Additional research that this study’s data could contribute to include further research exploring NP educational curriculum and perceptions. A follow-up on this study could improve NP telehealth etiquette and cost effectiveness, and patient satisfaction.