Virtual Clinical Experiences with Real Patients for Advanced Practice Nurses:
A White Paper

Catherine Corrigan, Doctor of Nursing Practice, Family Nurse Practitioner, 
Nurse Educator, Midwife, RN, RCN

In this white paper, the author presents the benefits for advanced practice nursing education from the perspective of the educator, regarding 1) the use of entrustable professional activities for competency acquisition, 2) telemedicine education, 3) remote clinical placement encounters with real patients, and 4) interactive patient-focused education in partnership with the practitioner. The unique attributes of an innovative telemedicine system that involves real patient encounters are detailed in relation to advanced practice nurses (APNs). Remote health care (live interactive videoconferencing using electronic communication), is known as telemedicine, whereas telehealth pertains to a broader scope of health care services.[1],[2]

Background

Health care delivery is rapidly changing with advancements in technology and an increasing demand for remote telehealth services to meet the health care needs of rural communities.[3] According to a 2021 report from the Center for Disease Control and Prevention (CDC), 37% of all adults in the United States use telemedicine.[4]  In 2021, as many as 94% physicians in Canada were using virtual care;[5] however, many other countries around the world have not had the same uptake, for instance Germany and Italy. Hungary does not have a modern telemedicine system and Australian health care providers prefer to use telephone rather than video conferencing.[5] New Zealand on the other hand, have a national telehealth service with a clinical technology platform.[6]

Among the many advantages of telehealth /telemedicine are:

1. Accessibility: access to health care services for individuals who are unable to visit a health care centre due to distance, mobility problems, transportation issues, or other reasons, can now receive health care services from the comfort of their homes, without the need for travel. This reduces the burden of travel costs and time and makes health care services more accessible.
2. Cost-effective: remote health care is often more cost-effective than traditional health care services as it reduces the need for expensive in-person visits and often reduces the need for hospitalization.[7] Telemedicine has the potential to reduce health care costs for both patients and health care providers.
3. Improved patient outcomes: remote health care can lead to improved patient outcomes[2] by providing early detection and treatment of conditions, better medication adherence with better patient-provider contact and improved disease management[8] to include self-care.7
4. Enhanced health care delivery: telehealth access to health care enables health care providers to reach a broader audience, improve patient engagement and enhance health care delivery by providing patient-centred, personalized care. Telemedicine care can be equal to in-person care for some acute and chronic disease states.[2,5]

Telemedicine can also be used to educate the health care workforce. Virtual learning was already well established, but the need for teaching and learning remotely was further accelerated by the Covid-19 pandemic that drastically restricted access to clinical sites for health care students worldwide. Health care organizations allowed access to essential practitioners only, limiting opportunities for nursing students to fulfil their practicum hours requirement.[9] The lack of clinal placement sites resulted in the need for a rapid transition to virtual teaching and learning platforms that facilitated the clinical experience for APN students.[10] The practicum experiences for APNs differ from general nursing students and are similar to their physician colleagues. Their clinical practicum experiences are often carried out as clinic/office visit encounters, more like medical student rotations. A purpose-built platform that accommodates a virtual interaction between a patient, a student and an assessor was developed. The ability to involve a patient in the clinical educational experience of advanced practice nursing students brings the traditional clinic/office encounter to life, meaning that the assessment, diagnosis, and management plan to include patient education, can be effectively carried out remotely. Health care professionals need to have the necessary knowledge to use these platforms efficiently, to allow them to provide virtual quality care. Exposure to innovative technology during their program of study will help students gain the necessary telemedicine competencies in addition to some of the required clinical competency component of their program. One method to assess competency attainment is with entrustable professional activities.

Entrustable Professional Activities

Health care education has experienced a paradigm shift in recent decades, from time-based learning to competency-based outcomes.[11],[12] The focus of entrustable professional activities (EPAs) is competency-based. EPAs are the breakdown of units of work (real-world tasks) into manageable components that students are expected to demonstrate for competency attainment.[13] EPAs are used in the clinical setting to explicitly detail work tasks, so that students are clear on what is required of them; for example, the step-by-step process for history-taking and conducting a physical exam. Assessors can evaluate student progress by joining in remotely on a real patient encounter. This approach allows for interactive dialogue between a student and a real patient, like a traditional patient visit. EPAs can be entered into technology platforms to help APN students identify areas for improvement, and gain confidence in their ability to provide quality care. EPAs are customizable, depending on the required competencies of an array of health care professionals, for example, internal (program), and external competency requirements, meaning those necessary for accreditation/licensure. Specific EPAs already in use by the medical profession, can be tailored for advanced practice nursing students and agreed upon by nursing faculty to standardize learning and assessments across an APN program. The use of EPAs was recommended by nursing in 2015[14] however, an evidence-based system to operationalize competency acquisition has not yet been established for advanced nursing students.[15] EPAs are currently used in Europe, North America, Australia, and Central America.[16] Now is the time for nursing to create a robust system to capture and validate competency attainment.

Educating the Telemedicine User

Evidence indicates that telehealth has a positive influence on patients’ health management.[4] It allows health care professionals to provide care remotely, which can be especially useful in situations where patients are unable to visit health care facilities, or where it is not feasible for health care professionals to travel to a patient’s location. However, it requires specific knowledge to effectively acquire the skill of using telehealth systems and to complete a remote clinical encounter.[2] Health care professionals must be equipped to adapt to telemedicine for clinical and communication skills to provide quality care management remotely.[17] A purpose-built, live tele-skills education and assessment software can provide quality health care while ensuring safe patient care in a virtual clinical environment that complies with best practice in telemedicine. Providers can us any telehealth solution that is deployed at their place of service/work to carry out remote patient encounters.

