Journal of Nursing Education

Educational Innovations 

Transitioning an Advanced Practice Fellowship Curriculum to eLearning During the COVID-19 Pandemic

Lisa M. Pierce, DNP, APRN, CPNP-AC; Meghan J. Weber, MSN, APRN, FNP-C; Colleen J. Klein, PhD, APRN, FNP-BC; Brad A. Stoecker, MD, ABFM

Abstract

Background:

The COVID-19 global pandemic brought mandatory shelter-in-place orders, disrupting traditional face-to-face teaching methods for advanced practice fellowship programs nationally, creating a challenge for fellowship program directors to preserve curriculum using nontraditional methods.

Method:

Using a variety of both web-based and app-based virtual platforms, a nationally accredited fellowship program converted traditional in-seat learning modalities to elearning platforms using both synchronous and asynchronous education.

Results:

Preliminary data indicate that knowledge acquisition and perceived fellow satisfaction are preserved despite the abrupt change to program delivery. Programmatic modifications were submitted to the American Nurse Credentialing Center for compliance and deemed as creative, innovative, and collaborative.

Conclusion:

Curriculum for advanced practice fellowship programs can be favorably converted to elearning using virtual platforms during a crisis. Through prompt reevaluation and restructuring, virtual platforms can replace in-seat didactic lectures, patient case studies, mentoring, and even simulation, while ensuring program continuation and compliance with accreditation standards. [J Nurs Educ. 2020;59(9):514–517.]

Abstract

Background:

The COVID-19 global pandemic brought mandatory shelter-in-place orders, disrupting traditional face-to-face teaching methods for advanced practice fellowship programs nationally, creating a challenge for fellowship program directors to preserve curriculum using nontraditional methods.

Method:

Using a variety of both web-based and app-based virtual platforms, a nationally accredited fellowship program converted traditional in-seat learning modalities to elearning platforms using both synchronous and asynchronous education.

Results:

Preliminary data indicate that knowledge acquisition and perceived fellow satisfaction are preserved despite the abrupt change to program delivery. Programmatic modifications were submitted to the American Nurse Credentialing Center for compliance and deemed as creative, innovative, and collaborative.

Conclusion:

Curriculum for advanced practice fellowship programs can be favorably converted to elearning using virtual platforms during a crisis. Through prompt reevaluation and restructuring, virtual platforms can replace in-seat didactic lectures, patient case studies, mentoring, and even simulation, while ensuring program continuation and compliance with accreditation standards. [J Nurs Educ. 2020;59(9):514–517.]

The outbreak of Coronavirus Disease 2019 (COVID-19) in the United States brought on significant challenges to the nation's health care systems. To mitigate the spread of coronavirus, strategies including social distancing and gatherings limited to no more than 10 individuals were released and were followed shortly afterward by stay-at-home orders by state governments (Centers for Disease Control and Prevention, 2020; Foster & Mundell, 2020). Health care systems across the country implemented revised meeting policies to maintain compliance with these recommendations, disrupting health care education across all levels and disciplines. Advanced practice provider fellowships, a name given to postgraduate transition-to-practice programs for both advanced practice registered nurses (APRNs) and physician assistants, were no exception. Fellowship program directors were challenged to consider various solutions, including the use of virtual learning modalities. Programs accredited through organizations such as the American Nurses Credentialing Center (ANCC) Practice Transition Accreditation Program needed to ensure compliance with accreditation standards during the pandemic.

Historically, APRN fellowship programs deliver curricular content through a combination of both in-seat didactic education and practiced-based learning in the clinical environment (Flinter, 2011). This article describes the processes undertaken by a fellowship program director and faculty to meet the needs of their learners and its accrediting body, the ANCC, in this unprecedented time using innovative electronic-based learning strategies. Since its inception in 2016, a year-long advanced practice provider fellowship program for novice primary care APRNs and physician assistants has included 1 day per week of in-seat curriculum with didactic lectures, procedural skills laboratories, case studies, simulations, and mentoring. Fellows spend the other 4 days in clinical practice.

