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Mary M. Rowan, Mary Steffes, Carol Flaten, Lori Rhudy and Nima Salehi

Keywords

simulation, telehealth, telemedicine, telenursing, nursing education, chronic disease management

Telehealth: A New Model of Care

Nurses entering the workforce in the 21st century face unprecedented challenges. The Affordable Care Act (ACA) has given millions of people access to the healthcare system. Furthermore, the changing demographics in the US are widely understood, with an aging population raising concerns about the cost of healthcare. At the same time, the nursing profession faces significant shortages. According to the American Nurses Association, the average age of employed registered nurses is now 50 years (http://www.nursingworld.org/nursingshortage). Workforce projections point to a 574,000 new RN positions by 2022. The changing access to health care services and an aging population, coupled with the shortage of nurses could spell a crisis. New models of care and the related technological tools are being developed to manage the projected increase in demand for services. One such model is telehealth—a broad term that includes the provision of healthcare when the provider and patient are at different locations.

According to the Centers for Disease Control and Prevention, 70% of deaths in the US are due to preventable conditions (www.cdc.gov). Healthcare in the US is undergoing a shift from hospital-based tertiary care to community-based health promotion and disease prevention. This shift has been accelerated by changes in reimbursement policies under the Patient Protection & Affordable Care Act of 2010 (42 U.S.C. § 18001). Nurses entering the workforce today must be prepared for a major role in delivering community-based or home-based care as the focus on disease prevention, health promotion and chronic disease management becomes prominent.
A significant number of nurses are expected to be engaged in providing chronic disease management that is aimed at reducing the frequency of hospitalization for this population. These nurses must be competent in using telehealth technologies to provide safe, quality nursing care to patients located at a distance from the care provider (e.g., patients in their home). The technology extends the reach of the healthcare professional and allows efficient and effective interaction with people seeking healthcare services. It is an essential component of the new models of care being developed for the 21st century (Benhuri, 2010; Murray, 2013; Sevean, Dampier, Spadoni, Strickland & Pilatzke, 2008).

Telehealth: What is it?

Telehealth is a broad term encompassing everything from tele-Intensive Care Units to remote monitoring of the status of individuals with chronic diseases living in residential facilities or at home. Sometimes communication is between healthcare providers and patients, but telehealth also makes it possible for providers to consult with specialists located elsewhere.

Telehealth is real-time two-way, interactive audio and visual communication, including the application of secure video conferencing or store-and-forward technology to provide or support health care delivery. Minnesota has been a leader in adopting policies to enable the use of telehealth technology. Under Minnesota law telehealth is defined as “the delivery of health care services or consultations while the patient is at an originating site and the licensed health care provider is at a distant site” (MN Telemedicine Act 2016). Depending on the types of providers engaged in telehealth, various modifications of the term may be used. For example, telenursing indicates that the provider is a nursing professional interacting with a patient who is located at a distant site while telemedicine might be the preferred term by physicians (Grady, 2014).

Telehealth technologies make use of a wide variety of tools and equipment that enable long-distance assessment, clinical decision-making, care coordination, consultation, and communication between patients and healthcare personnel. Current technology allows for very high quality videoconferencing directly with a patient or between providers. Telehealth technology also includes peripherals such as special stethoscopes, otoscopes, ophthalmoscopes, ultrasound probes, exam cameras, and weight scales, to name a few. These specialized peripherals send high quality digital data instantaneously to the provider. The caveat is that all of the technology used for sending or receiving personal health information (PHI) must be compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Protecting PHI is a key tenet of HIPAA. The complexities of telehealth—everything from using the new technologies to understanding the regulations, call for additions to traditional nursing curricula.

Nursing Education for the 21st Century

The School of Nursing received funding via the Provost’s initiative Enhancement of Academic Programs Using Digital Technology. One of the goals was to develop a new high-fidelity simulation opportunity, including the development of the necessary supporting content for the curriculum. The planning for the telehealth simulation began in 2013, with a goal of implementing a simulation in 2015.

Prior to the beginning of this project, faculty investigated the literature and determined that telehealth competencies for nursing were not well-defined. Furthermore, there was no delineation of the appropriate competencies for various levels of the baccalaureate nursing student (sophomore, junior, or senior). In order to determine competencies, specific telehealth activities that registered nurses currently perform were identified. From this basis, faculty defined core competencies that our pre-licensure nursing students need in order to be able to perform current nursing activities in telehealth as well as predicted future activities.

