Potential utilization of nursing teleconsultation in improving traumatic brain injury patient’s quality of life in West Java, Indonesia


Ganefianty, A. & Sukihananto  (July, 2018). Potential utilization of nursing teleconsultation in improving traumatic brain injury patient’s quality of life in West Java, Indonesia. Online Journal of Nursing Informatics (OJNI), 22(2), Available at http://www.himss.org/ojni


Traumatic brain injury (TBI) is a crucial public health problem that causes disability, and social and economic problems world wide. TBI patients in West Java are increasing every year which poses various problems in quality of life. Most patients receive follow-up and rehabilitation after hospitalization, but some cannot attend due to cost and transportation difficulties since they are scattered  in various areas across the island. Nursing teleconsultation is the provision of nursing services that can be administered to patients electronically in remote areas. In practice, nursing teleconsultation must be supported by qualified nursing knowledge, supportive communication technologies, and strategies to protect patient confidentiality, system and information security. Innovations in  nursing teleconsultation can potentially be applied in West Java to provide continuous nursing service to TBI patients without being constrained by the problems associated with distance and cost.


Traumatic brain injury (TBI) is a crucial public health problem that causes disability, and social and economic problems world wide (Roozenbeek, Maas, & Menon, 2013). Approximately 10,000 people develop TBIs each year which are the most common cause of health disability in people less than 40 years  old (Soberg et al, 2013). Indonesia has a population of about 250,000 people, of which almost a quarter live in West Java, an area of 35,377 km2 (Wikipedia 2014). In this densely populated region, with growing economic growth, the number of people using cars and motorcycles has increased rapidly in recent years which has contributed to an increase in road traffic injuries.

Rumah Sakit Dokter Hasan Sadikin Bandung (RSHS) Medical Records for  2014-2015 showed that patients admitted with accident incidence causing TBI increased by 14.5% and the mortality rate rose by 30%. The results of interviews with one of the neurosurgeons at RSHS stated that patients with major TBI were discharged home within one to two weeks of surgery. However, due to remoteness and transportation difficulties, follow-up and patient rehabilitation processes are challenging and encounter difficulties to access services. Currently, there is no structural support that provides information and ongoing care for trauma patients in West Java. TBI patients are usually referred from a local hospital in West Java to RSHS due to inadequate facilities and health personnel in the smaller institutions.

Patients with TBI experience impaired cognitive functioning, including attention disturbances, mind processes, memory, and other cognitive functions that can cause problems in the patient's quality of life (Gordon et al, 2016). The results of a study conducted by McAllister et al (2017) at RSHS showed that there was a large proportion of patients experiencing problems with the five dimensions of quality of life outlined by Euroqol: physical mobility, self-care, usual activity, pain, and anxiety, as well as intellectual function when patients are discharged from the hospital. The effects range from mild, moderate and severe problems. When a nurse's follow-up was done by telephone in the first month after the patient was treated, half of the respondents said they were still having impaired physical mobility, daily needs, or cognitive impairments such as memory and thought processes that greatly affected everyday life. Some patients also said it was difficult to conduct routine checks with RSHS because of the distance and access that is quite far (often a 8-12 hour drive).

Due to the considerable distance and the transportation difficulties to get to RSHS, patient follow-up and rehabilitation process often becomes a challenge for both patients and health professionals. Patients find it difficult to visit health care facilities regularly due to financial problems, transportation, or lack of mobilization. As a result, health professionals often lose information about the patient's condition after returning home from the hospital. Conversely, patients who are still experiencing problems in various dimensions of quality of life also have difficulty in consulting with health workers. In fact, the process of rehabilitation and health problems that are still experienced by patients after their return home from the hospital remain the responsibility of health professionals, including nurses.

With the various barriers that exist in the follow-up and rehabilitation of TBI patients, a service in line with technological development could provide a solution to TBI patients. One such solution is a model for long distance nursing service, better known as telenursing. Telenursing is the use of telecommunications and information technology to provide nursing services remotely (Kumar, 2016). Nursing teleconsultation is one of the easiest and affordable methods of telenursing to assist in the follow-up and rehabilitation of patients after returning home from the hospital (Robin, Xavier, & Agrawal, 2016). The purpose of this paper is to analyze the potential utilization of nursing teleconsultation to improve the quality of life of TBI patients in West Java, Indonesia.

