Journal of Nursing Education

Educational Innovations 

“Get Connected”: Integrating Telehealth Triage in a Prelicensure Clinical Simulation

Melissa DeFoor, MSN, RN, CLD, LCCE; Wendy Darby, PhD, CRNP, CNE; Vicki Pierce, EdD, MSN, FNP-BC

Abstract

Background:

The integration of telehealth simulation experiences enables nursing students to effectively care for postnatal clients through interactive video technologies.

Method:

Faculty created a telehealth postnatal triage simulation in response to a need for client interaction due to COVID-19 social isolation restrictions.

Results:

Telehealth triage is an inexpensive, engaging teaching strategy and formative assessment method that can be easily created with existing resources and implemented in a postnatal simulation experience.

Conclusion:

Faculty concluded that this telehealth simulation experience is valuable in meeting student clinical learning outcomes and its continued use after social restrictions are removed is recommended. In the future, effectiveness of the simulation experience should be studied and measured along with incorporation of inter-and intraprofessional collaboration activities. [J Nurs Educ. 2020;59(9):518–521.]

Abstract

Background:

The integration of telehealth simulation experiences enables nursing students to effectively care for postnatal clients through interactive video technologies.

Method:

Faculty created a telehealth postnatal triage simulation in response to a need for client interaction due to COVID-19 social isolation restrictions.

Results:

Telehealth triage is an inexpensive, engaging teaching strategy and formative assessment method that can be easily created with existing resources and implemented in a postnatal simulation experience.

Conclusion:

Faculty concluded that this telehealth simulation experience is valuable in meeting student clinical learning outcomes and its continued use after social restrictions are removed is recommended. In the future, effectiveness of the simulation experience should be studied and measured along with incorporation of inter-and intraprofessional collaboration activities. [J Nurs Educ. 2020;59(9):518–521.]

Although telehealth has been readily available for many years (Smith et al., 2018), the 2019 coronavirus (COVID-19) pandemic has created an environment where health care providers are increasingly using video-conferencing services to provide care while reducing the risk of exposure to the virus. Telehealth is defined as “the use of electronic information and telecommunication technologies in caring for clients” (HRSA, U.S. Department of Health and Human Services, 2020, p. 1). Effective telehealth delivery by RNs can ensure quality client assessment, promote person-centered care, and address client education needs (Ali et al., 2015; American Telemedicine Association, 2018). Interactive video-conferencing or virtual telecommunications allow nurses to better manage limited resources such as staffing shortages, quickly identify client concerns, and coordinate care (Ford, 2020; Gidora et al., 2019; Mataxen & Webb, 2019; Smith et al., 2018). Expertise in effective communication and comprehensive subjective and objective physical assessment are necessary skills for a telehealth triage nurse (Cady & Finkelstein, 2013).

In recent years, there has been a considerable amount of research on the use of telehealth during the postpartum period. Women's health issues such as lactation support, early identification of depression, coping with stress, unique nutritional needs, and contraception during the postpartum period have been studied (Harrington et al., 2019; Jafarzadeh et al., 2019; Kapinos et al., 2019; McCarter et al., 2018; Yang et al., 2019). However, acute postnatal complications have not been an extensively researched topic.

Integrating telehealth nursing simulation experiences into nursing education curriculum is part of the Essentials of Baccalaureate Education (Ali et al., 2015; American Association of Colleges of Nursing, 2008; Smith et al., 2018). Because of the COVID-19 pandemic, nursing education programs have encountered limited access to direct patient care experiences in hospital facilities and community settings. Therefore, faculty teaching a women's health course determined a need to develop and implement an innovative telehealth postnatal standardized patient simulation to provide nursing students with an opportunity to discover new methods of health care delivery and to incorporate student–client interaction through telecommunication. The purpose of this article is to describe the process of development, implementation, and evaluation of a telehealth activity that incorporates a standardized postnatal client who is experiencing complications.

