JMIR MEDICAL INFORMATICS

Bashir & Bastola

Original Paper

Perspectives of Nurses Toward Telehealth Efficacy and Qualityof Health Care: Pilot Study
Ayisha Bashir1, MS, MBBS; Dhundy R Bastola2, PhD
1

Department of Clinical and Translational Science, Creighton University, Omaha, NE, United States

2

School of Interdisciplinary Informatics, Information Science and Technology, University of Nebraska, Omaha, NE, United States

Corresponding Author:
Ayisha Bashir, MS, MBBS
Department of Clinical and Translational Science
Creighton University
2500 California Plaza
Omaha, NE, 68178
United States
Phone: 1 4027407394
Email: abashir@unomaha.edu

Abstract
Background: Telehealth nursing, or the delivery, management, and coordination of nursing care services provided via
telecommunications technology, is one of the methods of delivering health care to patients in the United States. It is important
to assess the service quality of the involved health professionals as well as the telehealth nursing process. The focus of this study
is the innovative model of telehealth care delivery by nurses for managing patients with chronic disease while they are living intheir own residence.
Objective: The primary objective of this pilot study was to examine whether telehealth technology impacts the perceived levelof internal service quality delivered by nurses within a telehealth organization. To address this research goal, the notion oftelehealth nursing service quality (TNSQ) is empirically tested and validated with a survey instrument.
Methods: Data were collected from nurses belonging to a home care agency based on interview questions inquiring about
facilitators and inhibitors to TNSQ. A survey to measure TNSQ based on the SERVQUAL instrument was completed by adjusting
descriptions of the original instrument to suit the context. Follow-up interviews were conducted to validate questions on therevised instrument.
Results: The findings of this survey research were positive, based on mean differences between expectations and perceptionsof TNSQ. This indicates satisfaction with TNSQ and shows that the quality of the service is higher than what the respondents
expect. The Wilcoxon signed-rank test using the P value for the test, which is .35, did not show a statistically significant change
between the median differences of perception and expectation. The total number of respondents was 13. Results indicate that
overall perceived service quality is a positive value (0.05332). This means the perceptions of the level of service are slightly
higher than what they expect, indicating there is satisfaction with TNSQ.
Conclusions: The responses to the interview questions and data gathered from the survey showed overall satisfaction with
TNSQ. The SERVQUAL instrument was a good framework to assess TNSQ. In a nutshell, the study highlighted how the telehealthprocess provides daily monitoring of patient health, leading to the benefits of immediate feedback for patients, family, andcaregivers as well as convenience of scheduling.
(JMIR Med Inform 2018;6(2):e35) doi: 10.2196/medinform.9080
KEYWORDS
telehealth; survey; telemedicine; telenursing

http://medinform.jmir.org/2018/2/e35/

XSL• FO
RenderX

JMIR Med Inform 2018 | vol. 6 | iss. 2 | e35 | p. 1
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Introduction
Background
Telehealth encompasses all facets of remote health careincluding clinical services provided using telemedicine, as wellas interactions with automated services, systems, or information
resources. It is the integrated use of electronic information andtelecommunications technology to support remote clinical healthcare, patient and professional health-related education, publichealth, and health administration [1]. The terms telehealth andtelemedicine have become intertwined in literature; in this study,
we use telehealth as a broad term that encompasses clinical andnonclinical services in contrast to telemedicine, which consistsof purely clinical services [2]. Given the success of telehealthin specialty health care services, the use of technologies totransmit health information and provide care across a distanceis poised to enter mainstream health service delivery [3,4].
Although many studies have assessed the cost-effectivenessand patient acceptance of this new method of service delivery,
the perspective of nurses as the service provider has not beenpreviously studied [5,6]. Thus, the aim of this study is toinvestigate telehealth nursing service quality (TNSQ) from thenurses’ perspective. To address this research goal, we developedand empirically tested the notion of TNSQ.

Role of Nurses in Telehealth
One of the evolving roles of nurses as they take on new
responsibilities of providing nursing service in home settings
is the use of information technology (IT). Telehealth nursing
focuses on patients’ long-term wellness, self-management, andhealth [1]. According to the American Telemedicine
Association, this IT solution provides nursing care across a
distance, empowering the care providers with the ability tomonitor, educate, follow-up, collect data, and provide
multidisciplinary care including remote interventions, pain
management, and family support in an innovative fashion [7].
It has been reported that agencies using telehealth have an
average patient-to-nurse ratio of 15:1, as compared with
non-telehealth agencies having a ratio of 11:1 [7]. Therefore,
telehealth nursing can make a tremendous difference inproviding patient care, particularly in rural or underserved areas
in states such as Nebraska, where there is generally a shortageof nurses and health care services, as well as resources can belimited [3]. In addition, in rural areas, many patients do notreceive timely health care interventions because of the lack of
specialist services [2]. Home health agencies with telehealthcapability caring for patient populations with chronic diseases
can take care of patients in their home setting and therefore fillthis gap. This provides convenience and a sense of security tothe patient, allowing timely nursing interventions under
supervised physician care [2,7].

