Teleconsultation in health and social care professions education: A systematic review

Abstract Introduction Teleconsultation education in health care and social work education is under‐reported. However, literature indicates that educating the workforce in teleconsultation skills is essential to continue with safe, high‐quality delivery of services and increases the likelihood of implementing teleconsultations in health care. Training for students should, therefore, be encouraged. This systematic literature review aims to investigate global experiences of teleconsultation training in undergraduate health care and social work education. Methods A systematic review of peer‐reviewed literature was undertaken. The review was guided by the Joanna Briggs Institute guidelines. Electronic databases were searched for eligible evidence. Studies were included only if they described and evaluated teleconsultation education for undergraduate health care and social work students. Results/Discussion This review shows that mandatory education in teleconsultation is limited in undergraduate health care and social work education. Narrative synthesis and analysis of 14 studies led to the development of two themes: pedagogical aspects, and perspectives on telecommunication and teleconsultation learning and teaching. Practical experiences with simulated patients or during clinical placements with real patients were the most common mode of delivery. Feedback on teleconsultation education was generally positive; overall, health care students felt more confident using teleconsultation and valued safety of learning through simulation. Conclusion Teleconsultation education is a legitimate way to expose students to telehealth. High satisfaction rates, increased knowledge and confidence in use indicate the positive impact this learning has on students. Nevertheless, further high‐quality research and guidance for educators are warranted.


| INTRODUCTION
Teleconsultation is defined as a consultation provided remotely by using information communication technology (ICT) such as telephone and videocommunication platforms. 1 Despite evidence highlighting that teleconsultations are as effective as face-to-face interventions in terms of health outcomes and costs, 2 further endeavours to develop and strategically implement digital technologies in health care systems are needed. 3 Literature suggests that teleconsultations are well established in care and management of long-term conditions. Nonetheless, the onset of the COVID-19 pandemic led to a surging number of teleconsultations via video or telephone worldwide. 4,5 National guidelines have been developed to acknowledge the way in which communication with patients has changed. 6 This guidance is necessary as teleconsultations require different skills in digital communication. 7 Teleconsultations must, therefore, be addressed in education and training for health care and social work professionals and students, in the same way that face-to-face communication is. 6,7 The Topol Review 8 briefly acknowledged the need for training future health care workers and predicted that remote consultations would replace most of the face-to-face interactions in the future. Educational initiatives for health care and social work professionals are, however, under-reported. 9 Furthermore, although universities are responsible for preparing the future health care workforce for a digitalised health care setting, 10 the guidance for delivering this education, especially at undergraduate level, is limited, 11,12 focussed on training at post-graduate level, or is geographically limited. 9,13 This limited knowledge and understanding of teleconsultation training in undergraduate education worldwide highlights the need for teleconsultation training in undergraduate education. 14 Limited knowledge and understanding of teleconsultation training in undergraduate education worldwide highlights the need for teleconsultation training in undergraduate education.
This systematic review aims to describe how teleconsultation learning and teaching is delivered to undergraduate health care and social work students in academic and clinical settings and to explore how teleconsultation learning and teaching is received by students and faculty.
The initial question guiding this review is: How is teleconsultation experienced and taught (delivered, implemented, assessed) in undergraduate health care and social work education?

| METHODS
This mixed-methods systematic literature review strategy was based on the Joanna Briggs Institute (JBI) guidelines, 14 and the reporting followed the PRISMA Statement (Supporting Information C).
Guided by the SPICE framework, 15 key terms were identified, and a search was conducted using the databases displayed in Table 1. Key terms were adapted for the requirements of each database. An example PubMed search strategy is provided in Supporting Information A.
The results of all searches were collected, uploaded to and stored in the literature management software EndNote. Three authors (AOM, LCW and VOC) independently screened the literature against the a priori defined eligibility criteria (Supporting Information D) and discussed below. Disagreements were resolved through discussion among the authors. Quality appraisal was undertaken using the JBI appraisal checklists (Supporting Information B).
To find underlying themes and concepts across the included studies, a thematic synthesis approach 16 was used. Quantitative and qualitative data from each study were compared, contrasted and summarised qualitatively.

