ORIGINAL ARTICLE

TELENURSING AS A CARE STRATEGY FOR CHILDREN WITH CONTINUOUS AND COMPLEX CARE NEEDS AFTER HOSPITAL DISCHARGE

Camila Lovato de Figueiredo1, Letícia do Nascimento2, Ana Carolina Cunha Almeida3, Júlia Gabriel Silva4, Caren Bertoldo Kaiser5, Eliane Tatsch Neves6

1 Universidade Federal de Santa Maria, Center for Health Sciences. Santa Maria, Rio Grande do Sul, Brazil. ORCID: 0009-0005-3384-5215. Email: camilalovato@yahoo.com.br

2 Universidade Federal de Santa Maria, Center for Health Sciences. Santa Maria, Rio Grande do Sul, Brazil. ORCID: 0000-0003-3806-1039. Email: let17eva@gmail.com

3 Universidade Federal de Santa Maria, Center for Health Sciences. Santa Maria, Rio Grande do Sul, Brazil. ORCID: 0000-0002-0105-4161. Email: anacarolinacunhalmeida@gmail.com

4 Universidade Federal de Santa Maria, Center for Health Sciences. Santa Maria, Rio Grande do Sul, Brazil. ORCID: 0009-0003-0235-1912. Email: juliagbriel@gmail.com

5 Universidade Federal de Santa Maria, Center for Health Sciences. Santa Maria, Rio Grande do Sul, Brazil. ORCID: 0000-0002-0199-134X. Email: carensbertoldo@gmail.com

6 Universidade Federal de Santa Maria, Center for Health Sciences. Santa Maria, Rio Grande do Sul, Brazil. ORCID: 0000-0002-1559-9533. Email: eliane.neves@ufsm.br

ABSTRACT

Objective: To explore the perceptions of nurses working in hospital pediatric settings and primary health care regarding the implementation of a telenursing service to follow children with continuous and complex care needs after discharge. Method: This is a qualitative study based on 18 semi-structured interviews with nurses from pediatric units of a university hospital and primary health care services in a city in Southern Brazil. Data were collected from March to June 2025 and analyzed using inductive thematic analysis. Results: Nurses viewed telenursing as a strategy that supports care for these children and noted the high prevalence of such cases in hospital settings. They reported structural and organizational barriers that hinder adherence, including workload burden, technological limitations, and families’ social vulnerability. Participants suggested establishing a municipal call center and implementing shared care across levels of the health system. Conclusion: Telenursing was considered feasible and innovative for caring for children with chronic and complex conditions; however, successful implementation requires investment in infrastructure and reorganization of the Health Care Network. The development of shared care models between hospital services and primary health care, strengthened counter-referral pathways, and clinical protocols is recommended to consolidate this model.

Descriptors: Telenursing; Child Health; Chronic Disease; Pediatric Nursing.

What is already known:

• Children with continuous and complex care needs often rely on life-supporting technologies, present high morbidity and mortality rates, and require home-based care.

   

• Telehealth is a promising tool to support continuity of care for children with chronic conditions.

   

• Studies exploring health professionals’ perspectives on telenursing organization within Brazil’s public sector remain scarce.

What this article adds:

• Hospital and primary care nurses recognize telenursing as a viable strategy to expand access and continuity of care for children with continuous and complex care needs after hospital discharge.

• It reveals specific structural and organizational barriers, such as workload burden, technological limitations, and families’ social vulnerability, that hinder implementation of telenursing in Brazil’s public health system.

• It indicates the need for shared care models between hospitals and primary care, supported by counter-referral pathways and clinical protocols, to strengthen the Health Care Network.

• It expands knowledge on telenursing in pediatric care in the Brazilian context, an incipient field, and contributes to public policies aimed at digital equity and reorganization of the Health Care Network.

INTRODUCTION

Advances in Brazilian public health policies, together with social, economic, and sanitary transformations, have driven a pediatric epidemiological transition characterized by a growing number of children living with chronic conditions(1). Among these children, classified as children with special health care needs (CSHCN), a subgroup consists of those with continuous and complex care needs(2).

These children present severe chronic illnesses or multiple health diagnoses, depend on life-supporting technologies, and face high morbidity, mortality, and hospitalization rates. They require continuous, specialized, and multiprofessional care(3). Although no official national epidemiological data exist on CSHCN in Brazil, a study conducted in three cities with children under 12 years old identified a prevalence of 25%(1).

