eHealth and Telemedicine Strategies to Reduce Nursing Turnover

Introduction and Problem Background

Nursing turnover rates are a serious issue for hospitals: they are costly and result in lost time and energy in continuously training new staff (Twibell, 2012). Identifying the main reasons for nursing turnover and addressing them can lead to better nurse retention (Trivellas, Gerogiannis, & Svarna, 2013). The cost of replacing a single nurse has been estimated at approximately $82,000, according to research published in the Journal of Nursing Administration (Twibell, 2012). As Twibell (2012) reports, job satisfaction is the primary reason new nurses leave, and the poor sense of job satisfaction is related to excessive workloads and nurses' inability to guarantee patient safety.

While Twibell (2012) suggests that these issues can be addressed through pre-screening strategies such as "pre-hire job shadowing" and "behavior-based interviews," this project highlights the growing interest among nurses in eHealth and telenursing, which uses electronic monitoring to assist caregivers and help patients feel more comfortable (Barret & Wallis, 2013; Mills et al., 2013; Odeh, 2014). eHealth and telemedicine can be effective innovations that enable nurses to achieve job satisfaction by helping them feel that they are providing better care, making patients more comfortable, and preventing workplace fatigue.

Nursing is a dynamic industry that requires continual education and development of both nursing strategies and technological capabilities. When the industry falls behind the times, it can produce negative consequences within the organizational workplace. Nurses who enter the field face the challenge of coping with an inadequate system that does not allow them to reach their potential or take advantage of developments that could greatly enhance the quality of care they provide to patients.

The inability to overcome this challenge can lead to job dissatisfaction, stress, and work fatigue — especially when nurses are burdened by overwork resulting from high turnover rates. Not only is a lack of nursing retention a self-perpetuating problem, but the system is structured to fail as the core issues at the heart of nursing turnover are never directly addressed.

The innovative change recommended for overcoming this challenge is to implement eHealth services in the hospital, integrating Digital Age technology into the nursing floor in a way that is compatible with nursing aims, patient expectations, and organizational objectives. eHealth includes the use of electronic medical records, telemedicine, and e-medicine approaches to nursing that can add substantial value to the nurse's ability to feel job satisfaction, deliver quality care, and manage time more effectively (Trossman, 2014).

The problem of nursing turnover in this hospital is attributed to a variety of factors. As Twibell (2012) notes, the primary factor in lack of nursing retention is job dissatisfaction, which is related to the nurse feeling overworked, unable to provide quality care to patients as a result of poor organizational management and staffing, and general workplace fatigue. Twibell (2012) suggests that the problem is that the wrong nurses are being hired; however, research and interaction with nursing colleagues indicates that the deeper issue is the absence of a sufficiently developed technological system that could ease the burden nurses experience in today's fast-paced, interconnected environment where patients expect responsive, high-quality care.

The proposed solution is to implement eHealth services at the hospital to positively develop working conditions and enable nurses to deliver optimal care through electronic medical records and telenursing. eHealth is a growing strategy that allows nurses to provide long-distance care and improve patient monitoring through direct connectivity, provided that the proper procedures and supports are in place (Odeh, 2014).

By lacking a proper organizational framework attuned to the needs and demands of patients and nurses today, the hospital fails to provide the kind of leadership and management that makes employees want to stay. The main issue is not that nurses are unsuited for the profession but rather that the workplace environment does not support the innovations recognized by nurses and patients as congruent with the way modern society operates — electronically and digitally, with instantaneous connections made possible by advancements in communications and records-keeping technology. Through cloud computing for electronic medical records retrieval and telenursing technology for round-the-clock patient monitoring, nurses could reach the professional heights they naturally expect, having completed the extensive education demanded of them prior to entering the field.

The main contributor to this problem can therefore be explained as a lack of adequate oversight by administrators who may be unaware of the progressive systems available for implementation — systems that could positively impact worker morale, reduce turnover rates, and save costs associated with training new nurses. By educating the administration about eHealth options and the beneficial outcomes they can produce, a positive solution to this problem can be effectively realized.

Rationale for eHealth Innovation

Nursing turnover is costly for hospitals, which must hire, train, and equip new nurses each time turnovers occur (Twibell, 2012). Hospitals lose millions of dollars per year as a result of nursing turnover. This problem can be addressed by adopting an innovative change in the way hospitals empower nurses. By identifying the causes of turnover — low job satisfaction, overwork, and an inability to provide quality care — the hospital can boost nurse retention and reduce costs (Mbemba, Gagnon, Pare, & Cote, 2013).

