www.journalofnursingregulation.com 27 Volume 9/Issue 3 October 2018 Comparing Nurse Practitioner Student Diagnostic Reasoning Outcomes in Telehealth and Face-to-Face Standardized Patient Encounters Laurie Posey, EdD; Christine Pintz, PhD, FNP-BC, WHNP-BC, RN, FAANP; Quiping (Pearl) Zhou, PhD, RN; Karen Lewis, PhD, CHSE; Pamela Slaven-Lee, DNP, FNP-C, CHSE; and Chaoran Chen, MEd Introduction: Standardized patient (SP) encounters support development of nurse practitioner (NP) students’ diagnostic reason- ing ability in a uniquely authentic way. Telehealth technologies present an opportunity to increase access to SP experiences. Aim: We evaluated NP students’ diagnostic reasoning performance in telehealth-enabled SP encounters (TSPEs) compared to face-to-face SP encounters (FSPEs). Methods: This study used a randomized, crossover design. A convenience sample of 41 participants were assigned to one of four treatment groups: FSPE/pneumonia first, TSPE/pneumonia first, FSPE/asthma first, or TSPE/asthma first. Faculty evaluators used the Diagnostic Reasoning Assessment (DRA) to rate students’ observed diagnostic reasoning performance and SOAP (subjective, objective, assessment, and plan) notes and assessed whether their diagnoses were correct. Results: There were no significant differences in students’ DRA scores or ability to make the correct diagnosis between TSPE and FSPE. However, a sequence effect was noted for DRA score. Students who experienced TSPE first had significantly lower DRA scores than on their subsequent FSPE encounters. In addition, both sequence of cases and sequence of encounters had a significant effect on students’ ability to make the correct diagnosis. Students who experienced either asthma or FSPE first were more likely to obtain the right diagnosis. Conclusion: This study provides evidence that students can demonstrate equivalent diagnostic reasoning in TSPEs and FSPEs. Future research should investigate the effectiveness of TSPEs in different settings to teach and assess varied clinical practice competencies with diverse groups of NP students. Keywords: Diagnostic reasoning, nurse practitioner education, standardized patients, telehealth, virtual simulations D iagnostic reasoning is the ability to make an actionable diagnosis based on clinical data (Rajkomar & Dhaliwal, 2011) and is one of many essential nurse practitioner (NP) independent practice competencies. Diagnostic reasoning is a problem identification process that leads to clinical decisions about a patient problem (Bowen, 2006). NP students must learn to collect and analyze appropriate clinical data to develop dif- ferential diagnoses and formulate a treatment plan for a patient (Appel, Wadas, Talley, & Williams, 2013). Evidence of diagnostic reasoning is observed in students’ ability to use advanced assess- ment skills to differentiate between normal, variations of normal, and abnormal findings and to employ screening and diagnostic strategies to develop correct diagnoses (National Organization of Nurse Practitioner Faculties, 2017). The attainment of diagnostic reasoning skills is essential for NP students to practice effectively and safely (Croskerry, 2009) and is an important component of academic preparation leading to successful licensure. Developing sufficient diagnostic reasoning ability requires practice and clini- cal experience; however, gaining clinical experience is sometimes difficult with the challenge of securing sufficient clinical place- ments. Educational programs must explore alternative ways to prepare learners for the complexities of independent practice (Giddens et al., 2014). Clinical Simulations With Standardized Patients One alternative to real patient encounters is clinical simulations in which NP students engage with standardized patients (SPs). SPs are lay people trained to present as symptomatic patients with specific medical conditions in the context of carefully scripted case scenarios. These scenarios provide equivalent experiences for each student (Barrows, 1993). SP encounters offer a more authentic educational experience than high-fidelity mannequins, which are limited in the ability to replicate realistic human characteristics and contextual responses within an unfolding patient encounter. Active learning strategies such as the use of SPs encourage inte-