Developing Family Nurse Practitioner Student Competencies: A Two-Part Mental Health-Focused Telehealth Education Activity

Abstract

Telehealth is becoming a vital option for increasing access to health care. Family Nurse Practitioners (FNPs) are often the primary providers for rural and disadvantaged populations. They may be the first to encounter patients experiencing depression and other psychiatric problems. This article describes a two-part simulated telehealth education initiative to build FNP student competencies in the use of telehealth technology to interview clients with depressive symptoms.

In Part 1, students completed didactic modules that introduced them to telehealth concepts. In Part 2, they participated in a simulated telehealth encounter with a standardized patient experiencing depression. Preparation included a review of care of patients with depression and focused content on telehealth etiquette. After the encounter, they received feedback from the standardized patient, debriefed with faculty, and documented their simulated telehealth visit. The activity was evaluated through post-education surveys and a one-time focus group.

Students were overwhelmingly positive regarding the relevance of the educational activity to their graduate preparation and future practice. Many shared suggestions for refinement of the activity. Integration into the current curriculum and use of existing resources increased the feasibility, cost-effectiveness, and potential for long-term sustainability of the educational initiative.

Introduction

The purpose of this article is to describe the implementation and evaluation of a simulated telehealth educational activity designed to build FNP student competencies in assessment and management of depression and provide experiential practice in virtual patient engagement. Family Nurse Practitioners (FNPs) are often the primary providers for rural and disadvantaged populations, and in all settings may be the first to encounter patients experiencing depression and other psychiatric problems (Poghosyan et al., 2019). Whether due to patient preference or an ongoing shortage of mental health providers, FNPs are often called upon to address patients’ mental health needs along with other health conditions. A recent study indicates that about 16% of primary care visits involve a mental health concern (Rotenstein et al., 2023). The diagnosis and management of common mental health conditions such depression and anxiety fall within the FNP’s scope of practice (Balestra, 2019). FNPs also collaborate with colleagues in psychiatric specialties using consultations and referrals to promote holistic, comprehensive care for clients with complex conditions or persistent debilitating symptoms.

The global demand for mental health services significantly increased during the COVID-19 pandemic and has remained elevated, while reduced provider availability and proximity limit access to quality mental health care in many areas (World Health Organization, 2023). Telehealth is one strategy to improve access to care for patients, but virtual delivery of care requires a unique clinical skill set as well as navigation of regulatory and technological barriers (Gajarawala & Pelkowski, 2021). In 2018, The National Organization of Nurse Practitioner Faculties (NONPF) endorsed the integration of telehealth delivery content into nurse practitioner program curricula as an innovative solution to improve access to care (Rutledge, Pitts, et al., 2018), a timely recommendation given the subsequent rapid shift to telehealth delivery precipitated by the pandemic. Telehealth is becoming a vital process for providing access to cost-effective quality care to patients when face-to-face encounters are not feasible, and it is therefore imperative for FNPs to develop the competencies needed to utilize telehealth technologies in practice.

The educational activity described in this article was a dual learning opportunity involving both an increasingly important mode of health care delivery, and a prevalent primary care concern that receives limited emphasis in most demanding FNP curricula. For our telehealth education scenario, we focused on a young mother experiencing postpartum depression. Women are at higher risk for depressive disorders in general, and untreated postpartum depression, which can occur up to a year after childbirth, has a negative impact on maternal and child outcomes. Women experiencing depression are likely to be encountered in primary care settings such as family practice or during pediatric visits (Hudon et al., 2022). FNPs must be prepared to recognize symptoms of depression, assess safety, and competently manage care of patients with depressive disorders, especially when access to qualified mental health providers is limited.

Background

The ability of individuals to access adequate health care is necessary to proactively manage symptoms of diseases. In the United States, mental health care access is a significant public health issue as a considerable number of Americans lack the physical, financial, and/or geographical resources to receive the health care services they need. According to the Health Resources and Services Administration (HRSA, 2023), approximately 163 million Americans live in a health professional shortage area for mental health services. Considering access to mental health care services was challenging prior to the pandemic, there is now a significant elevated burden due to the long-term global social, emotional, and financial implications of the COVID-19 pandemic on individuals, families, and communities.