Literature review

The articles used in this literature review were obtained from EBSCOHost, Google Scholar, Wiley, and Proquest using the terms "telenursing", "nursing teleconsultation", "traumatic brain injury", "TBI's quality of life" and "TBI in West Java ". These terminologies were used in combination so that the literature results were more specific.

Traumatic brain injury (TBI) is defined as non-degenerative and noncongenital abnormalities that occur in the brain, as a result of external mechanical forces, which are at risk of causing temporary or permanent disturbance in cognitive, physical, and psychosocial function, accompanied by a decreased or loss of awareness (Satyanegara, 2010). Because TBI causes interference with some functions in a person's body, it will have an impact on the person’s quality of life. Good quality of life is optimal achievement in the mobility, self-care, usual activities, pain / discomfort & anxiety / depression dimensions (Brooks 1996; The EuroQol Group 1990). In other words, the quality of life of TBI patients will return to optimal levels if there are no problems in these dimensions.

Telenursing is the use of telecommunications and information technology to provide nursing services remotely, including the provision of nursing care using a camera or computer technology (Kumar, 2016). Telenursing also uses technology for home patient care with, for example, immobilized patients, patients living in hard-to-reach areas, or patients with chronic illness. Telenursing may provide patient education, nursing teleconsultation, physical examination or medical examination results at a distance.

Telenursing is increasingly being used around the world because of the many advantages gained by patients isolated from necessary health services. One type of telenursing that nurses can utilize is nursing teleconsultation, an electronic communication that provides healthcare consulting services in hard-to-reach areas (Kumar, 2016). Deldar, Bahaadinbeigy & Tara (2016) concurred that nursing teleconsultation is defined as a consultation using communication and information technology to eliminate geographical and distance problems.

Teleconsultation is now widely used in health care areas because of these benefits. For patients, teleconsultation facilitates access to health care, especially for people living in rural / remote areas or those with disabilities, since teleconsultation can save time and transportation costs as they can access services directly from home. For healthcare providers, teleconsultation may provide an opportunity to extend their ongoing care and knowledge beyond hospital walls (Aggarwal, Ploderer, & Veter, 2015).

Nurses work closely with patients, as individuals, families, and communities in both healthy and sick situations to provide holistic care for the whole person. Nurses are often responsible for the patient's condition both when the patient is in hospital care and after the patient is at home, in order to achieve optimal patient life quality. Nursing teleconsultation can support continuous nursing care without being impeded by the problem of distance or access difficulties.


Research on teleconsultation is growing since teleconsultation can be done by various health professions, including nurses. Robin et al., (2016) conducted a study on the benefits of using nursing teleconsultation in remote areas. The study was done to evaluate the effectiveness of nursing teleconsultation using an integrated call center at a trauma center in New Delhi, India. Patients call the center where the phone is connected to the attending nurse informatics specialist (NIS) on shift. The NIS analyzes and verifies patient data based on the available electronic health record (EHR). If the patient's problems are related to home-care treatments such as tracheostomy or colostomy treatments, fever management, and so on, NIS provide necessary education over the telephone. If any problems that occurred required further consultation, the NIS would consult with the appropriate physician. The NIS also documented all teleconference records into the Computerized Patient Record System (CPRS). The results showed that the patients routinely contacted the call centers for problems related to orthopedics (41%), neurosurgery (31%), surgery (22%) and other departments (6%). The conclusion of this study was that nursing teleconsultation is a cost-effective way of delivering nursing care to traumatized patients in remote areas.

Santos, Alkmim, Antunes, Ferreira & Marcolino (2016) studied the use of nursing teleconsultation in Minas Gerais, Brazil. The Telehealth Network of Minas Gerais (TNMG) is a public telehealth service that has provided telediagnosis and teleconsultation services in 853 cities in Brazil by 2016. Home based patients can contact general practitioners, specialists and nurses and receive a response within 24 hours, while issues requiring consultation with other departments will be answered within 48 hours. There were 30,258 consultation requests with nurses from June 2007 to February 2014 consisting of general nursing consultation questions, wound care, childcare, emergency care, surgical care and elderly care. The results of this study indicated that nursing teleconsultation can be useful for patients especially for those with limited income living in remote areas.

