Rural and medically underserved areas face health care workforce shortages, especially in primary care (Burrows et al., 2012). Because health professions students' clinical learning environments influence their practice locations on graduation, rural clinical experiences are important for nursing students seeking employment in a rural health care environment (Barrett et al., 2011). Nursing schools are increasingly using online education to improve the accessibility of nurse practitioner (NP) education to students in rural areas. These students require instruction and practice in rural health skills including telehealth and working effectively in health care teams. Didactic content is adaptable to online delivery, but translation of hands-on clinical learning to an online environment poses unique challenges. This article describes the development and pilot implementation of an innovative simulation designed for online NP students to increase their skills in telehealth consultation by collaborating with prelicensure baccalaureate nursing degree (BSN) students. The simulation provides NP students with practice applying rural telehealth skills and exposes NP and BSN students to nursing roles for RNs and NPs in the rural health care system.
Rural Telehealth: Meeting Health Care Needs
Training the future nursing workforce to use telehealth has enormous potential to increase access to quality health care for underserved populations in rural areas (Speyer et al., 2018). Telehealth includes consultation with patients and other providers for the provision of clinical care, remote monitoring, m-health (i.e., mobile technologies), and the provision of patient and provider education (Rutledge et al., 2017). Knowledge and skills required for nursing telehealth practice include ethical awareness, coaching skills, a supportive attitude, the ability to combine telehealth with clinical skill and judgment, and communication skills (van Houwelingen et al., 2016). Successful telehealth training requires an approach that addresses all of these areas.
Simulation in Nursing Education
The simulation laboratory provides an ideal environment to teach students the skills required to effectively engage with patients and other health care providers using telehealth technology. Telehealth simulations have been shown to be acceptable to students and useful in teaching clinical reasoning (Merritt et al., 2018; Posey et al., 2018). One common simulation strategy involves the use of human actors called standardized patients (SP) to simulate common clinical scenarios. SP simulation has been used successfully for evaluating clinical skills as well as for teaching interprofessional consultation and care management (Estes et al., 2016). SPs are especially useful in teaching communication skills where human responses such as empathy and eye contact are important (MacLean et al., 2017).
Teaching Consultation and Intraprofessional Collaboration
Nursing intraprofessional collaboration (e.g., RN to NP) is common in real-world practice, particularly in rural areas where there are health professional shortages. Training in effective clinical communication skills is vital to safe and effective care in such environments. Team-based telehealth training that includes nurses from different educational backgrounds has been shown to be an effective strategy for teaching telehealth communication skills (Rutledge et al., 2014). In addition, telehealth technology can enable collaboration and remove hierarchies that may impede care (Rutledge et al., 2017). A recent Cochrane review found that although distance consultation is a key skill in patient care, there is currently no high-quality evidence to guide training (Vaona et al., 2017). There is a need for ongoing research to support telehealth consultation training.
Developing a Telehealth Consultation Simulation Model
The educational model described in this article was developed at the college of nursing of a public university in the southwestern United States. In addition to its on-campus prelicensure BSN program, the college of nursing operates an online BSN-to-doctor of nursing practice (DNP) program with four NP specialties. DNP faculty developed the telehealth consultation simulation model in collaboration with BSN faculty, information technology staff, and simulation laboratory staff.
Faculty from both programs identified relevant learning needs related to intraprofessional telehealth consultation in the rural environment. Desired outcomes for both groups of students included professional role development and proficiency in and comfort with the use of telehealth technologies for patient assessment and intraprofessional communication. The clinical simulation is also an opportunity for students to demonstrate appropriate use of clinical skills and documentation tools taught in their respective programs. BSN students used the situation, background, assessment, and recommendation (SBAR) format, and the NP students used the subjective, objective, assessment, and plan (SOAP) format.
Professional Role Development
The BSN students' role development was focused on learning the RN scope of practice within an outpatient clinical environment. Their learning included an opportunity to practice the critical thinking and independent judgment necessary to effectively practice in that context. The BSN students also practiced performing and documenting a focused patient interview and review of systems. The BSN students then had the opportunity to provide a concise organized report to the NP students.