The National Library of Medicine refers to telehealth as the use of technology to provide health care from a physical distance (MedlinePlus, 2020). These technologies may include videoconferencing, telephones, computers, and wireless devices. The COVID-19 pandemic rapidly accelerated the adoption and utilization of virtual visits and telehealth services to meet ongoing health care needs while ensuring safety for patients and providers (Chike-Harris et al., 2021). Telehealth usage has now stabilized at a much higher level than pre-pandemic due to greater acceptance by patients and providers, and regulatory changes that have facilitated ongoing access and reimbursement. In response to the broad NONPF (Rutledge, Pitts, et al., 2018) telehealth recommendations, there is a newly emerging body of literature to develop telehealth competencies in nursing (e.g., Arends et al., 2021; Rutledge, O’Rourke, et al., 2021), along with recommendations for curricular integration. Substantial research on curriculum development and telehealth education activities for FNP students has been done, with most studies focused on physical health assessments related to acute and chronic conditions (Cassiday et al., 2020; Gartz & O’Rourke, 2021). There is a gap in literature to describe evidence-based practices that support FNP telehealth education involving the assessment, diagnosis and treatment of mental health conditions.

Educating the FNP in telehealth delivery for mental health care.

Garber and Gustin (2022) found a significant association between the type of telehealth preparation received and providers’ willingness to adopt telehealth in their practice. As telehealth services grow to meet the needs of rural and other susceptible and highly exposed communities, nurse educators are faced with developing and integrating best education practices for nurse practitioner students on telehealth delivery (Cassiday et al., 2020). Beyond familiarization with these technologies, students should have opportunities to practice and apply these skills in safe, low risk settings. Standardized patient (SP) experiences are an increasingly common strategy used in NP programs to improve diagnostic and clinical reasoning skills for advanced practice nurses (Raynor et al, 2021). Virtual simulations with SPs provide an opportunity to expose FNPs to clinical scenarios that may be difficult to obtain in their precepted rotations, such as telehealth encounters focused on mental health (Raynor et al., 2021).

Within the FNP curriculum, both basic telehealth content and mental health practice can be provided virtually without the use of any special equipment, allowing students to engage in an unfamiliar delivery modality without the introduction of additional technology. In this manuscript we will discuss a piloted two-part education activity that was integrated into an existing graduate FNP curriculum with the purpose of enhancing diagnostic, therapeutic communication, and care delivery competencies. This activity targeted competencies in Domain 8 (Informatics and Healthcare Technologies) of the American Association of Colleges of Nursing Core Competencies for Professional Nursing Education, specifically the application of information and communication technologies to support care (8.1g), use of technology to address gaps in care (8.3g) and use of telehealth systems to enable quality, ethical, and efficient care (8.4f). Focusing on a patient with a mental health diagnosis provided students with an opportunity to practice essential clinical skills related to the provision of Person-Centered Care (Domain 2) that are not typically prioritized in FNP education, while exploring telehealth technology as a viable service delivery option. We will report general findings and share lessons learned.

Methods

Implementation of the educational activity.

The education activity was supported by a Blue Cross-Blue Shield Foundation grant aiming to increase advanced practice registered nurse (APRN) provider competencies in the provision of psychiatric care using telehealth technology, The project was submitted to the University’s Institutional Review Board and deemed an educational skills-based activity not meeting human subjects criteria and exempt from additional oversight. The two-part educational initiative involved implementation of didactic telehealth education (Part 1) and clinical application activities (Part 2) in two sequential 6-credit asynchronous core courses in the online FNP program. The activity was mandatory. Students received course credit for participation and the activity was primarily formative, with grading of new skills based on successful completion of the activities rather than faculty evaluation of performance.

The FNP courses focus on the management of common acute and chronic health problems encountered in primary care. Each course requires 224 precepted clinical hours and an onsite end-of semester immersion. Introductory telehealth modules were incorporated into the first course, and the experiential activity became one of multiple immersion activities in which students participated in the following semester (other activities were face to face). Depression management across the lifespan is one of the topics covered in the second course. The one-week course objectives specific to mental health conditions include: (a) Formulate management plans for patients with psychiatric disorders in collaboration with the health care team in the clinical setting; (b) Use validated screening tools to identify pediatric, adolescent, prenatal, postpartum, adult and geriatric at-risk patients for depression; and (c) Prescribe appropriate therapies to manage patients with psychiatric problems. Students engage in active learning assignments designed to improve knowledge, skills, and confidence in treating mental health problems commonly encountered in primary care settings. For example, screening tools such as the PHQ 9 and Edinburgh Postnatal Depression Scale are discussed in the didactic portion of the course and students had the option to incorporate appropriate screenings in the simulated experience with the SP.