Importance of the Study
This study is important and significant for several reasons. First,
nurses’ perspectives toward telehealth service quality (SQ) is
researched through a case study and validated with a survey
instrument. Second, a positive role of telehealth nursing andhttp://medinform.jmir.org/2018/2/e35/

XSL• FO
RenderX

Bashir & Bastola
related technology toward patient care is highlighted. Third, itestablishes how telehealth provides daily monitoring of patient
health, which has benefits of immediate feedback for patients,
family, and caregivers as well as convenience of scheduling.
Quality of service is essential for the telehealth performanceand viability of the service; therefore, it is important to assess
the SQ of involved health professionals as well as the telehealthnursing process [6,8].

Service Quality
Among different characteristics of service, the quality of service
in the health sector shapes the experience of care beyond
technical competence. In the conceptual model of IT-SQ, it has
been described as a comparison between levels of perceived
services and consumer expectations [9], where the author
suggests that SQ has a functional component concerned withhow the service is delivered and a technical component
concerned with what is delivered. This concept is implemented[10] by suggesting that SQ can be measured as the “gap”
between the customers’ expectations of service and theirperceptions related to the quality of service actually being
delivered. In other words, SQ is a comparison of expectations(E) with perceptions (P) and can be represented as SQ=P−E[11]. This concept was further described and operationalized[9], leading to the development of the SERVQUAL instrumentfor SQ [10,11].

Telehealth Nursing Service Quality
The conception of SQ has more to do with the “manner” inwhich employees deliver services to their customers, rather thanthe outcome of the service [11]. In a similar vein, TNSQ is thesynthesis of the perceptions of the telehealth nurses from thefunctional and interactive aspects of telehealth interventions.
In addition, the SQ items consisting of tangibles (TA), empathy(EM), assurance (AS), reliability (RL), and responsiveness (RS)are the dimensions measured by the SERVQUAL instrument[10]. Furthermore, these are applicable to the measurement of
TNSQ [8,12]. In this study, the SERVQUAL instrument is
modified and utilized to measure TNSQ [10] (Table 1). The
SERVQUAL dimensions developed [10] and revised for thisTNSQ study are described in Table 1.
Traditionally, the quality of nursing care was perceived to relate
to the degree to which patients’ physical, psychosocial, andextra care needs were met [13]. The consequences of quality
care were interpreted as therapeutic effectiveness where thetherapy provided by nurses was perceived to positively affectpatients’ healing. In other words, it referred to “how” the coreservice is delivered [14]. In health care services, expression ofcompassion and empathy by doctors or nurses is an example offunctional quality, which also applies to telehealth nursing [13].
Telehealth nursing aims to propagate and advance the processof nursing quality care by enhancing the attributes of empathy,
assurance, attention to detail, interpersonal and communication
skills, responsiveness, and reliability, while adding convenienceto the process [14,15]. Thus, telehealth nursing quality is
described as a multidimensional construct that encompasses
attributes such as empathy, assurance, and reliability.

JMIR Med Inform 2018 | vol. 6 | iss. 2 | e35 | p. 2
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Bashir & Bastola

Table 1. Adapting general service quality (SERVQUAL) dimensions to telehealth nursing service quality (TNSQ).
Serial number anddimension

General definition

TNSQ definition

1

Tangibles

The physical evidence of service

Physical facilities, equipment, and appearance

2

Reliability

The consistency of performance and dependability

The consistency of performance and dependability of telehealth nursing services

3

Responsiveness The willingness and readiness of employees to provide service

The willingness and readiness of nurses to provide service

4

Assurance

The confidence communicated by the service provider

The confidence communicated by the telehealth nurse orprovider5Empathy

The service provider’s efforts to understand the customer’s needs
and then to individualize the service delivery

The nurse’s effort to understand the customer’s needs andthen to individualize the service delivery

This study follows a research approach in which perspectivesof telehealth nurses were elicited through a case study andadministration of a survey (Multimedia Appendix 1). Expected
results include a better understanding of nurses’ perspectivesof telehealth interventions and quality of the health care services
provided. Here, telehealth nursing quality is defined from thenurses’ perspectives as a comparison of expectations (E) about
telehealth nursing services with perceptions (P) using theformula TNSQ=P−E. TNSQ attempts to capture nurses’
expectations and perceptions of telehealth nursing services as
they impact patients.

Service Quality and the SERVQUAL Instrument
As discussed previously, TNSQ is assessed using a modified
version of the SERVQUAL instrument. The SQ encompasses
2 related components, namely, technical and functional quality[11]. The technical (core) component is defined as the “what”
performed during the service. This concept is implemented [10]by suggesting that SQ has a functional component concernedwith “how the service is delivered” and can be measured as the“gap” between the respondent’s expectations of service andtheir perceptions related to the quality of service being delivered[10,11]. To understand the gap between how the technologicalservice is delivered and “what is delivered,” it is important tomeasure the SQ of different advanced information andcommunication technologies in various industries [16].
Previously, these SERVQUAL items have been used as areliable and valid measure of SQ because of the dimensionality,
item compositions, validity, and disconfirmation paradigm usedin its measurement. The “type of technology” has a direct effecton barrier reduction, attitudes, and quality and quantity ofcommunication [16]. There is a link between potential SQ facets
and health care organizations’ adoption of health careinformation technologies and telehealth [17,18]. SERVQUAL
and its improved versions are still widely used for measuring
SQ in various sectors including health care, justifying
SERVQUAL as an appropriate tool for TNSQ [6,12]. In thelast 2 decades, the SERVQUAL instrument has been refinedby the creators [10] to the useful acronym RATER: reliability,
assurance, tangibles, empathy, and responsiveness [10,12]. The
rationale behind the development of the general instrument isthat although each service is unique in some aspect, there areother aspects that are applicable to all services in general[12,13]. This is also the case for evaluating SQ in telehealth.
For example, in Greece, SERVQUAL was used to assess the
http://medinform.jmir.org/2018/2/e35/