Background

Telehealth and Telenursing

Telenursing, a form of telehealth, enables nurses to consult with clients remotely through audiovisual technologies, as well as traditional telephone conversations (Lister et al., 2018; Mataxen & Webb, 2019). Telehealth nursing triage is considered an emerging area of expertise in the health care continuum (Mataxen & Webb, 2019). Hollander and Carr (2020) reported that telehealth has been used for COVID-19 screening to prevent mass surges to the emergency departments. Triaging clients via telehealth can provide nurses with an opportunity to discuss health care issues and navigate clients to the pertinent method of care, such as continued home care, scheduling of office visits, or escalate to emergency treatment (Li et al., 2017). Nurses working in the obstetrical field have been providing telephone advice to clients for many years; however, specialized training is required to conduct these telehealth telephone calls (Ward, 2020). This professional training allows nurses to provide safe and effective postpartum education and consistent postdischarge assessments, as well as screen for signs and symptoms of postpartum depression (PPD) (McCarter et al., 2018).

Telehealth for Postnatal Care

Shorey et al. (2017) used an asynchronous mobile health app for new postnatal clients that provided psychoeducational support to improve parenting outcomes. The app sent push notifications, or mobile text message alerts, by midwives; however, there was no face-to-face interaction. Researchers found that the app provided social support for parents, but there was no statistical significance in reduction of PPD (Shorey et al., 2017).

Conversely, McCarter et al. (2018) conducted a study that aimed to use digital technologies including text messaging, electronic mail, and/or follow-up telephone calls for nursing staff to provide consistent methods for support to clients during the postnatal period. During this study, participants completed an Edinburgh Postnatal Depression Scale (EPDS) at four different time points in the early postpartum phase. If nurses deemed participants to be at high risk for harming themselves or others, or if they scored more than 13 on the EPDS, they would be referred to a health care provider or the emergency department, depending on the severity of the situation. Although challenges arose such as nursing time constraints and technology delays, the study concluded that clients felt reassured knowing that nursing support was readily available if needed. The use of this technology significantly reduced postpartum client stress and improved postpartum mood (McCarter et al., 2018).

A study by Kapinos et al. (2019) analyzed the characteristics associated with the use of video-conferencing among postnatal breastfeeding clients and lactation consultants. Telelactation was used to provide clients with the needed support for breastfeeding complications related to improper latch, pain and soreness, decreased milk supply, breast pump usage, and potential breast infections. Clients reported that the video calls were beneficial in the postpartum period (Kapinos et al., 2019). This was the only study found to incorporate video technologies into nursing practice during the postnatal period. Interestingly, one study participant suggested a routinely scheduled video conference with the lactation consultant every month (Kapinos et al., 2019), thus indicating a potential need for more video telecommunication. With the emerging use of telehealth, there is a significant need to incorporate education regarding these technologies into nursing curricula (Ali et al., 2015). More specifically, there is a need to conduct telehealth simulations that address women's health issues in the early postnatal period.

Prelicensure Telenursing Curricula and Simulation

Although the Essentials include informatics and technology application as an expectation of nursing students, integrating telehealth content into existing curriculum may pose unique challenges for faculty, such as lack of faculty experience with telehealth and current overly extended curricula (Ali et al., 2015; American Association of Colleges of Nursing, 2008; Badowski et al., 2019). Lister et al. (2018) conducted a study that incorporated a telenursing simulation with prelicensure students. They reported that students not only enjoyed the experience but found it beneficial in improving nursing students–client communication and increasing knowledge of incorporating new technologies into practice (Lister et al., 2018). Ensuring continuity of the telehealth simulation experience from one clinical group to the next is often maintained by using a standardized patient and script.

