RESEARCH
The Effect of Telenursing on Referral Rates of
Patients With Head Trauma and Their Family’s
Satisfaction After Discharge
Akram Shahrokhi, MSc ■ Jalil Azimian, PhD ■ Atousa Amouzegar, MSc ■ Sonia Oveisi, PhD
ABSTRACT
We aimed to assess the effect of telenursing on referral rates
of patients with head trauma and their family’s satisfaction
after discharge. Seventy-two patients with head trauma were
randomly allocated to equal intervention and control groups.
The caregivers in both groups were provided with 1-hr
face-to-face training on patients’ home care and educational
booklets, 2 days before discharge. The cell phone
numbers of the telenurse was given to the caregivers of the
intervention group. Then, the patients in the intervention
group were followed up every week through phone calls by
the telenurse for 12 weeks and the patient status checklists
were completed. Caregivers in the intervention group could
call the telenurse any time they desired. The health status of
the control group was followed once by a phone call after 12
weeks. Data were analyzed using SPSS software, version 19.
E
ach year, about 1.7 million head traumas occur in
the United States, leading to nearly 52,000 deaths
and 275,000 hospitalizations (Hinkle & Cheever,
2014), about 1.1 million of whom are treated and
discharged from hospital (Brunner, Smeltzer, Bare,
Hinkle, & Cheever, 2010), and a considerable number
(80,000–90,000) suffer from long-term disability (Hinkle
& Cheever, 2014). During 2012–2013, 55,427 individu-
als were referred to three main trauma centers in Tehran
because of head trauma, who were mainly (74%) men
and the main causes of trauma included road accidents,
falls, and beatings (Aligholi & Safahani, 2015). Head
trauma is a major reason of referral to trauma centers in
Iran; 18.9% of admissions in three great teaching hospitals
in Tehran, capital of Iran, had occurred because of head
Author Affiliations: Department of Critical Care Nursing (Mss Shahrokhi
and Amouzegar), Nursing & Midwifery Faculty (Dr Azimian), and School
of Nursing and Midwifery (Dr Oveisi), Qazvin University of Medical
Sciences, Qazvin, Iran.
The authors declare no conflicts of interest.
Correspondence: Atousa Amouzegar, MSc, Critical Care Nursing
Department, Nursing & Midwifery School, Qazvin University of Medical
Sciences, Qazvin, Iran (atousa.amouzgar@gmail.com).
DOI: 10.1097/JTN.0000000000000382
248 WWW.JOURNALOFTRAUMANURSING.COM
Copyright © 2018 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited.
Ultimately, 33 patients with a mean ± SD age of 31.12 ±
10.83 years were studied in the control group and
35 patients with a mean ± SD age of 34.11 ± 12.34 years
were studied in the intervention group (p = .098). The 2
groups differed significantly with respect to referral rates;
39.4% of the participants in the control group referred
to physicians whereas only 25.7% of the patients in the
intervention group needed to refer to physicians (p =
.017). Also, the mean times of referring to a physician
differed significantly in both groups. In general, 53.8% of
the caregivers were satisfied with the telenursing program.
Follow-up programs using telephone calls were effective and
would lead to higher caregiver satisfaction.
Key Words
Caregivers, Head trauma, Outcome assessment, Patient
care, Telenursing
trauma (Ghodsi, Moez Ardalan, & Daroughehdar, 2002).
Incidence rate of head trauma in the central region of Iran
was 429 per 100,000 population, so 4,290 patients with
head trauma had been admitted to Kashan hospitals dur-
ing a 2-year period (Fazel et al., 2008).
Head trauma can lead to several complications, rang-
ing from mild concussions to coma and death (Hinkle &
Cheever, 2014). Traumatic brain injury is the leading cause
of death and disability worldwide and imposes a great bur-
den on the health care system (Langlois, Rutland-Brown,
& Wald, 2006; Vafaee et al., 2013). The most common
complications after head trauma and brain injury include
coma, urinary and respiratory tract infections, septicemia,
wound injury, meningitis, and brain abscess (Białkowska,
Sowa, & Maksymowicz, 2012; Hinkle & Cheever, 2014).
