Attaining Mutual Goals in Telehealth Encounters: Utilizing King’s Framework for Telenursing Practice

Interacting in the Virtual Care Environment

The methodologies utilized in the virtual care environment consist of three technologies: clients interacting at a distance through immediate real-time interaction utilizing audio and visual communication means, store and forward technologies, and remote patient monitoring technologies. In this section, the authors discuss these three ways of interaction and some of the ways they can support the nursing process.

Immediate real-time interaction is used when the nurse/provider and the client are communicating directly with each other. One technological method used for this type of interaction is the telephone and/or smart phones. Telephones and cell phones are available and familiar to most clients. Telephones are not a new technology, and cell phones have taken off with many persons choosing a cell phone over a wired telephone line. Both telephones and cell phones impact the ability of the nurse to interact directly with clients. This type of technology requires excellent verbal and sometimes excellent texting therapeutic communication skills. These interactions can be used for providing basic information to clients through education, counseling, answering questions, or for follow-up phone calls for ongoing evaluation or client observation, and nurses can utilize this means of communication to set and meet mutual goals.

Videoconferencing is another method of immediate real-time interaction. It encompasses a variety of equipment including the use of cameras, video cameras, webcams, computer-based desktops or laptops, and other portable communication computer processing devices, such as a smart phone or smaller computer tablet that permits direct face-to-face interaction between nurse/provider and client. In comparison to a standard telephone or simple cell phone, this method of real-time interaction allows the nurse and client to see one another during a care encounter. By adding a visual as well as audio component to the exchange, the nurse can perform visual assessments. The visual component of the technology enhances the nurse’s ability to more readily recognize nonverbal communication patterns that may not be picked up through just a verbal exchange. For the client, it might be easier to interact with the nurse since both the senses of sight and hearing complement one other. Video conferencing can also be enhanced by diagnostic peripheral assessment tools that can be added to the system capabilities. These peripheral devices are attached to telehealth cart or on another mobile device with the video conferencing capability. Nurse assessment can be further enhanced with digital cameras, blood pressure devices, stethoscopes, otoscopes, scales, glucose monitoring devices, cardiac monitoring, dermatology and ophthalmology scanners, and other instrument scopes that allow the nurse/provider to capture client assessment information.

Store-and-forward technology is another means of interacting with a client and combines the use of a camera, computer, microphone, and image management software. Nurses trained to use this technology are able to collect client information and then forward the information to a provider in real-time or asynchronously. With store-and-forward technology use, there may or may not be verbal communication between a nurse and client. The interactions may occur through the medium of technological representation. However, it is a means of facilitating access to care when a real-time encounter initially may not be needed, or not possible, thus providing efficiencies, while also serving as means to connect patient and health care resources.

Remote patient monitoring provides for continuous tracking of some health indicators by a nurse. The technology used to capture remote patient monitoring includes devices that are directly attached to a client (halter monitor) where a number of measures might be collected and at some point during a day or at multiple points during a day forward the information to a provider, often times a nurse. The nurse is able to assess these data from a remote monitoring device to document trends and changes in physical assessment. The remote monitoring systems can also alert a nurse as to a critical assessment that may warrant immediate response and follow-up. These healthcare alerts can be transmitted to providers on a real-time basis and provide clinical decision-making support, helping the provider detect issues earlier, intervene earlier, and avoid the need for hospitalization (Rantz et al., 2013).

These are simple examples of telehealth technologies available for current and future applications by nurses to assist clients in achieving optimal health outcomes in clinical practice. King’s conceptual framework and theory of goal attainment easily align with these types of telehealth technologies and provide a guiding framework as nursing care continues to intersect with technological advancements.

King’s Conceptual Framework

King’s general systems framework and related concepts are applicable to the use of telehealth technologies to extend nursing practice. The interactions of the personal, interpersonal, and social systems can all be influenced by individuals and the use of technology. King’s concepts of perception, time, space, communication, interaction, and decision-making all apply and serve to enhance telehealth encounters by nurses.

In the personal and interpersonal systems, nurses practicing from King’s framework recognize that all persons, including themselves, are dynamic, open, goal-oriented systems. Nurses and clients both come to situations with unique understandings and unique perceptions. King (1981) defined perception as “an awareness of persons, objects, and events” (p. 20). In telehealth, the perceptions of both the nurse and client of the virtual environment need to be considered. For some, the virtual care environment may be either a place of stress or comfort or a blend of both, depending on the perception of the technology being used to facilitate the nurse-client interaction. The nurse or the client may come to an encounter with previous positive or negative experiences with technology to engage in healthcare transactions and goal attainment. How telehealth technologies may influence communication patterns and perceptions of a communication must be considered. The process of making transactions and creating mutual goals may take place without actually being in the same time and location. One way of addressing these issues is through the education of the nurse/provider and the client as to the use of the technology and how it can facilitate access to healthcare.