Using trained standardized clients in a telehealth simulation can provide students with a real-life simulation experience that facilitates consistent learning (Powers et al., 2020). The International Nursing Association of Clinical Simulation and Learning (INACSL, 2016) defines a standardized or simulated patient (SP) as “a person trained to consistently portray a patient in a scripted scenario for the purposes of instruction, practice, or evaluation” (p. S45). Powers et al. (2020) reported that students appreciated for the opportunity to provide care for live patients in a simulation setting. Studies by Smith et al. (2018) and Lister et al. (2018) revealed that the incorporation of telehealth informatics into simulations gave students insight into the importance of using telenursing services in practice, as well as increasing their confidence in using these technologies.

Method

Within the context of COVID-19 guidelines for social distancing and the need for remote clinical simulation experiences, a team of clinical and didactic nurse educators created a post-natal complications telehealth triage simulation experience that addressed the clinical learning outcomes for senior prelicensure baccalaureate nursing students enrolled in an obstetric course. The team consisted of nurses with diverse backgrounds including several obstetrical nurses and two family nurse practitioners. Although team members had extensive triage experience, no one had direct experience with video telehealth. The lead instructor and clinical supervisors established prebriefing and debriefing expectations, as well as a telehealth triage script that aligned with didactic content (Table A; available in the online version of this article). To prepare for the simulation experience, students were required to review didactic content and complete presimulation questions pertaining to postnatal clients, including postpartum hemorrhage (PPH), PPD, and mastitis. Each student also received a copy of the patient's hospital medical record and an electronic EPDS calculation tool to use during the simulation experience.

Telehealth Triage Postnatal Clinical SimulationTelehealth Triage Postnatal Clinical SimulationTelehealth Triage Postnatal Clinical Simulation

Table A:

Telehealth Triage Postnatal Clinical Simulation

Experienced clinical supervisors served as an SP (INACSL, 2016). The lead instructor conducted a training session with each clinical supervisor SP to maintain consistency with the delivery of the script and patient information to meet student learning outcomes. A nonpublic-facing video-conferencing tool that was free to students served as the method of communication between nursing students and the telehealth client (U.S. Department of Health and Human Services Office for Civil Rights, 2020). Eight groups of five to six students were assigned and provided with an individual group link to access the telehealth video-conference room where the simulation experience would take place. Within the simulation scenario, it was expected that nursing students would assess the client for signs and symptoms of at least three potential postnatal complications. The simulation experience was accessible through various readily available technologies, such as a cell phone, tablet, laptop, or desktop computer. Prebriefing with the lead instructor and students occurred in this video-conference room. Because students had never participated in a telehealth simulation and the COVID-19 pandemic was adversely affecting many students, faculty established a psychologically safe environment by thoroughly explaining role and technology expectations, inviting student questions, and providing reassurance that the activity was not being graded (INACSL, 2016). Debriefing, which lasted approximately 10 to 15 minutes, occurred in the video-conferencing room at the completion of each group's simulation. Faculty and the SP participated in these debriefing sessions per INACSL Standards (2016). Although the entire simulation lasted approximately 30 to 45 minutes, 2 days were required for all eight groups to complete the simulation experience.

Results

Formative Assessment of Learning Outcomes

This telehealth simulation experience met learning outcomes and was an effective formative assessment. Students were able to communicate effectively with the client, interpret risk factors and findings, as well as formulate a plan of care. Video-conferencing allowed students to see nonverbal cues such as affect, grooming, and state of awareness, as well as assess a general survey of the environment. These video assessment findings helped students to identify early signs and symptoms of PPH, PPD, and mastitis and thereby achieve their learning outcomes.

The importance of improving nursing students and client communication with motivational interview techniques and empathetic statements was identified as a need and added to future prebriefing and debriefing expectations accordingly. Faculty determined that subtle prompting by the SP was being enacted. To address this issue, pauses were incorporated into the script to allow the students time to analyze symptoms and ask pertinent questions related to the review of systems and subjective assessment data. To aid students in developing communication skills, students in the nursing program use a Situation Background Assessment Recommendation (SBAR) tool. To accentuate the importance of identification in inter- and intraprofessional communication, faculty will consider adding Identification (ISBAR) to our SBAR communication tool (Powers et al., 2020).