The following activities were identified:

• Assess a patient’s capacity to use telehealth
• Train and support patients and families using telehealth technologies
• Triage incoming calls and alarms in telemonitoring centers
• Analyze and interpret incoming biometric data derived from self-measurement devices
• Perform a home environment assessment remotely using telehealth technologies
• Perform a focused physical assessment of a patient in a remote location using telehealth technologies
• Use therapeutic communication to educate and support health promotion activities via videoconference
• Use technology to ensure interprofessional coordination of care
• Evaluate and adjust a patient’s plan of care

We found a gap in our curriculum regarding knowledge, skills, and abilities related to telehealth technology in general. Ultimately, this project facilitated the development of content and learning materials needed for senior nursing students to gain an understanding of telehealth and its use for chronic disease management.

Project Planning: Creating a High Fidelity Simulation

The faculty team developed a project plan and began creating the necessary supporting documents for the telehealth simulation. Students had previously completed courses in nursing informatics and public health nursing. They had completed both content and experiential learning with in-person home visits or community-based nursing care. They had also studied content about chronic health conditions and completed clinical experiences with older adults. This previous learning provided a frame for the simulation experience, and we developed more specific telehealth content to enhance the curriculum. The materials we developed to support the telehealth simulation included the following:

• Project planning guide
• Preparation materials for students including class content specific to telehealth nursing
• A case study for use with the simulation (older adult with cardiac failure)
• A script for the standardized patient actor
• A script for the student in the role of family member (adult child of the patient)
• Observer guides for faculty and student peers
• Orientation guide for preparing students for the 3 roles: observer, family member, visiting nurse
• Objectives for the “visiting nurse” including guidelines for conducting a teleconference home visit
• Faculty debriefing guide
• Evaluation survey

We explored various types of telehealth equipment currently used for interacting with patients in their homes. After exploring costs, ease of use, and other features of the available equipment we determined that we could simulate the telehealth visit using equipment and services readily available at the university. The WebEx web-conferencing system is HIPAA-compliant and supported by the university and was a cost-effective and reliable option for connecting the student nurse with the standardized patient (actor).

Additionally, we planned a schedule and workflow for the event that included an orientation for the learners, the plan for implementing the nurse-patient encounter, and the guide for the post-simulation debriefing. Logistical planning included testing the WebEx for use with the computer in the nurse location and testing computer tablets for use in the in the simulated patient’s home setting. We prepared a plan for using telephone back-up in the event that the WebEx or internet connection failed.

Image 1: Student Nurse videoconferencing with Patient in Telenursing Control Center
Image 2: Patient Actor videoconferencing with Nurse in Simulated Home Setting

Implementation

We implemented the inaugural telehealth simulation with 141 senior nursing students participating. The students were located on the Minneapolis and Rochester campuses. The standardized patient was located in Minneapolis.

This simulation event took place in the School of Nursing Bentson Healthy Communities Innovation Center, a 10,000 square foot simulation and laboratory facility. We initiated a teleconference using WebEx and located the student in the role of the public health visiting nurse in a room simulating a telehealth monitoring center. The student sat in front of a computer connected to the internet in order to initiate the web-based videoconference (Image 1).

The Bentson Center has two rooms designed to look like a home setting. The standardized patient and a student portraying his adult child were in this room with the computer tablet connected to the internet for access to the web-based video conferencing system (Image 2). In a third room, faculty and student observers watched the videoconference interaction on a computer screen in real-time. We modified the set-up slightly for our students located on our campus in Rochester. In this instance, two students were in the nurse role and interacted with the patient located in Minneapolis via a computer and WebEx. Two students observed on a computer screen from a separate location. The arrangements on both campuses worked equally well.

Additional faculty and staff were present to orient students to the process, direct them to the various locations depending on their role, and to the debriefing room following their encounter. Faculty observers facilitated the debriefing session in a meeting space at each campus location.

The entire senior nursing class participated in the simulation. Each student had a 15 minute orientation that included time for the students to read through their role instructions. The orientation was followed by a 20 minute encounter between the student nurse(s) and patient. Following the encounter, students were debriefed by faculty for approximately 20-30 minutes. Typically we had 8 students in each debrief session.

Our primary goal was for students to learn about telehealth as a viable strategy for working with people who have chronic illnesses. Prior to the encounter, students received simulated data about the patient’s health status (vital signs and weight showing a rapid gain in a short period of time – indicative of decompensation and fluid retention). Based on the information faculty provided about the case, the likely cause of the weight gain was fluid retention related to dietary sodium. The students needed to interpret the data and determine their plan for providing care.

Engaging in the simulation helped the students learned about telehealth and the various requirements, including the types of equipment and transmissions that were HIPAA compliant. However, the simulation turned out to be a rich educational experience beyond the primary goal of the activity. For example, students did not anticipate that challenges of talking with patients using lay language or conducting an assessment from a distance.

The patient script included prompts from the standardized patient about the recent loss of his wife as well as conflicting statements from the patient and his daughter about the quality of his diet. The patient described the challenges of learning to cook for himself since the loss of his wife. He stated a preference for eating at the local café and described his choices of food (high sodium). The patient also talked about the snacks he preferred (salty snacks). The daughter described her efforts to help by stocking her father’s freezer with prepared dinners (likely high in sodium). Tensions between the father’s self-determination and the daughter’s concern were apparent.

