Building Adult-Gerontology Acute Care Nurse Practitioner Student Competencies for Telemental Health Treatment Through Simulation

Abstract

Depressive disorders are common mental health conditions that are often undiagnosed or undertreated. Adult-Gerontology Acute Care Nurse Practitioners (AGACNPs) are educated in the management of acute and critically ill patients but are often uncomfortable identifying and treating mental health conditions. Telehealth instruction is useful in mental healthcare and is required as part of the AGACNP’s efficient patient care competencies. This article reports findings from a mental health-focused telehealth instructional activity integrated into an existing AGACNP curriculum. This instructional activity was designed to introduce students to telehealth delivery and build AGACNP competencies using telehealth technology to assess patients with depressive mood symptoms. A two-part instructional scenario included didactic course preparation and an experiential activity involving a virtual encounter with a standardized patient (SP). Student feedback on the telehealth experience was generally positive. However, they felt uncomfortable with the mental health component of the scenario, providing an opportunity for improved preparation of mental health screening and treatment.

1. Introduction

Telehealth services are common in many inpatient areas, particularly in hospitals that lack specialized services [1]. There is a growing body of literature to support improved patient outcomes with the use of telehealth services. Adult-Gerontology Acute Care Nurse Practitioners (AGACNPs) are educated in managing and caring for critically ill patients with complex medical needs, and they are frequently employed in inpatient units such as the ICU, ED, or other specialty acute care areas. Acute illness is associated with the onset of depressive symptoms or exacerbation of existing mental health conditions that negatively affect patient outcomes [2,3]. However, AGACNPs typically receive little instruction on identifying acute mental health needs for adult populations, particularly through telehealth delivery. This instructional activity was designed to strengthen AGACNP students’ competencies in conducting diagnostic interviews and managing care for older adults with depressive symptoms, using telehealth technology as a clinical training tool. This article reports findings from this mental health-focused telehealth instructional activity integrated into an existing AGACNP curriculum.

Mental health disorders, such as depressive disorders, are among the most common, yet undertreated, health conditions worldwide due to delays in diagnosis and barriers to accessing treatment and follow-up care [4]. Despite the increased prevalence of depression, most patients with depressive symptoms do not seek care. Older adults may view depressive symptoms as an expected response to the physical and psychosocial stressors associated with aging, or they may hold stigmatizing views that discourage seeking help for mental health challenges [5]. Timely diagnosis and assessment of safety risks are critical to improved patient outcomes, including the prevention of suicide. It is important to note that older adults have the highest rate of suicide among all age groups, largely driven by males [6]; undiagnosed and untreated depressive disorders may play a significant role in this adverse outcome [7]. The United States Preventive Services Task Force recommends screening of all patients where appropriate diagnosis, treatment, and follow-up can occur [8]. The ED is one such site, and studies have consistently shown that depression rates are substantially higher among patients in the ED than in the general population [9,10]. One retrospective study demonstrated that about 40% of patients who died by suicide had been seen in the ED during the previous 12 months [11]. Many patients seeking care for other acute illnesses in the inpatient setting also have comorbid depressive symptoms. It is estimated that as many as one in every three hospitalized patients experience some symptoms of depression [=2]. In addition, depressive symptoms are common among patients discharged from the ICU, and as many as 30% of those have clinical depressive symptoms in the next 12 months [3]. Acute care encounters offer opportunities for early detection of depression and other mental health comorbidities that can impact immediate and long-term health outcomes.

The National Library of Medicine refers to telehealth delivery as using technology to provide healthcare services from a remote location [12]. These technologies include videoconferencing, phones, computers, wireless communication, and wearable devices [12]. During the COVID-19 pandemic, people still needed medical treatment for acute problems, and exacerbations of other chronic conditions led to increased utilization of virtual visits and telehealth services. Telehealth continues to provide healthcare systems with an opportunity to deliver quality care services remotely while expanding access to specialized services to treat acute illnesses with the added benefit of reducing exposure to infection [13].