Technology Challenges

Although the development and implementation of the telehealth simulation exceeded our expectations, there were some challenges. Technology glitches occurred when there was poor internet connection or low bandwidth performance. Although these experiences were minimal, students, faculty, and/or staff experienced poor video and audio quality, frozen screens, or disconnection from the video-conference room. Cellular hotspots appeared to malfunction more frequently than wireless internet connections. When users experienced frozen screens or disconnection, they simply logged back in. There was only one issue that occurred with low bandwidth that required the user to access the simulation with audio only. Because patients frequently experience these types of issues when using technology associated with telehealth, this simulation was consistent with real-life nursing practice.

Telehealth Nursing Licensure, Etiquette, and Documentation Standards

As a result of this simulation, faculty and staff took a deeper dive into telehealth nursing licensure across state lines, telehealth competencies, legal aspects (i.e., confidentiality and Health Insurance Portability and Accountability Act requirements), as well as the use of nonpublic facing video-conferencing products and patient consent (American Telemedicine Association, 2018; National Council of State Boards of Nursing, 2020; U.S. Department of Health and Human Services, Office for Civil Rights, 2020). We noted that additional information related to telehealth expectations, telehealth etiquette, and documentation was needed for both faculty and students. In response to this need, an evidence-based telehealth triage documentation form was created (Figure 1). This form includes pertinent telehealth triage documentation, as well as a SCHOLAR triage algorithm which incorporate Symptoms, Characteristics, History, Onset, Location, Aggravating factors, and Relieving factors (Wheeler & Siebelt, 1997).

Teleheath triage documentation form.

Figure 1.

Teleheath triage documentation form.

Faculty Perception

A unique aspect of this simulation is its versatility as it can be used either remotely or on campus and the creation process requires a minimal amount of time from faculty. The simulation experience provided a unique opportunity for both faculty and students to participate in a postnatal telenursing triage clinical simulation from the convenience of everyone's home during social restrictions of the COVID-19 pandemic. Although no data were collected, anecdotal comments indicated that student perceptions were positive. Faculty are now highly motivated to share our triage form and process with other faculty members, and plans are underway to continue to integrate telehealth experiences throughout the curricula beginning with level 1 prelicensure nursing students.

Conclusion

This telehealth simulation experience was determined to be an engaging teaching strategy and an effective formative assessment that can be used even after social isolation restrictions are removed. Creating telehealth simulations and incorporating telenursing information activities into nursing curriculum is essential. Although faculty were pressed for time, the creation of this telehealth simulation experience used existing resources and was relatively easy to develop and implement. Future research that includes inter- and intraprofessional collaboration with students from other programs such as nurse practitioner students, counselors, and social workers is needed.