XSL• FO
RenderX

quality services provided by the hospital, after the hospital wastransferred to a new and modern location with up-to-datetechnology including telehealth services [12]. The study showedthat the transfer to the new premises and new telehealthequipment substantially improved all of the 5 dimensions;however, the most improvement was seen in the “tangibles”
dimension [12]. Other studies have been conducted in the healthcare industry using SERVQUAL instrument. The applicationof SERVQUAL instrument was beneficial in a study conducted
to optimize the telemedicine model in Korea, ultimately
improving the SQ of the telemedicine service providers byproviding a checklist of the critical-to-quality telehealthprocesses, requirements, and expectations of the involved parties[6].
SQ is generally conceptualized in terms of 5 dimensions:
tangibles, reliability, responsiveness, assurance, and empathy[10] (Table 1). One of the benefits of applying SERVQUAL
for health care to telehealth nursing is that the 5 dimensions canbe assessed overall as well as individually and the perspectivesof nurses can be assessed thoroughly [6]. In a nutshell, throughthis research, nurses’ perceptions about their ability to deliver
telehealth services to patients are collected.

Telehealth Nursing Service Quality and theSERVQUAL Instrument
SERVQUAL remains a valuable tool to assess quality of healthcare services and assess the perceptions of the patients andhealth care providers related to new equipment and new hospital
facilities [6,12]. The gap analysis method based on SERVQUAL
has been used to calculate patient’s perceptions related tohospital SQ [19,20]. Published research is lacking with the
instrument being used to measure nurses’ perspectives toward
telehealth quality. This is what makes this pilot study unique,as past studies have been conducted to determine the quality
attributes for telemedicine services from the perspective of thepatients and physicians [18,19]. There is a need to further
investigate the quality attributes for telemedicine services fromthe nurses’ perspectives, which have not been clearly defined
before [5,8]. The TNSQ survey contains questions belonging
to the 5 dimensions [10,12] (Multimedia Appendix 1). The gap
method of subtracting nurses’ expectations from perceptions ineach of the dimensions (using the survey) helps in assessing the
TNSQ [10]. The dimensions having the negative gap scoreindicate that there is a barrier or an inhibitor present in that
dimension; in the same manner, a positive value indicates that
JMIR Med Inform 2018 | vol. 6 | iss. 2 | e35 | p. 3
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Bashir & Bastola

there is a facilitator in that dimension. This study addresses thisgap in our understanding of telehealth care by developing
concepts and empirically assessing TNSQ. In addition, the SQ
items consisting of empathy, assurance, reliability, andresponsiveness are dimensions measured by the SERVQUAL
instrument [10]. These are reckoned to be applicable inmeasuring the TNSQ [6,10]. Further evaluation of the responses
helps in indicating the positive factors, barriers, and facilitatorsof TNSQ and ties the responses to the interview question related
to facilitators of telehealth barriers or inhibitors to nursing
quality care [6,12].

had more concerns related to the equipment and its functionality(which belongs to the tangibles dimension). Further evaluation
was added to the tangibles dimension in this study, relating totelehealth technology. These additions resulted in the increasein the number of questions from 21 to 25 (Multimedia Appendix
1). In addition, 3 open-ended questions were designed to gain
insight toward the positive and negative perspectives of thenurses related to telehealth interventions. Therefore, the original
instrument was revised by adjusting the descriptions to address
the context.

Methods

As described above, the SERVQUAL instrument was used tomeasure TNSQ. The VNA approved the survey. A digital
version of the survey was created using Survey Monkey, a Web
based software tool that was suitable for our project. Survey
Monkey is an online survey development cloud-based software
as a service company, with headquarters in San Mateo
California. The VNA’s chief executive nursing officer emailed
the weblink to all participating nurses, which included all 13
nurses employed by the organization. Participants were queried
about their expectations regarding quality of service with theincorporation of telehealth technology. Next, they were asked
to rate their perceptions of the actual performance (or delivery)of service in the context of telehealth technology. Perceived
levels of SQ with the use of telehealth technology were assessed
based on the previous definition of SQ, which is obtained by
the linear subtraction of service expectations (E) fromperceptions (P) for each scale item, using a 7-point Likert scale,according to the SERVQUAL instrument [10]. The complete
SQ instrument, which consists of a 25-item scale andaccompanying instructions, is included in Multimedia Appendix
1. In this appendix, the first section lists the questions used tomeasure the nurses’ expectations of service in the context oftelehealth SQ; the second section lists the items used inmeasuring their perceptions of the actual performance of service;and the third section includes the demographic questions and 3
open-ended questions. The modified SERVQUAL instrument
consisted of 25 items, which included the 5 original dimensions.
The first 7 questions belonged to the tangibles dimension (1-7),
questions 8 to 12 belonged to the reliability dimension (8-12),
questions 13 to 16 belonged to the responsiveness dimension(13-16), questions 17 to 20 belonged to the assurance dimension(17-20), and the last 5 questions belonged to the empathy
dimension (21-25).