These  two studies discussed successful utilization of nursing teleconsultation services with patients living in remote areas. According to Sutiono, Faried, McAllister,, Ganefianty,, Sarjono, Arifin, & Derrett (2017), TBI patients treated at RSHS are scattered in several areas in West Java, where geographical conditions include many mountainous areas, so that people have difficulty accessing transportation (Figure 1). The results showed that patients in general have a mobile phone so it is possible to do teleconsultation. In the first month after the patient returns home from the hospital, although the distance between the patient's home and RSHS is quite far away, most patients come back to the hospital for consultation with a neurosurgeon. But there are a small percentage of patients who cannot come to RSHS to consult because of cost and transportation difficulties. One of the patients said that he did not come to consult to RSHS in the first month after returning from hospital because he lives on the south coast of Sukabumi Regency, so it takes about 12 hours to drive to RSHS. To complicate the process, this patient was also experiencing problems with mobilization and had to depend on public transportation.

In the implementation, there are many challenges that nurses need to face to apply nursing teleconsultation, especially in West Java. Implementation of this method requires careful planning and supportive information technology systems. According to Deldar, et al (2016), the implementation of nursing teleconsultation should consider the level of education of nurses and patients. In answering consultation questions from the patient, the nurse must have high levels of knowledge and expertise to reduce miscommunication between patient and nurse, and to ensure directives given by the nurse are appropriate and useful. Niemi, Krappe & Hyrkkänen (2014) gave similar recommendations in their nursing teleconsultation research with foot ulcer patients in Finland: suitable education and expertise are important in nurses who do teleconsultation to ensure the quality of nursing services on an ongoing basis. Thus, nurses should have good knowledge and skills about communication systems and information technology, as well as nursing care of TBI patients.

The application of nursing teleconsultation also requires the support of advanced communication and information technology. Sorknæs and colleagues (2015) conducted research on teleconsultation in Denmark with results that showed that nursing teleconsultation can be done as long as a region has a good technology and communication system. Currently, a prototype for information system innovation has been developed in the neurosurgery section of RSHS, the Neurosurgery Reporting System (NeuroSyRS), a data processing system that provides patient data information, demographic data, medical history, patient conditions, or investigation which neurosurgeons can access via mobile phone (Faried, Arifin, Sutiono, & Yuniarto, 2016). This shows that preliminary utilization of information technology systems has begun at RSHS to care for TBI patients. So, it is possible that a nursing teleconsultation innovation can be applied in RSHS to provide the best and continuous nursing service without cost or access to transportation constraints for TBI patients.

Another aspect to consider when exploring the feasibility of a  nursing teleconsultation service for West Java includes legal and ethical considerations. In providing long-term nursing care it is necessary to have a general health policy (integrated) that regulates practice, outlines standard operating procedures, addresses ethics and professionalism, including security, patient confidentiality and protection of information provided. According to Luiselli and Fischer (2016), performing nursing services over the telephone, includes the maintenance of privacy and confidentiality of the patient especially for highly personal information that may be shared. In addition,  nurses must have a license to perform long-distance nursing care. This is in accordance with what is stipulated in the Regulation of the Minister of Health of the Republic of Indonesia Number 90 of 2015 that the development of health service patterns in remote and very remote health service facilities be carried out in the form of mobile health services, island cluster health services, and / or telemedicine-based health services provided by registered doctors, nurses, and midwives who are competent in their fields.

Conclusions and recommendations

Traumatic brain injury (TBI) is a critical public health problem that often causes disability, social and economic problems world wide. TBI patients in West Java are increasing every year causing various problems in the dimensions of quality of life. TBI patients treated at RSHS live in several areas across West Java but generally own a mobile phone. Most patients come back to the hospital for consultation with a neurosurgeon, but some patients find this prohibitive because of cost, long distances, and transportation difficulties.

Nursing teleconsultation is a viable alternative that could be made available to TBI patients living in remote areas across the island. Innovation nursing teleconsultation has good potential to be applied in RSHS so nurses can provide optimal continuous services for follow up and rehabilitation without the constraints of transportation, costs and access problems. This type of service could support TBI patients in West Java to improve care and patient quality of life.

In the process of implementation, nurses must have sound knowledge and skills related to communication systems and information technology, as well as nursing care of TBI patients. Nursing teleconsultation also requires the support of advanced communication and information technology systems, with attention paid to aspects of ethics, professionalism, security, patient confidentiality and the provision of reliable information to patients.


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