References

  • Ali, N. S., Carlton, K. H. & Ali, O. S. (2015). Telehealth education in nursing curricula. Nurse Educator, 40(5), 266–269 doi:10.1097/NNE.0000000000000149 [CrossRef] PMID:25689080
  • American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. https://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf
  • American Telemedicine Association. (2018). Telehealth nursing fact sheet. https://higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/3c09839a-fffd-46f7-916c-692c11d78933/UploadedImages/SIGs/Telehealth_Nursing_Fact_Sheet_04_25_2018.pdf
  • Badowski, D. M., Rossler, K. L. & Gill-Gembala, L. T. (2019). Telehealth simulation with motivational interviewing: Impact on learning and practice. Journal of Nursing Education, 58(4), 221–224 doi:10.3928/01484834-20190321-06 [CrossRef] PMID:30943297
  • Cady, R. G. & Finkelstein, S. M. (2013). Mixed-methods approach for measuring the impact of video telehealth on outpatient clinic triage nurse workflow. Computers, Informatics, Nursing, 31(9), 439–449 doi:10.1097/01.NCN.0000432126.99644.6c [CrossRef] PMID:24080753
  • Ford, K. (2020). Covid-19 and telehealth: Technology can help us triage a nation in crisis. https://www.medicaleconomics.com/news/covid-19-and-telehealth-technology-can-help-us-triage-nation-crisis
  • Gidora, H., Borycki, E. M. & Kushniruk, A. W. (2019). Effects of telenursing triage and advice on health care costs and resource use. Improving Usability. Safety and Patient Outcomes with Health Information Technology, 257, 133–139 doi:10.3233/978-1-61499-951-5-133 [CrossRef] PMID:30741185
  • Harrington, E. K., Drake, A. L., Matemo, D., Ronen, K., Osoti, A. O., John-Stewart, G., Kinuthia, J. & Unger, J. A. (2019). An mHealth SMS intervention on postpartum contraceptive use among women and couples in Kenya: A randomized controlled trial. American Journal of Public Health, 109, 934–941 doi:10.2105/AJPH.2019.305051 [CrossRef] PMID:31067089
  • Hollander, J. E. & Carr, B. G. (2020). Virtually perfect? Telemedicine for Covid-19. The New England Journal of Medicine, 382(18), 1679–1681 doi:10.1056/NEJMp2003539 [CrossRef] PMID:32160451
  • INACSL Standards Committee. (2016). INACSL standards of best practice: Simulation simulation glossary. Clinical Simulation in Nursing, 12(S), S39–S47.
  • Jafarzadeh, A., Maghsoudi, J., Barekatain, B. & Marofi, M. (2019). Effect of telenursing on attachment and stress mothers of preterm infants. Iranian Journal of Neonatology, 10(1). Advance online publication. doi:10.22038/ijn.2018.29890.1406 [CrossRef]
  • Kapinos, K., Kotzias, V., Bogen, D., Ray, K., Demirci, J., Rigas, M. A. & Uscher-Pines, L. (2019). The use of and experiences with telelactation among rural breastfeeding mothers: Secondary analysis of a randomized controlled trial. Journal of Medical Internet Research, 21(9), e13967 Advance online publication. doi:10.2196/13967 [CrossRef] PMID:31482848
