*Corresponding Author:

Mary Lou De Natale, EdD, RN, PHN, CNL

School of Nursing and Health Professions, University of San Francisco, 2130 Fulton Street, San Francisco, California 94117, USA; E-mail: denatalem@usfca.edu

ABSTRACT

The Covid-19 pandemic created a new opportunity for nursing students to connect to a community partnership through a Telehealth Virtual Clinical Program. The focus was on the client and the social determinants of health and the advocacy to bring hope to daily living. The nursing students' reflections are the foundation for clinical practice with their dedication to excellence, client safety, and person-centered care.

Key Words: Telehealth, community partnerships, nursing students, and communication.

INTRODUCTION

How can nursing students in a telehealth clinical practicum be prepared and address the needs of individual clients and families with physical, medical, spiritual, and psychosocial needs for health and wellness?                       

The opportunity to start a Telehealth “Virtual Clinic Program” beginning in March 2020 during the initial Covid-19 pandemic has made a significant difference in opening doors for students to be leaders for change in the community and within the Bachelor of Science nursing program (BSN). Academic nurses can benefit from partnership within the clinical setting to improve care and implement best practices in changing times [1]. Nursing education and clinical practice have an opportunity to provide the expertise in Telehealth to focus on providing care that is patient centered, preventative, collaborative, and cost effective [2]. The academic partnerships of a large urban University and two other local universities during the Covid-19 pandemic provided the connection to a clinical community with nursing students working to incorporate nursing knowledge and contemplative action for individual referrals in the local public health and county system.

As clinical faculty, it was important to find alternatives to clinical practice and partner with the community with nurses, social workers, and health providers. In this partnership nursing students focused on the following areas: access to a medical facility, transportation to doctor’s appointments, referrals for food resources, assistive devices, dental appointments, and financial support for housing. It was a learning process of guiding nursing practice and providing care to the clients on “What Matters” today as well as addressing key assessments related to Mentation, Medication, and Mobility (AFHS Systems and the 4Ms) [3,4]. Fulmer (2020) supports building on the care of older adults, reducing harm, improving satisfaction and optimizing value for patients, families, caregivers, health providers, and health systems (The Age-Friendly Health System [AFHS]). The nursing students were learning to develop skills in assessment        to support the BSN clinical competencies in these areas for the health and wellness of the population.

Background

This health crisis has impacted not only frontline staff and clinical leaders but all systems and communities. The COVID-19 pandemic did change universities’ academic nursing programs and their access to the clinical sites. Within the health field, schools of nursing were uniquely challenged during this time to develop the next generation of care providers [5]. The rapidly changing healthcare landscape presents a world ready for innovation, digital transformation, and accelerated knowledge with those experiences that could build on improving patient care, safety, and outcomes with nurses vital in this leadership [6].

The purpose of this research was to identify and support the outcomes of the BSN nursing student (s) and their leadership with application of the nursing process in the Telehealth clinical experience during Covid-19. The goal was to support the nursing students in their connection to the client with positive outcomes in learning for their professional career. Academic nurses need to engage with the community in a clinical setting in which care can be improved and best practices be supported during these changing times. As a health care system it has been a time to meet the public health needs of the community and have nursing partnerships with the health care systems [1]. Indeed, this Telehealth “Virtual Clinic Program” was that opportunity for the nursing students to connect to the needs of a community during Covid-19 in supporting the health care providers and community leaders. As partners in this practice site, the client referral and assessment was a priority for medical appointments, referrals for health care services, and a nursing student voice to connect individuals to health care services in their community. Initially, the BSN nursing students and faculty became partners with the two other nursing schools in March 2020 and positioned themselves as leaders and consultants for this program with case management opportunities. Initially, the Telehealth “Virtual Clinic Program” was a Covid-19 Shelter in Place (SIP) which was a component which supported the work with Collaborative Academic Practice Alliance (CAPA) and welcomed the local University Schools to the health department and the public health practicums.