The NP students' role development centered on team leadership and decision making. This required the NP students to actively listen to the BSN students' report via telehealth technology, provide feedback and direction, and then transition smoothly to engaging with the SP, also via telehealth technology. The students then were able to create and communicate a diagnosis and plan.
The telehealth consultation simulation pilot implementation took place in the Spring 2018 semester. DNP faculty recruited student volunteers from the first clinical management course in the family NP specialty, and BSN faculty recruited BSN student volunteers who were completing their final semester and preparing to enter practice. Participation was optional, and students were offered credit toward required clinical time, required volunteer hours, or extra course credit.
Faculty adapted the Objective Structured Clinical Examination (OSCE) process used for clinical skills assessment in the DNP program to create this learning activity. The standard OSCE model involves an SP and a student learner interfacing in an on-campus simulation laboratory with a faculty member observing. For the telehealth consultation simulation, the SP and BSN student were physically present in the simulation laboratory, but the NP student and observing faculty member were connected via videoconferencing (Zoom). The simulation laboratory's examination rooms are equipped with campus network-connected computers with webcams, and the off-site faculty and students used personal laptop computers with webcams. This simulated a rural outpatient clinic with an RN present and an NP available via telehealth. For this pilot implementation, the patient's chief complaint was chest pain, and the students were expected to differentiate whether the cause was likely benign (e.g., musculoskeletal) or more serious (e.g., cardiac). The SP provided standard information for both history and physical examination findings (via verbal reporting) in response to specific student questioning and examination techniques.
Telehealth Simulation Process
Before the simulation began, students were provided with the patient's vital signs, demographic information, and chief complaint. The simulation consisted of three phases. The first phase began when the BSN student entered the examination room and completed an initial assessment of the SP. The second phase started when the BSN student used the videoconferencing system to connect to the NP student to give report and provide any additional data requested by the NP student, including physical examination findings. In the third phase, the NP student interacted directly with the SP via videoconferencing to gather any remaining required information and discuss the assessment and plan. The encounter lasted 30 minutes, which required the student learners to manage their time together to achieve the desired outcomes.
Immediately following the simulation, the SP, faculty, and students engaged in a four-way communication process. The SP was invited to share feedback about the interaction with the BSN student in the room and the NP student via videoconferencing. This feedback allowed both students to gain insight into how their communication appeared to the patient. Comments such as, “I'd prefer if you include me in the conversation when I'm in the room,” and “It would be good if you turned the computer so I could see the screen, too,” helped the students to understand the patient's perspective of the telehealth consultation.
Next, faculty provided feedback focused on clinical proficiency using a checklist to identify the completeness and appropriateness of the history, physical examination, assessment, and plan. The checklist also included communication skills, such as making eye contact, introducing one's self, and professional rapport. Elements completed by the BSN and NP students were identified and discussed as appropriate for each role. Faculty then answered any remaining questions about the simulation. Finally, the students had the opportunity to discuss the boundaries of their roles, determine which communication strategies were effective, and make suggestions for improving the consultation experience.
Evaluation of the Simulation Project
The goals of this project were to enhance NP student proficiency and confidence in telehealth consultation and to foster professional role development. After the telehealth simulation, students were surveyed about the experience to determine whether the experience was useful in achieving these outcomes and how it could be improved. Faculty developed the survey based on the Technology Acceptance Model (TAM), which relates perceived usefulness and usability of technology to usage intentions (Venkatesh & Davis, 2000). The TAM was selected to guide evaluation because the usability of telehealth technology in a simulated environment influences students' proficiency for patient assessment and intraprofessional communication (Huang, 2013). The original model's concepts were adapted and applied to address the specific context of the telehealth consultation simulation.
A five-point Likert scale (strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree) was used to assess perceptions of the usability, usefulness, and relevance of the technology. In addition, an open-ended question (“Do you have any other comments to share about the simulated consultation experience?”) was added to capture any other perceptions of the experience. Faculty also evaluated the students' clinical proficiency by completing a skills checklist while observing the telehealth simulation.