  • Li, L., Lake, R., Raban, M. Z., Byrne, M., Robinson, M., Westbrook, J. & Baysari, M. T. (2017). Medication-related calls received by a national telenursing triage and advice service in Australia: A retrospective cohort study. BMC Health Services Research, 17(1), 197–207 doi:10.1186/s12913-017-2135-1 [CrossRef] PMID:28288619
  • Lister, M., Vaughn, J., Brennan-Cook, J., Molloy, M., Kuszajewski, M. & Shaw, R. J. (2018). Telehealth and telenursing using simulation for pre-licensure USA students. Nurse Education in Practice, 29, 59–63 doi:10.1016/j.nepr.2017.10.031 [CrossRef] PMID:29180228
  • Mataxen, P. A. & Webb, L. D. (2019). Telehealth nursing: More than just a phone call. Nursing, 49(4), 11–13 doi:10.1097/01.NURSE.0000553272.16933.4b [CrossRef] PMID:30893196
  • McCarter, D. E., Demidenko, E. & Hegel, M. T. (2018). Measuring outcomes of digital technology-assisted nursing postpartum: A randomized controlled trial. Journal of Advanced Nursing, 74, 2207–2217 doi:10.1111/jan.13716 [CrossRef] PMID:29772609
  • National Council of State Boards of Nursing. (2020). Nurse licensure compact (NLC). https://www.ncsbn.org/nurse-licensure-compact.htm
  • Powers, K., Neustrup, W., Thomas, C., Saine, A., Sossoman, L. B., Ferrante-Fusilli, F. A., Ross, T. C., Clark, K. & Dexter, A. (2020). Baccalaureate nursing students' experiences with multi-patient, standardized patient simulations using telehealth to collaborate. Journal of Professional Nursing. Advance online publication. doi:10.1016/j.profnurs.2020.03.013 [CrossRef]
  • Shorey, S., Lau, Y., Dennis, C.-L., Chan, Y. S., Tam, W. W. S. & Chan, Y. H. (2017). A randomized-controlled trial to examine the effectiveness of the ‘Home-But Not Alone’ mobile-health application educational programme on parental outcomes. Journal of Advanced Nursing, 73(9), 2103–2117 doi:10.1111/jan.13293 [CrossRef] PMID:28276086
  • Smith, T. S., Watts, P. & Moss, J. A. (2018). Using simulation to teach telehealth nursing competencies. Journal of Nursing Education, 57(10), 624–627 doi:10.3928/01484834-20180921-10 [CrossRef] PMID:30277549
  • U.S. Department of Health and Human Services, Office for Civil Rights. (2020). FAQs on telehealth and HIPAA during the COVID-19 nationwide public health emergency. https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf
  • U.S. Department of Health Resources and Services Administration. (2020). What is telehealth?https://www.hhs.gov/hipaa/for-professionals/faq/3015/what-is-telehealth/index.html
  • Ward, T. M. (2020). Risky business: Obstetric telephone advice, is there more on the line?Clinical Nurse Specialist, 34(2), 42–44 doi:10.1097/NUR.0000000000000503 [CrossRef] PMID:32068630
  • Wheeler, S. Q. & Siebelt, B. (1997). Calling all nurses—How to perform telephone triage. Nursing, 27(7), 37–41 doi:10.1097/00152193-199707000-00019 [CrossRef] PMID:9275765
  • Yang, R., Vigod, S. N. & Hensel, J. M. (2019). Optional web-based videoconferencing added to office-based care for women receiving psychotherapy during the postpartum period: Pilot randomized controlled trial. Journal of Medical Internet Research, 21(6), e13172 doi:10.2196/13172 [CrossRef] PMID:31199291

