Telehealth use in rural and remote health practitioner education: an integrative review AUTHORS

Introduction:  For rural and remote clinicians, quality education is often difficult to access because of geographic isolation, travel, time, expense constraints and lack of an onsite educator. The aims of this integrative review were to examine what telehealth education is available to rural practitioners, evaluate the existence and characteristics of telehealth education for rural staff, evaluate r Rural and Remote Health rrh.org.au James Cook University ISSN 1445-6354


Introduction
Accessing education in rural and remote settings can be challenging for health practitioners. Telehealth education with videoconferencing (VC) as a main delivery mode is widely researched. Research is well established for telehealth to provide patient education and follow-up appointments, but little is known about the impact of telehealth education using VC for rural and remote health practitioners, and several recommendations note the need for further exploration .

Telehealth as defined by the International Organization for
Standardization is the 'use of telecommunication techniques for the purpose of providing telemedicine, medical education, and health education over a distance' . For clarity, telemedicine has a narrower focus of clinical services that are remotely delivered, with the International Organization for Standardization definition as the 'use of advanced telecommunication technologies to exchange health information and provide healthcare services across geographic, time, social and cultural barriers' . VC is described as 'electronic form of communications that permits people in different locations to engage in face-to-face audio and visual communication. Also, a collection of technologies that integrate video with audio, data, or both to convey in real time over distance for meeting between dispersed sites' .
VC is one of the most common models of audio and visual technology used to provide telehealth and telemedicine. This article talks about telehealth predominantly and VC specifically as a form of providing health professionals from rural and remote locations an opportunity to connect with colleagues and gain support for patient care, refer patients and many other aspects that historically were a 'refer and treat' process, without connection to specialists in real time.
VC is becoming more widely used in telehealth, including to provide education to health practitioners in rural or remote settings. Quality education opportunities in rural and remote settings have traditionally been difficult to access because of geographic isolation, travel, time and expense constraints and often the lack of an onsite educator. Within telehealth, VC is promoted as a practicable alternative for educational opportunities , but like all new technology approaches, uptake has overtaken evidence for use. When establishing their own telehealth education approach, the authors found gaps in the literature related to how telehealth has been used for specific education in rural and remote settings, along with little evidence about education strategies and their modes of delivery strengths and weaknesses. Therefore, this review was undertaken to identify, evaluate and synthesise the available evidence for using telehealth for education of rural and remote healthcare providers.
The objectives of this integrative review were to: (1) determine the existence and characteristics of telehealth education in rural and remote setting; (2) evaluate current telehealth education models and resources; (3) establish the quality of education provided through telehealth along with the facilitators or enablers of a successful service; and (4) develop recommendations for supporting and developing an education model for rural and remote health practitioners through telehealth.  An integrative review was undertaken following the five-stage integrative review process described by Whittemore and Knafl consisting of problem identification, literature search, data evaluation, data analysis, and presentation.

Inclusion and exclusion criteria
Studies were included if they were published in a peer-reviewed journal and met the following inclusion criteria: (1) telehealth to provide targeted clinical education, training or supervision; (2) health practitioners including doctors, nurses and allied health; (3) rural or remote setting (including underserved). Studies were excluded if they (1) were written in a language other than English; (2) editorials, commentaries, news items, grey literature, could not be sourced, poorly constructed or written papers that made understanding difficult, and if their content did not meet inclusion criteria. In relation to inclusion criterion 1, targeted clinical education was related to education about clinical presentation types rather than health service process or mandatory education that is not focused on clinical practice. The authors chose to limit the inclusion of mandatory or process-driven education owing to the prescriptive nature of this type of education. The main area of interest was for patient outcomes, practice improvement, or clinician professional development.

Data extraction
One reviewer (MS) screened all records for relevance to the topic and excluded articles based on title or abstract that clearly did not meet the inclusion criteria. Two independent reviewers (PC, MS) assessed full-text articles for eligibility. Data were extracted by six reviewers (PC, MS, LT, SW, SWO, COB) and underwent consensus review until agreement was reached for final inclusion in the review.
Restrictions were not placed on study/methodology quality before information was extracted from articles and summarised into a table for review. The following data were collected from the included studies: first author, country of publication, aim, sample size, study design/methodology/intervention, relevant results/findings and recommendations, limitation/bias. This enabled a thematic summary of the studies' findings (see Table 2). 8 Table 2: Thematic summary of the included studies

Study selection
The initial search using the search terms within the six designated