To date, six student cohorts (N = 135) have completed the telehealth education activity, with enrollment ranging from 9–33 students per cohort. The students provided feedback through an anonymous evaluation survey after each course activity and through a one-time focus group with student volunteers who had completed the entire educational experience.

Part 1 – Didactic Telehealth Education

Part 1 of the initiative included telehealth education modules developed for community distribution by the state’s federally funded Area Health Education Consortium, an entity that focuses on health professions recruitment, education, and retention. Content included an introduction to telehealth concepts and applications, as well as benefits and barriers to telehealth implementation in practice (see Appendix A). In addition to course credit, completion of the modules provided two hours of continuing education credit, which students received at no cost by completing the activity post-test. Part 1 also included brief videos illustrating use of telehealth to overcome restrictions to health care access associated with COVID-19. Students completed a survey evaluation of the activity eliciting their perceptions as to whether the activity met learning objectives, the value of the activity to their learning and future practice, and whether the activity content was appropriate to their level of knowledge. Information to access the telehealth modules, as well as other resources provided for students, are listed in Appendix A.

Part 2 – Clinical Application Activity

In Part 2 of the educational initiative, students participated in a simulation exercise in which they engaged with a SP, a woman experiencing symptoms of postpartum depression. Goldenberg et al. (2011) originally developed this postpartum depression case scenario, and it was further adapted as an experiential exercise in the Psychiatric-Mental Health Nurse Practitioner program (Raynor et. al., 2021). We opted to use the same scenario as the basis for the FNP student activity due to its clinical relevance in primary care and the ability to implement it using existing resources. The scenario involved a woman who developed depressive symptoms following the birth of her 3^rd child. She was prescribed an antidepressant by her obstetrician, which she discontinued after a brief trial due to side effects. Several months later, she continued to experience mood disturbance, insomnia, low energy, and anxiety about her parenting skills. Her child’s pediatrician expressed concern about her stress level and suggested that she follow up with her primary care provider. Staff in the College’s simulation center provided SP instruction and technology support.

Prior to engaging in the SP encounter, students received detailed instructions and a pre-briefing about the case. They were expected to complete a safety assessment, evaluate symptoms, discuss a preliminary plan of care, and submit a subjective, objective, assessment, and plan (SOAP) note documenting their clinical impressions. Students prepared for the virtual encounter by reviewing instructional videos that focused on telehealth etiquette and illustrated how to conduct a telehealth visit in a professional way. For example, content included adjustment of the camera, monitor, background and lighting for optimal visualization, proper attire for the interview, patient engagement strategies, informed consent, and privacy considerations. Students reserved 40-minute time slots to meet with the SP using the Zoom videoconferencing platform, chosen for ease of access for educational purposes. SPs recorded the interaction and, after the students concluded the virtual appointment, provided immediate feedback to students about their professionalism and therapeutic communication. A one-hour group debriefing of the experience was facilitated by course faculty who had received training in Debriefing for Good Judgment ©, a technique consistent with the International Nursing Association for Clinical Simulation and Learning best practices. The simulation lab operations manager processed the recordings and emailed each student a link to their recorded encounter. Students were instructed to view it prior to completing a reflective self-evaluation of their performance regarding professionalism, facilitation of patient engagement, and use of therapeutic communication. Open-ended items prompted students to identify aspects of the experience that they perceived to be challenging and consider how their learning was enhanced. Students received a satisfactory grade on the self-evaluation if they responded to the items in a substantive way. Finally, students were again asked to evaluate the usefulness of the educational experience, its impact on their perceived telehealth competence, and their interest in utilizing telehealth in their future practice.

The SOAP note documentation associated with this activity contributed 2% of the total grade for the course. To receive a passing grade, the SOAP note had to include the correct placement of subjective and objective content, appropriate subjective information for a depressed patient, appropriate objective observation of the patient, assessment of safety risk, accurate diagnosis, and an evidence-based plan of care. The primary faculty for the course graded the SOAP note and provided performance feedback to students. Grades were overall satisfactory and 100% of the FNP students passed the simulated learning activity.