The BSN students (n = 10) found the telehealth software easy to use, with more than 75% of the students indicating they strongly or somewhat agreed to the questions about usability. The NP student participants (n = 19) responded even more favorably, with 100% indicating they strongly or somewhat agreed with the usability questions. One explanation for this difference is NP students had increased experience using videoconferencing as part of their online coursework. Both student groups believed the telehealth software was useful for consulting and communicating assessment information, with 100% and 89%, respectively, strongly agreeing or somewhat agreeing with statements about usefulness. More than 90% of students in both groups also agreed that the technology allowed them to demonstrate the skills required for rural telehealth practice, such as physical assessment skills, clinical reasoning, giving report, and communicating with one another and the SP.
Students also found the exercise relevant. Among BSN students, 80% somewhat agreed or strongly agreed that the simulation increased their comfort with telehealth technology, and all of the students believed the exercise prepared them to use telehealth in the future. Similarly, all of the NP students strongly or somewhat agreed with both statements. More than 96% of participants across groups strongly or somewhat agreed that the telehealth training was relevant and important to their future practice. All of the participants somewhat or strongly agreed that they felt positive about collaborative practice following the simulation.
Responses to the open-ended question were analyzed by theme. The themes that emerged were: 1) appreciation for exposure to telehealth, 2) perception of relevance to rural practice, 3) appreciation of immediate feedback from faculty, and 4) desire for more prebriefing about roles. The latter has been identified as an area of improvement for future versions of this simulation.
Faculty evaluators reviewed the clinical proficiency checklists with the students during the feedback sessions. This process provided an opportunity to assess whether students were performing at excepted clinical proficiency for their educational level. Faculty also used this time to assess professional role development with students by noting which students completed which elements of the simulated patient encounter and whether communication between the students was professionally appropriate. After completing the simulation and feedback sessions, all of the faculty evaluators reported that the BSN and NP students' clinical proficiency and role understanding was appropriate for their level, and no remediation was required to meet expectations of proficiency.
This intraprofessional telehealth simulation effectively addressed a previously unmet educational need of NP students. The increased awareness of rural telehealth practice, increased confidence in telehealth skills, demonstrated proficiency in telehealth communication, and experience working with other nurses in the telehealth context achieved through this project are positive steps toward producing NP graduates who are prepared for and interested in rural telehealth practice (Speyer et al., 2018). Given NP workforce trends, it is likely that graduates who are practice-ready in rural telehealth will be in high demand (Rutledge et al., 2018).
The BSN students had the opportunity to observe and interact with the NP students, which is not otherwise common because the NP students frequently are off-campus. This interaction provided an opportunity to enhance BSN students' understanding of the NP role and provided the educational scaffolding for future discussion about the differing roles of the RN and the primary care NP. This interaction also increased exposure to educational pathways for BSN students interested in eventually becoming an NP, thus widening another channel to increase the advanced practice nursing workforce in rural and medically underserved areas.
Strengths and Limitations
A strength of this telehealth consultation simulation was the use of tested and validated educational models to provide hands-on clinical training in an online educational environment (Merritt et al., 2018). The simulation was implemented with existing campus resources and did not require travel or the engagement of community clinical sites. Both students and faculty reported satisfaction with the experience.
A limitation of this project was the small number of student participants, making it difficult to draw conclusions about the generalizability of results to students in other cohorts or specialties. In addition, although faculty impressions of student performance were favorable, quantitative data about student proficiency were not collected. Future work should more rigorously assess the impact of telehealth consultation simulation on students' telehealth proficiency.
The authors plan to replicate the project with larger numbers of participants, including NP students in other specialties. More complex scenarios will be developed to present a more dynamic and robust simulated telehealth patient encounter and to engage the student team members at all levels of professional development.
An intraprofessional collaboration educational model allowing BSN and NP students to develop telehealth skills for rural and medically underserved areas was well received by both faculty and students. Postsimulation, participants reported comfort with telehealth technology, awareness of the relevance of telehealth to rural practice, and positive attitudes toward collaborative practice with nurses in other roles. This project successfully addressed a gap in preparing nursing students to meet rural health care workforce needs.
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