Student Outcomes from Telepractice Training in Clinical Education: Comparison
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Please note this is a comparison between Version 2 by Beatrix Zheng and Version 1 by Amanda Worek.

With an increasing demand for telepractice services, the need for telepractice education is more important than ever. In addition to learning how to deliver these services, certain clinical and technological skills learned through telepractice apply more broadly to in-person care. Evaluating students’ abilities to master these skills is necessary to ensure clinical skill competence.

  • clinical education
  • telepractice training
  • interprofessional education
  • self-efficacy
  • self-reflection
  • nursing education
  • occupational therapy education
  • speech language pathology education
  • physical therapy education
  • telehealth education

1. Background

Health profession graduate students are required to have a working knowledge of current clinical practices before entering both clinical rotations and professional working roles. Traditional academic competencies and classroom didactic materials are beneficial and safe ways to practice both patient-interaction skills and documentation practices while allowing for reflective discussion. Common instructional methodologies in health profession education include the use of simulation, role play, in-person client interactions, and most recently, virtual client encounters, to ready students for entry into their fields. Preparing students specifically for the virtual patient-care environment must be valued to keep up with the pace of integrative technologies that allow healthcare systems to offer accessible, secure, and effective care, raising expectations that students arrive with foundational knowledge in telepractice [1,2,3][1][2][3]. InThe this study, wresearchers here examine the value of utilizing telepractice as a teaching methodology in graduate education to ensure students’ growth in necessary clinical competencies across the advanced practice nursing (APRN), occupational therapy (OT), physical therapy (PT), and speech-language pathology (SLP) professions.