Families of children with complex care needs experience substantial challenges after hospital discharge, which heightens the need for safe, humanized, and accessible care. This support must begin during hospitalization to ensure a high-quality transition and continuity of care within the Health Care Network (Rede de Atenção à Saúde, RAS)(4-5).

Care for children with complex care needs extends beyond the hospital setting and strongly involves the family, imposing financial, technological, and emotional demands on daily home life. In this context, telenursing emerges as a remote follow-up strategy that strengthens communication between professionals and families, reduces the need for travel, provides educational support, prevents avoidable readmissions, and promotes equitable access to health services(6). This approach aligns with sustainable development goals (SDGs) 3 (good health and well-being) and 11 (sustainable cities and communities).

A preliminary review of the literature revealed international studies on telenursing for adults and children. However, evidence from Brazil remains scarce regarding its applicability in caring for complex care needs, particularly with respect to service organization, the nursing role, and integration with the RAS(7). This gap highlights the need to understand how a telenursing service may support follow-up care for these children after discharge.

Telenursing is considered a promising strategy to support families and professionals during the care transition by enhancing comprehensiveness, accessibility, and patient safety, which remain insufficiently ensured in the Brazilian public health system.

Thus, we asked: How could a telenursing service contribute to continuity of home-based care for children with complex care needs, integrating hospital and primary health care within the RAS? This study aimed to explore the perceptions of nurses working in hospital pediatric care and primary health care regarding the implementation of a telenursing service to support children with complex care needs after hospital discharge.

METHOD

This qualitative study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ).

The study was conducted in a university hospital in Southern Brazil, including the department of pediatric emergency, pediatric inpatient unit, pediatric outpatient clinic, and the pediatric intensive care unit (PICU) as well as primary health care (PHC) services in the same city.

Participants were nurses working in the study settings for at least 1 year. Nurses who were on vacation or on any type of leave during data collection were excluded.

Purposeful sampling was used, complemented by snowball recruitment, in which enrolled participants referred other eligible colleagues. Data collection was conducted both in person and online to ensure feasibility and broader participation.

The study included 18 nurses: seven from the PICU, two from the department of pediatric emergency, one from the pediatric inpatient unit, and eight from PHC services. Data collection ended when thematic saturation was reached, that is, when no new information emerged and theoretical density was considered sufficient to meet the study objective(8). Nine nurses declined participation, including those from the pediatric outpatient clinic, who reported limited contact with the target population.

Semi-structured interviews were conducted face to face or remotely via Google Meet between March and June 2025 by four undergraduate researchers. The interview guide was developed by the researchers, piloted with five nurses, and refined based on their feedback. The team was already familiar with the hospital and some PHC services from previous practical training experiences and revisited these sites to present the study and invite participation.

Interviews were conducted in private rooms in the health services or remotely, audio recorded, and lasted an average of 11 minutes. Field notes were written immediately after each interview, and no repeat interviews were performed.

Interviews were transcribed verbatim and analyzed using Braun and Clarke’s inductive thematic analysis approach(8). No software was used to manage the data. Transcripts were not returned to participants because information was confirmed during the interviews. Data were organized into three thematic categories: nursing care for children with continuous and complex care needs; implications of telenursing for these children and their families; and feasibility and limitations of implementing telenursing in this context.

This study was approved by the Research Ethics Committee (opinion no. 6.043.036; CAAE no. 68554123.4.0000.5346). All participants provided written informed consent. For remote interviews, consent was obtained electronically using the platform https://www.autentique.com.br/en. Confidentiality was maintained using alphanumeric codes with service acronyms: “P” for participant, “PICU,” “PED” for department of pediatric emergency, “INP” for pediatric inpatient unit, and “PHC.”

RESULTS

Of the 18 nurses included, 10 worked in hospital services and eight in PHC. All participants were women. Time since graduation ranged from 8 to 28 years (mean, 15.55 years). Regarding postgraduate education, four participants held a MSc (22.22%) and two held a PhD (11.11%). In addition, 17 nurses (94.44%) reported having lato sensu specialization in areas such as family health, obstetric nursing, public health, preceptorship in the Brazilian Unified Health System, mental health, occupational health, adult/pediatric/neonatal intensive care, pediatric and neonatal nursing, maternal-child health, and pediatric oncology.

