Abstract
Telenursing services are widely used to support individuals with inflammatory bowel disease in several countries. Nurses supporting this population must manage diverse symptoms and care needs, but many report challenges in responding to telephone consultations. This qualitative study aimed to identify and describe the specific elements of telenursing practice for patients with inflammatory bowel disease in Japan, and the aspects that nurses consider important in remote care. Semi-structured interviews were conducted with 20 nurses who had extensive experience in telenursing for inflammatory bowel disease, who were selected through purposive sampling. Data were analyzed using inductive content analysis. Participants had a median of 10 years of telenursing experience. Six categories of practice were identified: (1) educate and inform in advance, (2) clarify the situation and needs, (3) assess worsening symptoms and decide the response, (4) recommend responses to worsening symptoms, (5) respond to issues other than physical deterioration, and (6) nurse-to-patient contact. Three key elements were highlighted as essential to effective telenursing: establishing a coordinated system, clarifying the role of telenursing, and improving nursing skills. These findings provide a clearer understanding of telenursing practices and offer guidance for enhancing support for individuals with inflammatory bowel disease.
Keywords
Introduction
Telenursing is defined as the delivery of nursing and services that rely on telecommunication technology to overcome the barriers of time and distance, including remote nursing interventions, health education, ongoing monitoring, and aftercare (McVey, 2023). It is part of both telemedicine and telehealth and is a form of nursing care that patients receive at home. For the purpose of our study, we focused specifically on telenursing services delivered to patients in their homes by remote nurses, rather than those provided in clinical settings, such as local health centers. The deployment of communication technologies, including telephones, is typically constrained by the availability of appropriate infrastructure, but their proactive integration into medical practice is both necessary and highly beneficial (International Council of Nurses, 2025). The coronavirus-19 pandemic dramatically intensified the use of telenursing in many countries (Rutledge & Gustin, 2021). Previous studies have reported positive effects of providing services by telephone, including reduced costs and improved outcomes for people with cancer, chronic obstructive pulmonary disease, congestive heart failure and diabetes (De Leo et al., 2023; Mun et al., 2023).
Inflammatory bowel disease (IBD) is a disease of unknown cause that results in chronic inflammation of the small and large intestine. Typical forms of the condition are ulcerative colitis and Crohn’s disease. The main symptoms are bloody mucus-coated stools, diarrhea, abdominal pain, fever, weight loss, nausea/vomiting, and anemia. It is often characterized by periods of remission where symptoms settle down and flare-ups where symptoms worsen (Turner et al., 2021). A consensus statement on support for IBD patients emphasizes that nurses should help patients improve their quality of life and that personalized care plans should be provided by IBD nurse specialists and by phone or email (Kapasi et al., 2020).
Background
A review found that telephone support provided by IBD nurses reduced costs, general practitioner visits, accident and emergency visits and hospital admissions (Gravina et al., 2023). Common reasons why people with IBD consult nurses over the phone include worsening health condition, changes to appointments for consultations and tests, taking IBD medication with other medications, and lifestyle, especially mental health (Kawakami et al., 2023). Many people with IBD prefer being able to consult nurses by phone, and regard it as a lifeline (Bager et al., 2018). However, providing effective support requires nurses to have broad knowledge and skills to address diverse symptoms and management needs. Nurses have also reported difficulties in responding to telephone calls (Barbosa Ide et al., 2016; Koivunen & Saranto, 2018) because the process involved time-consuming, difficult communication with patients and clinical decision-making.
Several nursing practice frameworks and models for telenursing have been previously proposed (Barbosa Ide et al., 2016; Greenberg, 2009; Larson-Dahn, 2000; Nagel & Penner, 2016; Purc-Stephenson & Thrasher, 2010), but these primarily focus on general standards, procedures, and communication strategies in telecare. Little is known about the specific practices nurses use when providing telephone support to individuals with IBD, particularly during periods of disease exacerbation when timely intervention is critical. In these cases, appropriate treatment adjustments are essential to prevent progression to severe illness. This study therefore aimed to identify and describe the specific elements of telenursing practice for patients with IBD in Japan, and to explore the aspects that nurses perceive as important in providing remote care. In doing so, the study sought to contribute to the development of practical knowledge to enhance the competence of nurses engaged in IBD telenursing.
