Advanced Clinical Practice Fellowships

Applying Nursing Best Practices of Telepractice to Live Chat at Niagara Region Public Health


In order to increase accessibility for clients seeking the support of a public health nurse online, Niagara Region Public Health’s (NRPH) Reproductive/ Child Health department began piloting the use of live chat software in late 2019. Prior to this, clients could connect with a nurse solely through telephone or attending community-based clinics. By expanding nurse telepractice to include live chat, public health nurses were tasked with transforming their relationship building and assessment skills into digital nursing skills.

With the arrival of COVID-19 pandemic, just a few months later, live chat service expanded to support the COVID-19 Call Centre within the Pandemic Response Division, addressing the increased client need for access to nurses with COVID-19 related inquiries. Public health nurses each began fielding 20+ live chat conversations a day, and live chat accounted for 25% of incoming communication to the Pandemic Response Division. Due to the brief time between the live chat pilot and the expansion of live chat services, organizational supports could not be fully established. Nurse feedback provided in the early stages of live chat adoption offered important insights on the increased need for supports to improve user confidence in live chat telepractice. This feedback also highlighted the need for additional supporting guidance documents for the public health nurses providing live chat.

The RNAO Advanced Clinical Practice Fellowship project focused on the creation of a best practice guidance document for public health nurses using live chat for client services. The fellowship began with an environmental scan of external organizations’ use of live chat/ instant messaging and their associated practices and policies. Next, a cross-section of Niagara Region’s live chat trained staff were surveyed to gain further understanding about their confidence in telepractice and preferred types of professional support. A review of current literature and the College of Nurses of Ontario’s Telepractice Guideline provided the framework for a live chat best practice guideline to support public health staff. Lastly, based on the aforementioned steps, recommendations were made to enhance sustainability and support the growth of telepractice at Niagara Region Public Health.

Overall Learning Goal
Throughout the fellowship, collaboration was key and allowed partnerships to form between disciplines, departments and organizations. The overall learning goal of this fellowship was to increase knowledge and experience in the guideline development process. This fellow planned to solidify knowledge in providing educational supports to nursing/ clinical staff specific to live chat telepractice. These goals were accomplished through various learning objectives.

The first objective was to complete an environmental scan of external organizations and Niagara Region nurses using live chat/ instant messaging for client services. This scan included a survey that summarized their live chat use, confidence levels, learning needs and gaps and strengths present within the available organizational supports. By connecting with other organizations and key internal stakeholders, this fellow gained leadership skills and relationship building skills. This fellow gained knowledge of how to create effective surveys through working alongside the data analyst and discussing desired outcomes. After the completion of the survey, data was analyzed and themes were drawn from the responses. The learning here was two-fold as this fellow gained insight into staff learning needs and experiences while learning valuable skills in the design, administration and analysis of a survey.

Next, this fellow conducted a literature review, which provided further context to the digital landscape of nursing and virtual care. Working with the knowledge translation advisor, this fellow learned and applied a methodology for the critical appraisal of literature and the steps to create a guideline. Conducting the literature review, provided knowledge on current virtual care trends, recommended training methods for staff and best digital practices. Through attending the Family Health policy and procedure working group, this fellow learned the processes involved in policy, procedure and guideline creation. This fellow solidified this learning by writing the live chat best practice guidance document, with accompanying recommendations for digital client services. Through discussions and meetings about my findings, this fellow developed further leadership and advocacy skills as a voice for nursing telepractice.


Patient/ Client Population Outcomes
The target population for this fellowship was public health nurses who use live chat for client services at Niagara Region Public Health (NRPH). The goal was to create supportive resources such as a best practice guidance document based on the feedback gathered from the staff survey, and incorporating findings from the environmental scan and literature review. Organizational and practice changes made as a result of the knowledge gained during this fellowship and the resources created will improve overall nurse confidence and their access to live chat telepractice support resources. Since the completion of the best practice guidance document, the live chat service has continued to expand as more nurses are trained. The most recently trained live chat nurses have expressed that having a written guidance document helps them to feel more supported and confident in their telepractice.