Many head trauma survivors live with major disabilities,
including physical, cognitive, mental, emotional, and be-
havioral defects (Haffejee, Ntsiea, & Mudzi, 2013; Vafaee
et al., 2013). Considering the complications mentioned,
the possibility of readmission increases in patients with
traumatic brain injury. Therefore, follow-up is a major
part of health care services to establish a consistent and
dynamic health care relationship with patients to increase
their knowledge and improve the function of patients
and their families (Behzad, Bastani, & Haghani, 2016;
Volume 25 | Number 4 | July-August 2018
Zakerimoghadam, Bassampour, Rjab, Faghihzadeh, &
Nesari, 2009).
The family, as the main social unit, plays a key role
in the patients’ sense of well-being and their ability to
adapt to different conditions. Moreover, lack of knowl-
edge about the treatment process could create anxiety in
families (Imani, Dabirian, Safavibiat, & Payandeh, 2015).
Since caring for patients with head trauma could lead to
changes in family roles, weak social adaptation, social
isolation, anguish and sorrow, anxiety, depression, and
financial problems in the family, such families experience
lower quality of life and need to be supported (Arango-
Lasprilla et al., 2011; Brunner et al., 2010; Chiou, Chang,
Chen, & Wang, 2009; Hinkle & Cheever, 2014). Consider-
ing that one of the main reasons for treatment program
failure and undesirable reaction to the prescribed treat-
ment is the weak or partial adherence to the treatment
program, and that follow-up after discharge could pre-
vent lack of adherence, telenursing could be an effec-
tive method for communicating with patients and their
caregivers (Kamrani et al., 2016).
Telenursing can be an effective method for communica-
tion with patients and their care providers for information
exchange, education, and health-related knowledge by
health care personnel (or nurses, etc.…; Kamrani et al.,
2016). Telenursing is also applicable for home care providers
(Maserat, Samadi, Mehrnush, Mohamad, & Zali, 2011).
Among the technologies used in telenursing, the telephone
is frequently used, as it is more accessible (Rahnavard,
Bastani, & Rajabi, 2013). By phone, families can find the
answers to many of their questions (Imani et al., 2015).
Considering that phone follow-ups and distant training
to patients by nurses have not been investigated in Iran,
the present study aimed to assess the effect of telenurs-
ing on the referral rate of patients with head trauma and
their family’s satisfaction after discharge. The results of
this study could be used to improve health care programs
in the country.
PATIENTS AND METHODS
This randomized controlled trial investigated 72 patients
with head trauma, who were admitted to eight hospitals
in Tehran, Iran. The Ethics Committee of Ghazvin Uni-
versity of Medical Sciences approved the study (Code:
D/20/9376), and the trial was registered at the Iranian reg-
istry of Clinical Trials (IRCT1N2014110919868). The study
population consisted of patients with head trauma and
the person or people taking care of them at home. Writ-
ten informed consent was obtained from the participants
after informing them about the aims and methods of the
study. The sample size was calculated to be 56 patients
considering a power of 80%. Therefore, considering a
dropout rate of 20%, 72 patients were recruited (36 in
each group).
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Sampling was based on the convenient sampling
method, according to the inclusion and exclusion criteria
and the recruited participants were randomly allocated
to intervention and control groups, 36 patients in each
group, using block randomization. Patients or caregivers
who used services provided by nursing consultation cent-
ers at home or did not answer the phone calls of the tel-
enurse for three consecutive weeks were excluded from
the study (n = 4, three in the control group and one in
intervention group; Figure 1).
The inclusion criteria consisted of patients who were
18–60 years of age, with a Glasgow Coma Scale score
of 11–15, admitted to the hospital for the first time after
trauma, without known urinary or respiratory infections,
infected or had Grade 3 and 4 pressure ulcers and diabe-
tes mellitus, and had undergone thoracostomy and per-
cutaneous endoscopic gastrostomy. The inclusion criteria
for caregivers consisted of being literate, spending at least
12 hr caring for the patients, having access to phone (cell
phone or telephone), no auditory or speech disorders,
not working in the health sector, and willingness to par-
ticipate in the study.