Background

Electronic learning, elearning, is a mixture of online learning using various virtual modalities and has become ever-increasing over the past decade. The U.S. Department of Education (2010) reported on the efficacy of online learning, noting that in older learners (including both higher education and medical education), results are favorable, with learning outcomes equivalent or modestly better than traditional face-to-face learning (U.S. Department of Education, 2010). Additional studies reveal that the combination of online and traditional curriculum results in higher engagement, higher examination scores, and better understanding of nursing fundamentals (Sheikhaboumasoudi et al., 2018). Nursing education is beginning to explore the use of video platforms, such as the use of Flipgrid, a video discussion platform created by Microsoft®, for doctorate of nursing practice (DNP) students in place of traditional written journaling, as well as for engaging graduate nursing students in discussions (Sebach, 2020; Serembus, 2020). Elearning can reduce content time in half compared with learning presented in-seat, and it also allows students to work at their convenience and in a preferred environment (Emanuel, 2020). Klimova (2018) noted elearning as a valuable tool in the medical education and training of health care professionals. Moreover, literature reviews on medical students' education indicates that learning is best done through short lectures, 15 minutes or less, followed by assessments and feedback (Molloy et al., 2019).

Method

Curricular Delivery Redesign

Intentional curriculum design aimed toward preserving all aspects of the program, including role socialization, peer support, and faculty mentoring in addition to the clinical content, was critical to maintaining the quality of the program. The faculty team researched available platforms for elearning. Sources used included a review of literature and benchmarking with local nursing and medical education experts, primary and secondary school teachers, and members of the health care system who were familiar with innovative virtual learning platforms. Different faculty members identified potential virtual platforms. A use case analysis was then conducted by the team using the proposed virtual platforms to allow all faculty the opportunity to test the access as well as to experience the platforms in action. Nontraditional learning modalities and supplemental educational resources were also identified to promote discussion and align with the recommendations by Molloy et al. (2019) on keeping elearning strategies to a short (less than 15 minutes) duration followed by an assessment and faculty feedback. Each learning modality was evaluated using the following criteria: features of the platform, accessibility, ease of use, and cost (Table A; available in the online version of this article).

Learning Modality Criterion Evaluation

Table A:

Learning Modality Criterion Evaluation

Features

The review of available features on each virtual learning platform served as the initial evaluative component for the use case. Captivating, innovative platforms were prioritized as a means to gain learner interest, engagement, and attention. A basic PowerPoint® program with voiceover for a standard didactic lecture exists; however, some platforms offer features that increase the visual stimulation to promote learner engagement. Vyond is a program, for example, that allows the creator to use animation and music to translate a traditional presentation into a story that comes to life (Vyond, 2020). Prezi is another example of a presentation platform that uses stimulating graphics and allows video recording of faculty during the presentation to allow for a product that demonstrates increased engagement and effectiveness over traditional PowerPoint (Moulton et al., 2017). Screen-castify is a web extension exclusive to the Chrome web browser that allows users to record their computer screen in real time into a high definition video (Screencastify, 2020). Following the creation, the screencast is downloaded into Google Drive and a hyperlink is used for sharing. Preference was given to platforms that were intuitive for users and required few instructions or tutorials.

Accessibility

This fellowship program services a large geographical area, with both rural and urban locations. Internet access varies, necessitating an appraisal of each platform or modality in terms of accessibility, including the feasibility of downloading in remote locations. Some virtual platforms were web-based and others were app-based, and some required a download to a computer.

Cost

Cost of the platforms ranged from free up to $649 for an annual subscription. Preference was given to those programs that were free of charge and those allowing a monthly subscription term that could be purchased during the pandemic phase when needed and then cancelled when the regular fellowship schedule resumed postpandemic. Faculty reviewed all the above criteria; recommendations were discussed, with the program director making the final determination.

