The implementation of the Patient Protection and Affordable Care Act (ACA, 2010) is changing the landscape of health care delivery due to the increased number of insured individuals and demands for health care cost reductions (National Advisory Committee on Rural Health and Human Services, 2015). Telehealth is a tool that can increase access, reduce health care costs, and improve outcomes [American Telemedicine Association (ATA), 2018]. Recognizing the impact of the ACA on health care delivery, the Institute of Medicine (IOM, 2010) has called for nursing education to shift from acute care practice experiences to those in community and public health settings, focusing on prevention and health promotion, which help reduce health care costs (National Conference of State Legislatures, 2011). Motivational interviewing (MI), a health promotion technique, is an evidence-based communication technique that helps patient to transition to healthier lifestyles (Miller & Rollnick, 2013). Moreover, the Essentials of Baccalaureate Education include the application of patient care technologies, clinical prevention strategies, and population health in nursing curricula [American Association of Colleges of Nursing (AACN), 2008)]. The inclusion of telehealth nursing with MI in nursing education is way to address this shift in health care. The purpose of this study was to examine the effectiveness of a telehealth simulation-based experience (SBE) with MI among postlicensure nursing students.
Telenursing uses technology to deliver nursing care and conduct nursing practice in a variety of community-based settings (ATA, 2018). The U.S. Department of Health and Human Services defines telehealth as the use of technology to deliver health care, health information or health education at a distance. Up to 65% of hospitals connect with patients at a distance (American Hospital Association, 2018). Health care settings use telecommunications and health care technologies to communicate with patients every day (ATA, 2018). However, inclusion of specific content and language regarding telehealth, which is a telecommunication, is virtually nonexistent in nursing curricula (Ali, Carlton, & Ali, 2015; ATA, 2018). A survey completed by Ali et al. (2015) noted that only 42% of baccalaureate nursing programs reported offering students exposure to a telehealth learning experience. Additionally, only 57% of the deans and directors responding to the survey felt confident their nursing faculty would integrate telehealth into the existing curriculum.
Some nursing programs are starting to use telehealth SBEs (Mennenga, Johansen, Foerster, & Tschetter, 2016; Shaw et al., 2018). Simulation mimics clinical situations, allowing participants to develop the knowledge, skills, and attitudes necessary to respond to realistic situations (International Nursing Association for Clinical Simulation and Learning Standards Committee [INACSL], 2016b). Mennenga et al. (2016) examined a telehealth simulation in a rural home and found gains in knowledge about telehealth nursing concepts among baccalaureate nursing students. Shaw et al. (2018) explored the use of telepresence technology in simulation. They found telehealth is both feasible and accepted in distance education for nurse practitioner students. Finally, Lister, Brennan-Cook, Molloy, Kuszajewski, and Shaw (2018) found that prelicensure nursing students had improved confidence with telehealth nursing skills following a telenursing simulation intervention with a telepresence robot. These study findings support further exploration on the effects of telehealth SBE on student's knowledge, skills, and behaviors toward telehealth.
Miller (1983) developed MI as a radical approach to treat patients using a conversational, patient-centered approach rather than existing confrontational counseling methods. Motivational interviewing accepts the patient unconditionally, without judgement, and evokes their own motivation and readiness for lifestyle change (Miller, 1983). Since its inception, MI has been found to be successful in areas outside of addiction, such as health promotion (Miller & Rollnick, 2013). Lundahl et al. (2013) completed a systematic review and meta-analysis of randomized clinical trials of MI in medical settings. Their review examined the effect MI had on patients and found a statistically modest advantage for MI in areas such as body weight, sedentary behavior, self-monitoring, and dental caries.
Linking telehealth to MI is a new health care approach for which there is much opportunity for study and implementation. A qualitative synthesis of 23 studies published between 2010 and 2015 evaluated technology-delivered adaptations of MI (TAMI). In this synthesis, Shingleton and Palfai (2016) concluded a high acceptability and positive health-related behavior change as a result of the technique. The TAMI approach offers advantages in underserved or difficult to reach populations such as rural areas, homebound, and those who feel stigmatized in traditional settings (Shingleton & Palfai, 2016). Another study investigated a nurse-driven MI/telehealth intervention for in-home diabetes self-management. Young et al. (2014) found significantly higher self-efficacy scores on the Diabetes Empowerment Scale, as well as in satisfaction surveys, among those receiving the MI/telehealth intervention. These studies show how MI/telehealth is growing in clinical practice. In addition, MI/telehealth meets national initiatives that focus on patient-centered, evidence-based, clinical prevention techniques to promote health and manage illness (AACN, 2008; Quality and Safety Education for Nurses, n.d.).