The American Association of Colleges of Nursing recently updated its recommendations for competencies in nurse practitioner instructional programs to include the use of telehealth for efficient patient care [14]. The National Organization of Nurse Practitioner Faculties (NONPF) endorses integrating telehealth delivery content into nurse practitioner (NP) program curricula as an innovative solution to improve access to care [15]. NONPF’s AGACNP independent practice competencies include mental health and cognitive assessment and diagnosis of common mental health comorbidities in the context of acute and chronic illness [16]. While AGACNPs are typically not primary providers of mental healthcare, they must be prepared to identify safety risks and address mental health concerns in collaboration with other providers to meet complex patient care needs.

There is very little information in the literature related to best practices for instructing AGACNP students on the use of telehealth in service delivery, particularly for mental health services (i.e., telemental health). Most NP telehealth education focuses on the use of telehealth for rural outpatient services. However, we know that hospital-based telehealth can enable access to specialized care and improve patient care and overall hospital performance [17]. As telehealth services are increasingly integrated into the acute care inpatient arena, advanced practice nurse educators are challenged to use best practice standards to design teaching strategies that build AGACNP student competencies in telehealth delivery. Beyond familiarization with these technologies, students should have opportunities to practice and apply these skills in safe, low-risk environments. Telehealth simulation experiences are one way to accomplish this instructional activity. Standardized patient (SP) experiences are an increasingly common strategy used in NP programs to improve diagnostic and clinical reasoning skills for advanced practice nurses [18]. Using SPs in telehealth instruction can provide an opportunity to expose AGACNPs to clinical scenarios that are difficult to obtain in the clinical setting, such as telehealth focused on mental healthcare service delivery [18].

AGACNPs must be prepared in telehealth service delivery to meet the growing demands of the widespread use of telehealth technology in various healthcare settings. In this article, we present the findings from a mental health-focused telehealth instructional activity integrated into an AGACNP curriculum, aimed at strengthening AGACNP student competencies in using telehealth technology to assess simulated patients with depressive symptoms. Our telehealth instructional scenario focused on an older adult patient in the emergency department setting. Older adults, as previously discussed, often do not seek care specifically for depressive symptoms, and their symptoms are also frequently overlooked or misdiagnosed by non-psychiatric healthcare providers. Therefore, it is essential that AGACNPs, as crucial providers of care for geriatric patients, can recognize and accurately assess risks in this vulnerable population. The multifold purpose of the student encounter with the standardized patient (SP) was to (a) expose AGACNP students to a clinical situation previously not emphasized in the curriculum and (b) allow them to develop their diagnostic interviewing and treatment skills on a real-life “patient” with a mental health condition (c) via simulated telehealth service delivery.

2. Materials and Methods

As part of a Blue Cross Blue Shield Foundation (Columbia, SC, USA) grant to increase AGACNP and FNP (non-psychiatric specialty) competencies in providing psychiatric care using telehealth technology, nursing faculty incorporated didactic telehealth instruction (Part 1) and clinical application activities (Part 2) into two sequential core courses in the AGACNP program. The project was submitted to the University’s Institutional Review Board (IRB) and was deemed an educational activity not meeting human subject criteria, thus exempt from further IRB oversight. Students received course credit for participation. Grading was largely based on the successful completion of the diagnostic interview rather than faculty evaluation of performance, although students submitted a graded SOAP note associated with the activity. This will enable students to have an opportunity to practice and apply their interviewing skills in this context in a safe, low-risk environment. Four student cohorts (n = 63) completed telehealth instruction and the clinical activity. Student feedback was elicited through an anonymous survey after each course activity and a one-time focus group with a group of student volunteers who had completed the entire instructional experience.

Part 1 of the initiative included telehealth instructional modules developed by the state’s federally funded Area Health Education Consortium (AHEC) for healthcare providers. This entity focuses on health professionals’ recruitment, preparation, and retention. Content included an introduction to telehealth as a service delivery framework and potential applications, as well as benefits and barriers to telehealth integration in practice. The modules provided two hours of continuing education credit and course credit, which students received by submitting a copy of the certificate of completion they obtained after completing a knowledge-based post-test for the activity. Part 1 also included brief videos illustrating the use of telehealth to overcome restrictions to healthcare access associated with COVID-19. Students completed a survey evaluation of the activity, eliciting their perceptions as to whether the activity met learning objectives, the value of the activity to their learning and future practice, and whether the activity content was appropriate to their level of knowledge (see

Table 1. AGACNP Student Evaluation of Didactic Activity ¹.