Methods
Design
This study employed a qualitative descriptive approach, which is particularly suitable for obtaining straightforward accounts from participants about their experiences. This approach is grounded in the work of Sandelowski (2000), who emphasized its utility in health research when rich, low-inference descriptions are needed. It is further supported by Bradshaw et al. (2017), who advocate for its practical relevance in nursing and midwifery contexts. While content analysis (Elo & Kyngäs, 2008) was used as the method of data analysis, the overall design aligns with qualitative description, allowing for a structured yet flexible exploration of participant perspectives.
Study Context
Japan has a universal health insurance system. Insured medical institutions can claim a fee for a subsequent consultation by telephone for patients who have undergone an initial consultation at the medical institution if, after a second consultation, the patient or their representative requests a therapeutic opinion directly or indirectly (including by telephone or video call) and the necessary instructions are given (Ministry of Health Labour and Welfare, 2024). Nurses play a supporting role when physicians provide this opinion, and support provided by nurses alone is not eligible for additional fees. These practices are embedded in routine clinical care rather than being organized as a separate telephone triage service, and the extent to which telephone support is provided, as well as the specific forms of implementation, vary across institutions. In Japan, patients with IBD are typically treated by gastroenterologists in hospital settings. Moreover, some physicians specialize in IBD care. Although there is no officially recognized qualification for IBD nurse specialists in Japan, some nurses have extensive experience in the care of IBD patients and have developed expertise in this area. The presence of nurses who specialize in IBD varies by region and institution, and their involvement in telephone-based support is often informal and embedded within broader clinical workflows.
Recruitment, Inclusion, and Exclusion Criteria
Participants were recruited using purposive sampling to ensure that they met the study criteria and could provide relevant information about telenursing practices for people with IBD. Registered nurses were eligible if they (1) provided telenursing for people with IBD, and (2) had at least 1 year of experience of doing so. Nurses who only answered the phone and obtained patients’ personal information, without providing further advice, were excluded. The third and fifth authors suggested potential participants, and the first author sent the study description and eligibility criteria confirmation letter by mail or email. For those who expressed a willingness to participate, the first author explained the study in detail and arranged interview dates and times. Nurses were recruited from a wide range of urban and rural areas, and across regions of Japan.
Data Collection
Data collection took place from June 2023 to June 2024 using semi-structured, audiotaped interviews. Interviews were conducted either online or face-to-face, depending on the interviewee’s preference. Online interviews were conducted via Zoom. Face-to-face interviews took place in a private room within the facility where the participant was employed. When more than one participant was at the same facility, the first author asked each person’s preference for an individual or focus group interview. Ten nurses from four facilities preferred a facility-based focus group interview rather than individual interviews, and the rest preferred individual interviews. Before the interview, participants were asked to complete a short survey that included open-ended questions about their sex, years of IBD nursing experience, years of IBD telenursing experience, whether their facility has a manual on telenursing, how often they receive phone calls, and whether they have to meet any particular requirements before they can answer phone calls.
A semi-structured interview guide with open-ended questions was developed by the first, second, and fourth authors, drawing on previous studies (Greenberg, 2009; Kawakami et al., 2023; Nagel & Penner, 2016). The initial interview guide is at Appendix 1. This interview guide was prepared for use with both individuals and focus groups. First, nurses were asked about the main topics covered during telephone consultations and their responses to each topic. For the most frequent topic, symptom exacerbation (Kawakami et al., 2023), we asked the participants to share their practices in detail, including how they assessed patients’ conditions, made decisions, responded to patients, and evaluated worsening symptoms. The interviewer asked if the nurse ever contacted patients by phone, and if so, about the purpose and content of the contact. The interviewees were asked about their perceptions of what was important and the specific actions involved in answering the phone. Interviews were focused on interactions with patients aged 18 years and older. This is because, in our experience, telenursing with pediatric patients involves significant interaction with parents, and there are aspects of practice that differ from working with adult patients.
The interviewers were the first author, who has experience in IBD nursing practice and research, and the fourth author, who is an undergraduate student with knowledge of IBD. Before data collection, the first author observed a telenursing session with IBD patients to enhance interpretive accuracy. In total, the first author carried out 13 interviews and the fourth author carried out one interview. A pilot interview was carried out to ensure the quality of the interview guide, and resulted in no changes. The results of the pilot interview were therefore included with the other interview results in this study. The interviewers were also advised on how and in what order to ask questions, to encourage the interviewees to talk more. To ensure the accuracy of participants’ narratives, they were recorded verbatim.
