key: cord-0681981-mqvu3ygf
authors: Rutledge, Carolyn M.; O'Rourke, Jennifer; Mason, Anne M.; Chike-Harris, Katherine; Behnke, Lyn; Melhado, Lolita; Downes, Loureen; Gustin, Tina
title: Telehealth Competencies for Nursing Education and Practice: The Four P's of Telehealth
date: 2021-01-19
journal: Nurse Educ
DOI: 10.1097/nne.0000000000000988
sha: b732b4854d206d169b7d2114ef5fe3605f5bdb00
doc_id: 681981
cord_uid: mqvu3ygf

Telehealth is a rapidly growing health care delivery modality with advanced practice nurses as key providers. This growth has occurred without critical consideration of provider training. Training requires the development of competencies situated within a framework. PROBLEM: Standardized telehealth competencies for advanced practice nursing are missing. The purpose of this article is to describe the development of telehealth competencies for education and practice. APPROACH: Using the Four P's of Telehealth framework (planning, preparing, providing, and performance evaluation), a modified Delphi technique was used to identify, develop, and evaluate telehealth competencies. OUTCOMES: Competencies were arranged around telehealth domains, expected activities, and outcomes. Effective use of the competencies to guide curriculum development, practice, and future research related to telehealth was identified. CONCLUSIONS: Providing education with competencies aligned to the Four P's Telehealth framework will provide learners with tools to assume leadership roles in all phases of telehealth implementation, delivery, and refinement.

are transforming from traditional in-person encounters to telehealth visits. The National Organization of Nurse Practitioner Faculty (NONPF) published a position paper in 2018, supporting telehealth in nurse practitioner (NP) education. 7 They provided strategies, competencies, and evaluation guidelines for incorporating telehealth modalities within the NP curriculum. Hilty and colleagues 8 reinforced the need for telehealth competencies and emphasized that faculty and practicing providers be adept at clinical skills and technology to teach students.

Despite recommendations for provider training in telehealth, a recent 2020 review of the literature revealed a lack of standardized basic telehealth educational competencies. 6 For example, competencies were either adapted from nontelehealth competencies or not structured for actual application to practice. 6, 7 This is demonstrated by Hilty and colleagues, 9 who created competencies related to mobile health and application development using a combination of the Accreditation Council of Graduate Medical Education framework with a literature review on teaching and learning. They referenced competencies provided by the Royal College Canadian Medical Education Directives for Specialists and telepsychiatry.

In a 2016 study using Delphi methods, 32 competencies were identified as relevant to teaching nursing students about telehealth; however, the competencies were grouped around professional activities rather than core telehealth elements essential for practice and were based on nursing practice in the Netherlands. 10 Arends and coauthors 11 developed a list of 22 telehealth provider competencies for NP student education based on a review of the literature and geared toward training in an educational environment rather than training for future practice. Sharma and colleagues 12 proposed competencies for medical students consisting of 3 domains for digital care: (1) digital communication and website manner, (2) scope and standards of care, and (3) virtual clinical interactions. Curriculum development resources for each domain were also provided in the article, although literature was limited.

Well-defined telehealth competencies should align with a comprehensive telehealth framework that addresses the KSAs necessary for telehealth practice; however, this is lacking in the literature. 13 The Four P's of Telehealth framework was developed previously by Rutledge et al 13 to address educational practice needs evident for interprofessional teams as health care attempted to address the COVID-19 pandemic. Rutledge et al determined that interprofessional students benefited from a framework that was not only comprehensive and based on a review of the literature but also included the process of assessing system needs, planning, implementing, and then evaluating a telehealth program. This framework aligns with both curriculum development and clinical practice and can be transitioned to providers from varying professions.

The purpose of this article is to describe the process used to identify existing telehealth competencies and to further develop and apply them for advanced practice registered nurse (APRN) education and practice. The Four P's of Telehealth framework guided the assessment of existing competencies, identification of gaps, and development of a more comprehensive list of competencies for APRN telehealth education and practice. 13 By defining the constructs within the framework and aligning competencies, faculty and learners understand the required KSAs important for the following: (1) planning: identifying required information needed to begin a telehealth program; (2) preparing: establishing/setting up a telehealth program;

(3) providing: delivering care using telehealth; and (4) performance evaluation: assessing, analyzing, and refining telehealth programs based on data.