2. The Importance of Telepractice Education and Outcome Measurements

Prior to the pandemic, despite increases over time in the use of virtual client encounters in clinical practice, telepractice education had remained limited across health professions [15,16][4][5]. Given the pre-existing rise in telepractice service delivery and the now massive increase in its use due to the pandemic, the necessity for telepractice education within health profession programs has become pertinent for students to meet graduation requirements and market needs as they enter the workforce. Traditionally, health profession educators design and arrange learning experiences for graduate students and measure outcomes from both clinical learning and classroom experiences to capture skill competency and the understanding of instructional content. During in-person patient simulation and live-patient encounters, student skill competencies can typically be observed and quantified based on rubrics or checklists that mirror national board requirements and accreditation standards in APRN, OT, PT and SLP in areas such as patient handling, evaluation and intervention methodologies, professional reasoning, and documentation. Measuring student outcomes from learning experiences informs graduate programs that students are acquiring the necessary skills for clinical competence and that learning activities are effective in developing competence.
With the arrival of the novel coronavirus disease (COVID-19) as a global pandemic in the spring of 2020, clinical practices and health profession educators were thrust into the utilization of virtual platforms as a service-delivery medium [4][6]. For some time, telepractice has been accepted as a viable clinical service delivery modality by APRN, OT, PT and SLP professions when appropriate for client needs [5,6[7][8][9][10],7,8], yet relatively few clinicians utilized virtual visits prior to the pandemic. In OT, Furniss reported that 34% of therapists who responded to an American Occupational Therapy Association (AOTA) survey (n = 599) reported having completed at least one telepractice service prior to April 2020 [9][11]. Forty-six percent of the AOTA survey respondents reported having completed at least one session as of January 2021. In PT, an American Physical Therapy Association (APTA) survey (n = 5400 PTs, n = 1100 PTAs) completed between April and May 2020 reported that 2% of respondents provided live video consults prior to the COVID-19 pandemic, whereas, during those early months of the state of emergency, 50% of practitioners provided telepractice services [10][12]. The American Association of Nurse Practitioners (AANP) conducted two surveys in May 2020 (n = 4800) and August 2020 (n = 4000) to examine the impact of COVID-19 on APRN practice [11][13]. While pre-pandemic telepractice utilization was not reported, 51% of APRNs reported a transition to telepractice in May 2020, which increased to 63% by August 2020 [12][14]. An October 2020 survey (n = 13,539) completed by the American Speech-Language Hearing Association (ASHA) reported that prior to the pandemic, 4.8% of SLPs provided telepractice services [13][15], although a 2002 ASHA survey (n = 1667) found that as many as 11% of respondents utilized telepractice [14][16]. ASHA’s October 2020 survey found that at that time, 71.5% of respondents reported having utilized telepractice [13][15]. As a result of this increase in telepractice provision across professions, it is possible that consumers and providers will desire continued access to remote services, making the need for education in this delivery method more important than ever.
In health profession education, the foci of competency are typically centered around students’ successes in demonstrating knowledge, comprehension, and synthesis of concepts and skills foundational to client-centered care and practice. Ericsson and Lehman suggested that specific or deliberate practice focused on direct, required skills may support better outcomes for students, as they have the supports for repetition, engagement at appropriate levels of difficulty, time to correct errors, and informative feedback [17]. To enhance these learning encounters, educators are called to understand that how students apply learned concepts to deliverable skills is largely influenced by their self-efficacy, an essential component of Bandura’s social cognitive theory [18]. Relatedly, Dewey’s experiential learning theory [19] often guides the creation of learning experiences in health and medical profession education, where concrete experiences and active experimentation and practice are paired with self-reflection and meaning making. Assessment and intervention service delivery models (both in person and through telepractice), when paired with a self-reflection component, can support desired learning outcomes by allowing more opportunities for student self-assessment of their own learning, precipitate meaning making, concretize confidence, and support self-efficacy in acquiring and retaining skills [20]. Pasupathy and Bogshutz [21] and Lee and Schmaman [22] found that self-efficacy skills were positively correlated with SLP students’ clinical performance. Opportunities for self-assessment and self-reflection may enhance students’ understanding of where their skills lie, where there may be room for growth, and perceptions of self-confidence.
Although some health professions’ student outcome measurement tools may translate to some degree to the virtual service-delivery context, such as the Student Confidence Questionnaire [23] developed for use with occupational therapy students and the SLP Clinical Self-Efficacy Inventory [21] developed for use with speech-language pathology students, there are still limited resources for specifically assessing student competence through telepractice experiences. Some graduate programs, such as the University of Maine’s Speech Therapy Telepractice and Technology Program, have reported utilizing detailed practicum evaluation forms in which supervisors rate student performance on competency development at various timepoints in the training process [24]. Likewise, a University of Kentucky speech-language pathology program reported designing their pediatric, school-based telepractice curriculum around general knowledge and skills competencies established by ASHA’s Council on Academic Accreditation in Audiology Speech Language Pathology (CAA) [16][5], though details of how student outcomes were gathered were not reported.
Given the lack of widespread tools for tracking student outcomes in telepractice education, research on the use of outcome measures in this area is severely limited. Recently, McGill and Dennard reported on the use of a survey distributed to several speech-language pathology graduate programs that captured students’ perceptions of their knowledge and clinical skills related to telepractice [25]. In their restudyearch, only 20% of respondents reported having had experience providing telepractice services. They found that students with more experience in delivering telepractice services, as well as those who were further along in their graduate programs, demonstrated higher confidence in their knowledge and skills than those with less experience. McGill and Dennard’s study focused on capturing students’ perceptions of their knowledge and skills related to telepractice broadly at a single point in time, rather than before or after deliberate training, though their use of self-efficacy ratings and the content of the items used in their survey have potential for use as pre- and post-training measures for tracking student outcomes. In this paper, we will present a tool originally designed to measure speech-language pathology student outcomes during telepractice training. While our tool was created prior to the publication of McGill and Dennard’s survey, it shares similarities in the types of competencies measured as well as in self-reflection methodology.