| RESULTS
A total of 586 records were identified by the database search. An additional 32 records were identified from screening the reference list of relevant papers. After removing duplicate records, the title and abstract of 360 records were screened, which resulted in 87 studies being identified for full-text evaluation. Of these, a total of 14 studies matched the eligibility criteria ( Figure 1).
The study characteristics and main results are summarised in Table 2. Eight studies were conducted in the USA, 17-24 two in Australia 25,26 and the UK 27,28 and one each in Germany 29 and Spain. 30 The studies were published in 12 different journals between 2010 and 2020.
Out of the 14 studies identified, 12 studies included medical students. [17][18][19][20][21][22][23][24][26][27][28][29] One study included nursing students 30 and one other included allied health professional students. 25 None of the studies included social work students. Only one study interviewed educators. 27 The experiences and opinions of telehealth and teleconsultation education were assessed via mixed-methods study designs in seven studies. 17,18,22,26,[28][29][30] Qualitative research design was adopted by four studies. 19,23,25,27 Two studies evaluated students' experiences after a learning activity. 20,21 Two main themes were identified from the thematic synthesis: pedagogical aspects, and perspectives of teleconsultation teaching and learning. The former theme refers to various structures and characteristics in relation to how teleconsultation was delivered. The latter F I G U R E 1 PRISMA flow chart: Eligibility criteria were applied at all stages of article screening and assessment. Full texts were excluded with reasons Two main themes were identified from the thematic synthesis: pedagogical aspects, and perspectives of teleconsultation teaching and learning.

| Pedagogical aspects
Generally, teleconsultation courses were mostly optional or elective for students. 18,19 Only one study reported on mandatory training. 29 Where interactive sessions enabling students to practise teleconsultation skills were described, these usually occurred in small groups of 8 to 16 students 22,26,30 who were in some cases subdivided into groups of two to three students. 27,30 The teaching sessions varied in length and lasted between one and a half hours and 1 day. 17,22,25,26 Courses were also split up into two half days 22 or six afternoon sessions. 29 The learning outcomes for the courses focussed on knowing about the importance of telehealth, 22 the limitations and possibilities of telehealth in general, 18,25,26 knowing the differences between teleconsultations and face-to-face consultations and recognising the effect of telehealth on clinician-patient relationships. 18,26 Lectures were used at the beginning of a course to introduce the topic and to prepare students for practical sessions. 18,22,25,26,28 The content usually included definitions of telehealth 17,29 ; information on resources, tools and technologies 18,22,26 ; best practice examples 18 ; and business-related information such as reimbursement, data protection, privacy issues and medicolegal aspects. 18,22,26 The length of the lectures varied between 30 22 and 90 minutes. 17 Lectures were used at the beginning of a course to introduce the topic and to prepare students for practical sessions.
Following the lectures, most students had the opportunity to apply their skills and knowledge in a practical setting. Various activities included role-plays of telemedical encounters with patients 22,25,26 or other health care professionals, 28 observations of clinical teleconsultations 25,26 and site visits to hospitals and health institutions offering telehealth. 18,25 In two studies, students were exposed to real-life teleconsultations with patients during their practice placements. 17,27 Medical students primarily received individual feedback following a teleconsultation activity. 17,19,23,27,28 In some cases, feedback was provided to the whole group. 20,22 Clinical and communication skills and knowledge were assessed via a virtual objective structured clinical examination (OSCE), the so-called teleOSCE. 19,23,24 The assessment duration ranged between 11 24 and 20 minutes. 23 Approximately 5 minutes was allocated to the provision of feedback. 23,24 The patient cases included themes and topics previously covered in students' teaching. 20,23,28,30 The perceived preparedness for teleconsultations prior to explicit training was limited. 17,22 However, theoretical lectures, clinical and communication knowledge and skills acquired prior to teleconsultation courses positively influenced students' confidence levels, 25 and knowing the technical equipment used in teleconsultations was reassuring to students. 23 Exposing medical students to simulated interprofessional collaboration and communication scenarios increased selfrated confidence levels, and more interprofessional telecommunication training was requested. 28 The perceived preparedness for teleconsultations prior to explicit training was limited.

