Telehealth is used to deliver care to individuals who otherwise might not have access to a health care provider (Henderson, Davis, Smith, & King, 2014; Vaughn, Shaw, & Molloy, 2015). Advances in telehealth technologies have been useful in the delivery of primary care services by advanced practice registered nurses (APRN) (Erickson, Fauchald, & Ideker, 2015; Young & Ireson, 2003). Nurse educators are obligated to seek out opportunities to engage students on this topic of transformation of health care delivery through telecommunication tools (Dorsey & Topol, 2016). In this article, we describe a simulation experience designed to address the need to integrate knowledge, skills, and attitudes related to telehealth into nursing curricula and provide pediatric primary care APRN students with the opportunity to become familiar with telehealth equipment and critically think through a plan of care and collaborating with a remote provider.
Technology use in the health care arena has seen exponential growth over the past few decades (Fronczek, Rouhana, & Kitchin, 2017). One project attempted to answer this question by convening a panel of telehealth experts to discuss telehealth competencies relevant to nursing and the required knowledge, skills, and attitudes in four Delphi rounds (van Houwelingen, Moerman, Ettema, Kort, & Ten Cate, 2016). Fifty-one experts, including nurse educators, nurses, technicians, and clients, participated on the panel. They identified 14 relevant nursing telehealth-entrustable professional activities and 52 types of knowledge, skills, and attitudes to guide the integration of tele-health into nursing education. Students were assigned to read the article (van Houwelingen et al., 2016) on this project. However, due to time constraints, only three of the 14 identified nursing telehealth-entrustable professional activities are addressed by the simulation experience described in this article: coordination of care with the use of telehealth technology, providing health promotion remotely, and guidance and peer consultation.
Simulation and Telehealth
Simulation is an effective tool used to educate and expose all nursing students to multiple topics, including delivering care in multiple settings. Rutledge, Haney, Bordelon, Renaud, and Fowler (2014) conducted a three-phase workshop for practicing APRNs with varying specialties who were enrolled in a Doctor of Nursing Practice program. Within one phase, the authors used a telehealth simulation for students to explore the ways in which telehealth can be used to care for patients. Students performed a face-to-face and simulated telehealth visit on a standardized patient who lived in a rural area. Students completed a 5-point Likert-type survey developed by the authors after the simulation. Overall, the students gave the experience high ratings, felt comfortable with both visits, and expressed how they now understood the value of tele-health as it relates to caring for patients.
Advanced Practice Registered Nurses and Telehealth
APRNs are tasked with staying abreast of continuous advances in health care technology to be effective in delivering telehealth (Erickson et al., 2015). Health care agencies have been using APRNs to deliver care via telehealth across the country for several years (Henderson et al., 2014; Schlachta-Fairchild, Varghese, Deickman, & Castelli, 2010). One study conducted a survey with telenurses practicing in the United States, which included examining professional roles (Schlachta-Fairchild et al., 2010). Of the 1,700 participants, 27% held an advanced certification and reported using telehealth in 18 different clinical sites. The integration of telehealth experiences is essential to prepare APRN graduates for a technology-rich clinical environment (Hawkins, 2012).
Implementation of the Telehealth Learning Experience
Presimulation Student Preparation for the Telehealth Experience
Faculty assigned to the pediatric primary care APRN course designed the simulation discussed in this article after determining student learning objectives and the related nursing telehealth-entrustable professional activities (Table). Students viewed a module within their online didactic course on the basics of telehealth, which included a review of telehealth competencies, equipment, benefits, potential barriers, and reimbursement issues. Required reading assignments included published literature on the topic of telehealth (Henderson et al., 2014; van Houwelingen et al., 2016). A student announcement encouraged students to review all content covered during their pediatric courses prior to the simulation. Then, students attended their on-campus objective structured clinical examination, which included the telehealth simulation experience. Faculty informed students that the simulation was not for a great grade, but a learning opportunity; however, each group of students had to submit a SOAP (Subjective, Objective, Assessment, and Plan) note after the experience. Faculty provided a general head to toe assessment form similar to a typical patient documentation form as a guide during the simulation. In the presimulation overview, faculty notified students that the debriefing session would provide them with feedback on their performance.
Student Learning Objectives and Corresponding Nursing Telehealth-Entrustable Professional Activities (NT-EPA)
Telehealth Simulation Experience Design
Faculty used the International Nursing Association for Clinical Simulation and Learning (2016) Standards of Best Practice: SimulationSM during the design of the simulation experience. The International Nursing Association for Clinical Simulation and Learning standards guided faculty to create a quality experience that led to achievement of the expected outcomes. The student learning objectives were to demonstrate the use of telehealth equipment, demonstrate a focused assessment on a standardized patient using telehealth equipment, formulate a plan of care in collaboration with a remote provider, and provide health education to a remote patient and caregiver. Faculty assessed learner needs, created objectives, and designed the experience to address the overall purpose. The experience included two phases to simulate a telehealth visit in a school setting with a standardized patient (SP). Prior on-campus intensives included simulation; therefore, students were familiar with the process. Each simulation included 15 groups with two students per group. Faculty provided a how-to demonstration with the telehealth equipment, as well as a prebrief of the experience. A debriefing session occurred after each group's simulation. The simulation occurred in an examination room with routine health care equipment to simulate a school-based clinic. Just prior to the beginning of the simulation, students chose a role to assume—clinical presenter or remote provider. A volunteer SP assumed the role of an elementary student and faculty served as the school counselor. Faculty trained the SP and provided a case scenario that included prompts for anticipated questions. The training occurred several days before the event and included practice sessions. Faculty instructed the SP to answer “I don't know” if asked a question not addressed in the case scenario. In the school counselor role, the faculty member was able to observe and take notes during each simulation. The school counselor reviewed the patient's chart with the clinical presenter. The school counselor also assisted the student with answering questions if hesitation occurred.