During 2019/2020, a group of 59 advanced practice nursing faculty, funded under Health Resources and Services Administration grants, assembled to develop a telehealth education toolkit to provide faculty with the knowledge and resources needed to facilitate the integration of telehealth education into their curriculum. Representing 32 schools/colleges of nursing and 22 states from across the United States, the group quickly identified the need for competencies to guide the toolkit's development. A Competency Taskforce was formed from the larger work group to address this need. The taskforce was made up of 12 APRN faculty from primary care (family, adult, and pediatrics) and psych/mental health, experts in clinical practice, education, and interprofessional collaboration. The taskforce was led by 3 project facilitators with expertise in telehealth, education, and competency development. The taskforce followed a 3-phase modified Delphi technique to identify, develop, and evaluate/apply the telehealth competencies (Supplemental Digital Content, http://links.lww.com/NE/ A903, Figure) .

Using the Four P's of Telehealth framework as a guide, the taskforce first conducted a comprehensive review of the literature to identify existing telehealth competencies. The initial literature search was conducted in MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO to identify current literature describing telehealth education, practice competencies, and learning objectives. The search was limited to English-language peer-reviewed journals. Search keywords included telehealth, competencies, objective, education, nurse practitioner, telemedicine, and eHealth. Only 2 articles were uncovered, so a second search was undertaken.

An expanded search included PubMed, Scopus, and 3 of 35 EBSCOhost databases (ERIC, Psychology and Behavioral Sciences Collection, and CINAHL Complete). The search was limited to peer-reviewed journal articles and English language only and included publication dates starting with January 2006 and July 15, 2020, yielding 14 articles in the EBSCOhost databases, 52 in PubMed, and 14 in Scopus. Titles and abstracts were reviewed for relevance to advanced practice nursing telehealth competencies. Articles that focused on nursing or clinical competencies, utilization of telehealth to enhance education, telehealth education, informatics or informatics competencies, provider interest in or perception of telehealth, and utilization of telehealth within the clinical settings were excluded. After duplicates were removed, only 4 articles remained.

To further broaden the search, a third literature search was performed using the same electronic databases with the integration of the keyword physicians. This was an important keyword to broaden the search to include practitioners above entry level who have a similar scope of telehealth practice to APRNs. This search resulted in 328 articles in EBSCOhost, 276 in PubMed, and 20 in Scopus. Titles and abstracts were reviewed for relevance to advanced practice provider and physician telehealth competencies. After exclusion criteria were applied as per round 2, an additional 4 articles were included.

The resulting articles were reviewed, but few identified competencies that were based on telehealth clinical practice or applied to the Four P's framework. Two comprehensive articles 10,11 and the NONPF position paper on telehealth 7 were identified as key references to identify existing competencies. Next, the taskforce worked to identify gaps in the competencies as they related to the Four P's. Once the taskforce was satisfied with the initial development of the competency list, the second stage of the Delphi process was undertaken to evaluate and refine the competencies.

During the first round of competency refinement, a group of 12 APRNs with diverse backgrounds in telehealth, nursing education, and practice reviewed the competencies for fit. All telehealth articles were shared with the members of the group along with a template outlining the Four P's framework. Group members placed the competencies under 1 of the domains outlined by the Four P's of Telehealth, adding competencies that were missing, reframing competencies that were unclear, and removing redundancies. They further examined how the competencies could be applied to the KSAs for education and practice.

Once the initial review was completed, the competency list was distributed back to the larger group of 52 team members, and the same process of review was implemented. All suggested modifications were overseen by the authors of this article, and after rigorous discussions and further modifications, the competency list was forwarded for final review. A panel of 5 nationally recognized telehealth experts from different universities and telehealth practices evaluated the competencies for (1) gaps, (2) ease of use, (3) clarity, (4) importance, (5) redundancy, and (6) appropriateness. Based on their feedback, the competencies were further refined.

The resulting telehealth competencies, arranged around the Four P's framework, are outlined in the Learners will effectively perform telehealth visits/encounters.

Evaluating the impact and outcomes of the telehealth program

Develop an overall assessment plan for a telehealth program Access Financial impact Patient/provider experience Effectiveness Learners will evaluate the success of a telehealth delivery program.

The planning phase addresses competencies that enable the learner to plan for the implementation of a successful telehealth program. For learners to be competent in planning for a telehealth program, they must be able to select an appropriate target population, identify relevant health care issues, select technology that is feasible, and address the identified need. Learners determine the processes of identifying programmatic characteristics, benefits, and barriers to successful delivery. In addition, learners should determine requirements for distant and originating sites, identify the personnel needed as well as the telehealth champion (leader), and be able to identify and address reimbursement, legal, and regulatory issues.

The preparing phase occurs once the plan has been created and approved; this is when the telehealth program is established. During this phase, all required components for telehealth delivery must occur, including purchasing equipment, selecting a vendor, establishing technology support, developing protocols and workflow, and training personnel.