Since the communication was initially not in person, the nursing students were guided in a group orientation and clinical check-in meetings each morning and afternoon with guided questions for the first cell-phone contact visit and introduction. The questions were centered on the client with the initial introduction, reason for the referral and follow-up, priorities that the client may have on the call with the acknowledgement of the concerns and what matters to the client at this time. The nursing students were interested in learning and were professional in their communication with the community providers. The noted priorities were for the connection to the community resources and the assistance with the application for the client to receive the benefits within the county or public health system. Telehealth programs have assisted the client in overcoming the physical barriers of health care and providing patients and caregivers access to medical follow-up [7]. The opportunities for the nursing students to be involved with a health care team that help to provide education in clinical practice to support case management, health education, and knowledge of resources to access community services for nutrition, transportation, assistive devices, or caregiver in-home support services as needed by clients in the community.

Telehealth Nursing and BSN Students

Telehealth nursing allowed the nursing students to apply the nursing process and focus on the priorities of care with the use of a cell phone beyond the clinical in the acute care with client centered questions, daily / weekly goals, and a professional plan for evaluating outcomes and services. The value given to the human connection and the guidance to make the referrals to clinical practice noted by one of the nursing students: “This clinical has helped my nursing career and in learning to care for the person, family, and community and my future encounters in healthcare. It allowed me to understand the resources that I can use in nursing and help friends and family when they need assistance.” (Nursing Student, EL, fall 2021) These nursing students were able to help each client find hope, a purpose in living with supportive nursing care while reflecting on the human connection of “asking” what matters most to the client. Indeed, these first twenty-eight senior nursing BSN students worked tirelessly to ensure that clients were able to connect and support and hand-off to the next clinical group of nursing students beginning in March 2020 to present.

These senior nursing students were supported in their leadership with directed clinical hours in case management, health teaching, and critical judgment to meet clinical objectives. Students used a framework of innovation through technology to meet the clients and support access and advocacy. With the intention to support the needs of these clients in the community—the use of the cellular phone and virtual meetings with “Google Meet” and “Zoom” were the alternatives to making a human connection to the un-housed on the street, living in cars, or those trying to get access to the nearby motels housing the most vulnerable. The quality of the orientation to this experience, partnership with the social services and medical team in this county all collaborated—for the clients and their health care needs and support for housing—strength in practice and scope of nursing leadership.

 This program supported the nursing competencies and Standards of Practice for Nursing noted in the American Association of Colleges of Nursing (AACN, 2021) regarding: assessment, understanding the diagnosis, outcomes identification, planning, implementation, advocacy, and respect and learning equitable practice [8,1].

Additionally, the nursing students applied the foundational principles of Healthy People 2030 while “promoting health and well-being and preventing disease” with collaborative efforts to assess the “physical, mental and social health dimensions” of their clients support access to care and services for clients [9].

Reflections on What Matters Most

The nursing students participated in the post reflection narrative summary regarding their participation in the Telehealth clinical setting. The comments were based on the following themes: communication, care and compassion, advocacy and safety, teamwork and collaboration, and how this will influence their profession [Table 1].

Communication

The communication and weekly reflections support the client and the connection starts with a conversation and the question. “How to help the client today?” One of the students stated: “After ten minutes of speaking to my client for the first time, she cried and poured her heart out to me. I have never had that kind of experience, but I was prepared. Because of Telehealth, I have improved my therapeutic communication skills.” (Nursing Student, JR, spring 2020)

The importance of communication was further stated: “I feel like Telehealth taught me so much ….I believe that the most vital tool was that of communication. I also learned that this work is important.” (Nursing Student JF, fall 2020)

Care and Compassion

The care for another individual at a time of physical or psychological need is important in clinical nursing practice. A nursing student reflected that care is learning that every Telehealth client has a unique story of their own: “This experience changed me because I had no idea how much I could help someone over the telephone. I was grateful for the experience because I was able to use my nursing skills in a way that I had not used before. My client was struggling financially which was affecting how she cared for herself. She was not in need of hospitalization. My client had no family and no one to “check” on her and I became that “someone” for her when she needed it the most. We were able to connect her with resources regarding: urinary incontinence, legal consultation for the foreclosure on her home, nutritional meals delivered to her door, and education on advanced directives. It was amazing to think about how much we had helped her in a few short weeks.” (Nursing Student, TS, spring 2020)