Telehealth Triage Postnatal Clinical Simulation

Learning OutcomesAt the completion of the obstetric telehealth simulation, the learner will be able to:

Communicate effectively with client and peers utilizing audio-visual technologies.

Interpret pertinent risk factors and findings.

Formulate a plan of care based upon assessment findings.

Background: Client C.D.DOB: 4/17/2000 Client is 10 days postpartum: Client called the office and has left a voice message that she is experiencing pain in her right breast. She is also having difficulties with breastfeeding and feeling a bit defeated. She is requesting a telehealth service. Surgical History: 2 vaginal deliveries (2019, 2020); wisdom teeth extraction (2018) G2P2: 4/9/2019: vaginal delivery: 35 weeks, epidural, birth weight 2359 grams (5.2 lbs.);4/17/2020:vaginal delivery: 39 weeks; vacuum assisted, epidural, birth weight 4445 grams (9.8 lbs.).
Teaching Materials: Postpartum Depression (PPD) Edinburg Postnatal Depression Scale Calculation Tool, health record, Telehealth Triage Nurses Notes/Documentation form
Didactic Content: Mastitis, Postpartum Hemorrhage (PPH), Postpartum Depression
Pre-BriefingAddress any technology issues. Describe telehealth triage simulation process, expectations, and learning outcomes. Review the clients background information and health record. Orientate to the simulation lab. Each student nurse was encouraged to speak and interact as the primary nurse. There is only one role. Students can reach out to the instructor with the use of the CHAT videoconferencing feature. Review didactic topics related to postpartum telehealth.
Didactic Topics:Didactic Discussion Content:
SCHOLAR Triage(see Telehealth Triage Documentation Form)SCHOLAR acronym to gather subjective data and document findings=Symptoms, Characteristics, History: Onset and duration, Location, Aggravating or Associated Factors, Relieving Factors. Collecting subjective data/review of systems and a general survey/objective data that can be assessed during a telehealth video conference.
Telehealth Privacy and Confidentiality IssuesConsent Form “Non-public facing” videoconference technology Nurses note/Documentation Form/Date/Time/Findings
Effective CommunicationIdentify self. Use of empathetic statements: “Tell me more”, “I understand”, “What happened next”, “I'm sorry you aren't feeling well.” Active listening. Utilizing SBAR communication.
Mastitis, PPH, PPDDidactic review and question and answer period with students. Risks and signs and symptoms. Nursing interventions.
Telehealth Script: Live Patient and Anticipated Student Nurse Responses
Client Response:Student Nurse Response:
Student Nurse: Introduce themselves and inquire about the voice message requesting a telehealth service.
Client: Yes, I did. Thank you for calling me back!I've been trying to breastfeed this baby; I didn't try to breastfeed the first baby because she was so little and born early. But I thought since this baby was bigger, I would try to breastfeed him. I got help in the hospital, but they told me I had an improper latch and I ended up getting some blisters on my nipples. It was very uncomfortable initially. Now, the pain I've been having seems to be worsening. PAUSE(allow time for students to analyze and respond)Student Nurse: Empathetic Response: “I'm sorry you aren't feeling well.” -Mastitis: Should evaluate for mastitis based on symptoms reported. Should ask about temperature? Describe the pain? Is it localized to one area?
Client: I started noticing that not only is it painful but its tender too.Student Nurse: Mastitis-Should evaluate for mastitis based on symptoms reported. Should ask about temperature? Describe the pain? Is it localized to one area? Asks questions related to the symptoms (attributes of a symptom) redness, discharge, pain scale, fever, chills, etc…
Client: I see what looks like red streaks and I can barely breastfeed without crying and he's crying all the time because he's hungryStudent Nurse: Mastitis-Should evaluate for mastitis based on symptoms reported. Should ask about temperature? Describe the pain? Is it localized to one area?
Client: At first, I was just so cold and felt so bad, like my body hurt all over, even my bones hurt, I felt like I had a fever. I don't really have a way of taking my temperature, but I am shivering all the time and my skin feels hot.Student Nurse: I will report these findings to the healthcare provider. You potentially have an infection of the breast. In the meantime, you might try cold compresses to help with the pain. Students may also inquire if the Ibuprofen PRN listed on the health record has been helping with the pain.
Client: I'm tired and I just need help.Student Nurse: PPD-Should recognize that client appears disheveled, mentions crying a lot, and feeling defeated. Should ask about feelings? Potentially use EPDS tool for questioning? Ask if having thoughts of harming self or others.
Client: And, I googled that breastfeeding helped my uterus to contract and would helpmy bleeding be less but it seems to just have increased and is getting heavier and heavier.PAUSE(allow time for students to analyze and respond)Student Nurse: PPH-Should inquire about the bleeding. Ask questions such as how heavy is the bleeding, how often are you changing pads, color, etc.…?Describe how much of the pad is saturated.
Client: I don't know if it's because he's not nursing well and he's spitting up all the time. I just don't know. I think I remember at delivery they were worried about the afterbirth taking so long but they told me it would be ok.Student Nurse: Should inquire about the bleeding. Ask questions such as how heavy is the bleeding, how often are you changing pads, etc.…? Tell me more about the spitting. How is baby? How much spitting? How many wet diapers changed? How many bowel movements/loose?
