Ethics for the Telehealth Nurse

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With the increasing utilization of telehealth in the healthcare industry, it is vital that nurses become aware of the ethical principles involved in this hands-off, virtual approach to providing patient care. This course provides basic, ongoing, and applicable knowledge of nursing ethics to improve patient outcomes specifically for a telehealth nurse. All nurses are responsible for being familiar with the American Nurses Association’s (ANA) Code of Ethics for Nurses no matter the specialty they are in. The information offered in this course is being given as a guideline and does not replace the laws governing nursing practice. 

Introduction 

Although the utilization of telehealth has been incorporated into patient care for many decades, the impact of the COVID-19 pandemic has increased its prevalence in the industry; leaving many professionals with no choice but to adapt. With this recent change, most healthcare facilities were forced to create strategies that allowed them to not only prevent viral exposure but continue to provide quality patient care remotely. As a result, healthcare professionals faced many challenges, especially nurses (4). When considering that the nursing process has been taught, referenced, and utilized as one of the overarching ethical guidelines for hands-on nursing care for hundreds of years, it is evident that nurses have overcome many obstacles in a short period of time.  

It is vital for the telehealth nurse to continue to assess and interact with patient populations through this newer method of care while strictly following the ANA Code of Ethics for Nurses.  

Nursing Practice for the Telehealth Nurse 

The practice of telehealth allows a trained nurse the ability to communicate with patients and their families, provide assessments in real-time, and implement appropriate interventions virtually.   

The first telehealth nursing practice standards were published in 1997 by the American Academy of Ambulatory Care Nursing (AAACN) in response to the increased growth in popularity and utility of the field (1). The standards are divided into the domains of either Clinical Practice or Professional Performance; each standard has a set of competencies that the professional nurse must meet when practicing.  

Although telehealth nursing does not require direct patient contact, a nurse should uphold the same standards and ensure that their quality of care and compliance with ethical nursing practices does not change (4). It is of the utmost importance that the care provided remains patient-centered and quality-focused, and that the telehealth nurse continues to utilize the nursing process in all patient interactions.  

Code of Ethics for Nurses 

The ANA Code of Ethics for Nurses with Interpretive Statements is the non-negotiable framework surrounding how those in the nursing profession should incorporate both ethical and moral practices into their patient care (2). This code of ethics consists of nine principles that should be strictly followed, these include (2): 

1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. 
2. The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population. 
3. The nurse promotes, advocates for, and protects the rights, health, and safety of the patient. 
4. The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care. 
5. The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. 
6. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care. 
7. The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. 
8. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. 
9. The profession of nursing, collectively through its professional organization, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy (2). 

It is of the utmost importance that nurses abide by these nine provisions of the Code of Ethics for Nurses; this is no different for the telehealth nurse (2). 

Caring for a patient virtually does not relinquish the telehealth nurse of their duty to be accountable, responsible, compassionate, and respectful.  

Privacy

Telehealth nurses most often are in the same area as other nurses when working and interacting with patients, so it is crucial that patient confidentiality is ensured. The Code of Ethics for Nurses indicates that privacy must be maintained, and the patient should feel comfortable in disclosing sensitive information, even through the utilization of telehealth methods (2).  

Because the patient does not have the privacy of an exam room, the nurse should communicate to the patient that measures are in place to provide protection and privacy of their information during the telehealth visit. If the patient verbalizes concern in confidentiality, the nurse must document the patient concerning the patient record (5). 

Trust

The telehealth nurse has an obligation to initiate and ensure there is trust with the patient, as it is one of the main components of the Code of Ethics for Nurses (1,2,4,5).  

As the telehealth nurse, your patient must feel like you are giving accurate information when you are assisting them in making the right decision(s) for their treatment plan. When the patient makes the call to obtain information regarding their care, they are entrusting the nurse to have necessary and applicable knowledge. It is important to note that any initial information provided to the patient prior to consulting with a physician must be supported by evidence-based practices (5).  

Communication and Documentation

Any patient calls or interactions during telehealth visits must be documented. The nurse must communicate with the patient regarding their health or treatment plan in a way that is digestible allows them the opportunity to verbalize any questions or concerns.  

In order to ensure effective communication during telehealth visits, there are a number of things a telehealth nurse can do, these include: 

• At the beginning of the visit, provide a call back number in case the call is disrupted (allow the patient or family member to repeat the number back to establish the number is correct). 

• Allow the patient or family member to verbalize feedback if the visit met expectations and was satisfactory. 

• Ensure that the patient can hear and understand you clearly.  

• If the visit is through a virtual conferencing platform, ensure that you are incorporating forms of non-verbal communication such as eye contact, body language, and appropriate facial expressions that would be used in an in-person visit.  

• If necessary, explain the process of the telehealth visit and how it may differ from in-person.  

• Remain confident, unbiased, and professional while upholding patient confidentiality (3).

