Implementing solutions to improve and expand telehealth adoption: participatory action research in four community healthcare settings.

BACKGROUND: Adoption of telehealth has been slower than anticipated, and little is known about the service improvements that help to embed telehealth into routine practice or the role of frontline staff in improving adoption. This paper reports on participatory action research carried out in four community health settings using telehealth for patients with Chronic Obstructive Pulmonary Disease and Chronic Heart Failure. METHODS: To inform the action research, in-depth case studies of each telehealth service were conducted (May 2012-June 2013). Each service was then supported by researchers through two cycles of action research to implement changes to increase adoption of telehealth, completed over a seven month period (July 2013-April 2014). The action research was studied via observation of multi-stakeholder workshops, analysis of implementation plans, and focus groups. RESULTS: Action research participants included 57 staff and one patient, with between eight and 20 participants per site. The case study findings were identified as a key source of information for planning change, with sites addressing common challenges identified through this work. For example, refining referral criteria; standardizing how and when patients are monitored; improving data sharing; and establishing evaluation processes. Sites also focused on raising awareness of telehealth to increase adoption in other clinical teams and to help secure future financial investment for telehealth, which was required because of short-term funding arrangements. Specific solutions varied due to local infrastructures, resources, and opinion, as well as previous service developments. Local telehealth champions played an important role in engaging multiple stakeholders in the study. CONCLUSIONS: Action research enabled services to make planned changes to telehealth and share learning across multiple stakeholders about how and when to use telehealth. However, adoption was impeded by continual changes affecting telehealth and wider service provision, which also hindered implementation efforts and affected motivation of staff to engage with the action research, particularly where local decision-makers were not engaged in the study. Wider technological barriers also limited the potential for change, as did uncertainties about goals for telehealth investment, thereby making it difficult to identify outcomes for demonstrating the added value over existing practice.

Examining the use of telehealth in community nursing: identifying the factors affecting frontline staff acceptance and telehealth adoption.

AIMS: To examine frontline staff acceptance of telehealth and identify barriers to and enablers of successful adoption of remote monitoring for patients with Chronic Obstructive Pulmonary Disease and Chronic Heart Failure. BACKGROUND: The use of telehealth in the UK has not developed at the pace and scale anticipated by policy. Many existing studies report frontline staff acceptance as a key barrier, however data are limited and there is little evidence of the adoption of telehealth in routine practice. DESIGN: Case studies of four community health services in England that use telehealth to monitor patients with Chronic Obstructive Pulmonary Disease and Chronic Heart Failure. METHODS: Thematic analysis of qualitative interviews with 84 nursing and other frontline staff; and 21 managers and key stakeholders; data collected May 2012-June 2013. FINDINGS: Staff attitudes ranged from resistance to enthusiasm, with varied opinions about the motives for investing in telehealth and the potential impact on nursing roles. Having reliable and flexible technology and dedicated resources for telehealth work were identified as essential in helping to overcome early barriers to acceptance, along with appropriate staff training and a partnership approach to implementation. Early successes were also important, encouraging staff to use telehealth and facilitating clinical learning and increased adoption. CONCLUSIONS: The mainstreaming of telehealth hinges on clinical 'buy-in'. Where barriers to successful implementation exist, clinicians can lose faith in using technology to perform tasks traditionally delivered in person. Addressing barriers is therefore crucial if clinicians are to adopt telehealth into routine practice.

Factors affecting front line staff acceptance of telehealth technologies: a mixed-method systematic review.

AIM: To synthesize qualitative and quantitative evidence of front-line staff acceptance of the use of telehealth technologies for the management of Chronic Obstructive Pulmonary Disease and Chronic Heart Failure. BACKGROUND: The implementation of telehealth at scale is a governmental priority in countries including the UK, USA and Canada, but little research has been conducted to analyse the impact of implementation on front-line nursing staff. DATA SOURCES: Six relevant data bases were searched between 2000-2012. DESIGN: Mixed-method systematic review including all study designs. REVIEW METHODS: Centre for Reviews and Dissemination approach with thematic analysis and narrative synthesis of results. RESULTS: Fourteen studies met the review inclusion criteria; 2 quantitative surveys, 2 mixed-method studies and 10 using qualitative methods, including focus groups, interviews, document analysis and observations. Identified factors affecting staff acceptance centred on the negative impact of service change, staff-patient interaction, credibility and autonomy, and technical issues. Studies often contrasted staff and patient perspectives, and data about staff acceptance were collected as part of a wider study, rather than being the focus of data collection, meaning data about staff acceptance were limited. CONCLUSION: If telehealth is to be implemented, studies indicate that the lack of acceptance of this new way of working may be a key barrier. However, recommendations have not moved beyond barrier identification to recognizing solutions that might be implemented by front-line staff. Such solutions are imperative if future roll-out of telehealth technologies is to be successfully achieved.