The most advanced and innovative way to address this problem is to reshape the organizational environment by implementing eHealth services such as telemedicine (Kruklitis, Tracy, & McCambridge, 2014). Telemedicine has been shown to reduce the stress nurses experience from overwork, increase job satisfaction, and boost the nurse's feeling of being able to provide quality care (Potter, Mueller, Mackinney, & Ward, 2014). It can therefore be an effective means of empowering nurses and reducing turnover.

By changing the workplace organizational environment and making it more appealing to individuals who want to provide nursing in the Digital Age, this innovative technique will help reduce nursing turnover rates and thereby help to avoid the high costs associated with turnover. Simultaneously, it will boost workplace organizational culture and morale by making nurses feel more in touch with the potential afforded by digital technology (Kissack & Callahan, 2010).

With new nurses who have come to adulthood in the Digital Age being familiar with digital interfaces, it is natural that they would view eHealth as a welcome advancement and an acceptable method of meeting patient needs and providing quality care. For this reason, telehealth is on the rise and is being viewed as the next step forward in providing patients with the care they desire while making nurses feel more capable of delivering the quality expected of them (Trossman, 2014; MayoClinic, 2015). While eHealth is being tried in various hospitals around the country, there is still substantial room for growth and implementation. In hospitals where it has not yet been adopted, this project will serve as an educational resource to supply the material whereby proper support can be instituted to make telenursing a reality for nurses, improving overall job satisfaction and thereby reducing turnover rates.

The rationale for this innovation rests on the understanding that eHealth is not merely a novel technique — it is the way that young professionals are accustomed to communicating and keeping records. Bringing these processes into the hospital will eliminate the dissociative transition between the world outside the hospital and the organizational culture within it. It will enhance nursing practice and provide nurses with greater job satisfaction, thus helping to reduce nursing turnover.

Stakeholder Identification and Analysis

Patients, nurses, physicians, family members, and administrators are all stakeholders in the innovative change recommended here. A unit manager will oversee the eHealth department and will thus have authority in the implementation process; the manager's interest stems from the role of an administrator seeking the best possible course to quality care, and the manager's influence is seen in the leadership potential of the role throughout the process. An educator will be needed to provide the guidelines set forward in this project and ensure that the proper steps are taken and the necessary support system is provided for nurses using the telenursing technology, in line with recommendations from researchers in the field (Lee, Lee, & Kim, 2016). A quality improvement office will assess levels of quality care, and staff nurses will facilitate the telenursing department as part of standard protocol. Family members will also be involved in the delivery of telemedicine as they assist loved ones in the transition process.

The hospital administration will have significant power, interest, and influence in the adoption of a telenursing strategy. The administration holds the power to deny or approve the implementation process, making it the most powerful stakeholder. Its interest in approving telemedicine lies in the potential to improve workplace conditions, boost nursing retention, and reduce costs — saving administrators from having to balance budgetary concerns with hospital objectives long-term. The administration's influence is also promotional: if it supports the project, it can cultivate a positive morale centered on the implementation of telemedicine. While eHealth is still relatively new to the industry, convincing the administration that its adoption would improve organizational culture, increase job satisfaction, and reduce turnover would be a top priority. The data available on how and why eHealth can benefit both nurses and patients will need to be presented convincingly to ensure positive support from this stakeholder.

Nurse practitioners will need to be educated on how to properly implement eHealth and telenursing strategies, the appropriate support systems to follow, and the most effective methods of providing quality care via telenursing platforms. Training will be a top priority. Their power in the innovative process lies in their position to utilize telemedicine, grow in experience with it, and through it improve patient care and their own working experience. Their interest stems from their desire to perform their jobs to the fullest, and this change will promote that. Their influence will come from those who are experienced with telemedicine or have a positive outlook on it; these nurses will be able to generate positive attitudes among colleagues and help sway the administration to adopt the technology.

Physicians will also need to be informed about the role of telenursing in the hospital and how it facilitates patient care. Their positive support will be instrumental in providing a high level of morale for employees and in giving adequate attention to the change process. Their power in the project comes from their ability to recommend practices to the administration and provide backing. Physicians collaborate with nurses in the field, can observe that happier nurses are more effective, and can see that a strategy like telemedicine can improve worker morale. Their influence stems from their power to impress upon the administration the importance of telemedicine; their interest in the project stems from their collaboration with nurses and their shared desire to provide a positive patient experience.