Learning Platforms

As the curriculum was converted into elearning, both asynchronous and synchronous education was created. Canvas was selected as the online learning management platform. The platform was free to educators and students/fellows at OSF HealthCare, as a contract/user agreement was already in place. Program faculty created a course, using Canvas to upload documents and create a program schedule with assignments and modules.

One of the most valuable and innovative platforms for this fellowship's elearning was Flipgrid. This web-based and app-based video platform is being used weekly to maintain curriculum in role transition, mentoring, and simulation. After creating a “grid,” or class, for the advanced practice provider fellowship, faculty were able to create a topic of discussion using a written or video-based prompt. Fellows were then able to record a short video (length set by faculty, from 15 seconds up to 5 minutes) to discuss assigned content for the week. Recorded videos are only available to faculty and other fellows in the program. A traditional in-seat weekly session titled “Highs and Lows,” where fellows articulate the best and worst aspects of their last week, either personally or professionally, has been converted to Flipgrid. This activity has been a critical component to continuing the peer mentoring and role transition standards of the program. Fellows and faculty can reply to each post, adding to the interaction and engagement. An ongoing Flipgrid topic titled “Role Transition” is continually available for fellows to post a video journal related to a struggle or challenge they are facing in practice.

Another innovative use of Flipgrid was the creation of case-based simulation experiences. Historically, a simulation for this program includes the use of a standardized participant, or actor, to play the role of the patient. In the prepandemic state, the standardized participant memorizes a script of the patient history and key examination findings, elicited by a fellow over the course of a 15-minute visit. During the pandemic, simulations were created using abbreviated standardized participant scripts, limited to a chief complaint and a brief history in a 2-minute recording using the Flipgrid platform. Using the Canvas learning management system, the Flipgrid simulation case was assigned to fellows for viewing, immediately followed by a private, faculty-proctored question-and-answer session where the fellows can inquire about additional details of the history and physical examination findings, leading them to a final diagnosis and plan of care. The entire case is completed within 15 minutes, aligning with the time allotted for simulation and reflective of the scheduled visit time of 15 to 20 minutes for acute visits in a typical ambulatory clinic.

A new cohort of fellows was onboarded during the transition to elearning. Usually, fellows are greeted in person by their senior cohort of fellows as they create a unique and memorable first day. Through Flipgrid, the senior fellows recorded a Flipgrid topic about their experiences as a new provider to help normalize the fears that new fellows may be facing.

In addition to scheduled lectures, prerecorded voice-over presentations were created using the aforementioned platforms Vyond and Screencastify. Both platforms were chosen for their captivating visual content and ability to be used for various content. A novel tactic for the use of Vyond was the creation of an animated, visually stimulating short film that depicted the steps to creating SMART (Specific, Measureable, Attainable, Realistic, Time-bound) goals (Doran, 1981). The fellows were assigned viewing of the Vyond video through a hyperlink embedded in Canvas and were then asked to create their own SMART goals. Screencastify was used to create short presentations (under 10 minutes to facilitate engagement) followed by a group discussion assignment through the Canvas discussion board. Another use of Screencastify for the advanced practice provider fellowship during the pandemic was to teach the primary care providers the nuances of the Medicare wellness examination by visually demonstrating how to document the visit in the electronic medical record.

As faculty considered ways to engage fellows and stimulate conversations in unconventional asynchronous learning modalities, podcasts were explored as a viable option based on feedback from previous fellows. Podcasts can augment current content covered by program faculty and create self-directed learning (Hurst, 2019). One example was a medical podcast hosted by an infectious disease physician, taking the listener through an interesting patient presentation and clinical course. Another assigned podcast by a professor of clinical neurology walked through causes, differentiation, and treatment of tremors. In each case, the fellows were assigned to listen to the pod-casts and engage in group discussion or debate on Canvas to provide reflection and embed learning.

