With the rapid adoption of telehealth as a modality to provide quality health care at a distance, measures need to be in place to ensure that remote care affords patients with the same sense of well-being as in-person visits. Barriers to the utilization of telehealth include the loss of personalization and therapeutic communication (Cowan et al., 2019; Kocsis & Yellowlees, 2018; Wiljer et al., 2019). To combat these barriers, telehealth providers must be educated on the interpersonal skills and environmental requirements that are needed during a telehealth visit. These are known as telehealth professionalism or telehealth etiquette.
It is important to note that telehealth professionalism not only encompasses therapeutic communication with the patient but also addresses several areas that contribute to a seamless telehealth visit at both the originating and distant sites (Gustin et al., 2020; Maheu et al., 2018; Rutledge et al., 2017). This article describes how one graduate nursing program combined a telehealth professionalism activity with telepsychiatry training in an existing clinical course for advanced practice registered nurses (APRNs). Reports of a pretest-posttest are presented, along with student comments from debriefing and a short essay evaluation.
BACKGROUND
Telehealth is defined as providing care at a distance using telehealth technologies such as remote patient monitoring, asynchronous or synchronous visits, or mobile health (Rutledge et al., 2017). Telehealth has been shown to improve patient outcomes and increase access to health care (Conrad et al., 2020), with health outcomes comparable to in-person visits (Crawford et al., 2016; Kocsis & Yellowlees, 2018). With the COVID-19 pandemic, social distancing has greatly increased the use of telehealth modalities to connect health care providers to their patients for acute and chronic disease management, including mental health services (Conrad et al., 2020). Because of its increased use, it is essential that health care providers be familiar with all aspects of telehealth, including telehealth professionalism, while upholding standards of care.
Telehealth professionalism encompasses both provider and environmental standards for telehealth visits: a clean, clutter-free view of the distant site by the patient; establishment of privacy; minimization of disruptions; proper use of telehealth equipment; provider persona (choice of clothing, demeanor); proper therapeutic communication techniques; and the interpretation of the patient's body language (Gustin et al., 2020; Rutledge et al., 2017). These soft skills, an integral part of telehealth to increase both provider and patient satisfaction, are often overlooked, even though they are directly supported by several professional organizations (Gustin et al., 2020; Maheu et al., 2018; Rutledge et al., 2018; Shore et al., 2018). It is essential that professionalism be part of general telehealth education, whether integrated into the health care curriculum or prior to its use (Crawford et al., 2016; Gustin et al., 2020; Wiljer et al., 2019).
TELEHEALTH ACTIVITY
The Doctor of Nursing Practice curriculum (adult-gerontology, family, pediatric, and psychiatric-mental health nurse practitioner) at a college of nursing in the southeastern United States has telemedicine elements scaffolded throughout. The current module focuses on telehealth professionalism and contains a self-paced online module composed of two video lectures with pretests and posttests, followed by a face-to-face (F2F) 90-minute discussion during an on-campus learning-intensive activity. Students initially completed a self-paced module with a pretest to assess prior knowledge. They then viewed two prerecorded video lectures: 1) a 25-minute lecture on telehealth professionalism and therapeutic communication developed by faculty and 2) a 12-minute lecture on telepresenter and teleconsultant roles developed by the medical academic center's center for telehealth.
The first video discusses the essentials of therapeutic communication: provider skills with verbal and nonverbal communication, recognition of patient nonverbal cues, and ideal environmental considerations (e.g., proper placement of the camera, looking at the camera to simulate eye-to-eye contact, and appearance and privacy of the distant site). The second video provides a brief introduction of roles and responsibilities. The final step of the module is a posttest with identical questions to the pretest and an essay question requesting student feedback.
After watching the videos, students participated in a F2F 90-minute discussion on the evidence-based management of depression during pregnancy, an already established on-campus activity within their weeklong learning intensives. To introduce telepsychiatry and reinforce skills learned in the telehealth module, the activity was augmented with a prerecorded telepsychiatry visit between a psychiatric-mental health nurse practitioner and a standardized pregnant patient. This provided students the opportunity to apply knowledge gained from the telehealth module to identify appropriate therapeutic communication, professionalism elements, and provider-patient roles. The program assessment project was deemed exempt by the institution's review board.
EVALUATION
A pretest completed by 59 students to assess preexisting knowledge had a low average score (67 percent) with item discrimination indices between -2.4 percent to 32.7 percent, indicating that most students lacked knowledge of telehealth soft skills and telehealth roles. The posttest, after students viewed the two prerecorded lectures, was completed by 96.6 percent of students (57/59). It yielded an average score of 92 percent with increased discrimination indices of 24.1 percent to 81.4 percent, suggesting that the information presented through the lectures increased student knowledge regarding telehealth professionalism and telehealth roles. The trend in student feedback was similar for the posttest short essay feedback question and centered on the recognition of subtle nuances needed to perform a successful telehealth visit, as illustrated by one student's comment: "This module was very informative and made several points that I never considered to be important during a video encounter."
The F2F portion of the telehealth activity was deemed valuable as an adjunct to the self-paced module. For most students (93.9 percent), the content increased confidence in the managing of depression in pregnancy. Student evaluations acknowledged appreciation of the modeling of interdisciplinary collaboration among APRNs. Overall, students indicated a desire to obtain future content in a similar format throughout their APRN education. Debriefing provided verbal student feedback, for example, "It was valuable to see a case in which referral for mental health care was modeled" and "Seeing our faculty demonstrate screening and communication was very helpful."
DISCUSSION AND CONCLUSION
The format of this telehealth activity showed promising results in educating APRN students about telehealth professionalism, therapeutic communication, interdisciplinary collaborations, and the application of these skills within a telepsychiatry visit. Student feedback was supportive and indicated the need for similar experiential activities to be integrated within the curriculum. As no student satisfaction survey was completed for the F2F activity, it was difficult to separate feedback for the overall weeklong in-person learning intensive and those specific to the telehealth activity. Another limitation was the large group size for the F2F activity, which limited participation by all students.
This article describes one model for combining telehealth professionalism and telepsychiatry training in a multifocal APRN program. APRN students benefit when they learn how to perform an effective telehealth visit and experience the impact of telehealth professionalism on provider and patient satisfaction. The results of this activity support its continued use for this clinical course, with minor adjustments to address the identified limitations.
The 21st century APRN will need education and preparation to perform effective and successful telehealth visits. Preparing APRN students to deliver telehealth is important to their education to practice in an ever-changing health care environment. Support for the practice of telehealth and telepsychiatry continues to grow, yet research on how and where to best provide APRN students with this content is inconclusive. We continue to evaluate the essential competencies for telehealth that APRN students should possess and the most advantageous methods to teach this vital information.
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