Data were collected through a patient status checklist,
including demographic characteristics of the patients and
the caregivers, the patient’s condition upon discharge,
during and at the end of intervention, and the outcome of
care (readmission, occurrence of pressure ulcer, duration
of pressure ulcer healing in case of having pressure ulcer
at discharge, and the time of readmission after discharge).
The content validity of the checklist was approved by the
expert opinion of 10 faculty members of the Department
of Nursing of Ghazvin University of Medical Sciences, and
internal consistency was confirmed by a Cronbach α of
0.82. Norton’s scale was used to determine the risk of
pressure ulcer formation.
The content validity of the caregivers’ satisfaction
measurement tool was also approved by the expert opin-
ion of 10 faculty members of the Department of Nursing
of Ghazvin University of Medical Sciences.
Phone calls were made using cell phones or landlines.
For both groups, 2 days before discharge, the patients’
caregivers (one or two of the closest people who cared for
the patients) were trained face-to-face (60-min session) on
how to care for the patients at home during one session
and then they received a booklet with the same content.
The cell phone number of the telenurse was given to the
caregivers of the intervention group. During a period of 12
weeks after discharge, the telenurse contacted the caregiv-
ers of intervention group weekly by phone calls and the
patient status checklists (Figure 2) were completed. More-
over, caregivers in the intervention group could call the
telenurse any time they desired (Table 1). For the control
group, necessary instructions were given before discharge
(similar to the intervention group) and one phone call
WWW.JOURNALOFTRAUMANURSING.COM 249
Figure 1. Flow diagram for study enrollment.
was made to ask the patients’ status after 12 weeks and
they did not get any contact from telenurse before 12th
week of intervention for study group.
None of the patients in both groups had Foley and
external catheters at discharge and they were not used by
any patient during the 12 weeks of study.
Data were analyzed using SPSS software, version 19.
Chi-square, Mann–Whitney, and independent t tests were
used as appropriate. A p value of less than .05 was con-
sidered as statistically significant.
RESULTS
Thirty-three patients with a mean ± SD age of 31.12
± 10.83 years were studied in the control group, and
35 patients with a mean ± SD age of 34.11 ± 12.34 years
were studied in the intervention group (p = .098). Of the
68 studied patients, 50 were men and 18 were women.
With respect to referral rates, 39.4% of the participants
in the control group referred to physicians whereas only
25.7% of the patients in the intervention group needed
to refer to physicians (p = .017, χ2 test). The mean ± SD
number of referrals were 1.33 ± 2.07 and 0.28 ± 0.51 in
the control and intervention groups (p = .005, independ-
ent t test).
The most common reason for referral to physicians in
both groups was headache and vertigo and no significant
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difference was found between the two groups in this re-
gard (p = .392). The most frequent order was readmis-
sion (38.4%) in the control group and magnetic resonance
imaging (22.2%) in the intervention group (p = .222, χ2
test). In control group, 38.47% of those who had referred
to a physician had readmitted, but despite no readmis-
sion in study group, there was no statistically significant
difference between two groups (p = .139). But clinically,
6.1% readmissions in the control group are notable in
the present study, which shows high rate of readmission
after head injury. The main causes of readmission in the
present study included hydrocephaly, headache, nausea,
and rhinorrhea, which were unpreventable, as they are
common complications associated with head trauma.
Moreover, in 25.7% of cases, the caregivers contacted
the nurse, and the most frequent reason for calling the
nurse was headache and vertigo, comprising 33.3% of the
phone calls.
With respect to satisfaction with the telenursing pro-
gram, we found that 46.1% of the caregivers emphasized
on the necessity of follow-up by the hospital, and 57.7%
of the caregivers emphasized on the existence of a refer-
ence source for calling to ask patient-related questions
and existence of a follow-up program for the patient.
In general, 53.8% of the caregivers were satisfied with
the telenursing program. The positive characteristics of
Volume 25 | Number 4 | July-August 2018
Figure 2. Questions related to weekly call.