Advocacy and Safety

 The nursing world is advancing to a more electronic means and advocacy for the client is important to monitor at every call on the electronic record: “We advocated for our patients when they were not communicating with us or picking up the phone, so we asked for a “wellness check” due to previous medical background. We were worried that the client had another stroke. Fortunately, the police officer that was sent to the home and relayed back that she hadn’t been able to hear the phone.” (Nursing Student, GL, fall 2021)

Teamwork and Collaboration

Each of the students supported teamwork and collaboration and as stated, “It took an entire semester for me to get my client some mental health services due to the structure and system in place in the county. Through this experience, I was able to see the importance of having an advocate for these clients as they would be left without vital services if they were without someone to support them.” (Nursing Student, SY, fall 2021) Another nursing student commented: “I had an opportunity to learn to provide patient-centered care, support client safety, communication, and advocacy. At the end of the semester, my Telehealth client was appreciative of the help given for his planned surgery --it was teamwork.” (Nursing Student, JB, fall 2020)

Future as a Professional Nurse

The students were influenced by this Telehealth program and their professional practice and the reasons for choosing nursing and it was their interaction and knowledge of the community resources that changed their practice while supporting the client. Each of the students had their personal application to the future of nursing as commented by several of the nursing students: “Part of being in this program was that of learning a new nursing role in Telehealth advocacy for each patient." (Nursing Student, KM, fall 2020) While another nursing student had a philosophy of her own: “This semester, I learned that there are many barriers to becoming a more compassionate health care professional.” Additionally, I learned that there are many barriers to care, and these barriers cannot be dismantled until they are understood.” (Student, NA, fall 2020) The personal reflections were also noted with the client determining the direction of the care for the nursing support related to: “This experience has certainly made me feel much more fulfilled and happy knowing that I made a huge difference in these people’s lives. It has reminded me that nursing is truly about being a healing presence for others and also emphasized my love and passion for the nursing profession.” (Student, EJ, spring 2020)

Outcomes and the Telehealth Program

The nursing case management and collaboration started in the spring 2020 with the Department of Public Health mandates based on Covid-19 provided a new role for nursing and community outreach. This Telehealth “Virtual Clinic Program” is a partnership in the community that was able to give the students insight into the social disparities and the academic practice alliance. The following is one student’s reflection on how she made a difference for one individual client at time. It was her nursing journey that extended the walls of the hospital into the community. As one of the senior nurses reflected on her communication with her client stated: “Thank you… I appreciate you so much.” In the simplest of terms the nursing student reflected: “What would a 74 years old male with the history of a spinal injury as a result of a fall be able to do without help and support?....He had been living on the street for some time and now is being housed in a travel lodge motel after being assigned to a case manager and nursing student.” (Nursing Student, JK, spring 2020)

Outcomes for Professional Development

The Covid-19 epidemic has accelerated the opportunities for the nursing students in the community to improve the health and wellness of the frail, isolated adults in the community, and address the needs of a community. The program outcomes of this Telehealth “Virtual Clinical Program” have enabled the nursing student to have a leadership role in the profession, apply principles of technology to patient care, and delivery safe equitable care to those in the Telehealth community that have been unable to speak for themselves with a need for care and compassion. The consensus of the group of nursing seniors involved in this clinical program is that: “Telehealth relies on being able to be a great listener and a great advocate…..this unique type of care allows the focus on one client at a time. By doing this we focus solely on the one specific client at a time, case by case, and listening directly and purposefully. This is patient centered care at its core, and it is what we hope to provide for every client we come across in our line of work no matter the boundaries or challenges that arise.” (EM, spring 2020) Additionally, another nursing student valued the following: “I have had some of the best experiences of my life and these will help me as a nurse. I was able to learn the skills of effective communication in order to help make my client’s life a little better than it was before.” (Nursing Student, DS, fall 2020)