Analytic results are presented across three thematic categories.

Nursing care for children with continuous and complex care needs

Participants described complex care needs consistently with the literature.

I understand it as any child with a chronic condition or a life-threatening, limiting disease… children who need some medical device to sustain life and who depend on health technologies. (P3 – PICU)

They are children with chronic diseases who require specialized, continuous follow-up, which limits their development, both cognitive and overall. (P14 – PHC)

Nurses highlighted the high prevalence of these children in hospital settings and a more limited presence in PHC, which varies by catchment area. Home visits were described as essential to bring services closer to families and to address non-urgent needs.

In our area we have few, and they usually receive more targeted care for their demands in the hospital network. We follow them at home with supply distribution, prescription renewals, and support for nonurgent issues. (P15 – PHC)

We are seeing more and more children with these more complex conditions. The increase is striking. (P17 – PHC)

Incidence is high, especially for readmissions. Besides prolonged hospital stays, these children are more susceptible to disease exacerbations. (P3 – PICU)

Given the current context, we recognize fragilities in the Health Care Network, especially in the articulation between services, between primary and tertiary care. (P3 – PICU)

Care was described as child- and family-centered, spanning clinical, social, and environmental dimensions. Nurses emphasized technical and clinical care, network coordination, the nursing process, and health education with caregivers.

We must look at the child as a whole: basic needs like feeding, comfort, sleep, eliminations; support network; family dynamics; social issues; and any specific care needed… Who is the caregiver? Who is responsible for the child? What is the home environment like? (P17 – PHC)

We work both in direct care and in guiding mothers on care practices and how to improve them. We also learn from them, because each has her own way, especially when the child has been chronically ill for a long time; they [mothers] have their own knowledge. (P12 – PICU)

Nurses were often sought as a reference point for guidance.

Some mothers think of calling, for example, the ICU. It has happened more than once that they call to ask us questions. I see this as a sign that we may really need this tool [telenursing]. (P12 – PICU)

Sometimes they call our service and we try to clarify doubts, but it is not always enough and they still come in. I believe that if they could see us demonstrating equipment and procedures in a more visual way, it would be better. (P4 – PED)

Frequent telephone requests from caregivers to PHC and the PICU indicated trust in nurses and the need for formal, continuous communication channels to support day-to-day home care.

Repercussions of telenursing for the care of children with continuous and complex care needs and their families

Telenursing was perceived as a viable strategy to facilitate access to health services, reduce unnecessary travel, and maintain continuity of care through sustained connection with families, although some participants noted limitations for detailed remote assessment.

Regarding feasibility, I am not sure, but the importance is clear. It helps maintain the bond, because many children do not return for follow-up appointments; they are scheduled with specialists but sometimes do not attend. (P6 – PICU)

It would definitely make a major difference, because most of these children live in municipalities far from the University Hospital… care is often delayed due to demand… and then there is still the wait for transportation. (P4 – PED)

I do not think it would be feasible to implement a telenursing service, because through teleconsultation you cannot assess the child in an emergency, nor guide certain procedures adequately. (P5 – INP)

Health education and support for continuity of home care after hospital discharge were described as important benefits.

I believe that all the guidance we give in an in-person consultation could be provided through telehealth services. (P1 – PHC)

Many issues can arise after discharge… Instead of bringing the child to a health post or outpatient clinic, teleconsultation could clarify many doubts and solve many problems. (P7 – PICU)

It helps guide and reassess how the caregiver manages care: reducing infection risks, preventing unnecessary visits to emergency due to “I do not know how to clean the nose,” “I do not know how much water to give,” “Do I need gloves for catheterization?” (P9- PS-Ped)

Participants highlighted that telenursing could promote safety and autonomy among caregivers who, after leaving the hospital, rely almost exclusively on family support. Continuous follow-up was considered essential for emotional support.

Support is very important. The caregiver knows they are not alone, that they can call when needed, and that a professional will be available. (P17 – PHC)

It would help improve care and support a more organized routine. Parents often feel lost. (P2 – PHC)

Regarding the potential impact on outcomes, nurses emphasized early resolution of complications, prevention of harm, and reduced rehospitalization.