Data Analysis, Rigor, and Reflexivity
We used inductive content analysis following established guidelines (Elo & Kyngäs, 2008). This approach was considered appropriate because the specific practices of IBD telenursing have not been sufficiently examined, and the approach allowed categories and themes to be derived from the nurses’ descriptions of their practice. The analysis was carried out in three phases—preparation, organization, and reporting. To ensure trustworthiness, the study applied the criteria of Lincoln and Guba (1985) for credibility, transferability, dependability, and confirmability.
During the preparation phase, we transcribed the full interview recordings into Microsoft® Word® documents, which were then used as the units of analysis. Each author transcribed their own interview recordings and carefully reviewed the transcripts multiple times to ensure a comprehensive understanding. Whole interviews were selected as the unit of analysis, and the authors read the transcribed material multiple times to gain a comprehensive understanding of each participant’s story and nursing practice. Participants’ comments were recorded in a way that allowed the interview situation to be imagined as realistically as possible, including silences and pauses during their comments.
During the organizing phase, we first carried out open coding, followed by the creation of subcategories and abstraction. Codes were compiled in a coding sheet and grouped by semantic similarity. Investigator triangulation was conducted for the first eight interviews, with independent coding and discussion among authors. The second author contributed to resolving discrepancies and enhancing dependability. The results were shared with co-authors, physicians, and five participating nurses for peer review and feedback. Minor wording adjustments were made based on participant input.
Data analysis was conducted manually using Microsoft® Excel® 2021, and descriptive statistics were calculated using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).
Trustworthiness
Trustworthiness was ensured by applying Lincoln and Guba (1985) four criteria, which are detailed below. Credibility was enhanced via investigator triangulation, peer debriefing, and member checking. Independent coding and collaborative discussion among authors helped ensure that interpretations were grounded in the data. Feedback from participating nurses further validated the findings. Transferability was maximized by providing rich descriptions of the research context, background of the participants, and the specific practices of IBD telenursing to enable readers to assess their applicability to other settings. Dependability was addressed by maintaining a clear audit trail of the analytic process, including coding sheets, decision logs, and documentation of revisions based on peer and participant feedback. Confirmability was strengthened via reflexive practices, such as repeated transcript reviews and collaborative interpretation, which helped minimize researcher bias and ensure that the findings reflected participants’ perspectives. These strategies were integrated throughout the research process to ensure methodological rigor and transparency.
Ethical Considerations
The study protocol was reviewed and approved by the Ethics Review Committee of the Faculty of Medicine of Tokyo Medical and Dental University (Approval Numbers: M2022-338, approval date: April 20, 2023). After the researcher explained the purpose and overview of the study, all the participants gave written informed consent. In the case of online interviews, the researchers mailed the informed consent form to participants in advance. At the beginning of the online interview, the researcher explained the study purpose and procedures, and participants were asked to complete the consent form during the session. The researcher then confirmed the signed form visually via the video screen before proceeding with the interview. After the interview, participants returned the signed consent form to the researcher by mail. The participants were informed that their participation was voluntary and that they could withdraw from the study at any time for no reason. Personal information from the interviews was anonymized and handled with care to ensure that individuals could not be identified. All interview data were stored on a password-protected USB device, which was kept in a locked cabinet. In accordance with the guidelines of the institutional ethics committee, the data will be retained for 10 years following the completion of the research project. After the interview, each participant received a 3,000-yen Quo card (approximately $20 USD) as a token of appreciation for their participation in the study.
Results
Participant Characteristics and Telenursing Systems
Overall, 20 nurses from 11 facilities participated in the interviews, all of whom were women. Seven of the participating facilities were hospitals with at least 20 beds and four were clinics with no beds. All participants worked in outpatient clinics and specialized in nursing care of IBD patients, including telephone consultation. One participant (participant J) was a Certified nurse specialist in chronic care nursing, and all others were registered nurses. All facilities provided telephone consultations as voice-only rather than videophone, so the patients’ appearance or nonverbal cues could not be observed. The frequency of telephone consultations varied across facilities, with nurses answering approximately 1–2 calls per month in some settings and up to 7–8 calls per day in others. These figures reflect the total number of calls received per facility, not per individual nurse or patient. Nurses had a median of 10 years of nursing experience and telenursing with people with IBD. All nurses responded to telephone consultations alongside their work in outpatient clinics. Nurses at two facilities collected information by referring to a manual listing items related to major symptoms of IBD. Nine facilities specified requirements to be able to engage in telenursing, including familiarity with patients attending outpatient clinics and the ability to work across both telephone consultations and outpatient services (Table 1).