The COVID-19 continues to be an ongoing crisis; it is a real-time lesson in equity, leadership, social justice, ethics, and patient care with an educational shift [5]. This pandemic will forever shift the educational landscape and learning and place active collaboration across sectors in the community for equity at the heart of all efforts to maintain and increase the use of telemedicine, for the benefit of all [5,10]. The hope is that these nursing students will use the lessons learned in the Telehealth “Virtual Clinic Program” to be advocates for care, community resources, and changes in health for the clients they will be privileged to serve. The Telehealth program continues to be that partnership that can help improve the health of a community with the recognition that each client is respected and their health needs addressed.

Limitations of the Telehealth Program

This research is ongoing and new partnerships are evolving each semester with nursing interns. One barrier noted at the time of starting this virtual clinic was the gap in knowledge in preparing providers for Telehealth and the lack of education in Telehealth in nursing programs [11]. Initially, there were only limited faculty involved in the partnership and restricted opportunities with Covid-19 addressing the underserved and homeless. These faculty researchers were dependent on the initial referrals, programs opened for new services, and priorities within the county. The initial program had to develop a team to build on computer documentation developing assessment tools, health infographics, and health education for the clients. The health care system had a call to action but not only by nursing but other specialty areas in public health or behavioral health.

In the last two years, there have been limitations to available resources for the clients and the community due in-person closures and Covid-19 restrictions. However, with the availability of the Covid-19 vaccine and specific vaccine programs helped to support the improvements in access to services, new housing, improved transportation or outreach, and medical care follow-up and Telehealth care appointments within the county. There was always a priority for funds within the county for the homeless and the underserved. Though this community worked together to develop this partnership there were individual roles that were not defined and with lack of public health nurses in the county.

In summary, this program started with an invitation to three university nursing programs to be a part of call to action with clients and case management referrals within the county during the Covid-19 pandemic—a time of humanitarian need. There remain more opportunities to serve as individuals whether faculty or student with leadership in health care literacy, translations for health education, computer-assisted training and health fairs for all age groups. This community has the hope that this Telehealth program can continue to broaden the scope of practice with the support of additional health care professionals and community workers working together to improve population health outcomes.

Table 1. Guided Reflections from Nursing Students

Note: Guided Reflections-Authors support copyright and permission

REFERENCES

1. Bettencourt, A. Vance, AJ, Burns, J. Bell, SA. Costa, DK. Maximizing the academic model in the era of Covid-19 and beyond. Nursing Outlook 2020; 68 (5), 542-544. doi.org/10.1016.j.outlook.2020.04013

2. Wijesooriya NR, Mishra V, Brand PLP, Rubin BK. COVID-19 and telehealth, education, and research adaptations. Paediatric Respiratory Reviews 2020; 35:38-42. doi.org/10.1016.j.outlook.2020.04013

3. Lesser S, Zakharkin S, Louie C, Escobedo MR, Whyte J, Fulmer T. Clinician knowledge and behaviors related to the 4Ms framework of Age-Friendly Health Systems. Journal of the American Geriatric Society 2022; 70(3): 789-800. doi.org/10.1111/jgs.17571

4. Fulmer, T. (2022). Age-friendly health systems: A guide to using the 4Ms while caring for older adults, Institute for Health Improvement (IHI).

5. Dewart G. Corcoran L, Thursk L, Petrovic K. Nurse Educator Today, Nursing education in a pandemic: academic challenges in response to Covid-19; 2020; 92. doi.org/10.1016/nedt.2020.104471

6. Kavanagh, JM. Sharpnack, PA. Crisis in Competency: A defining moment in nursing education. The Online Journal of Issues in Nursing (OJIN). 2021; 26 (1). Manuscript 2. 1-11.

