As the American population continues to age, individuals age 65 years and older who reside in rural areas have increasingly complex health conditions (Baernholdt et al., 2012; Centers for Disease Control & Prevention, 2017; Meit et al., 2014; Rural Health Information Hub, 2017). In addition, access to health care services for rural residents continues to be a major challenge (Alverson et al., 2004). Telehealth has become a widely used health care delivery method of providing health care to patients by nurse practitioners (NPs) (Erickson et al., 2015; Young & Ireson, 2003). NP faculty are charged with integrating the use of innovative health care delivery methods, such as telehealth, into NP education to ensure graduates can meet the health care access demands of the populations they serve. This article describes reinforcing NP telehealth didactic curriculum and competencies through application in a clinical environment.
NP education curricula are guided by the National Organization of Nurse Practitioner Faculties (NONPF) Core Competencies (2017), which recommend “Advocacy for improved access, quality and cost-effective health care” (p. 4) and “Integrates appropriate technologies for knowledge management to improve health care” (p. 8). In addition, NONPF released a statement in 2018 further supporting the use of telehealth in NP education (NONPF, 2018).
A review of the literature demonstrates recent implementation of telehealth into NP education with evaluation. Telehealth has been implemented in didactic and simulation curriculum, including presentations, online assignments, and simulation scenarios (Ainslie & Bragdon, 2018; List et al., 2019; Smith et al., 2018). Students self-reported increased confidence levels in telehealth knowledge following didactic curriculum and satisfaction with the opportunity to practice a skill in simulation rarely experienced in the clinical setting (List et al., 2019; Smith et al., 2018). Rutledge et al. (2017) used a multimodal approach to integrate telehealth etiquette and interprofessional collaboration into didactic and simulation curriculum and practice immersions. The multimodal approach also assisted NP students in developing knowledge, comfort, and competence in the use of telehealth (Rutledge et al., 2017).
Academic-practice partners conveyed to NP faculty from a midwestern land-grant university their desire for family NP (FNP) student graduates to have training in telehealth to prepare them for family practice positions in frontier and rural communities (Conde et al., 2010). Concurrently, the FNP program graduates communicated to their NP faculty during exit interviews they believed they were unprepared to use telehealth.
Telehealth continues to evolve as does the literature addressing telehealth implementation across multiple professions. However, a gap exists in the literature regarding telehealth competencies. A single set of telehealth competencies has not been formally recognized, but standards for telehealth in nursing have been recognized (American Academy of Ambulatory Care Nursing, 2018; American Nurses Association, 2018; National Council of State Boards of Nursing, 2014). More recently, 16 standards related to nursing telehealth processes and practice have been disseminated (American Academy of Ambulatory Care Nursing, 2018).
Using the NONPF guidelines, literature findings, and academic-practice partner and student feedback, NP faculty at a midwestern land-grant university performed a needs assessment in their FNP curriculum in the area of telehealth. The results of the needs assessment indicated a gap in telehealth didactic, simulation, and clinical curriculum in the FNP curriculum. To address the gaps identified in the literature review and found in the curriculum, NP faculty members applied for and received Health Resources and Services Administration grant funding to support the development of telehealth competencies and didactic and simulation curriculum in collaboration with a Telehealth Advisory Board.
A Telehealth Advisory Board consisting of NP faculty, urban and rural health care providers who use telehealth, members of the Board of Nursing, academic-practice partner leadership, national telehealth provider organizational leadership, a telehealth consultant, and health insurance and reimbursement representatives collaborated to develop 22 telehealth competencies based on national guidelines, evidence, and experiential knowledge (American Academy of Ambulatory Care Nursing, 2018; Hilty et al., 2017; van Houwelingen et al., 2016). These competencies guided the NP faculty in the development of curriculum and simulation education for the FNP students. NP faculty wanted to further reinforce the didactic and simulation curriculum with planned telehealth clinical experiences.
Providing telehealth clinical experiences that enabled FNP students to apply and demonstrate knowledge and competence was of primary importance to the NP faculty. To meet this need, meetings with the NP faculty and academic practice partners were held to determine what types of telehealth modalities were being used within their organizations. NP faculty also wanted to verify whether the health care providers engaging in telehealth were academically and experientially prepared and willing to precept the FNP students.
The primary type of telehealth delivery method offered by the academic practice partners for clinical placement was live video patient visits from remote and hub locations with primary care and specialty care providers. The clinical practice service lines available for telehealth experiences identified by the clinical organizations included rural family practice, emergency, intensive care unit, long-term care, specialty consult, correctional health, and school health.