The goal of the providing phase is to deliver care to patients effectively and efficiently using telehealth. This occurs for learners during their clinical rotations and future practice. The providing phase can be divided into 3 sections. The first section includes setting the stage for the visit, introductions of all parties present for the visit, provider-patient agreement on reason for the visit, telehealth visit expectations, reconfirmation of consent, and an explanation on how to handle emergencies and technical difficulties. The next section consists of conducting the history and physical examination, which may or may not include using peripherals. The final section allows for establishing the diagnosis and creating a plan. This includes appropriate documentation, referral as indicated, scheduling of follow-up visits, and the provision of the plan to the patient using technology. Evaluation of the student for the clinical experience can be conducted using evaluation tools based on the required competencies. Gibson et al 14 recommended using a tool for the telehealth preceptor to evaluate the learning's competencies but also suggested that the learner evaluate preceptors as a telehealth role model.

The performance evaluation phase includes understanding the impact of a telehealth program by conducting an evaluation. It is only through such evaluations that the programs can be refined, and data can be produced to lobby for further implementation of telehealth programs. Telehealth programs must track outcome measures on the provider, patient, setting, and services. Learners should be introduced to the National Quality Forum's (NQF's) framework for evaluating telehealth programs and other measurement tools as they are developed. The NQF Telehealth Framework was developed as a standard for telehealth evaluation and includes access to care, financial impact and cost of the program, both provider and patient experience, and effectiveness of the program. 15 

The final phase of this project was to determine the effectiveness of using the competencies to guide curriculum development and practice related to telehealth. The telehealth competencies can be used to enhance or develop telehealth curriculum in graduate health professions programs as a stand-alone course or integrated across the curricula. Telehealth education based on these competencies was formulated around a published multimodal approach to telehealth education that includes didactic content, simulation/experiential learning, projects, and clinical encounters. 1

The competencies provide a clear overview of didactic content that is needed within the curriculum and can be delivered in-person or virtually via live lectures, narrated presentations, videos, and assignments. Content related to the planning phase should include (1) telehealth definitions;

(2) identifying populations, settings, and health care issues appropriate for telehealth; (3) legal, regulatory, and reimbursement issues; (4) benefits and barriers to telehealth; and (5) equipment/technology opportunities.

Content related to the preparing phase includes (1) obtaining and integrating needed equipment; (2) protocol development, refinement, and implementation; (3) consent, confidentiality, security, protected health information, and Health Insurance Portability and Accountability Act compliance; (4) telehealth etiquette; (5) clinical assessments; and (6) technology skills. The development of protocols and consents can be used to determine skills related to preparing for the start of a program. Developing skills related to technology may require the learner to have actual hands-on experience. The Center for Telehealth Innovation, Education, and Research at Old Dominion University has developed a series of videos that address telehealth etiquette as well as conducting physical examinations through videoconferencing without the use of peripherals. These videos can be found on YouTube under "ODU Telehealth Training Videos Playlist." 16 The approaches presented here have been designed for 100% virtual settings without the need for standardized patient, equipment, or in-person encounters.

In the providing phase, the learner receives didactic content on how to become an active learner in a clinical setting and the importance of the 3 phases of a telehealth encounter. Finally, in the performance evaluation phase, learners receive didactic content allowing them to assess telehealth delivery programs by becoming familiar with metrics that reflect the assessment of access issues, financial impacts, experiences, and system analysis. 15 Simulations/Experiential Learning Many schools struggle to provide clinical placements that allow live telehealth experience. 1 By combining simulation with didactic preparation, the most common approach to nursing education, students develop not only knowledge but also competence and comfort with telehealth. 17 Simulation for telehealth, like for in-person visits, can occur through cases that are provided by other learners or standardized patients. Simulation matches most closely with the competencies related to the preparing phase of the Four P's framework: specifically, by preparing the learner in (1) telehealth etiquette, (2) clinical assessment, and (3) technology use.

Experiential activities are used to aid learners in collaborating interprofessionally through group activities. One example is a mock telehealth visit with a standardized patient who is seen by a team of learners from various professions (medicine, nursing, occupational/physical therapy, pharmacy, and social work). The interprofessional team learns to work together to optimize the patient's visit and plan of care. When standardized patients are unavailable, learners can use written cases to aid them in "acting" as patients for fellow classmates.

When developing a curriculum, faculty can use the competencies to create learner projects. By combining student projects with didactic content and simulation, students are required to think critically about the challenges and benefits of telehealth. 17 Projects have been used for the planning phase by having learners develop a telehealth proposal, allowing the educator to determine whether the learner has met competencies. Specific content for the proposal can include identifying what services will be provided; legal, regulatory, and reimbursement issues; cost; populations and settings; and benefits and barriers to the program.