Information About the Nurses and Telenursing Systems Used in Each Facility.
Note. IBD = inflammatory bowel disease.
Hospitals with at least 20 beds.
“w” indicates web-based interview; “f” indicates face-to-face.
Group interviews were only carried out with participants at the same facility.
Telenursing for Patients with IBD
This study identified two main sets of findings: six categories of telenursing practices used by nurses to support individuals with IBD, and three key elements that nurses perceived as essential for effective telenursing. The six categories of practice were: (1) educate and inform in advance, (2) clarify the situation and needs, (3) assess worsening symptoms and decide the response, (4) recommend responses to worsening symptoms, (5) respond to issues other than physical deterioration, and (6) nurse-initiated patient follow-up. These categories reflect the sequence of actions nurses take when responding to telephone consultations and highlight the breadth of their responsibilities.
In addition, three overarching elements were identified as important for enhancing the quality and sustainability of telenursing: (1) Establish a coordinated system, (2) Clarify the role of telenursing, and (3) Improve nursing skills. These elements represent structural and professional considerations that support the delivery of high-quality telenursing.
The following sections present a narrative summary of each category, with illustrative quotes from participants. A detailed breakdown of categories, subcategories, and codes is provided in Table 2.
Elements of Telenursing for People with Inflammatory Bowel Disease.
Note. IBD = inflammatory bowel disease.
Educate and Inform in Advance
Nurses helped patients monitor their own health and seek advice when needed so they could make the most of the telenursing service. Specific instructions were given on the signs of relapse and when to call, depending on the patient’s characteristics. Some nurses also provided information in advance on the range of consultations and requests they could respond to over the phone. For example, some nurses informed patients in advance that telephone consultations would prioritize matters related to worsening physical conditions. This was because nurses conducted telephone consultations alongside outpatient duties, and the time available for telephone consultations was limited.
Our hospitals don’t openly allow telephone consultations, except in cases of deteriorating health conditions. This is because we can’t handle phone calls alongside the outpatient clinic. (ID 5)
Clarify the Situation and Needs
Nurses listened to the reason given for the call by patients and others, including for deteriorating health conditions. They also confirmed whether the consultation was urgent for the patient. When callers mentioned that their condition was worsening, nurses asked about both symptoms characteristic of IBD and systemic symptoms. They also considered diseases that need to be differentiated from IBD, such as enteritis and irritable bowel syndrome. To accurately identify symptoms, patients were informed about possible behaviors to use after symptom exacerbation, such as taking non-prescription medication. Patients were asked about possible triggers for symptom worsening, such as medication adherence, or stressful life events and diet. The purpose of these questions was for the nurses to obtain the necessary information over the phone.
Nurses also used different methods, such as checking symptoms using an existing scale. If the caller was someone other than the patient, the nurses asked the caller to relay the patient’s own words about their complaint or condition. When the patient’s needs were not clear, the nurses made efforts to understand them by offering answer options drawing on the patient’s usual life and characteristics. The nurses also asked detailed questions over the phone about possible embarrassment.
Patients in their early twenties, such as university students are embarrassed and reluctant to talk about anal lesions, but we ask straightforwardly and elicit the necessary information so as not to make them ashamed. (ID1)
Assess Worsening Symptoms and Decide the Response
When they received calls about deteriorating physical condition, nurses first assessed the condition. They considered whether early medical attention was needed, or whether the situation could be followed up at home. Table 3 summarizes the signs and symptoms used by IBD nurses to decide what action to take. Abdominal symptoms that warranted early consultation included visible bloody stools, persistent diarrhea, more frequent defecation and ileal symptoms. Conditions that could be followed up at home included no worsening of symptoms, intermittent or mild symptoms and being able to appropriately inform the nurse about symptoms over the phone.
The degree to which symptoms are a sign of deterioration varies widely from person to person, but I would rate the persistence of visible bloody stools in the case of ulcerative colitis and the presence of ileal symptoms in the case of Crohn’s Disease as a sign that they should go to a hospital. (ID 1)
When deciding how to respond to worsening symptoms, the nurses consulted with physicians when they could not decide on their own.