Explain how a nurse conducting telehealth nursing interventions may have a stricter adherence to ethics than face-to-face encounters?

By what reasoning would the effect of software compliance and security standards jeporadize the ethical behavior of a telehealth nurse?

Nursing documentation via telehealth is no different than in-person clinical settings, and it must embody the nursing process, Code of Ethics for Nurses, and your facility’s documentation protocols (4).  

ANA Principles for the Telehealth Nurse 

In addition to the ANA Code of Ethics for Nurses and the AAACN Scope and Standards of Practice for Professional Telehealth Nursing, the ANA has 13 principles of connected health that the telehealth nurse must follow, these read (3): 

1. The use of connected health technologies does not alter the standards of professional practice when delivering healthcare, conducting research, or providing education. Developed by each profession, in this case nursing, these standards focus on the healthcare professional’s responsibility to provide lawful, evidenced-based and high-quality personalized care regardless of the method of delivery, grounded in the Nurses Code of Ethics. 
2. As connected health is a method of healthcare delivery, the healthcare provided is subject to the same healthcare laws and board oversight as the healthcare provided in-person. Healthcare professionals should understand, however, that due to the nature of connected health business models, certain interstate commerce, fraud and abuse another applicable state and federal laws not commonly encountered when delivering healthcare in-person may apply. 
3. Healthcare services delivered via connected health technologies should prioritize improving access to quality healthcare that is guided by best available evidence, accepted clinical standards, and best practices. These services must include deployment of appropriate technological modalities which meet the patient’s needs, are practical and easy to use, and align with specific patient location and care setting. 
4. Professional practice and healthcare delivery, regardless of venue and channel of delivery, mandates that healthcare professionals meet state specific regulatory and institutional requirements in accordance with scope of practice. Due to variations in practice rules and regulations across states and facilities, providers must practice respective of these variations whilst delivering care via connected health. 
5. Nursing and other healthcare professions are responsible for developing their own competencies to ensure the safe, effective and competent delivery of healthcare via connected health technologies using a patient-and family-centered team-based approach. 
6. Healthcare services delivered via connected health technologies should be congruent with in-person care and must adhere to the best available evidence that represents current and emerging interdisciplinary standards of care, while recognizing the limitations inherent in technology to ensure optimal patient-centered outcomes.  
7. When using connected health technologies, the integrity and therapeutic value of the patient-healthcare professional relationship should be established, maintained, and promoted via connected health. 
8. Safeguards must be taken with the transmission of electronic information and communication conducted using connected health technologies in all connected health practice settings. This practice upholds the highest level of ethical conduct in the secure management of patient health information, patient privacy and confidentiality and protection against unauthorized breach of information. This includes informing patients of the use of third-party technology providers, the risk of disruption in the integrity of those providers’ data management practices, and a commitment to protecting patients from such event. 
9. Documentation requirements for healthcare services delivered via the utilization of connected health technologies should be consistent with requirements applicable to all other patient encounters. 
10. Patients involved in a connected health encounter should be informed about the process, the inherent risks and benefits, and their rights and responsibilities, in compliance with applicable federal and state laws. Informed consent for connected health may not need to be independent from other informed consent for treatment although mechanisms for obtaining electronic consent should comply with applicable federal and state laws. 
11. The safety of patients and healthcare professionals must be ensured. Hardware and software compliance with safety and security standards, the appropriateness of a connected health approach to the situation and demonstrated patient and provider user competency are essential components of safe connected health practice. 
12. In order to inform connected health, and ensure the best outcomes, it is essential that the assessment, evaluation, and study of all aspects of connected health are ongoing and systematic. This research should include key stakeholders as primary informants and the resulting evidence utilized in the development and implementation of connected health guidelines and best practices. 
13. Policies governing the practices and reimbursement of healthcare should be continuously updated and modernized to allow for the integration, national adoption, and sustainability of connected health (3). 

Although the telehealth nurse solely relies on the utilization of technology in order to interact with patients, this does not allow for altering of professional standards; providing quality-focused and patient-centered care is always required. 

Additionally, it is unethical for the telehealth nurse to falsely indicate time spent in teaching and discharging. Time spent gathering discharge follow up and future appointments should not be counted as patient interaction, if conducted prior to making the call to complete the after-visit discharge summary. The nurse is responsible for knowing the laws in their state in accordance with their scope of practice for telehealth (2). 

Conclusion 

No matter their specialty, field, or scope of practice, all nurses are accountable for their actions. Although the healthcare setting may vary, a telehealth nurse must be knowledgeable of their facility’s expectations during patient interactions as well as how to effectively deliver quality care virtually.  

With the prevalence of the utilization of telehealth continuing to rise in the healthcare industry, it is vital for the telehealth nurse to ensure they are abiding by the ANA Code of Ethics for Nurses, consistently upholding professionalism, and overall, ensuring patient confidentiality. 

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