Case Study Site
The Visiting Nurse Association (VNA) of Omaha was selected
as the case study site because it employs telehealth interventions
for patient care and because of its geographical proximity; in
addition, the VNA telehealth nursing staff was willing toparticipate in the study. The organization’s website provides
information regarding the telehealth home care process. After
VNA agreed to participate in the study, preliminary interviews
were conducted to understand its telehealth environment. To
determine the extent of telehealth service provided by VNA andthe characteristics of the participants receiving telehealthinterventions (age of the patients and types of diseases being
addressed), the deidentified patient data (no name or personal
identifying values) were obtained from VNA. This consistedof the list of patients who were under VNA care or recently
discharged in February 2016. These were all home care patients
who were using telehealth services in their own residence. The
median age of 205 patients was 74 years, including a total of
128 females and 77 males. The monitoring period of the patientsis calculated from the day the patient starts receiving VNA
telehealth services and ends on the date they are discharged
from VNA. The median monitoring period of a patient was 25days. The VNA data showed majority of these patients were
suffering from chronic disease, were aged above 70 years, andwere residing in a home care setting (for more than 3 weeks).
This facilitated the research to determine the role of telehealthtechnology in helping elderly patients living with chronic diseasein their home setting.
The methodology of conducting the TNSQ consisted of thefollowing steps: (1) survey research, (2) preliminary interviews
to understand the telehealth environment, (3) use SERVQUAL
to measure TNSQ—adapted from the original instrument by
adjusting the descriptions to suit the context, and (4) follow-up
interviews to validate questions on the revised instrument.

Survey Research for Telehealth Nursing Service
Quality
The interview at VNA set the baseline for collection ofquantitative analysis data. A questionnaire was designed basedon SERVQUAL instrument and its 5 dimensions, namely,
tangibles, reliability, responsiveness, assurance, and empathy[10]. Looking toward the domains of TNSQ, and bringing
together the responses to the interview questions, the nurses

http://medinform.jmir.org/2018/2/e35/

XSL• FO
RenderX

Measurement

General Perceptions of Visiting Nurse Association of
Nebraska Telehealth Staff
The primary objective of this study was to examine whether
telehealth technology impacts the perceived level of internal
SQ delivered by nurses within a telehealth organization.
Therefore, an in-depth interview was conducted with VNA staff
to elicit and analyze the perspective of the telehealth nursing
team. VNA services include companion care, infusion pharmacy,
home care, home health technology, hospice, and palliativecare. VNA telehealth nursing services include monitoring thepatient through assessment and collecting data, heart rate, bloodpressure, weight, oxygen saturation, and temperature.

JMIR Med Inform 2018 | vol. 6 | iss. 2 | e35 | p. 4
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Bashir & Bastola

Figure 1. Telehealth system.

For the interview, the VNA telehealth team consisted of 3
members: the central station clinician, the clinical manager, andthe chief operating officer. The proceedings of the interview
were recorded with permission from all participants. The
research questions were investigated during the interview,concentrating on the positive and negative aspects of telehealth.
This team of nurses highlighted the process of telehealth patientcare and daily monitoring. Every patient admitted to VNA
services receives a disease-specific home telehealth kit and an
educational session on using the equipment (Figure 1). Other
members of the household or caregivers may monitor the healthcare process. The patients are triaged according to their vitals.
The central station clinician is responsible for the initialinterpretation of the data and contacts the patient with any healthcare concerns, including blood pressure changes, weight gain,or oxygen level fluctuations. They work closely with physicians,
case managers, and other health care providers. The admitting
nurse sets a plan with the patients, so they understand theprocess. One VNA case manager nurse monitors the patient,although different staff may monitor on weekends. Manypatients are stable patients; however, others have urgent needs.
The service is available 24 hours a day, 7 days a week. The
current volume of patient load is manageable, and the maximum
is 220 patients.
The below-mentioned interview questions addressed the factorsthat the nursing staff considers vital toward improving qualityof patient care and whether telehealth played a role in providing
this to patients. The staff shared perspectives on telehealthcontributing and enhancing quality of care as well as barriers
and inhibitors to providing quality nursing care via telehealthas described below:
1.
2.

What are the positive facilitators of telehealth contributing
or enhancing the quality of care?
What are the telehealth barriers or inhibitors to nursing
quality care?

The telehealth facilitators contributing and enhancing the qualityof care mentioned by the VNA during the interview included
quality of life and improved communication with health care
http://medinform.jmir.org/2018/2/e35/

XSL• FO
RenderX

providers, patients, and caregivers. Some of the telehealthnursing staff statements recorded during the interview include
the following:
Telehealth interventions improve patient day to day
living and enhanced the quality of life. The telehealthsystem is positive for the VNA as it emphasizes patient
safety. It provides independence as well as a sense of
security to the patient and caregivers, due to daily
monitoring.
Telehealth improved communication with health careproviders, patients and caregivers. This allowed
clinicians to customize patient care quickly andeffectively. As a result, the cardiologist andpulmonologist trust the VNA and this trust are gained
over time due to their good work ethics and effective
delivery of clinical services to the patients.
Telehealth interventions are helpful to patients,
caregivers and for physician feedback, which leads
to everyone’s ease of mind. During discussion withstaff it was noted the organization’s desire to add
electronic
healthrecords(EHR)
andvideoconferencing capability to their services. Theirgoal for adding videoconferencing is to improvetimely communication by adding physician, patient,family and telehealth staff on board at the same time
for consultation. [Telehealth nursing staff]