When I can’t tell whether abdominal symptoms are due to worsening IBD, I report the situation to my doctor and seek their judgment. (ID 9)
However, many nurses took the lead in guiding the response to worsening symptoms. Nurses informed physicians of the evaluation results and decision-making policy and obtained their approval. When symptoms were obviously deteriorating, nurses often used their own judgment to instruct patients to visit a hospital as soon as possible.
The signs of relapse are so individualized that it is sometimes difficult for us to determine for ourselves. We tell the doctor our decision on whether the patient should be seen in hospital as soon as possible, or whether they can be followed up at home and make sure there are no differences between the doctor’s and the nurse’s assessment. (ID11)
Factors Used During Telenursing to Determine Whether People with Inflammatory Bowel Disease Should Visit a Hospital.
Recommend to Patients How to Respond to Worsening Symptoms
When patients called with worsening symptoms, nurses made suggestions for managing the symptoms and subsequently assessed the change in their physical condition. When recommending a hospital visit, nurses guided patients toward dates and times that would enable them to be seen and treated efficiently. In some cases, patients were asked to increase their dosage of medication, restart medicines or change elements of their diet.
If patients have an enema at hand and are told by the doctor to adjust the frequency, I tell them to try increasing the use from about twice a week to every day. (ID3)
Nurses instructed patients on self-care for worsening IBD symptoms. This included adherence to medication, stress reduction, the need for rest and whether to see a doctor. Nurses evaluated patients’ physical condition after responding to symptom exacerbation.
Respond to Issues Other Than Physical Deterioration
Responses to issues other than physical deterioration were divided into those shared with other professions or when help was requested by nurses, and those primarily managed by nurses. Nurse-initiated responses included mental health concerns, self-care, and dietary support.
Patients with Crohn’s disease often ask me, “I have a dinner with friends tonight—is it okay to eat this kind of food?” Being able to casually consult over the phone seems to give them a great sense of reassurance. (ID19)
Nurse-Initiated Patient Follow-Up
Some nurses contacted patients who did not arrive for appointments or whose condition might have deteriorated further since their last visit. Nurses also called to inform patients about test results or to provide instructions about protocols.
Patients in their teens and 20s may stop taking medication and stop seeing their doctor when they are in remission. . ., so I make a note of the patients who do not turn up and call them to encourage them to see their doctor. (ID18)
Important Aspects of Telenursing of IBD Patients
The factors perceived by participants as important to telenursing were categorized into three categories. The three categories were: establish a coordinated system, clarify the role of telenursing, and improving nursing skills.
Establish a Coordinated System
Nurses emphasized the importance of fostering a positive attitude toward telephone consultations and promoting collaboration among institutions, healthcare providers, and patients. Specific measures to improve collaboration included sharing information about patients who were often consulted by telephone in multidisciplinary meetings.
We share key information with the doctor, and we decide on the direction of care together. We always try to make sure we’re on the same page so that treatment proceeds smoothly. (ID7)
Clarify the Role of Telenursing
Participants highlighted the need to define the nurse’s responsibilities in telephone consultations. This included standardizing the content of discussions and clearly delineating the scope of nursing practice.
In my clinic, we are responsible for deciding whether a patient should come to the clinic or not and for giving instructions for self-administration of medication, but I think it is important to define some of the nurses’ roles to ensure safe and efficient telenursing. (ID3)
Improving Nursing Skills
Nurses recognized the importance of gaining experience and developing the ability to respond effectively to telephone consultations. They stressed the value of building rapport with patients through outpatient visits, understanding their backgrounds and self-management abilities, and showing empathy during calls.
If we know enough about our patients—not only their IBD, but also their background and self-management skills—we can use telephone calls to provide them with coping strategies that will work for them. (ID 11)
Nurses also felt that it was important to gain experience in handling telephone consultations efficiently. They mentioned knowing how to gather information on areas that are harder to understand or explain, and making good use of existing information. Because nurses respond to telephone consultations in parallel with their outpatient duties, they also require experience in managing this balance.