Questions	n	%
The relevance of this telehealth training to my graduate student needs was:
Average	7	31.82
Above average	13	59.09
Excellent	2	9.09
Based on my experience and knowledge, the educational level of this activity was:
Too basic/basic	1	4.76
Appropriate	20	95.24
Complex	0	0.00
After participating in this activity, my interest in learning more about telehealth delivery has
Increased significantly	4	18.18
Increased somewhat	8	36.36
Stayed the same	10	45.46
At this time, what is your level of interest in incorporating telehealth into your future practice?
Very interested	7	31.82
Some interest	10	45.45
Unsure	3	13.63
Little interest	1	4.55
No interest	1	4.55
Before this training, what training or experience did you have with telehealth? (choice = no training or experience)
No	17	77.27
Yes	5	22.73

¹ The table shows the frequency tables for selected questions for Telehealth Post-Training Survey. The result indicated 59.09% rated the didactic content as “above average” to the question “The relevance of this telehealth training to my graduate student needs was:”, and 95.24% responded “appropriate” to “Based on my experience and knowledge, the educational level of this activity was:”. Nearly 55 percent reported they had increased interest in learning more about telehealth as a result of the activity. Nine percent of respondents had no interest or little interest in incorporating telehealth into future practice. Lastly, 22.73% marked yes to “Before this training, what training or experience did you have with telehealth? (choice = no training or experience)”.

).

The purpose of Part 2 of the clinical initiative was to allow AGACNP students to gain hands-on experience with a real-life “patient” with a mental health diagnosis. The experiential activity coincided with course content on mental health assessment and care in acute settings. Staff in the College’s simulation center provided SP instruction and technology support in collaboration with course faculty. The SP was stationed in one of the rooms within the Center for Simulation and Experiential Learning (SAEL), designed to mimic an emergency department setting. The student logged into the telehealth device, which enabled them to see the SP and vice versa.

The scenario centers on a 72-year-old male patient who was brought into the emergency department by ambulance for right ankle pain from an accidental fall. After the AGACNP treats the patient’s ankle injury, the patient’s adult child, who accompanied him to the ED, expresses concerns about the noticeable changes in the patient’s demeanor and his decrease in sleep and activity level since his spouse’s death six months ago. He wonders if these factors precipitated the accident. Upon further assessment, the AGACNP student finds the patient has moved past the most acute phase of grief but is still mourning the loss of his spouse and endorses depressive symptoms, including sadness, low energy, poor sleep, and loss of interest in previously enjoyable activities. He has been taking Zoloft prescribed by his primary care physician for about three months.

Our faculty team developed this depression case scenario based on everyday experiences most likely encountered by an AGACNP. Students were given detailed instructions and a pre-briefing about the case. They were expected to complete a focused health assessment, evaluate symptoms, discuss a preliminary care plan, and submit a subjective, objective assessment and plan (SOAP) note documenting their clinical impressions. Didactic content concerning the diagnosis and care of patients with depressive disorders, including suicide risk assessment, was presented in course lectures and assignments before the SP activity. Preparatory content for the telehealth activity also included a review of instructional videos demonstrating telehealth etiquette and expectations for professionalism during the virtual encounter. For example, telehealth education preparation included setting up the video screen, adjusting the background and lighting for optimal visualization, proper attire for the interview, patient engagement strategies, informed consent, and privacy considerations.

Students reserved 30 min time slots to meet with the SP using the Zoom video conferencing platform, chosen for easy access for instructional purposes. SPs recorded the interaction and, after the students concluded the virtual appointment, provided immediate feedback to students about their professionalism and patient-provider communication skills. The SAEL operations manager processed the recordings, emailed each student, and assigned clinical faculty a link to each assigned student’s recorded encounter. Permissions to access the recordings were granted only to the assigned clinical faculty, course faculty and each student for review. Clinical faculty members are practicing AGACNPs who interface with groups of up to eight AGACNP students throughout the semester to provide individualized supervision and feedback.