Results
Data Analysis
This study discovered qualitative and quantitative results. A
weblink for the survey was provided via email to all the VNA
participant nurses. A total of 13 nurses responded to the survey.
The survey was generated using a Web-based software tool,
Survey Monkey. The data were downloaded from Survey
Monkey and processed using SPSS version 22. Descriptive
statistics of expectations, perceptions, and gap scores were
calculated; the total number of respondents was 13,
JMIR Med Inform 2018 | vol. 6 | iss. 2 | e35 | p. 5
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Bashir & Bastolanonparametric and not normally distributed. To compare paired
means for continuous data that are not normally distributed, thenonparametric Wilcoxon signed-rank test was performed. The
result from these data is explained in the quantitative analysis
and gap score analysis section (Tables 2-4).

Qualitative Data Analysis
The VNA telehealth staff responses to the questions asked
during the exploratory interview showed how the telehealthmethods were helping the nurses to achieve good quality patientcare, at the same time, providing peace of mind to the clients.
These results were possible because of early interventions andmonitoring. The telehealth team considered improved qualityof life and peace of mind as the most important factors toward
providing good quality patient care. The positive facilitators oftelehealth, contributing or enhancing quality of care mentioned
by VNA, were related to patient safety and quality of life andimproved communication with health care providers, patients,
and caregivers. In addition, TNSQ is achieving highest standards
through the incorporation of technology and teaching patient’s
personal health habits. Some of the barriers mentioned in theinterview consisted of incompatibility and inconsistency ofequipment in some cases. For example, the inability to add
diabetic patients to their service was an issue at this time becauseof glucometer incompatibility in some patient’s equipment. The
response to the open-ended questions in the survey matched the
response to the interview questions related to facilitators andinhibitors, as shown by the dimension mapping (Multimedia
Appendix 2).

Quantitative Data Analysis
The survey instrument was approved by the University of
Nebraska Medical Center (for the University of Nebraska at
Omaha) institutional review board (IRB) for protection of humansubjects, as it involved survey and interview of nursing

professionals. It was qualified as exempt (IRB # 472-16-EX).
The data collected from online survey (quantitative data), focus
group case study, and interviews (qualitative data) were used
to find existing perception of nurses regarding TNSQ. Afterapproval, the surveys were administered through an online
software tool to VNA participants as the VNA office was thecase study site. The original SERVQUAL instrument was
modified by adding technological aspect of the telehealthinterventions to the tangible section of the questions. First, therespondents were asked the expectation of SQ because of theincorporation of telehealth technology. Next, the respondents
were asked to provide perceptions of the actual performance(or delivery) of service because of telehealth technology. Then,the perceived levels of SQ because of the incorporation oftechnology were assessed by the linear subtraction of service
expectation (E) from perception (P) for each scale item.

Gap Scores Analysis
The distribution scale values obtained for the average telehealthservice expectation, service performance, and SQ scores arepresented in Tables 2-4. The gap scores are negative in thetangibles (1-7), responsiveness (13-16), and assurance
dimensions (17-20). These values demonstrate that the
expectations (E) of telehealth nursing service are higher than
the actual perception (P) of the service (Table 3,Multimedia
Appendix 1). The gap scores are positive in the reliability (8-12)
and empathy (21-25) dimensions, which means that theperformance in reliability is more than expectations. This has
a positive effect on the level of the nursing services within thetelehealth provider system based on the incorporation oftelehealth nursing services. The values of the items scored ona scale of 1 to 7 can vary from a possible minimum of 25 (25×1)
to a maximum of 175 (25×7). Therefore, the more positive thevalue, the higher the perceived telehealth service item (Table
2).

Table 2. Descriptive statistics.
Dimension

Minimum

Maximum

Mean (SD)

Skewness (SE)

Kurtosis (SE)Tangibles

−0.90

0.40

−0.50 (0.50)

1.80 (0.845)

3.19 (1.74)

Reliability

0

0.80

0.395 (0.27)

0.275 (0.845)

2.16 (1.74)

Responsiveness

−0.70

0

−0.12 (0.26)−1.33 (0.845)

2.16 (1.74)

Assurance−0.90−0.11 (0.36)−2.21 (0.845)

4.92 (1.74)

Empathy00.39 (0.36)

0.99 (0.845)−0.31 (1.74)

0.90

Table 3. Descriptive statistics.
Statement

Number of statements (N)Minimum

Maximum

Sum

Mean (SD)

Expectation

25

5.40

7.00

162.506.58 (0.415)

Perception

25

5.60

7.00

164.106.48 (0.43)

Valid N (listwise)

25

–

–

–

–

http://medinform.jmir.org/2018/2/e35/

XSL• FO
RenderX

JMIR Med Inform 2018 | vol. 6 | iss. 2 | e35 | p. 6
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Bashir & Bastola

Table 4. Hypothesis test summary of Wilcoxon signed-rank test.
Serial number Null hypothesis
1