Discussion
This study delineated six key categories of remote nursing practice that characterize how nurses support individuals with IBD. Greenberg’s (2009) Telephone Nursing Process Model describes three phases: gathering information, cognitive processing, and output. Elements in this study that corresponded to Greenberg’s “gathering information” included clarify the situation and needs and nurse-initiated patient follow-up. Greenberg’s “cognitive processing” included assess worsening symptoms and decide the response and “output” included elements such as recommend to patients how to respond to worsening symptoms and respond to issues other than physical deterioration. We also identified educate and inform in advance as an additional key element for effective remote nursing care for IBD patients, highlighting an aspect of care not explicitly addressed in previous research. A previous study has reported that patients who have never experienced a relapse after developing IBD or who had only been diagnosed for a short time may not recognize relapse symptoms (Tanaka et al., 2016). IBD symptoms are also highly individual, and patients themselves are therefore sometimes unsure whether they are experiencing a relapse (Tanaka et al., 2016). Educating patients about relapse symptoms and when to contact the hospital by phone can promote independence and is beneficial for both managing IBD and improving quality of life.
Clarify the situation and needs and assess worsening symptoms and decide the response were considered especially important practices for patients with IBD. Nagel and colleagues suggested a conceptual model of telehealth nursing, including knowing the person, which means being able to grasp the situation and accurately interpret the caller’s concerns (Nagel & Penner, 2016). In IBD, unlike other chronic diseases, there are no objective indicators such as blood pressure or blood oxygen saturation that will support assessment (Kamei et al., 2018). Comprehensively collecting information about IBD exacerbations and making decisions based on that information is therefore essential in nursing practice. The nurses interviewed in this study collected information on IBD-specific symptoms, similar symptoms found in enterocolitis, perspectives on IBS and potential triggers for worsening, incorporating key perspectives from the guidelines (Harbord et al., 2017; Kemp et al., 2018). Similarly, the manuals available at two facilities in this study were primarily used to collect information about symptoms. These items were included in clinical practice guidelines and therefore considered valid (Kemp et al., 2018).
In determining the severity of IBD, nurses’ views on abdominal and systemic symptoms and characteristics that indicated the need for a hospital visit or follow-up at home were also included in guidelines (Harbord et al., 2017). Larson-Dahn (2000) emphasized the importance of determining urgency through the integration and analysis of collected data as part of the practice of telenursing. Some decisions were made jointly by physicians and nurses, and some by nurses alone. Nurses took the lead in cases that were easy to determine, such as when IBD had clearly flared up. Consultation with physicians was used when it was difficult to determine whether patients’ condition had changed. In the decision-making process, nurses reported feeling isolated, stressed and pressured in telephone triage situations, or when they were unable to consult with other nurses (Purc-Stephenson & Thrasher, 2010). Interprofessional collaboration is an important part of the process in clinical decision-making (Nagel & Penner, 2016). The nurses in this study emphasized the importance of collaboration in telenursing, especially sharing information with other professionals to improve decision-making. Currently, especially in Japan, there are few nurses with the capability to handle telephone consultations. It is therefore important to establish a system that enables close information sharing with physicians and other professionals to facilitate joint decision-making.
The factors perceived as important in remote nursing in this study were categorized into the following three areas: establish a coordinated system, clarify the role of telenursing and improve nursing skills. Some nurses focused their responses only on addressing deteriorations in patients’ physical condition. One reason for this is staff shortages. Nurses respond to telephone consultations in parallel with their outpatient duties and the number of nurses who can provide telenursing is limited. This issue was also reported in a previous study (Purc-Stephenson & Thrasher, 2010). The most frequent reason for telephone consultations is deterioration in patients’ physical condition (Kawakami et al., 2023), and these patients have a high need for advice (Bager, 2014). The UK Consensus Standards for Health Care for IBD Patients recommends the use of telephone and email for individualized support (Kapasi et al., 2020). It is therefore appropriate to focus telenursing on responding to deteriorating health. However, future work is needed to develop a coordinated system to broaden the scope of support.
Few facilities in this study had established guidelines on telenursing, but nurses thought it was important to clarify and standardize the role of nurses in telenursing. Previous studies have mentioned that the use of protocols and guidelines for telenursing is a key element of quality and safety assurance (Larson-Dahn, 2001). Several intervention trials on telenursing have reported that protocols for telenursing have been developed, but details were not reported (Coenen et al., 2017). Developing guidelines based on the practices identified in this study may help to clarify the scope of nursing practice and reduce nurses’ difficulties.