| Perspectives of teleconsultation learning and teaching
Students reported positive attitudes and were generally satisfied with their teleconsultation learning experiences, which were described as relevant for future work settings, 17,21,22,24,25,29,30 beneficial, cool, effective, enjoyable, great, informative, inspiring, interesting, useful and valuable. 17,18,22,23,25 Students reported that the scenarios felt realistic 28,30 and would recommend the elective course to their friends. 18 Prior negative attitudes towards telehealth changed to positive attitudes following a teleconsultation course. 19,29 Overall, students emphasised that they would use telehealth in their future practice 23,25 ; however, students reported that more training would be helpful to fully understand the advantages of telecommunications and teleconsultations. 19 Some students highlighted limitations of teleconsultations such as changes in communication and relationship with patients due to the lack of face-to-face interactions 19 and missing cues in non-verbal communication. 19,27 Further concerns were related to the limited possibilities for physical examinations, which caused a shift in the focus to communication and history taking skills. 27 In one study, students received theoretical information on the possibilities and limitations of physical examinations. 17 To practise physical examinations, students were asked to simulate a physical examination via video-technology. 22 Various other issues impacted on the confidence levels and the experience of students in conducting teleconsultations: encountering technical issues, the dependency on technology and good internet connection 27,30 and the relationships with patients. 27 Generally, however, students preferred to focus on technological aspects in designated telehealth courses rather than combining skills with clinical and communication skills. 19 Despite the positive impact of learning and teaching on telecommunication skills, practical experiences with ICT were not associated with an improvement in technical skills. 30 In contrast, some students gained technological knowledge such as setting up a videoconference and taking clinical images. 25 Students highlighted the need for teleconsultation training prior to the assessment as a first exposure to teleconsultations during the teleOSCE was perceived as stressful. 19 Further training in telehealth before practical experiences 21  Generally, teleconsultation participation allowed students to practise communication skills.

| DISCUSSION
This systematic review aimed to describe how teleconsultation training in undergraduate health care and social work education is delivered, as well as to report on opinions and experiences associated with teleconsultation education.
In relation to how teleconsultation teaching was delivered, this review showed that it was often taught as an elective course rather than mandatory, meaning that students most interested in telehealth could pursue this as a specific learning opportunity. Mandatory training would ensure that all students have this learning opportunity and would highlight the importance of teleconsultation training within the undergraduate curriculum.
The main findings of this review were that there were a range of delivery methods including theoretical lectures, simulation-based learning and experiences in placements. The most common method was simulation-based learning, and few explored the students' experiences in placements. Simulation has been effectively used in health workers' education for several years, 31,32 and authentic, realistic case scenarios are appreciated and valued by students. 32 In contrast, a study that evaluated students' learning after working with recorded real-life general practitioner (GP) consultations found that students prefer to work with real patients rather than with simulated patients. 33 This review highlights the need for further exploration of a range of methods to inform future evidence-based teleconsultation education and the need for structured guidance for educators. The need for guidelines is reinforced by the desire and need of students to be educated on different technology applications and processes in the health care field (i.e., telehealth). This education should be considered, as telehealth is an emerging field. 1 Although students' perspectives of the teleconsultation learning were generally positive, none of the studies considered the educators' perspectives. This gap in information is crucial because educators are essential stakeholders in medical education and their opinion and perception of telehealth can shape their educational approaches.
The COVID-19 outbreak limited face-to-face encounters with patients, 33 and online learning was often offered as an alternative.
While students perceived online learning as insufficient to gain clinical skills, 34 reports on adapted placements to ensure patient encounters during the pandemic were published. 17,35 The exposure to teleconsultations increased the perceived likelihood that students would consider using teleconsultation in the future. The extent to which students felt confident in using teleconsultation, however, was not considered by the studies included in this review. As most studies reported that students with an interest in telehealth in general elected to participate in this learning, they may have held prior positive attitudes to the topic of teleconsultation. It is therefore difficult to fully determine the impact on their learning, 17  None of the studies described training for social work students, and limited evidence was reported in relation to undergraduate allied health professional programmes. 25,30 Therefore, most of the results relate to teleconsultation courses in medical education. This limitation highlights the need for research to explore a wider range of experiences and perspectives within health and social work. Insight into a broader range of health and social work students' perceptions and experiences would illuminate the enablers and barriers to providing teleconsultation courses in those disciplines.
While there were limited reports of educators' perspectives, their opinions on teleconsultation education revealed important insights in their willingness and perceived preparedness to teach and facilitate students' learning. 39 Wentink et al. 40

| CONCLUSION
As the use of telehealth increases, it has become more important to educate and prepare the future workforce. This review summarised current approaches in teleconsultation education for undergraduate health care and social work students. Attention must be drawn to the limited evidence to guide how this education could be implemented in health care and social work education and how effective this education is and its impact on healthcare practice in general as well as interprofessional collaborative practice. More international, interprofessional research on effective implementation of teleconsultation education in undergraduate health care and social work programmes is warranted. The diverse and emerging nature of teleconsultation education suggests that the development of a standard curriculum, informed by the findings of this review and the views of educators and students, may benefit the sector more broadly.