Test

The median of differences between expectation (E) Related-samples Wilcoxon
and perception (P) equals 0
signed-rank test

The scale items and sum of average showing higher positive
values indicate higher perceived telehealth service items (Table3). These values show that the perception of performance of
telehealth nursing service is overall more than the expectedlevel of SQ. The research generated 13 pairs of ranked data,
which are nonparametric, not normally distributed. To compare
paired means for continuous data that are not normally
distributed, and to compare paired means for ranked data, thenonparametric Wilcoxon signed-rank test is selected [21]. The
Wilcoxon signed-rank test using the P value for the test, whichis .353 (Table 4), did not show a statistically significant change
between the median differences of perceptions (P) and
expectations (E). Results indicate that the overall perceived SQ
is a positive value (0.05332), which means the perceptions of
the level of service is slightly higher than what they expect,indicating there is satisfaction with TNSQ.
The responses to the interview and data gathered from the survey
showed overall satisfaction with TNSQ. Some issues ofequipment malfunction and inconsistency in the telehealthequipment were pointed out by the respondents of the survey.
The results of this case study are helpful in reinforcing thepositive role of telehealth in impacting patient care andproviding alternative solutions to the management of chronic
disease. The VNA experience of implementing telehealthmethods in the case of chronic patients suffering from chronic
obstructive pulmonary disease (COPD) and heart disease isleading to better quality of life, as well as offering preventive
services at a lower cost. Elderly patients suffering from chronic
diseases, especially COPD and heart disease, are mostly
benefiting from the telehealth TH interventions [3,22].

Overall Perceived Telehealth Nursing Service Quality
Overall SQ is measured by obtaining an average gap score of
the SERVQUAL dimensions [10]. As shown in Table 2, theoverall average gap score for the SQ of telehealth nursing is0.05332. In other words, the overall perceived SQ is a positive
value (0.05332), which means the perceptions of the level ofservice are slightly higher than what they expect, indicating
there is satisfaction with TNSQ. Overall average gap score for
the SQ is calculated as (TA+RL+RN+AS+EM)/5=0.05332.

Demographics and Open-Ended Questions
All the 13 respondents who completed the survey were female,and majority of them were aged 35 years or older. In addition,
most of the respondents were seen to have earned a bachelor’s
degree in nursing. The responses indicate that the nursing staff
considered the convenience of scheduling and monitoring
patients daily as a benefit of telehealth nursing. This was likethe response of the focus group interview question related tothe benefits and facilitators of telehealth interventions leading
to peace of mind of the patients and the nursing staff. These
responses belong to the tangible dimensions, highlighting thebenefits of technology, like the findings documented by previous
studies [3,23].
http://medinform.jmir.org/2018/2/e35/

XSL• FO
RenderX

P value

Decision.35

Retain the null hypothesis

The second open-ended question was asked to get the nurses’
perspectives related to what they liked most about telehealth.
Eight of the responses obtained mapped mainly to the reliability
dimension and one each to the tangibles and responsivenessdimensions. This indicated that the nurses like the security ofmonitoring the patients daily, which adds to the convenienceand immediate review of the information, adding validity to theprevious open-ended question and interview questions. The
final open-ended question was intended to get the perspectiveof what the nurses did not like about telehealth. A total of 9participants responded, and majority of their responses mapped
to the tangibles dimension and only one to empathy. The
responses highlighted the nurses’ perspectives related to what
they did not like about telehealth, and these responses were on
the same pattern as the interview question part b, emphasizing
the barriers or negative aspects of TNSQ. The responses mostly
belonged to the tangibles dimension related to equipment
malfunction, inconsistency of technology, and update issues(Multimedia Appendix 2). There are similar findings
documented in previous studies [3,24].

Discussion
Principal Findings
The responses to the interview and data gathered from the survey
showed overall satisfaction with TNSQ. Some issues ofequipment malfunction and inconsistency in the telehealthequipment were pointed out by the respondents of the survey.
The results of this case study are helpful in reinforcing thepositive role of telehealth in impacting patient care andproviding alternative solutions to the management of chronic
disease. The VNA experience of implementing telehealthmethods in the case of chronic patients suffering from COPD
and heart disease is leading to better quality of life, as well as
offering preventive services at a lower cost. Elderly patients
suffering from chronic diseases, especially COPD and heartdisease, are mostly benefiting from the TH interventions [3,22].

Limitations
This research was an initial pilot study on TNSQ. Due to thelimit in time and resources, other telehealth nursing
organizations were not contacted; therefore, the sample size
was restricted to 13 participants belonging to the sameorganization VNA.

Implications for Future Research and Practice
Conducting nation-wide nursing telehealth quality service
studies would have a much more significant impact on researchand perceptions of nursing telehealth quality service. Future
research of telehealth interventions and chronic disease
management in elderly home care will be important. A bigger
sample size would allow comprehensive statistical data analysis
to be possible. Other telehealth nursing organizations that are
willing to participate in the survey will be contacted. More data
JMIR Med Inform 2018 | vol. 6 | iss. 2 | e35 | p. 7
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS
will be collected, and CHERRIES checklist for reporting theonline survey will be used as in this case study [25]. The user
experience of the consumers, patients, and health care providers
will be another aspect to follow-up. To understand the positive
implementation of telehealth nursing, it is important to dig
deeply into the successful models implemented, and learn fromthe barriers and obstacles that other organizations are facing in
relation to the telehealth nursing intervention methods [21].
Any researcher who may consider telehealth nursing for future
research should consider taking this survey to a larger numberof telehealth nursing professionals; this will give quantitative
validity. Comparisons with other nations such as Norway in

Bashir & Bastola
Europe, where telehealth implementation is successful, would
be of interest for research purposes [26].