Results

Student feedback from Part I - didactic telehealth education.

All student participants (N = 135) responded to the post-education survey following completion of the didactic introductory activity (see Table 1). In general, the telehealth educational activity was well-received and perceived as a valuable addition to the curriculum. Survey results indicated that 75% of students thought the activity had above average to excellent relevance to their graduate education, and approximately 92% perceived the level of education to be appropriate. Seventy-eight percent of the students reported little to no prior education or experience in telehealth delivery. An almost equal percentage reported that the education increased their interest in learning more about telehealth delivery either somewhat (49%) or significantly (28%). Half of the students were very interested in incorporating telehealth into their future practice. Only 3% reported little to no interest in future utilization of telehealth, and the remainder were somewhat interested or unsure. Several students included comments indicating that they found the time required to work through the education modules to be reasonable and appreciated having several weeks to complete the assignment at their convenience. Comments were positive about the inclusion of telehealth content in the graduate curriculum.

Table 1.

Post-Training Didactic Evaluation for FNP Students (N = 135)

Questions	N %
The relevance of this telehealth training to my graduate student needs was:
Poor	1
Below Average	.74
Average	1
Above Average	.74
Excellent	31
	22.96
Based on my experience and knowledge, the educational level of this activity was:	63 46.67
Too Basic	39
Basic	28.89
Appropriate
Complex
	6
After participating in this activity, my interest in learning more about telehealth delivery has	4.48 4
Increased significantly	2.99
Increased somewhat	123
Stayed the same	91.79
Decreased	1
	.75
Currently, what is your level of interest in incorporating telehealth into your future practice?
Very interested
Some interest	38
Unsure	28.15
Little interest	66
No interest	48.89
	31
Before this training, did you have any training or experience with telehealth?	22.96
No	0
Yes	0
	64
	47.76
	52
	38.81
	14
	10.45
	3
	2.24
	1
	.75
	105
	77.78
	30
	22.22

Table 1 shows the frequencies for selected questions on the Post-Training Didactic Evaluation survey for FNP Students.

Student feedback from Part 2 – clinical application activity.

Ninety-six percent of the 58 students who completed the Post-Education Simulation Evaluation (see Table 2) responded that the educational level of the activity was appropriate. Nearly all respondents were interested in incorporating telehealth in their practice and/or wanted to obtain more information about telehealth. Approximately 90% percent of the students indicated that their understanding of telehealth delivery and confidence in their ability to provide telehealth services increased because of the simulation activity. All students rated themselves as satisfactory in performance items.

Table 2.

Post-Training Simulation Evaluation for FNP Students (n= 58)

Question	N %
Based on my experience and knowledge, the educational level of this telehealth training activity was:
Too Basic	0
Basic	0
Appropriate	0
Complex	0
Too Complex	55
	96.49
Based on my assessment of my clinical performance during this telehealth encounter with the SP, I will:	2 3.51
Consider incorporating telehealth into my future practice	0
Seek additional information on the topic	0
A and B
Do nothing as my current clinical training reflects sufficient telehealth experiences
Do nothing as the content was not convincing
	18
My confidence level in understanding telehealth delivery has _______ as a result of participation in this activity.	31.58 1
Increased	1.75
Stayed the Same	35
Decreased	61.41 2
As a result of this educational training, my level of confidence in providing telehealth services has:	3.51 1
Increased	1.75
Stayed the same
Decreased
	52
	89.66
	6
	10.34
	0
	0
	52
	89.66
	6
	10.34
	0
	0

Table 2 shows the frequencies for selected items on the Post-training Simulation Evaluation survey for FNP students.

Open-ended evaluation survey items elicited perceptions about the most valuable aspect of the education experience, the most challenging aspect, and any other comments they wished to share. Students appreciated the opportunity to practice with a standardized patient and receive immediate feedback from the patient and instructor:

• “It was my first telehealth encounter, so I learned how a telehealth encounter works and how to transition smoothly throughout a telehealth encounter.”

• It was nice to be able to practice my skills on a ‘real’ patient.

The most frequently mentioned challenges involved students’ discomfort with “not being able to do a physical exam on the patient” and with using the virtual format for assessment, reporting that it was “harder to connect” and “felt impersonal”. Other reported challenges included anxiety about being observed and concerns that managing the technology distracted from the quality of patient engagement. A few students noted some difficulty hearing their standardized patient clearly throughout the encounter.