Students were instructed to view their recorded diagnostic interview and complete a self-evaluation focused on patient engagement and reflections on the encounter. Clinical faculty were assigned to review the SP encounter along with the documentation and provide feedback to the student. Faculty used a standardized rubric to provide feedback to students that is based on the AGACNP core competencies (7 of the 10 required) and a SOAP note grading rubric.

After the 2nd cohort completed the instructional activities, students were invited to participate in a 45 min virtual focus group to elicit more in-depth information about student perceptions of the instructional activity and any suggestions they might have for improvement. The group was led by two of the educational grant investigators with whom the students had no previous personal contact. Participation was voluntary, and three AGACNP students attended. Students verbally consented to recording the group, with no identifiable data to be transcribed or disseminated. Structured questions were used to elicit feedback, with time for additional comments at the group’s conclusion. Zoom meeting transcription was checked for accuracy by one of the focus group leaders, and the focus group leaders reviewed responses to the questions.

3. Results

3.1. Student Feedback from Part I—Didactic Telehealth Instruction

Student responses (n = 22) indicated that the educational level of the teaching was appropriate and that their knowledge of telehealth as a treatment modality had increased because of the instructional activity (see Table 1). Also, most students indicated that they would seek additional information on telehealth and consider incorporating this type of service delivery in their future practice because of the instructional activity. Students generally found the time required to work through the instructional modules reasonable and appreciated having several weeks to complete the assignment at their convenience. Most students had little to no previous telehealth instruction or experience and perceived the instructional activity as beneficial and appropriate based on their prior exposure (see Table 1).

3.2. Student Feedback from Part II—Clinical Application Activity

As with Part 1 of the experience, AGACNP students (n = 45) evaluated the usefulness of the simulation activity to their learning, its impact on their perceived telehealth competency, and their interest in utilizing telehealth in their future practice (see

Table 2. AGACNP Student Evaluation of SP Clinical Activity ¹.

Question	n	%
Based on my experience and knowledge, the educational level of this activity was:
Too basic	0	0
Basic	0	0
Appropriate	40	88.89
Complex	3	6.67
Too complex	2	4.44
Based on the telehealth information presented in this activity, I will:
Consider incorporating telehealth into my future practice	14	31.11
Seek additional information on the topic	5	11.11
A and B	23	51.11
Do nothing as my current clinical training reflects sufficient telehealth experiences	2	4.45
Do nothing as the content was not convincing	1	2.22
My confidence level in understanding telehealth delivery has as a result of participation in this activity.
Increased	35	77.78
Stayed the same	10	22.22
Decreased	0	0
As a result of this educational training, my level of confidence in providing telehealth services has:
Increased	32	71.11
Stayed the same	12	26.67
Decreased	1	2.22

¹ The table shows the frequency distribution for selected variables for AGACNP students. The results show 88.89% of participants marked “appropriate” to the question about the educational level of the telehealth training activity. A little over fifty-one percent (51.11) of participants marked that they would consider incorporating telehealth in future practice and seek additional information about telehealth (i.e., both “A and B”) to the question “Based on the telehealth information presented in this activity, I will:”. Nearly 78 percent reported increased confidence level in understanding telehealth delivery because of participation in this activity, and 71.11% reported increased level of confidence in providing telehealth services as a result of the educational activity.

). Open-ended questions included perceptions about the most valuable aspect of the instructional experience, the most challenging aspect, and any other comments they wished to share.

Students acknowledged the value of learning more about telehealth and appreciated the opportunity to practice with a standardized patient and receive immediate feedback:

“Great learning materials and resources for telehealth.”

“I’ve seen first-hand and participated in the care of someone using telehealth. It has become a huge advantage to our hospital and to the patient. We rely on the specialist at … on a daily basis for the evaluation and recommendations of care.”

“I thought this was a great experience. Maybe more of these encounters should be included in the course.”

“Great simulation. I think it helped my confidence performing a telehealth visit.”

The most reported challenge involved students’ inability to conduct a physical exam on the patient and not having additional physical exam and diagnostic test information on which to formulate a diagnosis and treat the acute physical health condition. Other reported challenges included needing more specific faculty feedback regarding individual performance and wanting more psych education. A few students noted that they felt the telemental health focus was not significant to them in their specialty:

“I would like to see a non-psych complaint for the non-psych students.”