Best practice in telemedicine warrants the use of specific mechanisms to protect the patient and the health care worker.[11] Ensuring security, by knowledge and compliance with telemedicine regulations, and obtaining patient consent prior to each telemedicine session are paramount. To maintain trust and confidentiality of patient data, users of telemedicine systems must comply with global data regulations; for instance, the Health Insurance Portability and Accountability Act (HIPAA)[18] in the United States or the General Data Protection Regulation (GDPR)[19] in Europe. A purpose-built system can be used to provide health care professionals with the necessary knowledge to use telemedicine software, conduct remote consultations and provide remote care. A customized telemedicine education platform can be used across all domains of professional health care and allied health care disciplines (Medicine, Nursing, Midwifery, Pharmacy, Speech Therapy, Respiratory Therapy and Physiotherapy). Indeed, any academic or corporate organization can make use such a platform to provide real case scenario experiences for stakeholders.

Clinical Practicum for Advanced Nursing Education

Clinical placement is an essential part of advanced practice nursing education that includes nurse practitioners, clinical nurse specialists, nurse anesthetists and midwives. However, finding and coordinating clinical placements can be challenging, and was especially difficult during the COVID-19 pandemic.[2] A purpose-based system was developed at that time to facilitate learning and assessment in the clinical environment for medical students, advanced practice nursing students and other health care professionals. The system provided opportunity to interact with patients in the real world, bringing the clinic experience of patient encounters to life for the student and instructor. The patient, student, and instructor all have their individual remote screens with features such as note taking, to enhance the interactive case-based virtual encounter and polls that can be used by the assessor. The virtual experience maximizes clinical exposure by connecting with patients who can safely participate from the comfort of their homes or wherever they live.

This approach is truly innovative as it includes patients in the learning and assessment experience, placing the learner in the virtual setting. An encounter session facilitates live, remote scenarios, where students learn from interactions with real patients in an instructor-moderated environment. Management of real patients will be individual, relevant, and applicable, like a traditional clinical scenario where students are required to demonstrate specific tasks for assessors. During a virtual patient visit, student documentation can be shared with the instructor in real-time. This allows for instant feedback from the assessor, which is important to ensure accurate documentation as each encounter is a real patient visit. Accurate clinical documentation is essential from several perspectives, be it the accurate recording of the patient encounter, hand-over of information to colleagues or the medico-legal perspective.

The instructor can benefit greatly with time management, meaning they can eliminate travel time various locations to assess a students’ progress. For example, a student can have a remote meaningful patient visit while being assessed on communication and history-taking from the instructor’s office. Patients may benefit from being involved and enjoy being part of the APNs learning journey, similar to public and patient involvement in research for example, where co-learning and reciprocal partnerships are key.[20]  

The ability to facilitate requirements for clinical practicum experiences remotely can greatly reduce the need for traditional on-site placements for partial clinical education hours of current and future learners. Some accrediting bodies are allowing up to 50% clinical training simulation hours[21] however, as a purpose-built platform pertains to real patient visits, it is possible that the percentage of remote patient visits allowed by accrediting bodies could be greater than 50%. A purpose-built system that facilitates remote clinical encounters can also facilitate interactive patient education sessions.

Patient Education

Patient education is an essential part of health care as it helps them understand their condition and how to manage it. This is especially important for patients with chronic disease conditions and long-term illnesses. Holistic, person centred, self-management support from health care providers equips patients with skills and support interventions to help them become confident in managing their disease states and improve their wellbeing.[22] This support can be offered remotely, from the comfort of the patient’s home and from a convenient space for the APN. Creating a positive video experience, allowing the patient to ask questions, and providing opportunity for the APN to educate the patient about their health condition, treatment options and self-care strategies, can be very beneficial to their health and well-being. This approach to patient education can offer several advantages over traditional methods, such as brochures or fact-to-fact interactions, including:

1. Accessibility: the platform can be accessed from anywhere at any time, making it convenient for patients who may have difficulty traveling or attending in person appointments.
2. Customization: patient education can be tailored to the specific needs and preferences of individual patients, allowing for a more personalized and engaging learning experience. For instance, a custom approach to patient education or demonstrations, and providing opportunity for patient understanding through teach-back or re-demonstration can be carried out.
3. Interactivity: interactive elements can be incorporated, for instance working in partnership with patients to establish goal setting and action plans that can be documented in real time. Studies have shown that patients are more willing to consider advice given to them when quality relationships between the nurse and patient are established.[6]
4. Standardization: all patients receive consistent, evidence-based information, through standardized scripts such as self-care guidelines and treatment options, reducing the potential for inconsistent messaging, miscommunication and/or misunderstanding.

The use of a telehealth platform through virtual interactive patient education sessions, can significantly improve patients’ awareness and lifestyles, to include their mental health status and overall health outcomes.[5]

Conclusion

The benefit of using real patients in the clinical practice experience of advanced practice nursing students is an innovative approach to the problem of clinical placement shortages.

The where, and how frequently to use a purpose-built system is at the discretion of the faculty in agreement with the patient, assessor/preceptor. A system that is purpose-built has many useful features to provide instructors, students, and health care professionals with the means to connect with patients in the real world in a meaningful manner. These include incorporating entrustable professional activities to inform students and allowing instructors to assess required professional competencies; knowledge and exposure to the telemedicine experience during real patient encounters; virtual clinic experiences for APNs, and patient education sessions for the health care professional that have proven beneficial to improve health outcomes.

References

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