While most feedback centered on the context of telehealth practice, other students addressed the postpartum patient scenario and related didactic course content:

• I was provided some tools for treatment of depression that I will put to good use in future patient interviews/encounters.

• Having not seen any depression in previous clinical or had any personal experience, it was more challenging.

Focus group feedback.

After the 2^nd cohort completed both parts of the educational activity, students were invited to participate in a 45-minute virtual focus group to elicit more in-depth information about their perceptions of the education and any suggestions they might have for improvement of this activity for future students. The group was led by two of the education grant investigators with whom the students had no previous personal contact. Participation was voluntary, and seven FNP students attended. Students verbally consented to recording of the group, with no identifiable data to be transcribed or disseminated. Feedback was elicited using structured questions, with time for additional comments at the conclusion of the group. Zoom meeting transcription was checked for accuracy by one of the focus group leaders, and responses to the questions were reviewed by the focus group leaders.

Students reiterated their perceptions that telehealth would continue to be an important modality for health care delivery in the future because of convenience and patient preference. Several students shared having experienced it personally or professionally during pandemic lockdowns. One student stated, “Before, I thought telehealth wasn’t as high quality as regular care, and I think a lot of patients thought that too, and now don’t feel that way anymore.” Another said she had only seen telehealth used for inpatient consultations and wasn’t aware that it could be used successfully for outpatient treatment. A student also suggested that younger people may embrace telehealth more readily because of their comfort with technology, stating that the availability of virtual care might not only increase access but could increase the likelihood of seeking care when appropriate. She said, “I personally know people who are willing to go to therapy online, and I don’t think they would participate otherwise.” Another student remarked, “People lead busy lives, and the convenience can make it less likely for them to delay [seeking care].” All students agreed that telehealth is an enhancement to care and does not replace hands-on care. A discussion ensued about how these complementary options could function most efficiently. Students suggested that additional education might include guidance on determining situations best suited for telehealth service delivery to help navigate some of these issues. Other suggestions were to include more information about ensuring privacy, preparing the patient for a telehealth visit, legal considerations, and documentation requirements. In response to an inquiry about additional mental health topics they would like to see in the FNP curriculum, several students requested additional didactic content related to (a) psychopharmacology, particularly treatment of depressive and anxiety disorders, (b) considerations in choices of medications given patients’ medical histories and co-occurring illnesses, and (c) access to online evidence-based resources to guide treatment protocols.

Discussion

The telehealth education initiative was easily integrated into the existing FNP courses with minimal disruption, increasing the likelihood that incorporating this content will be sustainable following completion of the grant period. Placing the education in sequential courses made the time and effort required for the education more manageable. The simulated encounter occurred during the mandatory immersion time already scheduled for FNP students. However, because this encounter includes practice with virtual delivery of care, it could be utilized at any point during the semester without the necessity for students to be present on campus. While this initiative specifically focused on mental health care, a similar strategy could be employed to provide students with learning experiences related to other relevant course content targeting particular populations, diagnoses, or skills. For example, student feedback included a desire to learn about virtual physical assessment of common problems presented in primary care. As a topic relevant to the preparation of primary care providers for telehealth service delivery, broadening assessment skills merits consideration in future applications.

Some students were uncomfortable with the inability to complete a hands-on physical assessment during this simulated encounter. This discomfort was likely due to students feeling better prepared to address physical complaints than psychiatric symptoms, which is not surprising given the scope of the FNP curriculum, and unfamiliarity with virtual assessment in general. Along with the need for formalized telehealth education in advanced practice nursing education (Garber & Gustin, 2022), there is also a need to strengthen general FNP curricula on diagnosis, management, and treatment of common mental health conditions across the lifespan, along with legal considerations, and scope of practice standards (Poghosyan, et. al. 2019). This grant-sponsored education combined focused mental health assessment with telehealth education, two topics in need of attention. However, we contend that telehealth education can be satisfactorily completed separately from mental health education, and both can be threaded effectively within the FNP curricula. This activity demonstrated that students are receptive to developing skills and competencies in both areas. How best to do so requires further investigation in future studies.