To incorporate the program content of professionalism, TEDTalks were used to stimulate learning. TEDTalks are engaging lectures under 18 minutes with a goal of generating ideas and conversation (TEDTalk, n.d.). Fellows were asked to choose a TEDTalk to summarize and then respond to others in a Canvas-housed discussions. Fellow choices ranged from learning how exercise impacts neurological function to debating on whether health care systems are prepared for digital health. Expanding discussion threads of learner responses demonstrated the effectiveness of learning and achievement of the curricular objectives.

Early Results

Preliminary feedback has been collected in the 4 weeks since implementing the curriculum online. Kirkpatrick's and Kirkpatrick's (2016) programmatic evaluation is historically used for this fellowship program, and Level 1 (reaction) and Level 2 (learning) data were collected anonymously from the fellows during elearning. Written permission was obtained from all fellows for sharing of aggregate data. All virtual platforms have achieved a mean score of 4.6 or higher on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) in regard to ease of use and a benefit to learning. Table 1 includes a brief synopsis of evaluative feedback using fellow responses. All the fellows adapted well to the multiple virtual platforms and required minimal technical assistance to access. The Canvas learning platform had occasional glitches that necessitated a restart of the program, possibly due to increased Internet usage nationally. Some fellows in more rural locations had difficulty uploading Flipgrids given limited broadband Internet speed and required a second attempt to upload their videos successfully.

Preliminary Feedback From Fellows Regarding Virtual Learning Modalities

Table 1:

Preliminary Feedback From Fellows Regarding Virtual Learning Modalities

Anecdotal faculty observations indicate the Flipgrid simulation was beneficial for fellow learning and provided a degree of realism to patient case studies. While faculty determined that learning objectives were achieved through fellow performance and discussion, it is not a replacement for the interaction achieved in a traditional simulation.

The ANCC requested each program director to submit an action plan for compliance with Practice Transition Accreditation Program standards during the COVID-19 pandemic. The ANCC response to our submission was noted as the following: “The OSF HealthCare Primary Care Fellowship Program despite these uncertain times has developed strategies to maintain the integrity of their fellowship through innovation, creativity, and collaboration. They are demonstrating compliance with the standards while also excelling their program forward with innovation during this pandemic” (L. Pierce, personal communication, April 22, 2020). Formalized programmatic quality outcomes derived from midprogram and end-of-program evaluative measures, as well as the comprehensive competency evaluation rubrics, will continue to be used as more definitive measures of success for the program and its changes in curricular delivery.

Conclusions and Implications

Multiple virtual platforms were used to convert a traditional advanced practice provider fellowship curriculum into an elearning format. Future uses of virtual platforms for fellowships should include the transition of standardized participant simulations to virtual video platforms (e.g., FaceTime® or Zoom) to allow a fellow to perform a telemedicine visit with a standardized participant. The COVID-19 pandemic has resulted in the proliferation of telemedicine visits in primary care practices, which will likely become common practice. Further research should be conducted to validate the efficacy of elearning for advanced practice fellowships over a longer period.

References

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  • Doran, G. T. (1981). There's a S.M.A.R.T. way to write management's goals and objectives. Management Review, 70(11), 35–36.
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  • Flinter, M. (2011). From new nurse practitioner to primary care provider: Bridging the transition through FQHC-based residency training. The Online Journal of Issues in Nursing, 17(1), 6 doi:10.3912/OJIN.Vol17No01PPT04 [CrossRef] PMID:22320872
  • Foster, R. & Mundell, E. J. (2020, March21). As mores states clamp down, 1 in 4 Americans now under ‘shelter in place’ order due to coronavirus. U.S. News & World Report. https://www.usnews.com/news/health-news/articles/2020-03-21/as-more-states-clamp-down-1-in-4-americans-now-under-shelter-in-place-orders-due-to-coronavirus
  • Hurst, J. (2019). Podcasting in medical education and healthcare. Journal of Hospital Librarianship, 19(3), 214–226.
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  • Sheikhaboumasoudi, R., Bagheri, M., Hosseini, S. A., Ashouri, E. & Elahi, N. (2018). Improving nursing students' learning outcomes in fundamentals of nursing course through combination of traditional and e-learning methods. Iranian Journal of Nursing and Midwifery Research, 23(3), 217–221 doi:10.4103/ijnmr.IJNMR_79_17 [CrossRef] PMID:29861761
  • TedTalk. (n.d.). Our organization. https://www.ted.com/about/our-organization
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Preliminary Feedback From Fellows Regarding Virtual Learning Modalities