Conclusions
SERVQUAL instrument was a good framework to assess TNSQ.
The main advantage of SERVQUAL was the ability to estimate
not only the overall level of satisfaction but also to identify thedimensions where perceptions transcended expectations(indicating performance excellence in the dimensions ofreliability and empathy) and dimensions where the experience
falls short of expectations (the dimensions of tangibles,
assurance, and responsiveness; Multimedia Appendix 2). Theinterview responses and data gathered from the survey showed
overall satisfaction with TNSQ.

Acknowledgments
The authors would like to thank the VNA of Omaha for their help and support regarding the telehealth nursing process. The
research was made possible because of the valuable insight and guidance of Dr Ann L Fruhling and Dr Deepak Khazanchi andthe cooperation and support of the faculty and staff of the School of Interdisciplinary Informatics, College of Information Scienceand Technology, University of Nebraska.

Conflicts of Interest
None declared.

Multimedia Appendix 1
The telehealth nursing service quality (TNSQ) survey instrument.
[PDF File (Adobe PDF File), 49 KB-Multimedia Appendix 1]

Multimedia Appendix 2
Responses to the open-ended questions.
[PDF File (Adobe PDF File), 30 KB-Multimedia Appendix 2]

References
1.
2.

3.

4.

5.
6.
7.
8.

9.

Shortliffe EH, Cimino JJ. Biomedical Informatics: Computer Applications in Health Care and Biomedicine (Health
Informatics) 4th ed. London, UK: Springer-Verlag London; 2014:541-560.
Doarn CR, Pruitt S, Jacobs J, Harris Y, Bott DM, Riley W, et al. Federal efforts to define and advance telehealth--a workin progress. Telemed J E Health 2014 May;20(5):409-418 [FREE Full text] [doi: 10.1089/tmj.2013.0336] [Medline:
24502793]
Black JT, Romano PS, Sadeghi B, Auerbach AD, Ganiats TG, Greenfield S, BEAT-HF Research Group. A remote monitoring
and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the
Better Effectiveness After Transition - Heart Failure (BEAT-HF) randomized controlled trial. Trials 2014 Apr 13;15:124[FREE Full text] [doi: 10.1186/1745-6215-15-124] [Medline: 24725308]
Hogan TP, Wakefield B, Nazi KM, Houston TK, Weaver FM. Promoting access through complementary eHealth technologies:
recommendations for VA's Home Telehealth and personal health record programs. J Gen Intern Med 2011 Nov;26 Suppl
2:628-635 [FREE Full text] [doi: 10.1007/s11606-011-1765-y] [Medline: 21989614]
Taunton RL, Bott MJ, Koehn ML, Miller P, Rindner E, Pace K, et al. The NDNQI-Adapted Index of work satisfaction. J
Nurs Meas 2004;12(2):101-122. [Medline: 16092709]
Yun EK, Chun KM. Critical to quality in telemedicine service management: application of DFSS (Design for Six Sigma)
and SERVQUAL). Nurs Econ 2008;26(6):384-388. [Medline: 19330973]
Peck A. Changing the face of standard nursing practice through telehealth and telenursing. Nurs Adm Q 2005;29(4):339-343.
[Medline: 16260998]
Yavas U, Babakus E, Westbrook KW, Grant CC, Deitz GD, Rafalski E. An investigation of service quality—willingness
to recommend relationship across patient and hospital characteristics. J Health Manag 2016;18(1):49-69. [doi:10.1177/0972063415625508]
Grönroos C. A service quality model and its marketing implications. Eur J Mark 1984;18(4):36-44. [doi:10.1108/EUM0000000004784]

http://medinform.jmir.org/2018/2/e35/

XSL• FO
RenderX

JMIR Med Inform 2018 | vol. 6 | iss. 2 | e35 | p. 8
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS
10.
11.
12.
13.

14.
15.
16.
17.

18.
19.

20.
21.
22.
23.

24.

25.
26.