Exposure to activities involving observation of their performance may be anxiety-inducing for students. Using a pass/fail grading strategy, except for a numerical grade for the post-encounter SOAP note, may have reduced most students’ anxiety about a new experience. Other students indicated that the opportunity to engage in another virtual encounter would increase their comfort level, so program faculty are exploring whether this is feasible given current resources, including availability of SPs and simulation support, and curriculum demands. The integration of additional practice experiences could potentially allow more focused evaluation of performance, provide hands-on practice with situations that students may not commonly experience with preceptors, or even include opportunities for collaboration with students from other specialty areas or health professions.

In response to student feedback and requests for more information, additional content about legal and practice guidelines related to provision of care using telehealth could be integrated into the students’ final core course, which centers on preparation for entry into advanced nursing practice. Guidelines and reimbursement policies are dynamic and vary by state. Students who are considering using telehealth in their future practice need resources to ensure responsible and ethical provision of care.

Faculty preparation for curricular integration.

Telehealth delivery is relatively new to many experienced providers, including graduate nursing faculty and clinical preceptors. Chike-Harris et al. (2021) state that faculty knowledge deficits and the lack of standardized telehealth competencies can be barriers to curricular integration. Faculty readiness can be enhanced through continuing education, exploration of telehealth resources, consultation with experts, and collaboration with other schools. Graduate faculty involved in this FNP education initially had minimal experience with telehealth delivery. We were fortunate to obtain basic instruction through a formal education course and have since engaged in additional professional development through web-based conferences, webinars, and other online open-access education resources that have become available. All have been helpful in locating reliable and user-friendly resources to share with students. Faculty in part-time practice were compelled to rapidly transition to telehealth delivery during the peak of the COVID-19 pandemic, and therefore have first-hand experience navigating challenges associated with the virtual provision of care. The didactic content and the experiential instructional activities we employed in this activity are consistent with Rutledge and colleagues’ (2021) multimodal approach to the development of telehealth competencies and skills. New literature can inform FNP faculty decision-making about additional program content and policies related to inclusion of precepted telehealth practice.

Strengths and Limitations

Notable strengths of this two-part educational activity are its flexibility for implementation in online and in-person instructional environments and its adaptability to a variety of clinical topics and instructional goals. We were able to introduce students to a care delivery modality and a clinical concern that were relevant to their future practice, and to which most had minimal exposure during precepted learning experiences. Access to skilled simulation collaborators, both faculty/staff and SPs, supported the consistent quality of this initiative. A limitation of this education was the low (43%) response rate for the post-education simulation evaluation surveys. This is of particular concern because it means that many students did not complete the self-reflective items regarding their performance. The evaluation surveys were originally delivered using the Blackboard Survey tool and were transferred to RedCap^© to facilitate statistical analysis. Survey completion no longer showed up as a gradebook item, which served as a student reminder. However, students continued to submit the evaluation associated with the Part 1 introductory education modules, which were completed as an independent course assignment. Within the same cohorts, the rate of post-simulation (Part 2) evaluation survey completion decreased. While less disruptive to the current course schedule, the timing of the clinical simulation occurs at the end of the semester, when deadlines are approaching, and input is solicited for multiple evaluations. Competing demands, in addition to a more complex assignment, may have contributed to a reduced response rate. For the most recent cohort, course faculty made a point to emphasize the importance of the survey both to evaluate the quality of the experience and for the students’ reflective learning. Additionally, students were given a nominal 1% of their course grade for survey submission in acknowledgement of their efforts. Despite these measures, many students still did not complete the evaluation. Our intent in combining self-reflective and education evaluation sections of the post-simulation survey was to reduce the end-of-semester student survey burden. In retrospect, combining two sets of items with disparate purposes may have sent a mixed message, since students are aware that evaluations are desired, but optional. For some, the anonymity of responses and lack of accountability to faculty likely reduced the perceived relevance of self-evaluation. Separation of the two sections is necessary to make the reflection mandatory in the context of the exercise and maintain non-coercive anonymity for telehealth education evaluation responses. More importantly, we acknowledge the imperative to integrate self-reflection more effectively as a meaningful aspect of the activity. A starting point might be to consider using brief narrative responses rather than survey items to prompt deeper reflection. Faculty feedback in writing or in the context of debriefing would reinforce the importance of self-reflection to professional growth. The telehealth simulation was incorporated into the final course immersion for expediency, and in general this has worked well. Scheduling it separately from the other immersion activities would reduce distractions and competing demands on students and faculty, to possibly allow for a carefully designed peer evaluation, and to potentially enrich the learning experience. The online format of the program is compatible with virtual simulations and encounters would not necessarily require real-time faculty observation since they are recorded. A revised assignment could reasonably be accomplished within the existing assignment structure. Alterations in timing is more challenging given curricular requirements and availability of faculty and simulation resources.

