Nursing Change Project The organization at focus in this nursing change project and the nursing managers in cohesion implemented an evidence-based nursing practice model in the health care organization. As noted in the work of Keele (nd) there has been several models that have provided contributions on the conceptual level to the implementation of evidence-based nursing. One of these models is the Stetler model (Stetler, 2001), also included is the Iowa model (Titler, et al., 2001), the John Hopkins Evidence-Based Practice Model (Newhouse, et al., 2007), the ACE Star Model (Stevens, 2004), the Caledonian Development Model (Tolson, Booth & Lowendes, 2008), and the Evidence-Based Practice Model for Staff Nurses (Reavy & Tavernier, 2008). (p.75) The model chosen by the organization and reported in this work in writing is most similar to the Evidence-Based Practice Model for Staff Nurses (Reavey & Tavernier, 2008). The process utilized for the Evidence-Based Practice Model for Staff Nurses is one that greatly mirrors the nursing process in terms of the assessment, diagnoses, planning, implementation, as well as the components used in evaluation. Added are analysis and synthesis of evidence, as well as integration and maintenance of practice change to complete this model.

II. Overview of the Model

The model of Reavey & Tavernier (2008) is such that involved staff nurses, a unit nurse manager, and the research staff of the hospital. In the present project, implementation the past research conducted on the procedure of change has served to document the necessity of the change as well as have institutional records on errors in this area. Reavey & Tavernier (2008) is reported by Keele to include ten important strategies as follows: (1) Identification of the practice problem/issue; (2) Collection and appraisal of the empirical evidence; (3) Collection and appraisal of the nonempirical evidence; (4) Summary across all evidence; (5) Integration of the evidence with clinical expertise, client preferences, and values in making a proposed practice change or decision; (6) Development of the proposed practice change in detail; (7) Consideration of the feasibility and organizational issues; (8) Evaluating the practice change; (9) Marketing the practice change; (10) Strategies for successful implementation and sustainability of practice change. (Reavey and Tavernier, 2008, paraphrased)

Telemedicine implementation was the change at focus in the study reported. Implemented in this project was a Telemedicine camera system in one of the school health-based clinic with the goal of assessing students from another school, by a physician direct link as well as other providers. This change took place due to funding cuts and each school nursing being required to acquire three or four schools to oversee the clinics rather than one or two in schools years before the economic problems began.

IV. The Evidence

Telemedicine is defined in the work of Puchala and Wozniak (2001) to be "the investigating, monitoring and management of patients and the education of patients and staff, using systems, which allow ready access to expert advice and patient information no matter where the patients or relevant information is located." (p.1) The work of Yellowless (nd) reports seven principles for the development of telemedicine systems including those stated as follows:

1 Telemedicine applications and sites should be selected pragmatically, rather than philosophically

2 Clinician drivers and telemedicine users must own the systems

3 Telemedicine management and support should be from the 'bottom up', rather than from the 'top down'

4 The technology should be as user-friendly as possible

5 Telemedicine users must be well trained and supported, both technically and professionally

6 Telemedicine applications should be evaluated in a clinically appropriate and user-friendly manner

7 Information about the development of telemedicine must be shared (Yellowless, nd, p.3)

From a functional point-of-view telemedicine, system configuration means that remote diagnosis takes place as well as "remote patient registration in addition to remote registration, monitoring, and transmission of EKG signals and other biomedical signals, remote measurement of blood pressure and pulse, body temperature and other physiological parameters." (, p.8)

One of the primary aspects of the telemedicine system is the teleconsulting module, which enables the physician the ongoing access to medical data on the remote server or to the experts in the medical center. The database must be able to guarantee "easy access and update from the different site on the Internet." (Yellowless, nd, p.9) The work of Mackert and Whitten (2009) reports the successful adoption of a school-based telemedicine system and state that a case study of the Telekidcare makes use of interactive television systems "located in the school health office to let school nurses interact with KUMC physicians to provide consultations to sick children." (p.1) The results of the study are stated to "point o factors to success both in...

(Mackert and Whitten, 2009, p.1)
The study concludes by stating that the "lessons learned from Telekidcare's success helps researchers and practitioner considering similar systems in other schools." (Mackert and Whitten, 2009, p.1)

In another study reported by the Children's Partnership, it is stated that the state of California "was one of the pioneers in telehealth among states, with programs operating in the early 1990s and enactment of one of the first state telehealth laws in 1996. The State now has the opportunity to extend this leadership by harnessing technology to meet the health care needs of children in schools." (Lazarus and Lipper, 2009, p.2)

Lazarus and Lipper additionally report that telehealth "the use of information and communications technology to provide health care at a distance -- is emerging as a valuable way to complement and expand the capacity of schools to meet the health care needs of children, particularly those who are low-income and living in medically underserved areas, while keeping them in school and their parents at work. Telehealth in schools is increasing access to acute and specialty care for children; helping children and families manage chronic conditions; facilitating health education for children, families, and school personnel; and increasing the capacity of school nurses and school-based health centers to meet the health care needs of students." (Lazarus and Lipper, 2009, p.2) Reported as benefits included in the school-based telemedicine system are those stated as follows:

(1) increased access to acute care;

(2) improved management of chronic disease;

(3) Improved access to behavioral and mental health care;

(4) added value to existing school-based health services;

(5) increased education, training, and support of school staff;

(6) more children kept in school and parents at work;

(7) Greater cost effectiveness; and (8) More efficient use of resources. (Lazarus and Lipper, 2009, p.4)

Lazarus and Lipper reports that managed care "has posed barriers to schools being able to bill insurance for services. Because Medicaid and CHIP often deliver services through managed care organizations, schools have had difficulty claiming dollars for Medicaid- and CHIP-enrolled children, unless the schools become a part of the managed care network in which the children are enrolled." (2009, p.4) As well, it is reported that many schools "also do not have the resources to create an effective infrastructure for billing public and private insurance entities. Some of these barriers can be addressed by having entities other than schools operate the telehealth program. Indeed, many school-based telehealth programs are operated by health care providers who are Medicaid and CHIP providers and have the administrative infrastructure to bill insurance." (Lazarus and Lipper, 2009, p.4)

Stated as well is that even when the school-based programs, to include telehealth programs are able to bill insurance for their services the revenue from insurance "is usually not enough to fully support these programs. Barriers to relying on insurance to sustain school-based health programs include insufficient patient volume, lack of insurance among many children, and the provision of nonbillable services -- such as individual and classroom-based health education, case management, referrals to other services, and education for parents and school staff." (Lazarus and Lipper, 2009, p.4)

Telehealth is reported as many times "more expensive than traditional in-person visits due to costs associated with broadband connectivity; equipment; equipment maintenance; technical assistance; and coordination of visits, including scheduling, setting up equipment, and communication with the remote health care provider" (Lazarus and Lipper, 2009, p. 5)

According to Lazarus and Lipper (2009) school-based telehealth programs "should make sure the program is filling a health care gap, not duplicating services. School-based telehealth programs should tailor their programs to fill gaps in community health care services." (p. 6) School-based telehealth is reported to require "…a multidisciplinary approach and good project management. Because there are so many components to school-based telehealth, it works best when representatives from education, school health, the local and distant health care community, the technology arena, and other stakeholders are involved in planning and implementation." (p.6)

V. Key Stakeholders

Key stakeholders…