King’s concept of space is highly relevant to telehealth. Space has a “relationship to perception, body image, and the way individuals use space” (King, 1981, p. 34). If an encounter is taking place in the virtual space, there is a question of how might the nurse and client feel connected yet be miles apart. The telehealth technology selected to conduct virtual care encounters has the ability to make the space feel vast or almost identical to a face-to-face encounter. When considering space, the concept of time must also be addressed in the context of perception and communication. King’s description of time takes into account how one values time, how it is perceived, and how interactions may feel time connected or bound in virtual care space. The virtual care spaces have the capability of saving time and accelerating the access to care for clients. Nurses may be able to more quickly engage in the process of goal attainment with clients. Engaging in a virtual encounter may be time saving, as it can reduce the costs of travel to a place for healthcare.

The social system is thrusting forward toward increasing access to virtual care spaces and environments. Clients and nurses are looking for more convenient and easier ways to increase access to care. Telehealth technology is a viable alternative to increasing this access. Authority, power, and decision-making by the client as a consumer and nurses as providers are being routinely used. Nurses may be in a unique position to have authority and decision-making capability when making choices about the best telehealth technology to enhance nursing practice.

King’s Theory of Goal Attainment

King’s theory of goal attainment focuses on the interpersonal system of her general systems framework that also includes interacting personal and social systems. One focus of the interpersonal system is the nurse-client relationship and mutual goal-setting. The process of goal attainment occurs when a client in need of nursing services enters a reciprocal relationship with a nurse where both parties are mutually present for a purposeful interaction (King, 1992). King (2007) stated that “the transaction process in the theory will not change, but the ways we communicate and interact have changed because of the multiple technologies available” (p. 110). Some nurses still believe that these interactions are best done in a face-to-face encounter where each party is physically present in a space. Regardless of the medium constituting the mutual interaction between a nurse and a client, there is a process of human interaction where perceptions, judgments, and actions on both the part of the nurse and client lead to a reaction, interaction, and transaction (King, 1981). Any human interaction is strongly influenced by the communication patterns of clients and/or nurses. In the interactions with a client, a nurse still completes the nursing process with or without technological assistance to “gather information, observe and measure parameters of clients, interpret the information, and give appropriate information to the client to help set goals” (King, 1981, p. 144). The client can “observe the nurse, ask questions, give information, and participate in setting goals” (pp. 144-145). The most important skill that a nurse needs is the ability to communicate effectively with a client to be able to use the nursing process in the most effective manner. Not all nurse-client transactions can be done through telehealth technology. Nurses need to use effective decision-making and clinical reasoning skills to determine when an encounter and care can be fostered through technology, or if an in-person encounter is best, or a combination of both.

Conclusion

Any form of telehealth technology employed to provide nursing care requires the nurse to become skilled in its use and have knowledge of best practices and value accomplishing these through the lens of facilitating goal attainment to improve health. It is critical that nurses demonstrate not only professional competency but also a confidence in an effort to support the client’s transition to this younger modality of care, which goes beyond the realm of on-site face-to-face care. Two major professional organizations that offer education and advice for nurses conducting telehealth encounters are the American Association of Ambulatory Care Nurses (AAACN) and the American Telemedicine Association (ATA). Both organizations offer standards and best practices for telehealth encounters.

Regardless of how and where an interaction between a nurse and client occurs, the core skill is communicating vital health information to set and achieve mutual health goals. Even though care may be virtual, there is still an interaction between the nurse and client that leads to some final transaction. The core elements of the nursing process are still occurring; it is just enabled differently through technology. Collaboration skills are also potentially enhanced as the nurse and client can network more freely via technology and expand the resources available in the social system for both the nurse and the client. Both the nurse and client need to become familiar with the use of technology and the safe ways of employing it for care. The nurse needs to select the right technology for the right care transaction and recognize when an on-site face-to-face encounter is really needed and warranted. A strong consideration of King’s concepts and theory of goal attainment provides a framework for nurses to implement a transaction process with their clients and develop goals and actions leading to improved health outcomes.