Bashir & Bastola

Parasuraman A, Zeithaml VA, Berry LL. A conceptual model of service quality and its implications for future research. J
Mark 1985;49(4):41-50. [doi: 10.2307/1251430]
Grönroos C. Innovative marketing strategies and organization structures for service firms. In: Berry LL, Shostack GL,
Upah GD, editors. Emerging Perspectives on Services Marketing. Chicago: AMA; 1983:9-21.
Fotiadis AK, Vassiliadis CA. The effects of a transfer to new premises on patients' perceptions of service quality in a general
hospital in Greece. Total Qual Manag Bus Excell 2013;24(9-10):1022-1034. [doi: 10.1080/14783363.2013.799328]
Rodríguez-Martín B, Martínez-Andrés M, Cervera-Monteagudo B, Notario-Pacheco B, Martínez-Vizcaíno V. Perceptionof quality of care among residents of public nursing-homes in Spain: a grounded theory study. BMC Geriatr 2013 Jun
28;13:65 [FREE Full text] [doi: 10.1186/1471-2318-13-65] [Medline: 23809066]
Snooks HA, Williams AM, Griffiths LJ, Peconi J, Rance J, Snelgrove S, et al. Real nursing? The development of telenursing.
J Adv Nurs 2008 Mar;61(6):631-640. [doi: 10.1111/j.1365-2648.2007.04546.x] [Medline: 18302604]
Eaves YD. A synthesis technique for grounded theory data analysis. J Adv Nurs 2001 Sep;35(5):654-663. [Medline:
11529967]
Khazanchi D, Shank M, Reynolds J. The impact of voice mail technology on internal service quality. J Customer ServMark Manag 1998 Sep 2;4(4):75-106.
Hogan TP, Wakefield B, Nazi KM, Houston TK, Weaver FM. Promoting access through complementary eHealth technologies:
recommendations for VA's Home Telehealth and personal health record programs. J Gen Intern Med 2011 Nov;26 Suppl
2:628-635 [FREE Full text] [doi: 10.1007/s11606-011-1765-y] [Medline: 21989614]
LeRouge CM, Garfield MJ, Hevner AR. Patient perspectives of telemedicine quality. Patient Prefer Adherence 2015;9:25-40[FREE Full text] [doi: 10.2147/PPA.S67506] [Medline: 25565781]
Darkins A, Ryan P, Kobb R, Foster L, Edmonson E, Wakefield B, et al. Care Coordination/Home Telehealth: the systematic
implementation of health informatics, home telehealth, and disease management to support the care of veteran patients withchronic conditions. Telemed J E Health 2008 Dec;14(10):1118-1126. [doi: 10.1089/tmj.2008.0021] [Medline: 19119835]
Choi KS, Lee H, Kim C, Lee S. The service quality dimensions and patient satisfaction relationships in South Korea:
comparisons across gender, age and types of service. J Serv Mark 2005;19(3):140-149. [doi: 10.1108/08876040510596812]
Sproull NL. Handbook of Research Methods: A Guide for Practitioners and Students in the Social Sciences. Lanham,
Maryland: Scarecrow Press; 2003.
Radhakrishnan K, Jacelon C, Roche J. Perceptions on the use of telehealth by homecare nurses and patients with heart
failure: a mixed method study. Home Health Care Manag Pract 2012;24(4):175-181. [doi: 10.1177/1084822311428335]
Silva GS, Farrell S, Shandra E, Viswanathan A, Schwamm LH. The status of telestroke in the United States: a survey ofcurrently active stroke telemedicine programs. Stroke 2012 Aug;43(8):2078-2085 [FREE Full text] [doi:10.1161/STROKEAHA.111.645861] [Medline: 22700532]
Young H, Miyamoto S, Ward D, Dharmar M, Tang-Feldman Y, Berglund L. Sustained effects of a nurse coaching intervention
via telehealth to improve health behavior change in diabetes. Telemed J E Health 2014 Sep;20(9):828-834 [FREE Full text][doi: 10.1089/tmj.2013.0326] [Medline: 25061688]
Eysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).
J Med Internet Res 2004 Sep 29;6(3):e34 [FREE Full text] [doi: 10.2196/jmir.6.3.e34] [Medline: 15471760]
Nagel DA, Penner JL. Conceptualizing telehealth in nursing practice: advancing a conceptual model to fill a virtual gap. J
Holist Nurs 2016 Mar;34(1):91-104. [doi: 10.1177/0898010115580236] [Medline: 25858897]

Abbreviations
AS: assurance
ATA: American Telemedicine Association
COPD: chronic obstructive pulmonary disease
EM: empathy
IT: information technology
RATER: Reliability, Assurance, Tangibles, Empathy, Reliability
RL: reliabilty
RS: responsiveness
SQ: service quality
TA: tangibles
TNSQ: telehealth nursing service quality
VNA: Visiting Nurse Association

http://medinform.jmir.org/2018/2/e35/

XSL• FO
RenderX

JMIR Med Inform 2018 | vol. 6 | iss. 2 | e35 | p. 9
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Bashir & Bastola

Edited by G Eysenbach; submitted 28.09.17; peer-reviewed by S Miyamoto, H Young, P Więch, S Assi; comments to author 15.03.18;
revised version received 18.03.18; accepted 05.04.18; published 25.05.18
Please cite as:
Bashir A, Bastola DR
Perspectives of Nurses Toward Telehealth Efficacy and Quality of Health Care: Pilot StudyJMIR Med Inform 2018;6(2):e35
URL: http://medinform.jmir.org/2018/2/e35/
doi: 10.2196/medinform.9080
PMID: 29802089©Ayisha Bashir, Dhundy R Bastola. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 25.05.2018.
This is an open-access article distributed under the terms of the Creative Commons Attribution License(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,provided the original work, first published in JMIR Medical Informatics, is properly cited. The complete bibliographic information,a link to the original publication on http://medinform.jmir.org/, as well as this copyright and license information must be included.

http://medinform.jmir.org/2018/2/e35/

XSL• FO
RenderX

JMIR Med Inform 2018 | vol. 6 | iss. 2 | e35 | p. 10(page number not for citation purposes)