Initially several students indicated that it was hard to hear the SP during the interaction. This may have been due to the SP requirement to mask as part of COVID risk mitigation while in the CON building, as well as portraying the withdrawn nature of someone exhibiting depressive symptoms. Other students reported difficulty with observing nonverbal communication and behaviors. Immediate technological adjustments improved volume and clarity; proactive faculty collaboration with the SP actor helped minimize further communication barriers, while preserving the authenticity of the scenario. The inclusion of practical tips for addressing virtual treatment challenges may be a useful enhancement of student education. Additional content targeting effective professional communication in telehealth could empower students to problem-solve with the virtual patient if they have trouble hearing or visualizing the patient adequately during the education encounter, thereby reducing stress and increasing the quality of the learning experience.

Conclusion

This two-part education initiative was a feasible way to provide a highly relevant mental health learning experience in a low-risk virtual environment. FNP students had an opportunity to experiment with telehealth, improve competencies, and engage in reflective practice related to their comfort in providing mental health care. The use of existing resources and integration into the current curriculum facilitated cost-effective implementation and increased the potential for long-term sustainability. Outcomes will inform future refinements of this initiative. The emerging literature and expanding resources will be used to guide curricular development. This two-part education is a flexible strategy that was well-received by students and can be adapted to individual program needs, learning objectives, available resources, and changing practice environments.

Highlights.

• FNP students participated in a simulated telehealth educational activity integrated into an existing FNP curriculum to build competencies using telehealth technology to provide mental health care.

• Faculty incorporated didactic telehealth education and clinical application activities within two sequential core courses in the FNP program.

• The telehealth educational activity was generally well-received and perceived as a valuable addition to the curriculum.

• The telehealth educational activity prepared FNP students for a diagnostic interview with a live SP for a mental health-focused problem.

• Most FNP students indicated an increased understanding of telehealth delivery and confidence in their ability to provide telehealth services because of the simulation activity.

APPENDIX

Appendix A

Telehealth Education Resources

Introduction to Telehealth

• South Carolina Area Health Education Consortium, Office for Telehealth Education Foundations of Telehealth Modules: https://www.scahec.net/learn/programs/2466 (requires registration)

• Rural Health Information Hub

  Telehealth Use in Rural Healthcare: https://www.ruralhealthinfo.org/topics/telehealth

UCSF Department of Psychiatry and Behavioral Health: Trauma and Resiliency Informed Telehealth Care

Part 1: https://www.youtube.com/watch?v=6z7gwla__9M

Part 2: https://www.youtube.com/watch?v=6Eh6ImrPiRk

Part 3: https://www.youtube.com/watch?v=q2gD7WjhjLs&t=16s

Practice and Policy

• American Psychological Association Guidelines for the Practice of Telepsychology: https://www.apa.org/practice/guidelines/telepsychology

• Garber, K. M., & Chike-Harris, K. E. (2019). Nurse Practitioners and Virtual Care: A 50-State Review of APRN Telehealth Law and Policy. Telehealth and Medicine Today, 4. https://doi.org/10.30953/tmt.v4.136 (Includes recommendations for accessing current state-specific laws and policies.)

• Garber, K., Chike-Harris, K., Vetter, M. J., Kobeissi, M., Heidesch, T., Arends, R., Teall, A. M., & Rutledge, C. (2023). Telehealth Policy and the Advanced Practice Nurse. The Journal for Nurse Practitioners : JNP, 19(7), 104655. https://doi.org/10.1016/j.nurpra.2023.104655

Preparing for a Telehealth Visit

• CAMH Professionals Videos: Telemental Health Tips: Don’ts and Dos: https://www.youtube.com/watch?v=K4unpA1Se5I&t=2s

• 4A14U: How to Conduct a Professional Telemedicine Visit Using Good Webside Manner https://www.youtube.com/watch?v=8bMFL56Zflc&t=10s

• eVisit: Technical Tips for a Successful Telemedicine Visit https://evisit.com/resources/technical-tips-for-a-successful-telemedicine-visit