To assess competencies in the preparing phase, learners can develop protocols or consents for a practice. Protocols address workflow design, scheduling, and troubleshooting visits (emergencies, connection issues). Projects addressing the performance evaluation phase have included the development of an evaluation plan for a telehealth program. This includes developing a list of questions that should be asked, methods and tools for collecting the data, and strategies for using the data once gathered.

By having the Four P's framework and the resulting competencies applied to practice development, their implication in real-world settings has been assessed. The Four P's framework and competencies were used in a medical school setting to prepare 10 specialty areas for telehealth delivery. The specialty areas were able to identify the specifics of the program they implemented to address COVID-19 and access to their existing patients. This included identifying the patient population to be served, the technology needed, the changes in the rules and regulations resulting from the pandemic, and reimbursement strategies (planning phase). Protocols and consent forms were developed, and the providers and medical students were thentrained in the delivery of telehealth with a specific focus on telehealth etiquette and providing a clinical visit without the use of peripherals (preparing phase). The telehealth programs in the specialty areas were then launched to provide care to their patients (providing phase). A plan was established for evaluating the telehealth program to refine its impact and to further support its use after the pandemic (performance evaluation).

Using the Four P's framework, the stage was set for telehealth implementation into practice. This enabled learners and providers to grasp the KSAs required to create or redesign telehealth programs for their practice needs.

Many of the telehealth programs that were quickly established are now planning to continue telehealth and are looking for guidelines that will help maximize their efficiency, effectiveness, and security while minimizing cost. The American Medical Association provides a guide for telehealth visits covered by Medicare and private payers, including type of service, frequency of visits, and Current Procedural Terminology codes. 18 This document, like many documents that have been created to address telehealth, focuses on the types of telehealth delivery and reimbursement issues. Such documents can be enhanced with competencies that are needed to maximize the telehealth delivery. The competencies presented in this article can be used to assess and refine existing telehealth programs as well as provide a structure for developing new programs. The competencies can serve as a checklist to guide program directors, administrators, and clinicians through a structured process of planning, preparing, providing, and obtaining a performance evaluation of telehealth.

Innovation through telehealth has expanded rapidly, especially in response to the 2020 COVID-19 pandemic, resulting in a greater focus on telehealth in clinical and educational settings. Unfortunately, it also amplified the limited existence of comprehensive competencies for telehealth. Advanced practice registered nurses have been at the forefront of telehealth for decades and play a significant role in delivering telehealth, identifying and using a variety of technologies, and understanding legal and regulatory requirements and their ramifications. As more professions embrace telehealth as a major health care delivery modality, nursing can play an even greater leadership role in integrating telehealth education into the health professions and curricula. The literature on telehealth educational activities and practice identifies specific activities, but no single article provides a comprehensive overview. Without a comprehensive overview of telehealth and expected competencies as provided in this article, education delivery will continue to be fragmented.

Much work related to telehealth has focused on enhancing practitioner knowledge and competencies. Providing education using competencies based on the Four P's framework will provide learners with the necessary tools to assume a leadership role in all phases of telehealth implementation, delivery, and refinement.

Supporting Clinical Adjunct Faculty to Develop Educator Competencies M any schools of nursing place responsibility for clinical teaching on adjunct faculty members who may be clinical experts but often have little formal education about how to teach. To support our clinical adjunct faculty in developing the educator role, leaders in our prelicensure nursing program developed an educational session based on one of the National League for Nursing Academic Clinical Nurse Educator Competencies: facilitate learning in the health care environment. 1 Clinical adjunct faculty were invited to complete an institutional review board-approved self-assessment survey based on the 11 task statements associated with that competency (used with permission). Participants (n = 23) rated their skills the lowest on 2 task statements: educational theories and evidence-based teaching strategies, and being able to connect clinical learning opportunities to course content. The survey results were used to implement an educational session including presentations, discussions, and a simulation focused on the identified task statements. After the session, participants reported higher ratings in some areas related to facilitating learning. An unexpected bonus was the enjoyment and appreciation the clinical adjunct faculty expressed for this social learning experience. As schools employ more adjunct faculty, academic leaders should assess the faculty members' ability to function within the scope of practice of the clinical nurse educator and provide the resources needed to help these valued individuals to reach their teaching potentials. This project took place as part of the 2018-2019 Emerging Educational Administrator Institute of Sigma Theta Tau, The International Honor Society of Nursing.

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Study: FM residencies need more telehealth training

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NONPF supports telehealth in nurse practitioner education

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Mobile health, smartphone/device, and apps for psychiatry and medicine: competencies, training, and faculty development issues

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It's not just FaceTime: core competencies for the medical virtualist

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