Entrance Into the Simulation
The faculty member introduced the learners into the simulation by portraying the school counselor and gave the following report:
The patient is a 9-year-old African American female, in the school office complaining of a red eye and itchy throat. The school record indicates that she takes Miralax® daily for constipation and that she does not have any allergies. There is a signed consent on file for her to receive healthcare treatment by the school nurse and remote healthcare provider when needed for non-urgent illnesses. I serve as the school counselor. I will stay in the room to assist you as needed. Her current vital signs that I obtained are blood pressure 100/72 mm Hg, weight 50 pounds, and a tympanic temperature of 98.9°C.
Phase One of the Scenario
The initial phase of the scenario began with the clinical presenter developing a relationship with the patient and communicating with the school counselor. The clinical presenter gathered a history on the patient and conducted a focused assessment in accordance with the chief complaint. A school health record, which included allergies, medications, immunizations, and emergency contact information, was available in the room. This interaction allowed the student to demonstrate the ability to gather a history and complete a focused assessment. Once the clinical presenter was comfortable with the information gathered, the next step was to collaborate with the remote provider.
Phase Two of the Scenario
The second phase of the scenario began with the clinical presenter connecting with the remote provider using video conferencing software. The clinical presenter then reviewed pertinent components of the history and conducted another focused assessment on the patient using the telehealth equipment, transmitting sounds and images to the remote provider. The remote provider and clinical presenter conversed with each other to develop an appropriate management plan. Education provided to the school counselor, as well as the patient, included the plan of care as it related to medications prescribed and appropriate follow-up. At this point, the providers could choose to communicate with the legal guardian over the telephone if they deemed it necessary.
Faculty who assumed the role of the school counselor led the debriefing session with each group of students. The Promoting Excellence and Reflective Learning in Simulation (PEARLS) conceptual framework guided the debriefing session. Faculty designed a clear debriefing strategy with scripted language as stated in the PEARLS framework (Eppich & Cheng, 2015). For example, faculty stated “Now that each of you are clear about the details of the case, let's talk about things that you think went well and things that were a little more difficult as it relates to managing this case.” Each debriefing phase, according to PEARLS, was included in the session. Faculty chose the learner self-assessment strategy for the analysis phase—a more learner-centered option—and used focused facilitation as needed to address performance gaps (Eppich & Cheng, 2015). The debriefing session concluded with an educator-guided summary, which included thoughts on the key learning points and the future health care possibilities related to telehealth (Eppich & Cheng, 2015). For example, faculty made the following statement: “In summary, one of the key learning points as it relates to telehealth is that for APRNs to remain effective health care team members, it is imperative to recognize common telehealth terms.” Students had another opportunity to interact with the telehealth equipment and ask additional questions.
Lessons Learned and Future Possibilities
The simulation experience occurred during the last semester of the program. Faculty did not seek approval from the institutional review board to conduct student research; therefore, students completed only an institution-created standard simulation experience evaluation. Students reported that the telehealth simulation gave them an opportunity to practice a skill to which they had limited exposure in the clinical setting. In addition, based on student comments, an earlier introduction to telehealth would be preferred. The introduction of telehealth earlier in the program creates an opportunity for faculty to design more experiences related to telehealth. Technology can facilitate student engagement and learning in distance accessible courses and also help to prepare the student for reality (Grady, 2011; Hawkins, 2012). In addition, it would be beneficial to include a pre–posttest to assess learning outcomes and telehealth knowledge, skills, and attitudes. This simulation experience has the potential to become an online experience that includes prelicensure students as the clinical presenter and APRN students as the remote provider.
As the use of telehealth expands, it is essential for APRN students to have experience with the technology. This experience highlighted the use of simulation as one strategy available to expose students to telehealth technology and integrate telehealth into the curricula. The success from the implementation of this experience has provided all APRN tracks at this school of nursing with guidance on how to implement a similar experience with their students. Currently, the family APRN students are participating in a similar experience with prelicensure students in the clinical presenter role. Integrating telehealth into nursing curricula for APRN students will need to include using telehealth-simulated experiences, as well as didactic content, to equip students with the knowledge, skills, and attitudes to care for patients.
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Student Learning Objectives and Corresponding Nursing Telehealth-Entrustable Professional Activities (NT-EPA)
|Student Learning Objective||NT-EPA|
|Demonstrate use of telehealth equipment (stethoscope and otoscope, ophthalmoscope, and dermatology scope attachments).||N/A|
|Demonstrate a focused assessment on a standardized patient using telehealth equipment.||Coordination of care with the use of telehealth technology|
|Formulate a plan of care in collaboration with a remote provider via video conferencing.||Guidance and peer consultation|
|Provide health education to a remote patient and caregiver.||Provide health promotion remotely|