The desired result over time was to improve both staff satisfaction with their ability to support clients and to ensure consistent, welcoming and effective online experiences for clients. Both clinicians and clients alike benefit from increased staff competence in digital health technologies. The fellowship highlighted a need for increased client feedback on NRPH’s online services in order to establish client needs and wants. The need for increased client feedback was addressed by activating a post-chat survey. This survey appears at the conclusion of a live chat encounter, and provides an opportunity for client perspectives to be noted and reviewed. Client feedback helps in the continuous quality improvement of Niagara Region’s digital services. Increasing opportunity for clients to report on their positive experiences and concerns will likely result in creating stronger client relationships with public health, as they will be given a voice.

Outcomes for Colleagues, Organization and Stakeholders
Public health nurses at Niagara Region were the main stakeholder group for this live chat best practice fellowship work. Staff were engaged throughout the process of writing the live chat guidance document by providing feedback, reviewing documents and engaging in conversations around their learning needs and previous experiences. These consultations provided staff the opportunity to be heard as valued subject matter experts in live chat telepractice. It also provided them with the opportunity to examine their own telepractice and engage in reflection. The feedback received from the staff survey highlighted themes and insightful quotes, which demonstrated the value of staff feedback. Nurses have gained organizational support as a result of this fellowship which will help their continued progress into virtual care.

Niagara Region Public Health has benefitted from the creation of supporting documents to complement the existing policies and procedures. Having staff that are knowledgeable and confident on online best practices will continue to benefit the organization as Best Practice Spotlight Organization. The connections made with external organizations through the survey helped to increase knowledge of the live chat landscape within Ontario. As resources and knowledge were shared NRPH established camaraderie with other groups pushing forward in digital engagement technologies. Plans are in place for establishing an external community of practice for live chat, which will help to continue discussions and reduce siloes in virtual care understanding.

Since the completion of the fellowship, clients have provided feedback on their live chat interactions using the post-chat survey. They frequently express satisfaction with the quality of service they have received. Clients will continue to experience consistent, effective and engaging online interactions with public health nurses because of their usage of the live chat guidance document. As staff gain confidence in their telepractice, clients will continue to have access to exceptional online nursing care.

Overall experience

Working through the fellowship process from learning plan to the completion of the fellowship goals has been empowering. There have been triumphs and challenges along the way that have contributed to this fellow’s personal and professional development.

Collaborating with other disciplines has been a positive experience that reaffirmed how nurses can continue to advance through working alongside other professions. The fellowship was a special opportunity to focus on a project that piqued this fellow’s interest, expanded this fellow’s skill set and filled a need within the organization. Having the opportunity to devote time to such a project has ignited a drive to further this fellow’s learning, support others in their learning, and to explore other facets of virtual nursing care.

Hearing about the experiences of other nurses in the monthly fellowship meetings was beneficial. Fellows were able to share and hear about the amazing work taking place amongst the other fellows, as well as the challenges and lessons learned. This provided a sense of cohesion amongst the fellows, and showed that nursing continues to evolve and excel regardless of nursing specialty. Examining digital health practices has highlighted the fact that nursing skills can be adapted to all environments and nurses can continue to reinvent ways of being, doing and knowing in nursing.

A favourite moment in the fellowship process occurred while reaching out to other organizations to inquire about their digital health practices. It was uplifting to receive responses from so many organizations who were also leaping into the use of online client services. Many expressed interest in continuing a relationship and developing a community of practice for the future. This was particularly exciting, as it provides potential to reduce silos between organizations exploring the digital realm. Knowing that Niagara Region’s digital engagement team is among the early adopters who can help to support other organizations in their digital transformation is an exciting realization. This fellow is hopeful that Niagara Region Public Health can help others continue to expand the boundaries of nursing in a way that is supportive of both nurses and clients as a result of this fellowship.