Community leaders will also want to be informed about the new implementation of telenursing in the hospital, as they can communicate this advancement to their constituents and participate in the transition process. Community leaders have power in the sense that they can influence the administration and demonstrate that patients within the community want to embrace eHealth services because of the quality of care they can provide. They can also give or withhold support to the hospital based on the administration's response to their request for eHealth. Their influence is both monetary and grounded in public relations. Their interest in the project stems from their desire to see the community served in the best manner possible by local hospitals.

The primary negative risk associated with stakeholders lies with the administration, which may be unwilling to provide funding for implementation. The evidence of the industry's inexorable movement toward eHealth as a result of total immersion in the Digital Age should help to address this negativity. Among nurses, polling indicates that positive outlooks are associated with telenursing implementation, providing significant reason to view this strategy as one that could improve overall job satisfaction (Barret & Wallis, 2013).

Evidence Review: Causes of Turnover and Effects of eHealth

The relevant literature indicates a consensus among researchers on the efficacy of telehealth in nursing, with the caveats coming from researchers emphasizing that appropriate implementation strategies must be followed, reviewed, and maintained for telehealth services to be truly effective. The need to adopt eHealth is driven by several converging forces: the demands of the Digital Age, nursing staff shortages, the demand for better quality care, and the need to boost job satisfaction and workplace morale. These themes are discussed below.

Twibell (2012) identifies the causes of nursing turnover as related to job dissatisfaction, work overload, and nurses' inability to provide quality care, thus lowering worker morale. Trivellas, Gerogiannis, and Svarna (2013) support these findings in their cross-sectional survey of nurses; they found that the impact of emotional intelligence on nurses' job satisfaction and intention to stay was high and that there was significant correlation between emotional intelligence, job satisfaction, and turnover intention. Their study indicates that turnover rates are directly linked to job satisfaction and management's ability to provide a better workplace culture in which nurses can work effectively without feeling overburdened.

Kissack and Callahan (2010) show that it is important for organizations to mindfully develop an organizational culture focused on developing staff, educating them, and reinforcing the provision of the best quality service possible. Their study provides a framework for why health care organizations should offer access to the best technology available in order to boost workplace culture and continue to develop nursing staff capabilities. These findings are supported by Heuvel et al. (2013), who demonstrate in their experimental study that workers do respond to micro-level processes within organizational culture and that effective management of change processes — with appropriate direction, objectives, and efficient strategies — is essential to boosting worker morale.

Mbemba, Gagnon, Pare, and Cote (2013) go a step further in their systematic review of the literature on nursing turnover. They identify eHealth and telehealth as factors that help improve nurse retention in rural areas, as the technology allows nurses to increase quality care by overcoming geographical obstacles and nursing shortages. Their study indicates that job satisfaction increases when effective application of available technological services is implemented to help nurses do a more efficient job in providing quality care.

Research on the effects of telemedicine and eHealth in nursing indicates that telemedicine is a positive step forward in helping nurses fill shortage gaps, overcome quality care obstacles, and increase job satisfaction — though specific caveats focus on the need for proper implementation for effective service.

Barret and Wallis (2013) provide a cross-sectional survey of nurses and find that interest in telehealth services is increasing; nurses generally view the service as something that could help them be more effective. However, the study also finds that there is not enough education available on how telehealth is beneficial, as nurses could only identify generic reasons for their interest in it. The study recommends that nurses be better educated about the specific ways in which telehealth services could benefit them.

Glinkowski et al. (2013) conducted a cross-sectional survey of nursing students to assess their familiarity with telemedicine concepts; their findings showed that the current generation of nursing students have been adequately prepared to embrace telemedicine services and are ready and willing to utilize the technology. The cross-sectional survey by Kleinpell et al. (2016) also shows that nurses in ICUs who use telemedicine are able to accomplish more tasks more efficiently, work together with other nurses and physicians more effectively through collaborative strategies, and boost their overall job performance, communication, and quality care skills. Kleinpell et al.'s (2016) findings are corroborated by Kozhimannil et al. (2015), whose survey of 306 rural hospitals found that telehealth services are instrumental in reducing costs, overcoming geographical obstacles, and filling staffing gaps.