this program, as stated by the caregivers, were as follows:
follow-up using phone calls, providing psychological sup-
port for the patients and their family, positive mental ef-
fect, providing required information, accessibility of an ex-
pert, and receiving needed information (42.3%; Figure 3).
DISCUSSION
We found that our telenursing program effectively reduced
referral to physicians as well as the number of referrals.
Moreover, it increased the satisfaction of caregivers
after discharge. Previous studies on patients with chronic
obstructive pulmonary disease (Caress, Luker, Chalmers,
& Salmon, 2009) and those who had underwent radi-
cal prostatectomy (Inman, Maxson, Johnson, Myers, &
Holland, 2011) have also shown the positive effects of
telenursing in reducing referral rates to emergency wards,
contact with the caregiving team, and even treatment
costs. However, in our study, we did not assess treatment

TABLE 1 Frequency Distribution According to the Cause of Caregiver’s Contact With the Nurse
in the Intervention Group
The Cause of Caregivers’ Contact With the Telenurse Frequency %
Headache and dizziness 3 33.34
Headache 1 11.11
Headache, dizziness, and hearing decrease 1 11.11
Dizziness, imbalance, and bathing 1 11.11
Secretion of the wound, removing suture, dressing change, and bathing 2 22.22
Nausea and vomiting 1 11.11
Total 9 100

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Figure 3. The viewpoints of caregivers.
costs, which is one of the limitations of the study, but
it is obvious that when referrals decrease, some of the
expenses are saved. Another previous study also showed
that telenursing reduced referral rates to medical centers
(Maserat et al., 2011).
We found that the caregivers were satisfied with the
telenursing program. This finding is consistent with two
previous related studies regarding the use of distant medi-
cal programs for supporting family members of patients
with traumatic brain injury and chronic obstructive pul-
monary disease. The researchers found that the partici-
pants evaluated distant learning positively and were satis-
fied with the program and believed that the nurses have a
protective effect in preventing and reducing readmission
and in turn the duration of admission (Rietdijk, Togher,
& Power, 2012; Sorknæs Madsen, Hallas, Jest, & Hansen-
Nord, 2011).
One other limitation of this study was the short du-
ration of the follow-up period. We suggest that further
studies be done using longer follow-up periods (at least
6–12 months).
CONCLUSION
Considering the nature of head trauma and its possible
complications, setting up a follow-up system in all trauma
centers and hospitals in Iran is necessary. Establishing a
comprehensive follow-up program using telephone calls
would be beneficial and affordable to reduce referral rates
and patient readmission, as well as to improve caregivers’
support and their higher satisfaction.
Treatment costs were not measured in this study, but
because telenursing had a statistically significant differ-
ence between the two groups on referral rate to the doc-
tor and the frequency of referral to the doctor, it can be
concluded that it has probably been effective in reducing
treatment costs. As in some studies, the effect of telenurs-
ing on cost reduction has been evaluated and its effect
has been statistically significant.
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Patient education and their caregivers have made them
more satisfied with telenursing services, and effective
communication with them, as well as the needs assess-
ment and follow-up program for the patients and their
caregivers improved accordingly the process. It seems
that establishing contact with the patients and their car-
egivers and assuring them of the availability of nurses can
improve their satisfaction. Nurse’s availability and com-
munication are two important aspects for patients and
caregivers that can increase their satisfaction.
Acknowledgments
This thesis is extracted from the master’s thesis conducted
in Ghazvin University of Medical Sciences. The authors
thank the patients and their families for their coopera-
tion during this study. They also thank the personnel of
the studied hospitals as well as the Faculty of Nursing of
Ghazvin University of Medical Sciences for their support.
KEY POINTS
• According to the results of this study, telenursing education
had an effective role in reducing the referral rates of patients
to health centers and physicians.
• The reduction of referral rates will reduce the treatment
costs such as doctor’s visit cost, transportation expenses,
and so on in return.
• Following patient’s status by their caregivers through
telenursing will not only improve the quality of care but also
have a positive effect on patients and caregivers emotionally
and spiritually because of the emotional support.
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