Patient encounters are instrumental in nursing education to integrate didactic learning with clinical experiences and prepare students for core client needs competencies evaluated on standardized examinations, including the National Council Licensure Examination (NCLEX(R)-RN). Unfortunately, the coronavirus (COVID-19) pandemic severely limited access to clinical experiences for undergraduate nursing students. With the CARES Act Supplemental Health Resources and Services Administration (HRSA) funding, the University of New Mexico College of Nursing utilized telehealth modalities to provide clinical opportunities for undergraduate nursing students who were also veterans. The goal was to lessen the impact of COVID-19 and increase the students' knowledge and perceptions of the use of technology in patient care. Telehealth resembles a type of primary care, and all care is virtual using a phone or tablet. It is a leading national health care model, providing care in the right place at the right time.
BACKGROUND
COVID-19 was the accelerant to using outpatient and virtual settings for nursing student clinicals. When the pandemic hit, nursing schools across the country lost inpatient clinical sites because of the possibility of transmission and the associated liabilities of infection. In New Mexico, a rural and economically poor state, the COVID-19 pandemic left vulnerable populations, including the elderly and chronically ill, isolated and unable to safely access medical care. As universities and community colleges were unable to provide meaningful clinical opportunities for undergraduate nursing students, telehealth modalities provided a mechanism to limit the adverse pandemic effects for patients, health professionals, and students.
Telehealth is the inclusion of technology to collect and disseminate information for monitoring and interpreting patient health (Majerowicz & Tracy, 2010). Patients can be connected to providers regardless of distance for assessment, diagnosis, intervention, consultation, supervision, and information. The integration of telehealth services during the pandemic allowed continued health care and improvement for patients with eating disorders (Raykos et al., 2021), provided cost-effective physical therapy options (Horton et al., 2021), and eased the transition of care from tertiary centers to home (Chovanec & Howard, 2021; Lapcharoensap et al., 2021). The addition and supplementation of telehealth modalities allowed for unique clinical opportunities for undergraduate nursing students.
The VA Home Telehealth program, started by the Veterans Health Administration in 2006, was a perfect setting to quickly ramp up clinical sites for students in their last two nursing school semesters. For the past 16 years, Home Telehealth units have been utilized at every VA location in the country. The data from the program support reduction in hospitalizations and emergency department (ED) visits and shortened hospital stays. In a pilot study, 72 veterans had 334 ED visits and 148 hospital admissions in eight months. After Home Telehealth program enrollment, ED visits decreased by 191 visits and hospital admissions decreased by 94, saving an average of $15,000 per veteran per admission (Bodar & Chalaron, 2020).
The Home Telehealth program is voluntary and free to every veteran who meets inclusion criteria. The focus is on those with newly diagnosed chronic conditions or a recent exacerbation. Referrals come from primary care physicians or at hospital discharge meetings. The goals are to stabilize the disease process through education, medication management, and support. After these goals are met, veterans are discharged from the program.
After providing consent, veterans are enrolled in the Home Telehealth program with one of the following diagnoses: heart failure, diabetes, chronic obstructive pulmonary disease, post-traumatic stress disorder, dementia, myocardial infarction, hypertension, obesity, and/or depression. During enrollment, they are given a hub (tablet) that transmits vital signs to the dashboard site for care coordinators (RNs) to monitor and act. Each RN manages a panel of 50 to 70 veterans; vital signs show up on the dashboard for daily review.
STUDENT CLINICAL EXPERIENCE
Students, who are also veterans, were recruited to participate in the University of New Mexico Veterans into Primary Care Nursing HRSA grant and VA Home Telehealth clinical. Before enrolling, students were required to obtain Without Compensation VA appointment, meaning that they pledged to follow governmental ethics, laws, and rules. Students were awarded scholarships for completing several of their required clinical experiences in primary care settings. Seven students participated during the time period from fall 2019 to spring 2022.
The clinical instructor, the nursing director for the telehealth program, was hired to facilitate the experience. During the first clinical week, students were given access to VA systems and cell phones that showed a University of New Mexico caller ID. Students learned the VA electronic health record and reviewed VA standard operating procedures, including how to handle a telehealth emergency mental health crisis, such as suicide or violence. In the case of a mental health emergency, students would verify the veteran's location, contact their instructor via TEAMs Instant Messaging, and remain on the phone while the instructor called emergency medical services and facilitated triage.