Client: Not only is my breast hurting but I am feeling weak and light headed and I don't' know if it's the fever or what. I'm even kind of worried I might have COVID. Would that make me feel weak and my heart race? I feel like the baby is fine they said she just has a little reflux.Student Nurse: PPH: Should inquire about the bleeding. Ask questions such as how heavy is the bleeding, how often are you changing pads, etc.…?COVID-Have you traveled outside of the country? Have you been exposed to anyone with a known positive case?
Client: I didn't pay a lot of attention to the bleeding at first because they told me when I left the hospital that it would increase because I would be moving around more but I seem to be filling up a pad a lot more. No, I have not been out of the country or around anyone who has tested positive.Student Nurse: PPH: Should again inquire about the bleeding. Ask questions such as how heavy is the bleeding, how often are you changing pads, etc.…? COVID: answered negative questions, should understand that client is most likely symptomatic from the blood loss.
Client: Sometimes 2 to 3 times an hour. PAUSE (allow time for students to analyze information and respond) Bright red. Sometimes large clots. Well you know it just hurts so bad and I'm tired and I feel so weird, I have called my mother, my sister, and my friend over to take care of the baby because I just can't deal right now.Student Nurse: Student should recommend having someone bring the client in to the hospital for evaluation since she is also symptomatic. Suggest calling emergency services to transport if no one is available to bring her in and recommend no driving. Students should recognize this is an excessive amount of bleeding.
Client: As students are offering recommendations and telling the client what they are going to report to the physician, the client passes out.Student Nurse: should know to call 911/Emergency Services
*Once the student states to call 911/Emergency services, the simulation is complete.
DebriefingBegin the debriefing with the following statements: “Let's begin by focusing on what happened throughout your conversation with the client without judging our performance.” The instructor will continue the conversation by stating, “What happened next?” Once the instructor has engaged students in reflecting upon the telehealth triage simulation experience, he/she will transition to a deep-dive analysis and reflection period.
AnalysisReflection Content:
Analysis of CommunicationThis telehealth triage experience was designed for students to have an opportunity to demonstrate effective communication. How did you respond to the client? What questions did you ask? What additional questions could you ask? Would you rephrase any of your questions? Which ones and why? Why did you respond in this way? What challenges did you face related to communicating through videoconferencing? Are there additional people with whom you communicated (peers? Instructor?) What other professionals might be helpful to you in this case? What empathetic statements were provided? What could you have said and when? When talking with patients in the hospital, how could you show empathy? What would you say and why? Examples include: Tell me more, I understand, what happened next, I'm sorry you aren't feeling well.
Analysis of Risks and Signs and SymptomsThis simulation experience was also designed to provide students with an opportunity to interpret postnatal risk factors. What statements did the client make that concerned you the most? Why? What actions did you take in response to the client's statements? Why? What were the risk factors? What were you thinking about as the patient shared her s/s? What risk factors/signs/symptoms were missed? How did you interpret pertinent risk factors and findings related to PPH, mastitis, and PPD? What additional information or resources do you need? What would you do differently? Why? What was the most significant or priority concern? Why?
Analysis of Nursing Interventions and Plan of CareIn this clinical experience student nurses were to formulate a plan of care based upon assessment findings. What was your plan of care for the client? What additional information did you need? What would you do differently? Why? How could you use this information when caring for patients in the hospital or another setting? Discuss how they felt when the client passed out. What information might be needed for the nurse to report to emergency services (i.e. address, history, etc.…) Who should be contacted and why? How did they respond to the client? How did they feel? Why did they feel this way?
Simulation Documentation and Evaluation of Simulation ExperienceEach student completes the telehealth documentation form and submits to their clinical supervisor. Students are given the link to complete a simulation evaluation.
Authors

Ms. DeFoor is Nursing Lecturer, Dr. Darby is Nursing Professor, and Dr. Pierce is Dean and Nursing Professor, Anderson College of Nursing and Health Professions, University of North Alabama, Florence, Alabama.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Ms. Celista Davis, Ms. Kendra Flanagan, Ms. Margo Simpson, and Ms. Amanda Hunt for their contributions to this telehealth clinical activity.

Address correspondence to Melissa DeFoor, MSN, RN, CLD, LCCE, Nursing Lecturer, Anderson College of Nursing and Health Professions, University of North Alabama, 1 Harrison Plaza, Florence, AL 35632; email: melissadefoor@gmail.com.

Received: May 14, 2020
Accepted: July 01, 2020

10.3928/01484834-20200817-08

Sign up to receive

Journal E-contents