The NP faculty and Telehealth Advisory Board determined that having the FNP students engage in telehealth clinic rotations in a hub location would provide the best learning environment. The hub location would provide for exposure to different telehealth service lines and a high volume of telehealth visits, as well as experienced and willing preceptors. In addition, the hub location could accommodate the number of FNP students enrolled in the final clinical practicum course. A total of 19 providers served as preceptors for this clinical experience. Eleven providers were NPs, and 8 were physicians; 14 providers were female and 5 were male. The age range of the preceptors was 37 to 62 years, with an average age of 45 years. All of the preceptors were White. The years of telehealth experience for the preceptors ranged from 1 to 5 years, with an average of 2.5 years.
The NP faculty determined FNP students who were best suited for inclusion in the telehealth clinical experience were FNP students in their final clinical practicum course. These FNP students were selected because they would have had exposure to all components of the telehealth curriculum and simulations offered in their FNP courses. The experience was not required given the students were in an FNP program and the focus of their clinical experiences was family practice; participation would have required some of the students to drive several hundred miles to the telehealth hub location. Therefore, any FNP student who elected not to participate completed their clinical experiences as previously planned with no impact on their final clinical practicum course grade.
A total of 22 FNP students participated in the clinical experience. Nineteen students were female and 3 students were male. Age range of participants was 25 to 42 years with a mean age of 30 years. All of the participants were White.
The NP faculty determined an evaluation of the clinical experience was needed from the students and preceptors at the end of the clinical experience. The evaluation of students by their preceptor would provide feedback on their ability to demonstrate competence in providing telehealth. The evaluation of their preceptor by students would provide feedback on the providers' competence level of serving as a telehealth preceptor. The Student Telehealth Evaluation and the Preceptor Telehealth Evaluation tools were created by the NP faculty and were based on the telehealth competencies developed by the FNP program.
The Telehealth Advisory Board reviewed both the Student Telehealth Evaluation and the Preceptor Telehealth Evaluation tools in a face-to-face meeting and provided written and verbal feedback for face validity for each tool. The tools then were finalized during a second meeting. The NP faculty obtained Institutional Review Board approval from the university for the clinical experience.
The Student and Preceptor Telehealth Evaluation tools included several criteria taken from the telehealth competencies developed by the FNP program. The criteria for evaluation addressed competencies in on-screen presence, communication, use of telehealth equipment, reimbursement, licensing, confidentiality, confidence, and competence. Each criterion was rated as “not met,” “met,” or “not observed.” The tool also included a section where preceptors could include subjective comments for each criterion, as well as a section for overall subjective comments. The “not met” evaluation option was defined as the student was not able to demonstrate competence in a criterion, whereas “not observed” was defined as not having an opportunity to demonstrate competency in a criterion. Descriptive statistics were used to report findings; frequencies and percentages were determined for each criterion.
Preceptors (n = 19) evaluated the FNP students on eight criteria relating to telehealth clinical experiences using the Student Telehealth Evaluation tool (Table 1). According to the preceptor evaluations, all of the FNP students met six of the eight criteria. The other two criteria, functioned as a member of the interprofessional team and confident when using the telehealth equipment, were met by 95% and 79% of the FNP students, respectively.
Preceptor Evaluation of Students (N = 19)
The FNP students (n = 22) evaluated the preceptors on 13 criteria relating to telehealth clinical experiences using the Preceptor Telehealth Evaluation (Table 2). According to the FNP student evaluations, all of the preceptors met eight of the 13 criteria; the other five criteria were met by 77% to 95% of the preceptors. Criteria related to troubleshooting equipment failure (n = 5, 23%), telehealth reimbursement considerations (n = 1, 5%), telehealth licensing (n = 1, 5%), and telehealth summary with follow-up care (n = 2, 9%) were evaluated by the FNP students as not observed. Telehealth reimbursement (n = 1, 5%), telehealth licensing (n = 1, 5%), and telehealth prescriptions (n = 1, 5%) criteria were evaluated by the FNP students as not being met.
Student Evaluation of Preceptors (N = 22)
The subjective portions of the evaluations then were reviewed using a thematic approach. The subjective comments provided by preceptors in their evaluation of students yielded themes that included professionalism, engagement, good communication, and asking appropriate questions. The subjective comments provided by FNP students in their evaluation of preceptors yielded themes that included use of the interprofessional team, a variety of experiences, knowledgeable, professional, maintained confidentiality, and welcomed questions.