The idea of telenursing is to postpone rehospitalization, prevent the family from traveling, address doubts, and prevent complications. (P3 – PICU)

There is a huge gap when you leave a PICU or inpatient unit after a prolonged admission with a severe diagnosis… then you go home alone with the child… often the condition is chronic and you have to manage everything yourself. (P7 – PICU)

Participants also discussed the role of telenursing in emergencies. Some considered it useful due to rapid access, while others emphasized the need for clear criteria, given the established effectiveness of emergency medical services such as the Brazilian Emergency Mobile Care Service (SAMU).

It would definitely help a lot. Even in situations like choking or drowning… (P11 – PICU)

We always guide families to call SAMU if something urgent happens. We would need to define clear criteria for accessing a telehealth service. (P13 – PHC)

I find it problematic in an emergency for families to call telenursing instead of SAMU; that would be inappropriate. Families must be clearly instructed that, in emergencies, they should seek emergency services. Telenursing should be used for ambulatory issues, not emergencies. (P3 – PICU)

Feasibility and implementation constraints of telenursing in the study context

Participants reported limited prior familiarity with telenursing directed to end users, noting that their experience was mostly during the pandemic or through professional-to-professional telehealth.

Only the UFRGS telehealth service. We can call or send photos when we have questions. (P2 – PHC)

I do not really know telenursing. My tele experience was during COVID, and it was medical care. (P7 – PICU)

I know such services exist, but usually in the private sector or for provider-to-provider telehealth. I am not sure whether telenursing is available. (P3 – PICU)

Key barriers cited included fragilities in the public network, outdated equipment, and families’ economic vulnerability, with many lacking internet access or mobile devices — factors that can compromise the quality of online consultations.

I think it could be viable, but management would first need to provide the minimum tools. Often the phone does not work, the internet is down… sometimes we cannot even call for tests or appointments, let alone have a phone available to conduct a consultation. (P15 – PHC)

Some families are very poor and do not have a cell phone. We tend to assume everyone has one, but some do not… I think this would be the main obstacle. (P12 – PICU)

Recognizing the nurse’s central role in telenursing, participants stressed that these consultations could not simply be added to existing routines due to current workload. They suggested creating a municipal call center, using accessible platforms such as WhatsApp or a dedicated app, establishing scheduling and triage protocols, and integrating PHC with specialized units through collaborative care.

I do not have availability to make calls all the time, and we do not even have an institutional WhatsApp for that… I know my children, so shared care and information exchange would help… The teleconsulting colleague will not do home visits; I will. (P17 – PHC)

Maybe a channel or an app — WhatsApp would make access easier than phone calls. For primary care, I think there should be a central hub rather than each clinic handling it. One professional dedicated to this demand, because PHC teams are already overloaded. (P14 – PHC)

In summary, while nurses acknowledged the contributions of telenursing to the care of these children and their families, they emphasized persistent challenges: workload burden, limited familiarity with telenursing, obsolete technological infrastructure in the public system, and families’ social vulnerability that may restrict access to suitable devices and internet for online consultations.

DISCUSSION

Participants associated children with continuous and complex care needs with the use of health technologies (eg, gastrostomy, urinary catheters) and with motor and cognitive limitations that frequently result in prolonged hospitalizations and highly specialized care. This characterization aligns with the concept of complex care needs reported in prior research(2).

Perceptions differed across levels of care: hospital nurses reported greater presence of these children in their services, whereas in PHC they were less frequent, although increasing. In this context, home visits were considered essential for follow-up, reinforcing the importance of an active nursing presence in the community, as shown by a study conducted in Southern Brazil that highlighted the role of home visits in the rehabilitation of children with chronic health conditions(9).

Discontinuity of care after discharge, coupled with limited problem-solving capacity in PHC, contributes to clinical deterioration and favors new admissions to high-complexity services(10). Telenursing emerges as a promising alternative to expand access, offer remote follow-up, strengthen bonds, and coordinate points across the network, bringing professionals and families closer together(4).

The reports emphasize nursing as a key actor in comprehensive care that addresses clinical and physiological needs alongside social, environmental, and family aspects that directly shape health and illness. This perspective is consistent with scientific literature recognizing nursing’s central role in comprehensive, humanized care(11).

Participants recognized the family’s central role in home care and viewed telenursing as a tool to support health education, extending guidance traditionally provided in in-person visits and reinforcing continuity of care. Demand for practical guidance was evident, as caregivers often contact PHC and hospital nurses by phone. This pattern underscores the need for greater accessibility and continuity in follow-up, which telenursing can support(12).