3. Telepractice Competencies in Clinical Education

While many training requirements inherently differ across APRN, OT, PT and SLP professions given the individual scopes of practice of each discipline, there is some degree of overlap in competencies that students must develop to practice as competent clinicians. Examples of these shared skills include building rapport with clients, effective communication with clients, caregivers, and related professionals, and in reliably and efficiently collecting data, including case histories. Many skills that practitioners must acquire across and within professions can be conceivably addressed through telepractice training (e.g., client interviews across professions, handwriting analysis in OT), while other skills may present greater challenges (e.g., vocal fold examination in SLP, balance assessment in PT) given logistical, safety, and technological barriers.
In nursing education, APRN students are required by the American Nursing Credentialing Center (ANCC) to complete a minimum of 500 direct clinical hours for certification [26]. Telepractice in a variety of synchronous and asynchronous modalities is considered direct care and therefore, meets the certification requirements. The National Organization of Nurse Practitioner Faculties (NONF) and AANP support the integration of telepractice into the APRN curriculum and have developed competencies associated with telepractice etiquette, assessment and technology skills, policy, legal implications, and documentation [5,27,28,29][7][27][28][29].
In OT, one telepractice-specific 2018 Accreditation Council for Occupational Therapy Education (ACOTE®) standard exists (std b.4.15) that addresses students’ need to understand the use of information and communication technologies in practice [30]. This accreditation requirement includes not only understanding telepractice technology but also knowing and using electronic medical record systems and virtual environments. AOTA’s position paper on telepractice outlines guidelines for use in practice, underscoring the importance of clinical reasoning and adhering to the AOTA Code of Ethics, following state regulatory boards’ rules and regulations and making decisions on a case-by-case basis [6][8]. As such, all these areas are important to develop through clinical education. Additionally, AOTA’s position statement emphasizes the value of telepractice use in OT practice, student education, and supervision [6][8].
In PT, there are no specific requirements in the 2020 Commission on Accreditation in Physical Therapy Education (CAPTE) standards related to telepractice [31]. Prior to the pandemic, students were not able to receive direct clinical hours that counted towards graduation requirements. Considering the pandemic, CAPTE provided allowances to graduate programs through a guidance document stating that clinical hours performed through telepractice could be counted as long as the learning experiences were equivalent to previous learning plans in ensuring entry-level competence upon graduation [32].
In SLP, the 2020 CAA standards [33] do not contain any requirements specific to the development of telepractice skills. However, ASHA’s Telepractice Practice Portal does outline guidelines for telepractitioners in recognition of the specialized skills necessary, such as the ability to understand appropriate models of technology used to deliver services, sensitivity to cultural and linguistic variables that relate to telepractice, and the need to remain current and knowledgeable in terms of national and state regulations [8][10]. Given the established guidelines, it can be presumed that practitioners should learn these required skills within the context of their certification process rather than on the job. While telepractice training has been viewed by the Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC) as valuable learning experiences for some time, prior to the COVID-19 pandemic, the CFCC did not allow telepractice hours to count towards graduation requirements. In response to the pandemic, the CFCC made accommodations to these clinical education requirements to allow telepractice sessions to count towards graduation requirements, currently through 31 December 2022 [34].

4. Results of Student Outcome Measures After Telepractice Training

Students were given pre- and post-training self-efficacy and self-reflection surveys. Through qualitative and quantitative analyses, students across disciplines demonstrated growth in all measured skill areas and reported overall increased confidence. Students with less prior telepractice experience reported greater increased confidence in seven measured competency areas than students with more prior telepractice experience. The number of completed sessions at the end of student placements was correlated with increased confidence for one measured skill area. Regardless of whether or not students had prior experience when starting their placement, as the number of telepractice sessions completed increased, thus did students’ confidence levels. The results of this study support telepractice as a viable clinical education tool for student growth and the use of self-efficacy and self-reflection as valuable tools for monitoring the effectiveness of telepractice clinical learning activities.

References

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