FNP students demonstrated reinforcement of their telehealth knowledge and skills in engagement, communication, asking appropriate questions, functioning as a member of the team, and maintaining privacy and confidentiality during telehealth clinical experiences. Rutledge et al. (2017) also noted that NP students need to have telehealth etiquette, collaborate with the interprofessional telehealth team, and adeptly use telehealth equipment to serve frontier and rural populations. Developing a set of telehealth competencies to guide telehealth curriculum and simulation and serve as a basis for clinical evaluation reinforced student telehealth competence. List et al. (2019) and Smith et al. (2018) also noted that integration of telehealth curriculum in NP education resulted in increased confidence levels in telehealth knowledge among FNP students.
Preceptors were evaluated as meeting the criteria for professional dress, appropriate setting, elimination of distractions, communication, use of equipment, maintaining privacy and confidentiality, confidence, and competence. A few preceptors were evaluated as not being able to demonstrate competence in addressing reimbursement, licensure, and prescription considerations. Some FNP students also indicated they did not have the opportunity to observe their preceptors provide a summary of the patient encounter at the end of the telehealth visit and did not observe their preceptors use appropriate resources to troubleshoot equipment failure. The overall outcomes of the students' evaluations of the preceptors demonstrate the preceptors are experientially prepared and competent to precept FNP students in telehealth. However, additional education on telehealth best practices may further support preceptors' knowledge and practice.
There were several limitations to this study. First, the sample size was small, and some of the participating FNP students also could have been exposed previously to telehealth in their RN role. The evaluation tools also need further reliability and validity testing. The study was implemented in an FNP program and may not be generalizable to other NP or advanced practice RNs (APRN) programs. Patient telehealth visits were not consistently scheduled during the clinical time FNP students spent with preceptors. FNP students also were not assigned to preceptors in each telehealth service line. Finally, technical and equipment issues also may have impacted the ability to connect for scheduled appointments and for a complete examination to occur.
Telehealth is an innovative health care delivery method used by APRNs that can improve access for patients in rural and remote areas. FNP students were able to demonstrate telehealth curriculum and competency reinforcement through application in a clinical environment. Preceptor and student evaluations were positive, despite limitations potentially impacting the ability for all evaluation criteria to be observed. As telehealth continues to expand and become increasingly used, it is essential that it becomes a part of NP education. Implementation of telehealth curriculum in NP education needs reinforcement through planned clinical experiences to prepare NP graduates to enter into practice with competence to meet the health care access needs of the populations they serve.
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Preceptor Evaluation of Students (N = 19)
|Criteria for Evaluation||Not Met||Met||Not Observed|
|The student was engaged throughout the telehealth clinical experiences||–||–||19||100||–||–|
|The student communicated with the patient and the interprofessional team appropriately||–||–||19||100||–||–|
|The student asked appropriate questions||–||–||19||100||–||–|
|The student functioned as a member of the interprofessional team throughout the telehealth clinical experience||–||–||19||100||–||–|
|The student was dressed appropriately for a telehealth clinical experience||–||–||18||95||1||5|
|The student maintained privacy and confidentiality||–||–||19||100||–||–|
|The student appeared confident when using the telehealth equipment||–||–||15||79||4||21|
|The student demonstrated competence in completing the telehealth clinical experience||–||–||19||100||–||–|
Student Evaluation of Preceptors (N = 22)
|Criteria for Evaluation||Not Met||Met||Not Observed|
|The preceptor was dressed professionally for the telehealth clinical encounter||–||–||22||100||–||–|
|The preceptor's clinical setting was appropriate throughout the telehealth clinical encounter||–||–||22||100||–||–|
|The preceptor eliminated potential distractions during the telehealth clinical encounters||–||–||22||100||–||–|
|The preceptor communicated appropriately with the patient and members of the interprofessional team||–||–||22||100||–||–|
|The preceptor used all telehealth equipment appropriately||–||–||22||100||–||–|
|The preceptor used appropriate resources to troubleshoot equipment failure||–||–||17||77||5||23|
|The preceptor discussed telehealth reimbursement considerations with the student||1||5||20||90||1||5|
|The preceptor discussed telehealth licensing considerations with the student||1||5||20||90||1||5|
|The preceptor communicated telehealth prescription considerations||1||5||21||95||–||–|
|The preceptor maintained privacy and confidentiality throughout telehealth clinical encounters||–||–||22||100||–||–|
|The preceptor summarized the telehealth clinical encounter and discussed follow-up care with the patient and the interprofessional team||–||–||20||91||2||9|
|The preceptor appeared confident when using the telehealth equipment||–||–||22||100||–||–|
|The preceptor demonstrated competence in completing the telehealth clinical encounter||–||–||22||100||–|