Participants also highlighted telenursing’s potential to provide emotional support to caregivers, especially after discharge in severe or chronic cases. Regular contact, even virtually, can strengthen bonds between families and the health team, promoting well-being and expanded care(13).

Another point raised was its contribution to organizing daily routines and maintaining the service–family connection. Preserving this connection is essential to prevent complications and rehospitalizations, underscoring the importance of regular follow-up(14), a finding reinforced by a study on telenursing for medically complex children after discharge that identified reduced rates of unplanned hospitalizations as a key outcome(15).

The study reflects on feasibility concerns related to the inability to perform complete physical examinations. While valid, this perspective does not nullify the benefits of telenursing for initial reception, guidance, and monitoring; rather, it positions telenursing as a complement to in-person care(16).

Regarding emergencies, telenursing may provide support, yet it should not replace immediate emergency care. There is a need to balance non-emergency support with the capacity to deliver rapid, effective guidance in urgent situations such as choking and drowning(17).

Concerning implementation, participants reported limited experience with this modality, citing mainly telemedicine during the COVID-19 pandemic. In addition to training gaps, they pointed to unstable internet and outdated equipment. These factors can directly compromise the quality of remote care, indicating that without adequate investment in technology and logistical support, telenursing becomes unfeasible despite professionals’ willingness(18).

Furthermore, many families’ economic vulnerability limits access to devices and internet connectivity, widening inequalities. Data indicate that 47.8% of Brazilian children aged 0-14 years live in poverty, illustrating the link between social vulnerability and chronic conditions(13).

Participants advocated a shared-care model across different points of RAS, capable of ensuring continuity without overburdening teams. This proposal aligns with international experiences in which telenursing assumes roles such as remote reception, discharge guidance, and monitoring, freeing on-site professionals for direct care(19). The analysis indicates that health services are often misaligned with families’ socioeconomic conditions. Implementing telenursing therefore requires sensitivity and accessibility for all users(20).

As practice implications, implementing telenursing safely and effectively requires acknowledging its potential, investing in technical training, reorganizing processes, and creating new care pathways. The study encourages initiatives that strengthen integration across levels of care and position nursing as a protagonist in building innovative care models.

Study limitations include the single-municipality setting and inclusion of only public-sector nursing professionals, which may limit representation of other professional experiences. The hybrid interview format (in-person and online) may have contributed to superficial responses.

CONCLUSION

Telenursing is recognized by nurses as a viable and transformative strategy in the care of complex care needs. Reported benefits include expanded access, continuity of care, reduced travel, emotional support for caregivers, and prevention of rehospitalizations. Challenges include technological infrastructure, workforce training and workload, and socioeconomic inequalities.

This modality enables reorganization of pediatric care for children with chronic conditions in Brazil’s public health system. Such reorganization requires building innovative care models that link hospitals and PHC, establish counter-referral pathways, incorporate clear clinical and ethical protocols, and promote digital equity to reduce access barriers imposed by social vulnerability.

Understanding nurses’ perceptions helps address gaps in organizing this modality, supports policy development, and indicates pathways to include telenursing as a component of the RAS, aligned with the principles of safe, humanized, and comprehensive care.

ACKNOWLEDGMENTS

We thank Vitória Camilly dos Santos Alves for her collaboration during data collection.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.

FUNDING

This study was supported by the Scientific Initiation Program conducted at a University Hospital in the Brazilian Hospital Services Company network in partnership with the Conselho Nacional de Desenvolvimento Científico e Tecnológico (grant no. 23477.003684/2024-86).

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Submission: 10-Sep-2025

Approved: 15-Oct-2025

Editors:

Rosimere Ferreira Santana (ORCID: 0000-0002-4593-3715)

Geilsa Soraia Cavalcanti Valente (ORCID: 0000-0003-4488-4912)

Gicelle Machineski (ORCID: 0000-0002-8084-921X)

Corresponding author: Camila Lovato de Figueiredo (camilalovato@yahoo.com.br)

Publisher:

Escola de Enfermagem Aurora de Afonso Costa – UFF

Rua Dr. Celestino, 74 – Centro, CEP: 24020-091 – Niterói, RJ, Brazil

Journal email: objn.cme@id.uff.br