The COVID-19 pandemic has compelled the health care industry to reevaluate traditional methods of health care delivery. During this period of rapid policy change, it has become imperative that nursing students receive suitable training during their didactic education to prepare them for evolving methods of care delivery, particularly telemedicine. Family nurse practitioner (FNP) students at a public university participated in a virtual telemedicine patient experience that engaged the use of a standardized patient (SP). The goal was to enhance the classroom experience while also improving preparedness. We implemented a pilot study to evaluate FNP students' perceived level of preparedness and satisfaction with a simulated telemedicine encounter utilizing an SP.
BACKGROUND
Health care during the COVID-19 pandemic shifted its focus from in-person delivery of services to telemedicine modalities to provide access to care while maintaining social distancing standards. Telemedicine was a rapidly growing health care sector even prior to the pandemic. It increased convenience and improved access to care across the country while boasting a 93 percent patient satisfaction rate in some disciplines (Shaverdian et al., 2021).
The pandemic was a catalyst for accelerated implementation. In March 2020 alone, the use of telemedicine services increased 154 percent with a continued upward trajectory moving into 2021 (Koonin et al., 2020). This increase encompassed expanded use for standard illnesses, the management of chronic diseases, and general wellness visits. However, despite the tremendous increase in utilization, colleges, universities, health care facilities, and community health providers continue to lack formal telemedicine education. Alarmingly, most medical providers who engage in telemedicine practices have received inadequate formal training on how to conduct a telemedicine visit. These facts point to a need for innovation within the structure of graduate education. Evidence-based approaches to education are critical for the continued delivery of technologically savvy, patient-centered care as recommended by the Quality and Safety Education for Nurses initiative (Cronenwett et al., 2007).
It is predicted that telemedicine will remain a major component of our health care delivery model, requiring accessible, formal telemedicine training (Pourmand et al., 2021). The value of telemedicine training, with the use of virtual SPs, has been highlighted in the fields of behavioral and mental health. Little research can be identified discussing the application of an SP experience for professionals collecting both subjective and objective data, particularly FNPs (Talbot & Rizzo, 2019). In addition, the federal government, state Medicaid programs, and private insurers have expanded coverage for virtual health care services, further accentuating the need for education on telemedicine delivery to meet billable standards of care.
Because the graduate-level FNP curriculum is shifting to an online method of delivery, educators continue to seek new methods to foster engagement in the virtual classroom while facilitating a sense of connectedness. Students' ability to feel connected to their learning environment is critical when looking to develop new skills using constructivist principles (Schroeder et al., 2021). In response to these identified needs within health care and education, we implemented a virtual SP experience intended to enhance student preparedness when engaging in telemedicine encounters while diversifying the online classroom experience.
Our study was based on the principles of constructivism, which speaks to the benefits of learning by doing rather than the passive acquisition of knowledge. By engaging students in a simulated patient experience despite their presence in a virtual classroom, we hoped to build student knowledge of the telemedicine encounter through immersion. This study was conducted to address two research questions: First, are students who participate in a virtual telemedicine SP experience satisfied with the experience? Second, do students who participate in a virtual telemedicine SP experience feel better prepared to engage in telemedicine encounters in practice?
METHOD
Following institutional review board approval, a mixed-methods study with a concurrent triangulation design was conducted as part of the scheduled curriculum in a web-based, synchronous, FNP course focused on patient care and professional role acclimation. A voluntary response sampling method was utilized. All students enrolled in this graduate-level course at a public university were presented with the opportunity via email to participate via blinded electronic survey.
Following the recruitment period, participants were asked to complete a faculty-developed survey containing five Likert-style questions to determine their current level of knowledge and comfort regarding the execution of a telemedicine patient encounter. As part of their class experience, students attended an hourlong, web-based lecture from an expert in telemedicine, followed by two 20-minute SP experiences. The SP experiences were scripted by course faculty and focused on a health issue that would require a focused examination. Faculty acted as the SP for the purpose of the exercise.
Students worked in groups of nine with preassigned roles (e.g., collect chief concern, history of present illness) to conduct a patient evaluation and collectively formulate their top three differential diagnoses, along with a plan of care. After each 20-minute SP experience, students engaged in a 10-minute debriefing with the course faculty to discuss their differential diagnoses, further develop a plan of care, and reflect on the challenges of the exercise. The SP experiences were not graded to allow for full immersion and encourage participation without the perception of penalty. At the end of the class period, a survey was distributed to the group. It included the same five Likert-style questions as the pre-experience survey for comparison and three open-ended prompts. Students were asked to reevaluate their perceived comfort with completing a telemedicine examination and reflect on their experiences and general satisfaction with the SP encounters.
Thirteen students completed the pre-experience survey; 10 completed the post-experience survey. The data were analyzed as separate aggregates with a comparison of Likert scale items between the pre and post data. Three categories were determined to be statistically significant with paired t-testing. The qualitative data were reviewed as individual participant responses using content analysis procedures to identify emerging themes. The recurrent nature of the emergent themes suggests that saturation was met within the sample size.
RESULTS
Following data analysis, three categories were determined to be statistically significant with paired t-testing. The mean value of students' perceived ability to collect a subjective health history using a telemedicine format was significantly higher post-experience (M = 2.38, SD = .870) than pre-experience (M = 3.40, SD = 1.075), t(21) = -2.507, p = .020. Similarly, the mean value for perceived ability to collect a comprehensive objective exam using a telemedicine format was significantly higher post-experience (M = 3.20, SD = .919) than pre-experience (M = 2.00, SD = .408), t(21) = -4.220, p = .000. Finally, perceived confidence to formulate a differential diagnosis using the information gathered during a telemedicine assessment was significantly higher post-experience (M = 3.10, SD = .568) than pre-experience (M = 2.15, SD = .689), t(21) = -3.517, p = .002.
Qualitative data regarding the experience of the activity were generally positive. Emerging themes from data analysis included an appreciation for why education on the telemedicine modality was critical for a new nurse practitioner, an appreciation for the challenge of conducting a timed history and physical in the telemedicine format, and improvement in students' reported confidence conducting a telemedicine examination post-experience.
DISCUSSION
Identifying methods to engage students with simulation in the online classroom can be challenging; however, the push to online programs of study for the FNP student population makes it critical to develop meaningful methods of student engagement in the virtual classroom. Limitations of this study include the sample size and the possibility that although no part of their course grade was impacted by the study and all responses were anonymous, students may have felt inclined to participate because of their course involvement
The transition toward the increased utilization of telemedicine modalities has been expeditiously accelerated by the pandemic and promises to be a permanent fixture in the health care landscape. There is now an unaddressed need to teach providers how to safely, effectively, and ethically conduct telemedicine encounters. The use of SPs in a virtual, telemedicine format for student nurse practitioners offers a solution for keeping students engaged and thinking critically while also developing valuable skills of telemedicine consultation. Standardized patients are already used virtually in the fields of behavioral and mental health. Our pilot study resulted in statistically significant improvement in FNP students' perceived ability to care for telemedicine patients while also garnering positive support regarding the effectiveness and value of the activity. Future application of this learning method will require larger scale, longitudinal studies to determine the prolonged impact as students transition to practice; however, our results indicate this is a promising inclusion to online graduate studies to improve confidence and perceived readiness for telemedicine practice.
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