Nurse Educator

Telehealth Simulation With Graduate Nurse

Practitioner Students
Margaret R. Emerson, DNP, APRN, PHHNP-BC; Lynne Buchanan, PhD, APRN-NP, BC;
and Amber Golden, DNP, APRN, AGPCNP-BC

ABSTRACT
Downloaded from https://journals.lww.com/nurseeducatoronline by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 10/14/2021

Background: Integration of telehealth preparation for nurse practitioner (NP) students varies across programs.
Problem: Nurse practitioner students had gaps in the preparation for using telehealth technology to deliver care and manage
specific disorders.
Approach: The purpose of this article is to describe the development and implementation of a telehealth simulation training
experience for NP students to prepare them for practice in rural settings.
Outcomes: Nurse practitioner students from various specialties completed the telehealth simulation training experience. The
change in presimulation/postsimulation confidence and readiness scores were statistically significant.
Conclusion: This telehealth simulation training experience provided an opportunity for NP students to engage in activities to
enhance their knowledge and preparation in providing care via telehealth in a rural setting.
Keywords: nurse practitioner students, simulation, telehealth simulation, telemedicine

Cite this article as: Emerson MR, Buchanan L, Golden A. Telehealth simulation with graduate nurse practitioner students. Nurse Educ.
2021;46(2):126-129. doi: 10.1097/NNE.0000000000000843

A
ccess to care in rural populations remains an on-
going challenge. Geographical barriers, limited
availability of specialty services, identification of
specific community needs, demographic variables, and the
remote, isolated nature of rural locations are all challenges
that can impede access to care.1-3 Telehealth provides a
mechanism by which rural communities can gain access
to specialty services such as psychiatry,4 and barriers to
accessing care can be managed.5 Potential benefits that
telehealth can provide include cost reduction for patients,
decrease in hospital readmissions, and improved health out-
comes.6 Clinical practices thatuse telehealth services should
be diversified to encompass specialty and primary care
delivery options3 and be congruent with the needs of the
communities the telehealth technology is trying to reach.
To meet the demands of rural communities, nurse practi-
tioners (NPs) and other providers need to be prepared with
the skills necessary to do so.6 The purpose of this article
Author Affiliations: Assistant Professor (Drs Emerson and Golden) and
Associate Professor (Dr Buchanan), College of Nursing, University of
Nebraska Medical Center, Omaha.
The authors declare no conflicts of interest.
Correspondence: Dr Emerson, University of Nebraska Medical Center, 42nd
and Emile, Omaha, NE 68198 (margaret.emerson@unmc.edu).
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s Web site (www.nurseeducatoronline.com).
Accepted for publication: March 16, 2020
Published ahead of print: April 20, 2020
DOI: 10.1097/NNE.0000000000000843
is to describe the development and implementation of a
telehealth simulation training experience used with NP
students to prepare them for telehealth roles in the rural
setting. The article provides an overview of the steps taken
to develop a telehealth training simulation, describes the
rationale and development for the learning objectives for
the simulation, discusses specific strategies incorporated
into the structure of the simulation that were used to
inform quality improvement steps, and discusses future
telehealth simulation training directions that stemmed from
our learning.
Problem
Best practices for NP educational experiences emphasize
the importance of identifying rural community needs while
addressing pertinent health care trends such as integrated
care, telehealth, and substance use.7 Yet, these clinical focus
areas and content integration in specific NP programs varies.
In a recent inquiry of our NP students, gaps were identified.
These gaps prompted faculty to devise a way in which to
ameliorate these knowledge deficits.
As telehealth services grow to meet the needs in rural
communities, educators need to explore how to prepare
our present and future NP students to provide telehealth
services. Beyond familiarization with these technologies,
practitioners should have opportunities to practice and
apply these skills in the clinical setting. Ensuring students
have direct clinical experience with preceptors who conduct
telehealth to deliver care in rural communities is challenging.

126 Nurse Educator • Vol. 46 • No. 2, pp. 126–129 • Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. www.nurseeducatoronline.com