7. Wosik, J, Fudim, M, Wosik, J. Fudim M., Cameron, B, Gellad, Z F, Cho, A, Phinney, D., et al. Telehealth transformation: COVID-19 and the rise of virtual care. Journal of the American Medical Informatics Association 2020; 27(6), 957–962. doi.org/10.1093/jammia/ocaa067

8. American Association of Colleges of Nurses. (2021). The essentials: core competencies for professional nursing education. https://www.aacnnursing.org/AACN-Essentials

9. Office of Disease Prevention and Health Promotion. (n.d.). Social determinants of health. Healthy People 2030. U.S. Department of Health and Human Services. https://health.gov/our-work/national-health-initiatives/healthy-people/healthy-people-2030

10. Lau J, Knudsen J. Reducing disparities in telemedicine, an equity-focused, public health approach. Health Affairs 2022, May; 41(5), 647-650. doi: 10.1377hlthaff.2022.00314

11. Annis, T, Pleasants, S, Hultman, G, Lindemann, E, Thompson, JA, Billecke, S, Badlani, S, & Melton, GB. (2020). Rapid implementation of a COVID-19 remote patient monitoring program. Journal of the American Medical Informatics JAMIA, 27(8), 1326–1330.

doi.org/10.1093/jamia/ocaa097

PEER REVIEW

Not commissioned. Externally peer reviewed.

1. Bettencourt, A. Vance, AJ, Burns, J. Bell, SA. Costa, DK. Maximizing the academic model in the era of Covid-19 and beyond. Nursing Outlook 2020; 68 (5), 542-544. doi.org/10.1016.j.outlook.2020.04013

2. Wijesooriya NR, Mishra V, Brand PLP, Rubin BK. COVID-19 and telehealth, education, and research adaptations. Paediatric Respiratory Reviews 2020; 35:38-42. doi.org/10.1016.j.outlook.2020.04013

3. Lesser S, Zakharkin S, Louie C, Escobedo MR, Whyte J, Fulmer T. Clinician knowledge and behaviors related to the 4Ms framework of Age-Friendly Health Systems. Journal of the American Geriatric Society 2022; 70(3): 789-800. doi.org/10.1111/jgs.17571

4. Fulmer, T. (2022). Age-friendly health systems: A guide to using the 4Ms while caring for older adults, Institute for Health Improvement (IHI).

5. Dewart G. Corcoran L, Thursk L, Petrovic K. Nurse Educator Today, Nursing education in a pandemic: academic challenges in response to Covid-19; 2020; 92. doi.org/10.1016/nedt.2020.104471

6. Kavanagh, JM. Sharpnack, PA. Crisis in Competency: A defining moment in nursing education. The Online Journal of Issues in Nursing (OJIN). 2021; 26 (1). Manuscript 2. 1-11.

7. Wosik, J, Fudim, M, Wosik, J. Fudim M., Cameron, B, Gellad, Z F, Cho, A, Phinney, D., et al. Telehealth transformation: COVID-19 and the rise of virtual care. Journal of the American Medical Informatics Association 2020; 27(6), 957–962. doi.org/10.1093/jammia/ocaa067

8. American Association of Colleges of Nurses. (2021). The essentials: core competencies for professional nursing education. https://www.aacnnursing.org/AACN-Essentials

9. Office of Disease Prevention and Health Promotion. (n.d.). Social determinants of health. Healthy People 2030. U.S. Department of Health and Human Services. https://health.gov/our-work/national-health-initiatives/healthy-people/healthy-people-2030

10. Lau J, Knudsen J. Reducing disparities in telemedicine, an equity-focused, public health approach. Health Affairs 2022, May; 41(5), 647-650. doi: 10.1377hlthaff.2022.00314

11. Annis, T, Pleasants, S, Hultman, G, Lindemann, E, Thompson, JA, Billecke, S, Badlani, S, & Melton, GB. (2020). Rapid implementation of a COVID-19 remote patient monitoring program. Journal of the American Medical Informatics JAMIA, 27(8), 1326–1330.

doi.org/10.1093/jamia/ocaa097