Revise

Student Name: Kelly Nhu Tran 1

Date: 10/19/2025

Problem of Interest

The healthcare sector is undergoing a profound change brought about by the need for technological development and growing pressure to incorporate models of care delivery that are both affordable and easily accessible. Telemedicine has taken center stage as a vital intervention to solve the disparities in health care, especially in rural and underserved populations, where shortages of healthcare providers, geographic isolation, and access to specialty care pose significant challenges to the provision of quality health care practices (Haleem et al., 2021). The community hospitals in the country, as the vital safety-net hospitals to about 60 million Americans who live in rural areas, are under pressure to institute and maintain telemedicine programs with high levels of operational, financial, and technological limitations.

The data available in the industry indicates that although the use of telehealth increased during the COVID-19 pandemic, rural hospitals are still grappling with the challenge of implementation sustainability because of poor broadband connections, limited reimbursement plans, lack of technology competency in the workforce, and the complexity of regulatory compliance (Bouabida et al., 2022). These systemic issues continue to create healthcare access inequities, which are leading to preventable emergency department visits, delayed access to essential specialist care, and eventually poor patient outcomes in rural areas that already face a disproportionate disease burden relative to urban areas.

Background Healthcare Administration Problem

The rural adoption of telemedicine is much lower than the rate in urban healthcare systems. This adoption gap points out the overall infrastructure gaps, such as a lack of broadband internet access in about 25 per cent of rural Americans, a lack of capital base to purchase the technology, and a lack of technical support facilities to support the sustainable program implementation. The Medicare and Medicaid reimbursement models used in the past offered low coverage of the telemedicine services, which posed a disincentive to poor hospitals to invest heavily in their facilities without assured revenue flow rates (Jaffe et al., 2020). Even though regulatory modifications in the COVID-19 phase opened up the possibilities of telemedicine reimbursement, there is doubt about long-term policy adjustments, which makes administrators reluctant to invest in the long term.

2 Operational Problem

Healthcare sector is experiencing a paradigm shift due to the demand to develop technological aspects and increased pressure to integrate models of care delivery that are affordable and accessible. The stage of telemedicine as an important intervention has become part of the solution to closing the gaps in health care, particularly in rural and underserved communities, where access to specialty care, shortage of healthcare providers, and geographic isolation are critical issues to the delivery of quality health care practices (Haleem et al., 2021). The community hospitals within the nation that serve as the essential safety-net hospitals to approximately 60 million Americans residing in rural communities are being stressed to integrate and support telemedicine programs with high operational, monetary, and technological constraints.

Information available in the industry shows that despite the fact that the number of telehealth uses grew during the COVID-19 pandemic, rural hospitals continue to face the problem of sustainability in implementation due to low broadband connections, insufficient reimbursements plans, workforce lack of technology competency, and complexity in meeting regulatory standards (Bouabida et al., 2022). These systemic problems persist in causing inequity in healthcare access which is contributing to avoidable emergency department visits, delay in accessing necessary specialist care and ultimately poor patient outcomes in rural regions with already-disproportionate disease burden compared to urban areas.

Operational Problem Core Elements to be Corrected (Constructs)

Core Element Briefly Explain Connection to the Problem

Staffing

Methodology

Two factors directly cause underutilization of services, namely low patient awareness and poor digital health literacy among older adults. It is established by applying an extensive patient education plan, simplify access to care, provide technology support initiatives, and perform specific outreach to create awareness and alter the preferences of individuals to use the appropriate type of virtual care.

Burnout and

Workload

Insufficient provider engagement caused by inefficient workflows, heavy documentation, technical problems, and a lack of incentive alignment are major obstacles to the program's success. It is fixed through re-designing workflow, changing productivity metrics, improving technical support, and leaders committing to making telemedicine a core service delivery.

Ideal State of Operations The optimal option is a smooth incorporation of telemedicine services as a common element

of care delivery, high rates of utilization in the appropriate patient groups, strong provider involvement and satisfaction, evidenced changes in the access metrics, and sustainable financial performance enabling further investment. Telemedicine can serve as one of the evidence-based tools in this ideal state to increase access to specialty care, decrease unnecessary emergency visits, improve patient satisfaction because of the convenient delivery option, and enhance the hospital's

3 competitiveness and its value to the community. Professional Practice Gap Statement...

Professional Practice Gap Statement AdventHealth Hendersonville has inefficient use of telemedicine, although it has

substantial infrastructure investment, accompanied by only 15 percent of the entire population with chronic diseases adopting the offered services, high non-emergency emergency visits, and an average of 3-4 weeks to see a specialist in case of telehealth use. The optimal state of the operation is a smooth integration of telemedicine as a standard requirement in the delivery of care, high utilization among the right populations, high provider involvement, evidence- based access improvements, and financially sustainable operations.