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

When telehealth preceptors are not readily available to
provide this educational experience for graduate students,
educators need to explore other options.
Standardized patient (SP) experiences are an increas-
ingly common strategy used in NP programs. Standardized
patients can provide an opportunity to expose students
to clinical scenarios that are difficult to obtain such as
telehealth. Understanding the development and utilization
of telehealth simulation training efforts to facilitate student
readiness for practice and allow students to develop clinical
skills and manage common disorders seen in rural settings
via telehealth is essential for faculty.
Approach
Graduate NP students were invited to participate in a
telehealth simulation training experience. The NP students
were informed that this would be an additional learning
opportunity, which focused on telehealth, and participa-
tion was voluntary. At the time of development, there were
no specific telehealth simulation trainings that focused on
rural needs. Foundational to the development of this expe-
rience was determining the objectives for the experience,
which needed to be congruent with National Organization
for Nurse Practitioner Faculty competencies for telehealth.8,9
Second, it was essential to ensure that the simulations
were adherent to the standards in the International Nurs-
ing Association for Clinical Simulation.10
Because rural communities will not have the same needs,
input was obtained from rural providers and community
leaders to determine the top concerns that impact health
within their surrounding communities. The faculty involved
in the development of the content for the telehealth simu-
lation training were purposeful in creating training expe-
riences that were based on real-world identified needs both
to prepare the students to manage these issues in the places
they could anticipate practicing on graduation and to pro-
vide more meaning to the experience itself. The needs iden-
tified from the community feedback included substance
use disorders, depression, and access to mental health as
priority areas. Based on this information, it was deter-
mined that the simulation learning objectives for the stu-
dents would focus on (1) understanding and applying
the diagnostic criteria for both major depressive disorder
(MDD) and alcohol use disorder (AUD); (2) implementing
interventions commonly used in the primary care setting to
address these disorders, highlighting motivational inter-
viewing and Screening Brief Intervention and Referral to
Treatment; (3) exploring medication options for these dis-
orders; and (4) familiarizing themselves with the use of
telehealth technology to manage care of patients with these
disorders.
To accomplish the learning objectives, the simulation
training was designed to take place in 3 stages. The first
stage consisted of online training delivered via a learning
management system (LMS) to familiarize the students with
telehealth concepts, motivational interviewing, and MDD
and AUD diagnostic criteria, along with treatment options
Nurse Educator • Vol. 46 • No. 2.
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
for these disorders. The content was developed using ex-
perts who were knowledgeable on the evidence-based prac-
tices and trends relevant to motivational interviewing,
psychiatry, and telehealth. In addition, to promote student
learning and reduce potential performance anxiety during
the actual SP telehealth simulation training experience, edu-
cational materials were provided in advance via the LMS.
The students were able to access these modules 4 days be-
fore the in-person simulation date.
The second and third stages were part of an in-person
training simulation day. The second stage was designed to
be completed in the first half of the in-person training simu-
lation day. During this time, students engaged in active
learning exercises that emphasized and reinforced the
objectives for the pilot project, reinforced important take-
away messages that students would need to complete a suc-
cessful telehealth simulation training experience with an SP,
and build confidence in their ability to do so. In the role-
playing exercises, students were paired up and assigned
to a faculty member. The students interviewed each other
using a previously developed case scenario, which focused
on MDD and AUD presentations based on realistic case
studies. The students took turns interviewing each other.
On completion of the interview, the assigned faculty mem-
ber, along with the student who was interviewed, provided
feedback, highlighting what went well and what could be
improved and addressed any question/concerns. Once all
the pairs completed the role-playing exercises, the larger
group reconvened to discuss how the role playing went.
The third stage was the actual student telehealth simu-
lated training experience completed with an SP who was
prepared to present with a mental health disorder. Each of
the students was expected to conduct an assessment of
an SP via simulated telehealth, followed by a debriefing
session. The students were directed to their own individual
rooms where they were responsible for initiating and con-
ducting a telehealth encounter with the SP via virtual video
conference technology. The assigned faculty and SP were in
a separate, private room. The faculty were strategically
placed so they could observe the student's visit encounter
from a patient's perspective. After the completed visit, the
SP and faculty member provided feedback and offered time
for the student to pose questions.
After the telehealth simulation training experience with
the SP, the students and faculty members gathered for a
group debriefing session. After the debriefing, students eval-
uated the overall telehealth training simulation experience.
The information collected during the debriefing sessions
and from the evaluation was used to inform quality im-
provement efforts before the second simulation.
Outcomes
A total of 11 graduate NP students completed the telehealth
simulation training experience. The first simulation con-
sisted of 4 NP students, 2 psychiatric mental health NP stu-
dents, 1 family NP student, and 1 adult gerontological NP
student. The students were asked to evaluate the materials
www.nurseeducatoronline.com 127
and activities related to his/her simulation experience on
a scale of 1 (strongly disagree) to 5 (strongly agree) with
an 11-item survey. The mean scores ranged from 4.75
to 5.00. The results of telehealth simulation evaluation
questions for the first simulation are provided in the Sup-
plemental Digital Content, Table 1, http://links.lww.com/
NE/A772.
Debriefing
During the debriefing sessions, the students in the first sim-
ulation identified that the telehealth simulation allowed