These prompts in the script provided openings for students to explore the patient’s situation, assess his level of edema and evaluate his dietary sodium intake. Furthermore, students had the opportunity to use therapeutic communication strategies including expressions of empathy and active listening techniques.

The Debrief

An advocacy-inquiry approach is used for debriefing simulations in the School of Nursing (Rudolph, J., Simon, R., Dufresne, R., & Raemer, D., 2006). Faculty who observe the simulation serve as the facilitators for the debriefing session. During the typical debrief session a conversation occurs among the group members. The focus is on the exploration of the thinking behind the various actions taken by the student nurses. For example, a faculty member may have observed that the student nurse didn’t respond to a question asked by the patient. The observation would be described along with an inquiry about what the student was thinking at that moment. Often this type of approach uncovers confusion or inaccurate assumptions that the learner holds. This uncovered assumption (mental model) can be corrected by the faculty member leading to new understanding by the learners. The group discussion is designed to encourage deeper reflection about the various choices made by the learners and allow them to self-identify gaps in their knowledge.

Results

The goal for students to learn about telehealth as a viable strategy for working with people who have chronic illnesses was met. The students improved their understanding of telehealth as a strategy for patient care. They became familiar with the various technical and legal requirements, including the types of equipment and transmissions that were HIPAA compliant. They discovered areas for improvement, such as how to communicate effectively.

The patient scenario provided multiple opportunities for students to demonstrate their ability to use professional, therapeutic communication techniques. Students also learned new ways of beginning and ending an interaction with a client. Students were challenged to stay focused on the patient via teleconference and realized that strategies needed to convey active listening and ask clarifying or relevant questions when communicating with a patient via computer are quite different from communication strategies used during in-person encounters.

Ninety percent of the students who completed the post-simulation evaluation (128 evaluations) indicated that they had significantly increased their awareness of telehealth as a method to provide health care. Eighty-seven percent said that the simulation significantly increased their awareness of the need to use plain language to teach patients. Overall, students received first-hand experience with the challenges of interacting with patients located at a distance from the nurse. In addition, the debriefing provided the opportunity for students to correct their mental models and increase their understanding of disease management while properly protecting personal health information. We repeated this simulation in the spring of 2016 with graduating seniors and had similar positive results.

Summary

An exploration of the nursing curriculum revealed a gap regarding telenursing as a viable strategy for the purpose of chronic disease management. Competencies for nursing students were identified and content was developed for existing courses. A high-fidelity simulation was designed to add an experiential component to the telehealth content in the curriculum. The simulated telehealth encounter engaged student nurses with a challenge to assess a patient located at a distance. Student attempted to interpret data, plan care, and implement appropriate strategies to maintain the health of a patient living with heart failure. The debriefing sessions led to new insights for the students.

Using available technology supported by the university made the simulation feasible and cost effective. The goals of the project were achieved. Lessons learned from the first implementation led to modifications of the simulation that streamlined some elements of the process, which is now included in the curriculum. We believe that this simulation was an important addition to the curriculum and helped to fill a gap that has been identified between typical nursing curricula and the experience of nurses in the field who are using these telehealth approaches to efficiently and effectively provide care to a variety of patients.

References

Benhuri, G. 2010. Teaching Community Telenursing with Simulation. Clinical Simulation in Nursing, 6(4), pp. e161-e163. doi:10.1016/j.ecns.2009.11.011

Grady, J. 2014. Telehealth: A Case Study in Disruptive Innovation. American Journal of Nursing, 114(4).

Minnesota Telemedicine Act. 2016. MN Statute 62A.671 Definitions § Subd 9.

Murray, T. A. 2013. Innovations in Nursing Education: The State of the Art. Journal of Nursing Regulation, 3(4), pp. 25-31.

Rudolph, J., Simon, R., Dufresne, R., & Raemer, D. 2006. There’s no Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment. Simulation in Healthcare, 1(1), pp. 49-55.

Sevean, P., Dampier, S., Spadoni M., Strickland, S., & Pilatzke, S. September (2008). Bridging the Distance: Educating Nurses for Telehealth Practice. The Journal of Continuing Education in Nursing, 39(9), pp. 413-8

Acknowledgements

We thank the University of Minnesota Provost for the 2013 Enhancement of Academic Programs Using Digital Technology grants program that funded this project.

We would like to acknowledge Jeanne Pfeiffer, DNP, MPH, RN, CIC, FAAN, Clinical Associate Professor, University of Minnesota School of Nursing, for her contributions regarding the development of telehealth competencies for prelicensure nursing students.