Current telehealth education models and resources
Within current telehealth education modules and resources, there were 10 themes identified: (1) improved practice change; (2) improved clinician confidence; (3) increased clinician knowledge; (4) improved self-efficacy; (5) increased clinical competency; (6) sense of community and interaction decreases isolation; (7) improved patient outcomes; (8) satisfaction, activity and reach equals acceptability and feasibility; (9) VC education is acceptable and feasible for rural and remote clinicians; and (10) weak measures used to identify success (see Table 2 for a summary of themes and subthemes of sessions, and all were focused on case study presentation. One study had added in a two-day onsite training session before using the usual Project ECHO model . One study also had their didactic session pre-recorded, and the debriefing as a live session. Telehealth sessions were regarded as being as beneficial as face-toface sessions , while the technology was often challenging to some participants . Educators' knowledge on how best to use telehealth or their technical ability also affected (either positively or negatively) the delivery and provision of education using this technology, and therefore the development of those providing education in this way should be ensured to improve delivery and outcomes .
Most of the education provided was delivered by specialists in the area or by multidisciplined teams and this appeared to have a positive effect by increasing and promoting the development of professional networks . Use of telehealth modalities for education also had other beneficial outcomes, such as feelings of decreased isolation for participants as well as an increase in the availability and access to education opportunities .
Participants who had undertaken telehealth education also had increased levels of self-efficacy and felt that they were able to better apply what was learned to clinical practice .
There appeared to be an increased sense of support being provided by using a telehealth education model, as well as increases in the levels of confidence of education recipients . Recipients also reported that they gained knowledge as a result of attending telehealth education sessions and satisfaction levels with education provided using this technology were high .

Quality of education provided through telehealth along with the facilitators of a successful service
Related to quality of education provided and facilitators of a successful service, there were three themes identified: (1) successful VC education has specific characteristics; (2) technology can support or hinder education in rural and remote communities; and (3) barriers to uptake include resourcing, scheduling and ease of use (see Table 2 for themes and subthemes). Specific recommendations were difficult to synthesise as the focus of education strategies used was extremely broad. This was complicated by limited evaluation of education strategies used and perhaps this is an indication that we are still in the phase of proliferation of publications that describe rather than evaluate a new intervention/approach. The few papers that do evaluate quality or outcomes of using a telehealth strategy for education may be the start of the professional conversation of questioning how to use a new approach like VC for telehealth education, most effectively for health professional education in rural and remote settings.
The 13 themes and subthemes distilled from the selected are presented in detail in Table 2. These included the following (theme names in italics).
Improved practice change, which focused on the changed practices of the clinicians as a result of engaging in the education provided.
This was closely linked to patient outcomes as a result, and to improved clinician confidence and increased clinician knowledge and improved self-efficacy.
Increased clinical competency related to tested clinical competence, whether this was tested or self-reported, and in some cases extended the scope of practice of the clinician.

Sense of community and interaction decreases isolation related to
being able to collaborate with peers, access support and as a result feel more connected and reduced stress related to being a healthcare practitioner in an isolated environment.
Improved patient outcomes related to measurable patient clinical outcomes and being able to access health care in a rural or remote environment for a broader scope of care.

Satisfaction, activity and reach equals acceptability and feasibility
was closely related to weak measures used to identify success; however, this would benefit from more robust outcomes-based research.
This study found improving practice change was a theme related to telehealth education provided to health professionals in rural and remote areas. However, the measures supporting this outcome were not rigorous. Future research related to quality measures of tangible outcomes is needed. This is not specific to VC education; measuring practice change as a result of education provided is more complex and needs careful planning to be able to creditably achieve clear outcomes because often training is not the only answer . While patient education can be measured directly by observing behaviour change and asking their intention to change behaviour, this is more complex to do with clinician education outcomes. There are many more factors involved in measuring outcomes of clinician education in addition to increased knowledge, intention to change practice and observed practice change. This would be an interesting and valid area of research to develop more effective approaches to measuring education outcomes within the health professional cohort.
In one integrative and thematic synthesis that investigated education and professional opportunities in rural and remote environments when using telehealth programs, engagement and participation was found to be further enhanced by the personalisation to the program, contributing value and meaning. This is closely linked to several of the current themes. For example, social isolation was reduced, and networking opportunities provided with the interactive learning were found to be most effective as an education technique for influencing patient outcomes . Regardless of geographical location, the use of telehealth to provide education to health professionals in rural and remote areas is seen as feasible, cost-effective and beneficial .

Limitations
The limitations in this study include variations in what defines a rural or remote area and the variety of settings where studies were undertaken. Another issue was the quality of the studies included.
Outcome measures were generally weak, and therefore recommendations cannot be made on this basis; however, if all studies were excluded for this reason, there would be very few to include in this study, and the authors feel that this is a finding in itself. The nature of the emerging work in this area means there is some way to go in improving the research design of education program evaluations in telehealth use for health practitioner education in rural and remote areas.

Conclusion
Telehealth education, and in particular VC, is seen as a viable, cost-