An MI/telehealth SBE in postlicensure nursing students was implemented in an online postlicensure degree nursing program to meet these initiatives. However, it was unknown whether the students gained any benefits from the experience. Therefore, the research questions were:
- Did participants feel the innovative telehealth SBE was beneficial to their learning?
- Does the practice of MI skills within the telehealth SBE advance participants' communication skills from their prelicensure nursing program?
- Have participants integrated MI in their current nursing practice as a result of the SBE?
The NLN Jeffries Simulation Theory (Jeffries, Rodgers, & Adamson, 2015) was used to guide the design, implementation and evaluation of this MI/telehealth SBE. The theory consists of seven concepts: context, background, design, simulation experience, facilitator and educational strategies, participant, and outcomes. The outcomes of the simulation affect the participant of the simulation, the patient, or the system. This study focused on measuring participant outcomes from the NLN Jeffries Simulation Theory. The original levels in the Kirkpatrick Model (Kirkpatrick Partners, 2018) were applied to the participant outcomes. The levels used in this study were reaction, learning, and behavior.
Simulated Telehealth Clinical Experience
The intervention of this study was a synchronous MI/telehealth SBE in which small groups of postlicensure nursing students in an online nursing course practiced MI together as a “tag team.” The tag team approach was adapted from a study by Levett-Jones et al. (2015). In this approach, each student in the group participated in the roles of nurse and observer. One student started the MI/telehealth SBE as the nurse and was given 4 minutes to practice the principles of MI while the other students actively observed the experience. After 4 minutes, an observer was “tagged” to become the nurse while the initial nurse then became an observer. The MI in the telehealth SBE proceeded as one fluid communication until all team members had the opportunity to be the nurse. A nurse faculty, knowledgeable about MI, played the role of the patient, otherwise known as the standardized patient (SP).
To be prepared for this synchronous MI/telehealth SBE, students asynchronously completed assignments the week prior to the experience. These included (a) reading assignments about MI technique, (b) watching web-based videos demonstrating MI, and (c) listening to two Advancing Care and Excellence (ACE) audio monologues (ACE-S and ACE-V) to provide a context for the MI/telehealth SBE. The ACE program was developed by the National League for Nursing (NLN, 2018), which is an ongoing initiative to improve the quality of care for vulnerable populations. This program provides free teacher-ready case studies with curriculum tools for use in many simulated health care environments.
Prebriefing occurred synchronously via an online video conference tool just prior to the MI/telehealth SBE. The faculty facilitator of the SBE instructed students on the tag team approach and assigned their place in the tag team. Students were also reminded this was a nongraded practice experience for MI. Immediately following prebriefing, the SP entered the video conference and the MI/telehealth SBE started, with students, faculty, and SP in the video conference room together. To maintain integrity of best practice in simulation (INACSL Standards Committee, 2016a), full group debriefing took place immediately following the SBE. Debriefing included students, faculty, and the SP.
Study Design and Sample
This exploratory descriptive pilot study used a survey developed by the investigators. The institutional review board at the study site identified this study as exempt. A convenience sample of 22 postlicensure nursing students, who completed the required course as a part of their RN-to-Master of Science in Nursing program, were recruited for this study. Participants were at various points in the program, and this course could be completed between winter 2016 through spring 2018. Opting out of this survey did not affect student progression in the program.
Recruitment occurred via e-mail with a link to the voluntary anonymous online survey through Qualtrics® with a secure server. Survey questions included demographics and questions to address the purpose of the study. Participants were presented with information about the study immediately upon opening the survey. Consent was provided by participants submitting yes to “I agree to continue with the survey” after reading the information. Internet protocol addresses were not collected to protect participant anonymity. Participants could exit the survey at any time and once exited, survey participation was completed.
Descriptive statistics were used to describe the participants and results to questions about the MI/telehealth SBE. Results were reported in percentages as calculated in Qualtrics.