By Week 2, the students were ready to work with patients. The day-to-day clinical experience followed the workflow described by the Student Clinical Telehealth Delivery System model. The students were assigned to one or two nurses who each monitored a computerized panel of patients. The students and nurse viewed alerts, such as changes in weight, blood pressure, or laboratory values, received during the late afternoon or evening utilizing a six-step process to review data and findings.
1. Alerts that needed follow-up were coded yellow or red and comprised the initial report.
2. A record review, with questions that potentially helped clarify the alerts of concern, was completed on the yellow and red alerts.
3. A laboratory review helped the student-nurse pair evaluate data trends relevant to the alert.
4. The student then assessed past and future appointments for corroborating evidence impacting the current alert, notifying the instructor using the Situation-Background-Assessment-Recommendation (SBAR) format and creating a plan prior to calling the veteran.
5. A call to patient was made initially by the student with the instructor on the phone. As nursing students gained confidence and skill, they began making the phone calls on their own. During the call to the patient, the students always informed the veteran that they were speaking with a nursing student.
6. The student documented all relevant information (documentation of televisit), which was cosigned by the clinical instructor, thus allowing engagement and input by other interprofessional team members.
DISCUSSION AND IMPLICATIONS
Students were unable to practice hands-on patient skills, such as Foley catheter placement, but the VA telehealth clinical experience provided students the opportunity to advance clinical judgment, conceptualize patient situations, and enhance therapeutic communication. The telehealth clinical delivery expanded the students' view of access provided by technology, including continuous care coordination that prevented exacerbations, ED visits, and hospital admissions.
Our students received state-of-the-art education in telehealth through their clinical experience with the VA Home Telehealth program. Many nursing programs do not have access to these programs; however, there are many approaches to integrate telehealth into nursing curricula. Introduction of telehealth into didactic on-the-ground or online coursework is an initial step, with the potential to integrate telehealth in simulation for both prelicensure and nurse practitioner students. Faculty collaboration with clinical agencies to establish a telephone intervention program would be a low-cost form of telehealth for student involvement. Finally, identifying and partnering with clinical sites that pivoted to and retained use of telehealth during the COVID-19 pandemic would be a beneficial strategy for nursing programs to embed telehealth into clinical courses.
The successful use of telehealth during the COVID-19 pandemic has propelled this as a permanent modality in our health care system (Bestsennyy et al., 2021). The National Academies of Sciences, Engineering, and Medicine's (2021)Future of Nursing 2020-2030 report underscores that technology such as telehealth mitigates barriers to patient care including transportation, geographical location, and social support and notes that the inclusion of telehealth training in nursing curricula is now crucial. The American Association of Colleges of Nursing's (2021) new essentials highlight the need for students to be educated in diverse clinical settings including primary health care settings. The VA Home Telehealth program demonstrates the primary care management of chronic diseases and prevention of negative sequelae. Telehealth clinical experiences provide students with opportunities to meet competencies and subcompetencies in 10 essential domains (see Supplemental Content for Table 1, available at http://links.lww.com/NEP/A357, which demonstrates the crosswalk of the experience to the 10 essential domains).
Integration of telehealth into nursing programs does not need to involve a major curriculum revision, but curricula evaluation is needed to identify where telehealth concepts can be integrated. Nurse faculty can investigate their own institutional resources related to telehealth and collaborate with other health care disciplines or clinical agencies already implementing telehealth. Faculty development of a step-by-step approach to integrate telehealth into their nursing programs could promote success of this clinical opportunity for students.
CONCLUSION
Collaboration with the VA Home Telehealth program was a welcomed opportunity to develop a new clinical experience for nursing students during the height of the COVID-19 pandemic. With clinical sites becoming more difficult to acquire, the use of telehealth programs can enrich student clinical experiences. Faculty development will be needed to acquire knowledge and experience with telehealth modalities. Students will need to be taught skills to foster caring patient relationships through technology.
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