Telenursing encompasses the delivery of remote nursing care services using telecommunication technologies and is rapidly expanding to allow more cost-efficient, accessible, and patient-centered health care outside of hospital settings.1 Telenursing poses challenges related to nursing assessment, monitoring, consultation, and patient education because of digital communication requirements.1 Preliminary evidence supports increasing telenursing curricula in prelicensure nursing education2; however, simulation literature incorporating standardized patient (SP) actor-to-learner feedback is limited. Simulation-based education is commonly used in nursing programs because it provides a safe and learner-centered environment.3 Simulation-based education using SPs that are trained to replicate interactive clients within different clinical scenarios creates a conducive and realistic learning environment for students to develop patient teaching and communication skills.3,4 A unique and valuable difference in simulation with SPs is the capability for students to receive feedback on their performance from the patient perspective.4 The purpose of this article is to describe the implementation and evaluation of simulated telenursing encounters using SPs trained to provide direct student performance feedback.
Thirty-two baccalaureate nursing students from a large Midwestern public university participated in the simulated telenursing encounters during the spring semester of 2020 that included the following demographic information: 5 males (15.6%), 29 Caucasians (90.6%) and 3 Hispanics (9.4%), 11 students from a rural residential background (34.4%), nonveterans (100%), and primarily between the age of 18 and 24 (96.9%). These students were introductory and intermediate students enrolled in an undergraduate ambulatory nursing care coordination, transitional care, and disease self-management education program. The learning experience was integrated into a regularly scheduled nongraded simulation and conducted via video conferencing software. The students participated in one-to-one 85-minute SP simulated telenursing encounters designed as disease self-management nurse visits. The facilitator was a faculty member certified in health care simulation education with over 16 years of simulation experience.
Communication Evaluation Forms
The simulation faculty created a student self-reflection and an SP feedback form focused on student communication skills. Each form included 10 statements such as "made the patient feel comfortable," "made the patient feel safe," "verbally explained information using basic terms," and "made good eye contact with the patient." Students and SPs independently rated their level of agreement with the statements using a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Both forms included a narrative section to provide 2 areas where students did well and 2 areas where they could improve. The last section of the self-reflection form was a narrative section for students to reflect on their achievement level of the simulation objectives. Neither the student's self-reflection nor SP feedback form data were collected by faculty, but rather used by the student and SP as tools to assist each with honest and transparent self-reflection/feedback. The SPs used the student feedback form as a reference to provide verbal feedback directly to the student.
Simulated Patient Training
The 8 SP participants were hired specifically for the ambulatory nursing education program and attended a 2-hour SP training with an experienced SP educator. The SPs had prior experience with face-to-face simulation experiences but not with simulation conducted via video conferencing software. Therefore, an additional 2-hour training was conducted with the SPs before the actual simulated telenursing encounter. The SPs viewed real-life examples of telenursing encounters, participated in a briefing of the telenursing encounter details, role-played with each other using the virtual breakout rooms, and received performance feedback. The SPs were also oriented to the faculty-developed standardized feedback form, which included statement prompts for providing constructive and appreciative feedback on their patient-centered communication techniques.
Simulated Telenursing Encounter Design
The clinical scenarios were developed using key elements of the NLN Jeffries Simulation Framework for SP Methodology: SP education, standardization, and incorporation of SP feedback in the debriefing.2 The clinical scenario designed for the introductory students featured a patient requesting an appointment to discuss their type 2 diabetes and was unknowingly experiencing symptoms of depression. The introductory students were expected to use the Patient Health Questionnaire-9 to perform routine mental health screening and recognize positive symptoms of depression that would require a primary care provider's attention and could be addressed through a telehealth encounter. The clinical scenario designed for the intermediate students featured a patient with type 2 diabetes, borderline high blood pressure, and need for additional healthy lifestyle disease self-management education. The students were expected to educate the patient about healthy nutrition, physical activity options, and where to access low-cost medications using educational materials developed by professional health educators and social workers.
The facilitator conducted a 15-minute prebriefing in the virtual main room, which included orientation to the general process and logistics, review of the experience objectives, and an introduction to the patient information. The 20-minute simulated telenursing encounters took place in individual virtual breakout rooms with 1 student and an SP. Students returned to the virtual main room with the group when they finished their one-to-one encounter, and then spent 10 minutes completing the self-reflection form, followed by a 20-minute debriefing. Students returned to the virtual breakout rooms with the SPs to receive one-on-one feedback for up to 15 minutes, and then returned to the virtual main room for a final 15-minute group debriefing with the facilitator.
After the simulation experience, participants completed a separate faculty-developed electronic simulation experience evaluation survey. The survey included 10 items eliciting perceptions regarding the design of the simulation experience, value of the experience, and faculty facilitation of the experience. Students rated their level of agreement or disagreement with each item using a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Students could also provide narrative comments about the overall SP encounter, the experience of receiving feedback directly from the SP, and opportunities for improving the simulated telenursing encounters.
Results
Atotal of 25 of 32 (78%) students completed the simulation evaluation survey, resulting in a mean score range from 2.00 (SD, 1.29) to 4.80 (SD, 0.41). The highest rated items included that the SP feedback was constructive and beneficial (mean, 4.80; SD, 0.41), useful for future clinical experiences (mean, 4.72; SD, 0.54), and conducive to selfreflection (mean, 4.64; SD, 0.49). The lowest rated item included the preference to receive only written feedback from the SPs versus feedback directly via in-person or virtually (mean, 2.00; SD, 1.29) and the perception that there was not enough information provided before the simulation (mean, 3.56; SD, 1.39). Students reported the SP feedback was the most helpful for improving future clinical performance and confidence. Students appreciated the opportunity to practice their communication and motivational interviewing skills. They also appreciated the immediate and individualized feedback from the patient perspective, perceived as more genuine and helpful than written feedback received in previous simulation experiences. Students also appreciated the opportunity to ask the SP questions about their feedback. Responses indicated learners prefer more preparatory information during the prebriefing and that future simulation scenarios should include other interprofessional students, uncooperative patients, and difficult conversations.
Conclusion
Nursing students reported positive learning perceptions of the simulated telenursing encounters and valued the individualized feedback they received from the SP regarding their communication skills. Individual SP feedback positively impacted student knowledge, confidence, and overall experience. Overall, the use of simulated telenursing SP encounters provided students a realistic patient care experience with quality feedback to support improved telenursing performance. Additional research investigating learner outcomes from simulated telenursing encounters using SP feedback is warranted.
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