Kirkpatrick's (2016) Evaluation LevelFree Text Responses From Fellows
Level 1: Reaction to virtual platformsStill nice to be able to connect with others via Skype and Flipgrid
I really liked the podcasts on tremors.
The opportunity to connect via virtual platform is beneficial.
I like the podcast concept. I would like to somehow do group case study. I get a lot from those.
Flipgrid is a beneficial way to do highs/lows. The combination of Skype meeting and independent study is a nice balance.
Minor technical glitches
I like when we meet together via Skype and have discussion about case studies that way.
Would like PowerPoint® presentations prior to lectures.
Level 2: Self-reported learning outcomes related to virtual platform activitiesHelped me to vocalize why I would order treatments and to consider what tests are absolutely necessary for a patient's condition
I learned we all do things a little differently and that's okay with regard to ordering labs; there is not a one-size-fits-all approach.
I enjoyed learning about the program and hearing others have the same thoughts and fears as I do as a new provider.
I am going to find out about getting the point of care testing in my office.
Shared decision is invaluable for patient/provider relationship.
I have a lot to learn. This will be very beneficial in the end.
Gabapentin is like water for tremors and [I learned] the 30-second assessment for differentiating Parkinson's from essential tremor.

Learning Modality Criterion Evaluation

PlatformFeatureAccessibilityCost
CanvasWeb based platform to disperse online curriculumHealth care system user agreement to allow multiple usersFree to those employed by the health care system
FlipgridWeb and app based platform used for short video recordings. Each faculty creates a class, or “grid,” and then modules, or “topics.” Maximum 5 minutes in length.Requires internet for learner to record and upload video. User preference for Gmail accountFree to educators and student
PodcastWeb and app access to updated medical or leadership topics lead by field expertsAvailable in app store or direct website for podcastFree to $2.99, some in-app purchases
PreziStimulating visual graphic presentation combined with video recording of presenterFaculty can create content online, download for distribution$7 to $59 per month per single user
ScreencastifyWeb extension for recording computer screen in real time to display a presentation, website, etc. while providing a virtual video lectureExtension to Google chrome, shareable link for distributionFree to $25.00 per month (to record over 5 minutes)
TEDTalkShort, web-based lectures by content experts on variety of topicsWebsite easily accessible, use search engine to find topic of choiceFree
VyondUses animation and sound to transform presentation into storyCreate content online, download or use shareable link$49 to $159 per month per single user
Authors

Dr. Pierce is Director of Advanced Practice Education and Fellowship Programs, Ms. Weber is Advanced Practice Provider Clinical Education Specialist, Dr. Klein is Advanced Practice Education and Research Scientist, and Dr. Stoecker is Medical Director of APP Fellowship Program, OSF HealthCare, Peoria, Illinois.

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

Address correspondence to Lisa M. Pierce, DNP, APRN, CPNP-AC, Director of Advanced Practice Education and Fellowship Programs, OSF HealthCare, 800 NE Glen Oak Ave., Peoria, IL 61603; email: lisa.m.pierce@osfhealthcare.org.

Received: April 24, 2020
Accepted: June 23, 2020

10.3928/01484834-20200817-07

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