Matusitz, Breen, and Wan (2013) show that eHealth services are an avenue toward better quality care in nursing, which corroborates the findings of Potter, Mueller, Mackinney, and Ward (2014), who demonstrated that telemedicine has a positive impact on easing the burdens of nurses and supplementing care. The meta-analysis of Rouleau et al. (2015) likewise points to positive impacts of adopting eHealth services in nursing, particularly in communications and information sharing, but also highlights negative impacts related to improper implementation and a lack of supporting infrastructure — indicating that eHealth implementation requires a strong support foundation to work effectively. The findings of Rouleau et al. (2015) are backed up by Taylor (2014), whose meta-analysis locates a variety of nurse perceptions of eHealth ranging from apprehension to enthusiasm and finds that nurses who have been educated on the benefits of eHealth, or who have had positive experiences with it, tend to view it more favorably than nurses who know little about it.

Stacie and Alberto (2014) indicate in their case control study that telehealth is an effective way to apply technological advancements to nursing, helping defray costs, increase quality care, and allow ICUs to be more efficiently monitored. Their analysis is supported by Trossman (2014), whose descriptive study reveals that telehealth services are on the rise, have a beneficial impact on nurses and patients, and can be implemented efficiently. Odeh (2014) likewise provides evidence of positive nursing experiences with telehealth in his assessment of seven nurses describing their use of eHealth services, while also pointing out the need for training and system support for effective implementation.

Kruklitis et al. (2014) describe the need for telemedicine in ICUs, identifying telemedicine as an application that helps increase quality care, cost-efficiency, and safe practices in hospitals. This study is supported by the findings of Kumar, Merchant, and Reynolds (2013), who show in their integrative review that telemedicine in ICUs is an efficacious and cost-effective strategy that facilitates positive developments among nurses in terms of reducing overwork, fatigue, and obstacles to providing quality care. Gutsche and Raiten (2013) likewise corroborate these findings in their systematic review of the effect of telemedicine on reducing costs in health care.

Fuhrman and Lilly (2015) provide a highly descriptive study of how ICUs benefit from telemedicine by sheltering nurses from alarm fatigue and allowing managers to more effectively fill nursing shortage gaps through the telemedicine system, which reduces the need for more physical bodies making active rounds. Fouad (2014) likewise shows that telemedicine in hospitals is an opportunity for learning advancements, procedural advancements, and better quality care deliveries, as well as for overcoming geographical obstacles to providing care. This finding is also supported by Darkins (2012), who describes telehealth services as an emerging strategy that is highly effective in remote and rural areas. The cross-sectional survey of Bhattacharya and Ramachandran (2015) found that the use of digital technology, IT, and eHealth services can boost job satisfaction among nurses and increase nurses' intention to stay.

Lee (2014) assesses the need for implementation of telemedicine as a result of the Digital Age and both patients' and nurses' familiarity with digital technology and its numerous applications. On how to properly implement telehealth services, Lee, Lee, and Kim (2016) show that emphasis must be placed on safety and clarity in systems processes, along with cultural awareness and cultural expectations, which can impact the way telehealth services are perceived; their study corresponds with the need for managers to use emotional intelligence, as identified by Trivellas et al. (2013).

Manchester et al. (2014) identify an adequate change theory model based on the Lewin change theory that can help to facilitate the process. Kvedar, Coye, and Everett (2014) identify the role that telehealth services can play in delivering high quality care and also identify the importance of involving the private sector along with advocacy groups and policy makers in the implementation process to ensure cooperation, collaboration, and coordination among the various stakeholders impacted by the innovative eHealth services strategy.

Hansen, Wilson, and Robertson (2013) describe a design, implementation, and evaluation process for implementing telemedicine that is based on an integrated approach utilizing experienced nurses, physicians, and tech support for a comprehensive framework. Mills et al. (2013) identify the positive aspects of implementing telemedicine but show in their integrative review that concerns remain about proper implementation and that a system not adequately supported will not work long-term. Likewise, Venktesh et al. (2014) show in their systematic review that the tele-ICU technology has substantially more research interest than the centralized monitoring system, supporting the findings of Mills (2013) and Hansen et al. (2013). Finally, Yesenofski, Kromer, and Hitchings (2015) identify the active leadership of nurses as a major factor in proper implementation, providing a more integrative and strategic effect, and also highlight evaluation methods for effective monitoring during the implementation process.

The problem of nursing turnover can be adequately and effectively addressed by implementing telemedicine in the hospital. As the research indicates, telemedicine is associated with positive benefits for the hospital, nurses, and patients: it reduces costs, improves quality care, reduces nursing fatigue, fills shortage gaps, and overcomes geographical obstacles. It is therefore recommended, in line with the supportive evidence above, that the hospital implement telemedicine in the ICU to reduce alarm fatigue, work overload, and fill shortage gaps in the nursing staff, thereby boosting job satisfaction and reducing nursing turnover rates.

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