Summary of Evidence The findings confirm that the issue of telemedicine integration costs is a major issue in

the industry that impacts the capacity of hospitals serving rural communities to deliver easy-to- access, high-quality care to underserved populations. AdventHealth Hendersonville is a bright example of how hospitals, whose technical infrastructure is sufficient, are facing significant operational challenges related to the translation of technology investment into its meaningful use and better results. The fundamental problem factors, which include patient engagement/digital health literacy/ Problem and insufficient provider adoption/workflow integration/ Problem, are interrelated and cause obstacles to achieving the potential benefits of telemedicine. The gap in professional practices between the current suboptimal use and the optimal seamless integration requires evidence-based approaches to cover both patient-facing and provider-facing aspects.

Purpose of the Integrative Review

This integrative review aims to synthesize and critically evaluate the existing empirical and grey literature to evidence-based interventions to enhance nurse staffing models and burnout reduction in rural community hospitals. In this research, the efficiency of different interventions, including acuity-based staffing tools, workload management systems, and supportive practice environments, will be analyzed on such key outcomes as nurse burnout, turnover intention, and patient safety indicators. The purpose of this review is to find relevant solutions applicable in practice to solve the operational and workforce problems of HSOs, such as AdventHealth Hendersonville, that are unique to the rural hospital setting. The results will be aimed at equipping healthcare administrators with condensed evidence-based information to make strategic decisions that can result in optimal operational and nurse retention, and eventual change in the quality of healthcare services extended to rural people.

Integrative Review Question(s) Which evidence-based practices are effective to increase the rates of telemedicine

utilization and sustainability of programs in rural hospitals with communities of predominantly older adults with chronic disease management needs?

Theoretical and/or Conceptual Framework

Description The Consolidated Framework for Implementation Research (CFIR) is the frame of

reasoning and acting on the issues of telemedicine integration into the rural community hospital and its frameworks. CFIR provides a comprehensive, multi-tiered framework that includes five key areas that affect how well something is implemented: the intervention's characteristics, the outer setting, the inner setting, the characteristics of the people involved,

4 and the implementation process. This framework is especially useful for looking at how telemedicine is adopted because it takes into account that successful implementation depends not only on how well the intervention works or how technically advanced it is, but also on how different factors, such as the organization, the people involved, the implementation strategies, and the outside environment, interact with each other. .

Theoretical Alignment Table

Practice-based Problem Constructs Theoretical Framework Elements

Patient Engagement and Digital Health

Literacy Deficits

Outer Setting (Patient Needs & Resources): CFIR acknowledges the role of needs, preferences, and resource limitation knowledge among external stakeholders, patients with low digital health literacy and technology access barriers in implementing success.

Patient Engagement and Digital Health

Literacy Deficits

Intervention Characteristics (Complexity and Adaptability): CFIR insists that interventions should be flexible so that they can accommodate a wide range of user needs and make them seem less complex so that they could be adopted by a wider range of populations with different levels of technological competence.

Provider Adoption and the Workflow Integration Barriers

The CFIR inner setting domain has an examination of such issues as organizational culture, leadership interaction, availability of resources, and staff capacity. All these may result in provider resistance, in-efficiency in workflow, and bad incentive structure.

Provider Adoption and Workflow Integration Barriers

Individual characteristics (knowledge, beliefs, and self-efficacy): CFIR does not ignore the role of such beliefs of interventions provided by the provider as his/her sense of effectiveness, his/her confidence in the use of new technologies, and his/her sense of the relative advantage in implementation..

5

References

Bouabida, K., Lebouché, B., & Pomey, M.-P. (2022). Telehealth and COVID-19 Pandemic: An

Overview of the Telehealth Use, Advantages, Challenges, and Opportunities during

COVID-19 Pandemic. Healthcare, 10(11), 2293.

https://doi.org/10.3390/healthcare10112293

Haleem, A., Javaid, M., Singh, R., & Suman, R. (2021). Telemedicine for healthcare:

Capabilities, features, barriers, and Applications. Sensors International, 2(2), 100–117.

Jaffe, D. H., Lee, L., Huynh, S., & Haskell, T. P. (2020). Health Inequalities in the Use of

Telehealth in the United States in the Lens of COVID-19. Population Health

Management, 23(5), 368–377. https://doi.org/10.1089/pop.2020.0186

Olawade, A. C. D., Olawade, D. B., Ojo, I. O., Famujimi, M. E., Olawumi, T. T., & Esan, D. T.

(2024). Nursing in the Digital Age: Harnessing telemedicine for enhanced patient care.