A response rate of 45% (n = 10) was realized. Demographic data revealed the majority age range between 30 to 39 years with 90% of participants identifying as White, non-Hispanic. Eighty percent of participants have between 6 and 10 years of clinical practice experience. Seventy percent felt “very comfortable” with technology.
When asked whether the MI/telehealth SBE was beneficial to their learning, all participants “strongly agree/agree” that the SBE telehealth nursing experience was beneficial to their learning. They also “strongly agree/agree” that this experience provided insights on a new clinical practice environment and that practicing MI was valuable. Only 40% would have liked to have had another exposure to MI/telehealth SBE. Written remarks corresponding with this question were noted as “I felt the one class was enough for the program. The class was well designed to the point that any more would be a duplicate of a class already paid for.”
When asked if the practice of MI within the telehealth SBE advanced their communication skills from their prelicensure nursing program, 80% of participants “strongly agree/agree” they would have liked to have learned MI skills during their prelicensure nursing education program. This research question was supported by participant comments such as “I learned it was an effective way of communicating with patients,” “an evidence-based communication strategy to assess patients' needs…,” and MI offers an avenue to use “more direct conversational techniques” when communicating with patients.
When asked if they integrated MI into their current nursing practice as a result of the MI/telehealth SBE, 50% of participants reported they integrated MI into their current practice. Comments included “helps tailor plan of care to each individual and promotes self-efficacy” and “I felt the patient was more involved in the plan of action.” One participant indicated a potential barrier as “a full MI does not fit into my scope of practice.” Two participants had yet to integrate MI, whereas one was already using it in practice.
Learner reaction is the first level of Kirkpatrick's model (Kirkpatrick Partners, 2018). All participants thought this MI/telehealth SBE was beneficial to their learning, with one participant commenting it “was a valuable live learning experience.” These findings support works conducted by Randall et al. (2016) where interprofessional health care students identified positively with the use of telehealth post interaction with an SP and subsequent experiences with patients in the clinical setting.
This MI/telehealth SBE provided the learning of MI skills, which is level two in Kirkpatrick's model (Kirkpatrick Partners, 2018). This is evidenced by 80% of participants responding they would have liked to have been exposed to MI in their prelicensure program. One student commented the experience was “a bit short” and would have liked an extended practice time. In this study, all participants agreed that MI/telehealth SBE gave them insights into a new practice area for nurses.
Of note, 60% of participants did not feel as though exposure to an additional MI/telehealth SBE during the program was necessary. Miller and Rollnick (2013) encouraged multiple practice sessions for practitioners to become proficient with MI. In addition, Kennedy, Apodaca, Trowbride, Roderick, and Modrcin (2016) articulated how a robust formal MI educational program and supervised training can enhance therapeutic communication between a patient and provider. Mullin, Saver, Savageau, Forsberg, and Forsberg (2016) conducted a study on the influence of a 22-hour MI course. They noted how MI skills require more time to achieve proficiency. Education and practice training of MI on telehealth platforms offers the potential to increase the capabilities of novice and practicing nurses to establish an authentic relationship with patients, in which the patient's motivation for change remain the priority (Elwyn et al., 2014).
The final research question addressed level three of Kirkpatrick's model. This level is the degree to which participants apply what they learned into their practice (Kirkpatrick Partners, 2018). The MI/telehealth SBE nursing experience changed the behaviors of postlicensure nursing students as 50% reported integrating MI in their current clinical practice. This reinforces the findings from Nesbitt, Murray, and Mensink (2014), in which graduate nursing students self-reported using MI skills 1 year after a remote SBE with MI. The other 30% reported they had already been using it in their practice. It is possible for nursing students to integrate new skills into their clinical practice through telehealth SBE.
This pilot study demonstrated how a MI/telehealth SBE affected the learning of postlicensure nursing students. The participants' self-reported outcomes met the first three original levels of Kirkpatrick's model of evaluation. Students reacted positively to the learning experience, identified that they learned a new communication technique, and self-reported integration of MI into their current practice as a result of this experience. Limitations to this study include a small sample size at a single site with a researcher-developed survey. This limits the generalizability of the findings. However, this pilot study stimulates the need for further investigation not only for nurse educators in graduate nursing programs but in undergraduate programs as well. Future research into the use of MI/telehealth for nursing students is needed in both postlicensure and prelicensure nursing programs to meet the national calls for inclusion of both technology and health promotion strategies in nursing education.
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