The nurses emphasized the importance of committing to patients daily to ensure smooth communication with them over the phone. Patients with IBD may have anal lesions such as hemorrhoids or fistulas. These are particularly difficult to assess over the phone because anal lesions are hard to identify visually, even for patients. People with IBD are also often embarrassed and hesitant to talk to a nurse on the phone. To solve this problem, nurses tried various techniques to obtain the necessary information. This included building rapport so that the patient is comfortable talking on the phone, and collecting information about the IBD condition by using simple scales and terminology that is easy to understand.
Larson-Dahn (2000) mentioned the importance of understanding patients’ background to provide the right support for the patient during telenursing. Nurses therefore need to understand various aspects of patients’ lives, and build a trusting relationship with them during regular consultations. Purc-Stephenson and Thrasher (2010) found that “developing and maintaining skill” was a key factor, emphasizing the importance of developing communication skills and creating training opportunities (p. 486). Providing support in situations lacking visual cues suggests that nurses require skills in active listening and communication techniques, including understanding how to detect nonverbal signs such as pauses in conversation or changes in voice tone.
Strengths and Limitations of the Work
This study had several strengths, but also limitations. First, the sample was limited to nurses from specific clinical settings, which may restrict the broader applicability of the findings. Second, although participants had varying levels of experience, all were employed in Japanese facilities, and nursing practices may differ in other contexts. For example, fecal calprotectin is useful as a marker to assist in the diagnosis of IBD and allows symptom monitoring at home, but it is not often used in Japan (Ankersen et al., 2021). Third, cultural norms and language may have influenced how nurses articulated their practices during telephone consultations. Further research is needed to explore whether similar practices are used in telenursing for individuals with IBD outside Japan. Fourth, there is a potential bias related to the characteristics of the researcher. In this study, the first author conducted most of the interviews with nurses and played a central role in the data analysis. The first author has professional experience in both nursing practice and research related to IBD patients. We took steps to enhance the credibility of the findings, such as having some data independently analyzed by other authors and obtaining feedback from all authors and several participants. However, the possibility of bias due to the first author’s background and interpretations cannot be entirely ruled out. Finally, this study may not have fully captured telenursing practices following surgical treatment, as only three participating hospitals provided such procedures. However, it was able to include telephone consultations related to key aspects of postoperative care for IBD patients, such as stoma management and nutritional therapy.
Recommendations for Further Research and Implications for Policy and Practice
The practice of telenursing is likely to vary with patients’ needs. Not all the telenursing practices identified in this study will be used with each patient, or on every call. In future, we would like to develop a more refined list of practices by patient need, and assess the consensus about the importance of each practice using a Delphi survey. We would also like to examine the effects on quality of care, nurses’ difficulties and patient outcomes of telephone support using lists. A telenursing practice list may help nurses starting to provide telenursing for people with IBD to understand the basic practice and scope of work of telenursing.
Conclusion
This study identified six categories of remote nursing practice for IBD patients. These included pre-education to ensure the effectiveness of telephone consultations, clarifying the situation and needs, and assessing worsening symptoms and deciding the response. Three categories were also identified as important elements of nursing practice: establishing a coordinated system, clarifying the role of telenursing and improving skills through experience. Some of these practices are included in IBD nursing guidelines and the theoretical framework for telenursing. The practices identified in this study will help nurses starting to provide telenursing for people with IBD to understand the basic practices and scope of work. Future research should refine the practices to reflect patient needs and opinions. It would also be useful to develop recommended practice suggestions based on the practices identified in this study. This list may improve the quality of care and patient outcomes, and decrease difficulties for nurses.
Footnotes
Appendix 1. Outline for Semi-Structured Interviews Used in the Study
Acknowledgements
Ethical Considerations
The study protocol was reviewed and approved by the Ethics Review Committee of the Faculty of Medicine of Tokyo Dental and Medical University (Approval Numbers: M2022-338).
Consent to Participate
After the researcher explained the purpose and overview of the study, all the participants gave written informed consent. The participants were informed that participation was voluntary and that they could withdraw at any time during the course of the study for whatever reason. Personal information from the interviews was anonymized and handled with care to ensure that individuals could not be identified.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by JSPS KAKENHI (Grant Number: 20K19049).
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The data that support the findings of this study are available upon reasonable request from the corresponding author.