Informatics and Health, 1(2), 100–110. https://doi.org/10.1016/j.infoh.2024.07.003

Appendix A: DHA Practice-Based Problem Literature Review Matrix Appendix A: DHA Practice-Based Problem Literature Review Matrix Operational Problem Source #1 Author/Date: Jaffe, D. H., Lee, L., Huynh, S., & Haskell, T. P. (2020). Theoretical Framework Implicitly based on models of healthcare access and utilization, focusing upon demographic and geographic hindrances. Research question/hypotheses: What patient demographics (age, region, urban/ rural, mental health status) are predictors regarding the use of telehealth in relation to face-to- face care? Methodology: A retrospective cohort study based on combined claims and survey data. Multivariate logistic regression was the primary method of analyzing the data. Findings and discussion: Discovered that some demographic variables were less predictive of the use of telehealth: adults (45 and older) (OR 0.684) and rural populations (urban vs. rural) (OR 1.543). This quantifies this issue of the problem of inequality of access in operation. In summary: The rapid shift to telehealth due to COVID-19 has exacerbated already existing disparities in access, leaving an operation-level problem in which some groups of patients continue to be underserved by new virtual care models. Future studies need to examine the factors behind these differences, such as digital literacy, trust in technology as well as platform design. Practical implications: The organizations should be eager to recognize vulnerable groups and develop support systems (e.g., technical assistance, low-tech options) to facilitate the digital divide and provide equitable service delivery. Yes, empirical research

Appendix A: DHA Practice-Based Problem Literature Review Matrix Operational Problem Source #2. Author/Date: Olawade, A. C. D., Olawade, D. B., Ojo, I. O., Famujimi, M. E., Olawumi, T. T., and Esan, D. T. (2024). Theoretical Framework: A narrative review which integrates evidence but without a single theoretical framework which unites the review; rather, it is concerned with practice and issues of ethics. Research question/hypotheses: How, why and what are the challenges, issues and significance of telemedicine in the present day nursing practice, including ethical issues? Methodology: An in-depth narrative review of primary research, systematic reviews, and policy documents (2010-2023) identified in databases, including PubMed and CINAHL. Findings and discussion: The analysis allowed identifying key themes: telemedicine improves triage and monitoring and poses significant operational challenges. This consists of alterations in work processes, necessity of training nurses and critical ethical and legal concerns concerning patient privacy, data security, and informed consent within a digital

Appendix A: DHA Practice-Based Problem Literature Review Matrix environment. Conclusion: Telemedicine is a revolution in nursing, yet the integration introduces new operational issues revolving around workplace workflow adjustments, ensuring clinician competence, and creating high ethical and information security standards. The next study must look into the development and the experimentation of particular frameworks in training, workflow integration and ethical principles specially tailored towards nursing telepractice. To achieve this, healthcare organizations should invest in nurse training, modify how they practice within the clinic and include telehealth in their practice process, and lobby legislators to establish explicit legal and ethical principles of telemedicine use. Empirical Research: No (It is a narrative review)

Appendix A: DHA Practice-Based Problem Literature Review Matrix Operational Problem.

Source #3 Bouabida, K., Lebouche, B., and Pomey, M. (2022). Theoretical Framework: An article which provides a summary of the various perspectives; it does not adhere to a particular theoretical framework but discusses issues of systems and user adoption. Research question(s)/hypotheses: How do the advantages, challenges, and opportunities of telehealth use in the COVID-19 pandemic look? Methodology: The methodology was based on a reflexive overview and discourse with the help of the analysis of the bibliographic sources in databases including PubMed and Google Scholar. Not a systematic review. Findings and discussion: The absence of human contact which decreases the quality of care, concerns related to privacy and data security, and the insufficiency of access and training on the patients and providers are identified as the key issues that contribute to the reduced efficacy of telehealth. Also demonstrates varying access levels of the various social and economic groups. Conclusion: Telehealth is an excellent and affordable type of care access, but it suffers numerous issues with care providers, data privacy, and equitable access that should be resolved before it can achieve its full potential. Future research implications: The present research raises further studies on the clinical, organizational, socio-economic, and ethical implications of telehealth in the short and long term. Practical implications: Health systems must address concerns of patients and providers with regard to their interactions with one another and the safety of their information. They must also enhance training and set regulations to ensure that all people have access to telehealth services.

Appendix A: DHA Practice-Based Problem Literature Review Matrix No concrete studies (It's a summary of the viewpoint/article)

Appendix A: DHA Practice-Based Problem Literature Review Matrix. Ideal State of Operations is a source.

Haleem, A., Javaid, M., Singh, R. P. and Suman, R. (2021). Theoretical Framework: A descriptive review of telemedicine capabilities, without reference to a specific theoretical framework. Research question(s)/hypotheses: What are the abilities, applications, constraints, and uses of telemedicine in healthcare? Methodology: Descriptive literature overview and combination of telemedicine applications and applications. Analysis and findings: The present paper discusses the most appropriate telemedicine system that must include all of the following features the chronic disease management, remote patient monitoring, e-prescriptions, convenient scheduling, the protection of the data, and the application of the latest technologies, such as AI and IoT. It emphasizes on a patient-centered, efficient, and user-friendly workflow. Conclusion: It can improve the situation of all persons by making hospital work more effective, efficient, and making it easier to allow people to receive care through Telemedicine. This is the most appropriate form of providing healthcare through technology. The further investigation of the topic should attempt to elaborate on the further evolution and implementation of more advanced technologies (AI, IoT, VR) into telemedicine platforms to expand their capabilities. Healthcare organizations must endeavor to adopt holistic telemedicine solutions, in terms of scheduling, EHR integration, remote monitoring, and secure communication so that they achieve a desirable and very efficient state of operation. Empirical Research: No (It is descriptive review)