them the opportunity to apply motivational interviewing
skills. Practicing these skills through role-playing along
with the SPs helped the students develop these skills and
improved the flow of their conversations. One student in-
dicated that it was helpful to see how life stressors includ-
ing the loss of a significant other and the loss of a job played
into mental health symptoms. Another student stated that
debriefing allowed them to identify what they should have
explored more when they were with the SP.
Before the second simulation, the telehealth simulation
training material was adjusted to incorporate the feed-
back received from the students in the first simulation.
This included adding additional role-playing exercises,
adding a presimulation and postsimulation assessment
of readiness and confidence, adjusting the student evalua-
tion of the overall simulation experience, increasing the
application of MDD and AUD guidelines during the sim-
ulation day, and increasing didactic content on motiva-
tional interviewing.
The second simulation consisted of 7 graduate NP stu-
dents (1 psychiatric mental health NP student and 6 family
NP students). The students in the second simulation were
again asked to evaluate the materials and activities related
to the simulation experience on a scale of 1 (strongly dis-
agree) to 5 (strongly agree) with a modified 11-item survey.
The mean scores ranged from 3.86 to 4.57. The results of
telehealth simulation evaluation questions for the second
simulation are provided in the Supplemental Digital Con-
tent, Table 2, http://links.lww.com/NE/A773. The students
in the second simulation were also asked to indicate their
level of confidence and readiness in completing a telehealth
visit both pre and post simulation on a readiness and con-
fidence ruler. The confidence and readiness rulers were
adapted from the literature. The Mann-Whitney U, a non-
parametric test, was used to determine the differences in
readiness and confidence scores of the students. The change
in confidence score was statistically significant (P = .017).
The change in readiness score was also statistically signif-
icant (P = .016). These changes indicate that simulation-
based learning with SPs was effective in increasing confidence
and readiness to complete a telehealth visit.
The following themes were identified among the stu-
dent comments in the second simulation: (1) practicing with
SPs was a way in which to create a training experience much
like actual clinical practice, (2) having relationships with
other health care professionals outside of his/her specialty
128 Nurse Educator • Vol. 46 • No. 2.
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
area to use as a resource when dealing with disorders not
commonly encounteredis important, and (3) the simulation
experience was helpful in understanding how different it
was meeting with an individual via telehealth vs in person.
Discussion
Telehealth can enhance access to care in rural settings.
Accordingly, graduate nursing programs need to provide
a means in which students can gain exposure and comfort
in delivering care via telehealth to promote utilization of this
type of technology. Providing telehealth via virtual experi-
ences can increase student knowledge and prepare students
to provide this type of care in the rural setting.11 Overall, the
telehealth simulation training experiences conducted for
this project intended to meet the needs of the community
while simultaneously providing an opportunity for NP stu-
dents to engage in a virtual telehealth visit.
The simulation scenarios were designed to be realistic
and address needs within specific communities that the
NP students within our program may eventually practice
in. Yet, we know that mental health is a top and common
concern for the broader rural populations, suggesting that
this virtual scenario has application in other nursing curric-
ulums as well.12
The team wanted a second mechanism to evaluate and
inform quality improvement efforts, also derived from the
student perspective. Both simulations used an evaluation
tool, which was completed at the end of the in-person day.
The tool was modified between simulation 1 and 2, but
many of the items were either unchanged or similar. Yet,
there were notable differences seen from simulation 1 to
simulation 2 in terms of mean scores. All of students in sim-
ulation 1 selected either strongly agree or agree for all the
questions on the evaluation in comparison to the broader
student responses received in simulation 2. This suggests
that simulation 1 was potentially more successful than the
second; however, there are plausible explanations for these
differences.
First, the student sample was smaller in the first simula-
tion, allowing for more time to discuss and explore ques-
tions posed during the first half of the in person simulation
day. Second, the materials were tailored to address needs
within the rural community, which happened to be focused
on psychiatric care. In reviewing the student sample for the
first simulation, half of the students were in the psychiatric
mental health NP program during the first simulation in
comparison to only 1 of the 7 in the second simulation. This
suggests that the scenarios should be tailored to program
area of focus.
Limitations
A small sample of NP students was used for both simula-
tions. Larger numbers of students would help to deter-
mine the effectiveness of this training experience. The
students were evaluated using questions that were devel-
oped for the use in this current pilot study and have not
been evaluated for reliability and validity. The readiness
www.nurseeducatoronline.com
and confidence rulers used in simulation 2 have demon-
strated reliability and validity in other populations but
have not been studied in the context of a simulation train-
ing experience.13,14
Future Directions
Future SP experiences should explore ways in which inter-
professional opportunities can be created through telehealth.
Feedback from the students indicated that combining in-
terprofessional education with telehealth technology can
equip future providers with the knowledge and skills needed
for interprofessional care regardless of geographic barriers.15
Face-to-face encounters alone do not adequately prepare
NP students for interprofessional collaboration when car-
ing for patients in rural and underserved areas.16 In addi-
tion, the rural clinical experiences are not providing the
capacity to meet the demands to facilitate rural telehealth
experiences. Conducting simulated telehealth experiences
are one possible solution to this challenge. Developing
real-life clinical scenarios using technology seen in prac-
tice is a means to fill this gap and prepare our future clini-
cians for work they will likely be doing.
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