“Would like content more applicable to my major. I am not a psychiatric NP student.”

“It was a good and unique experience that I am content with its addition to the course. I wish it was not so heavily based on psych, but it was a good experience regardless that left room for improvement.”

Suggestions focused on challenges with the encounter and continuing opportunities to practice skills and improve the evaluation process for students:

“Telehealth in many of the settings I see is beneficial for stroke management and telepsych purposes. I do find it difficult for telepsych to not be in person but will work on integrating it into my care.”

“I think one thing I need to improve on after watching the recording back is listening. There were times I thought the patient was finished speaking and I felt I interrupted her without intending to. This is especially important in psychiatric evaluations, so I will definitely be more cognizant of that going forward.”

“I would have liked to have specific faculty feedback on my performance during the telehealth visit (i.e., what I did good, what I did wrong, & where I need to improve).”

3.3. Focus Group Feedback

All student participants stated that the most valuable aspect of the instructional activity was engaging in the simulation and having the opportunity to practice a virtual encounter. One student said, “I’m very grateful that my first experience was just a practice in a safe setting.” However, the student participants agreed that engaging virtually with the SP was uncomfortable because they were so familiar with hands-on care: “I’m used to being in person with people. I feel like my personality comes across more when you’re actually face to face.” Also, independently conducting the encounter was a challenge due to their inexperience: “Right now it feels very isolated, and to me, that’s nerve-wracking as a new provider…. Rolling with it without being able to just kind of bounce ideas off of someone and make sure I’m on the right track makes me nervous.” All three students currently work as bedside nurses in ICU settings. A student who is employed at a large teaching hospital stated that she had colleagues who had transitioned to a new telehealth ICU program at her site. “My first thought was that there’s no way you could use telehealth to do an accurate assessment, especially in a critically ill population, but speaking with them, it’s like a new asset to healthcare. I think it will take some getting used to, and know the more practice with it, the more comfortable you get.” Another student who had previously seen telehealth used successfully to treat stroke patients was currently employed at a 4-bed ICU in a small rural hospital. She stated, “We use a tele-intensivist program with physicians all over the country, and they check in twice a day….and we really talk about every patient. That’s helped us keep sicker patients and also gives recommendations to the current physician.” Two of the students had not noticed a pandemic-related increase in the use of telehealth at their workplace. The third was enthusiastic about a remote electronic monitoring system that her facility had instituted: “I find that to be really interesting…. where the provider might be tied up with another sick patient, but your patient is crashing, or you need assistance, and just having someone chime in to give feedback and help troubleshoot either a machine or how to manage the patient. It’s something that my hospital will definitely keep on board.” All students were open to incorporating telehealth as part of their future practice, with some reservations. One student expressed concern that remote assessment would be inadequate: “Relying solely on the patient who is not always the greatest historian and/or telling us everything we need to know, it’s hard not to be able to use all those hands-on assessment skills, and I imagine in really acute situation they may not be able to tell you anything at all, and so then it becomes that the objective assessment is all you have.” Another noted that resistance to change would be a barrier to greater incorporation of telehealth in inpatient practice. “You know, it’s so funny we work in a field that is changing all the time, possibly those older, more seasoned providers not wanting to learn the new technology or converting to this platform because they rely so heavily on the physical exam or it’s so foreign to them, I foresee that to be a barrier.” The same student said that the limits to autonomy inherent in hospital systems where “things are sort of forced on us” could promote use of telehealth despite resistance: “So here’s this resource and it’s only via telehealth; in acute care we’re fortunate to have those resources.”

Some student discomfort stemmed from the mental health focus of the encounter. “I’m used to doing regular old H&Ps and assessments with inpatients in the hospital. But I also think that’s good too, because you don’t want to only have practice with the same type of patients you’re seeing every day in clinical. It’s good to get outside your comfort zone, especially in a safe environment.” Another student agreed that “As stressful as it was, I’m glad that it was a topic that I wasn’t comfortable with because if not, then I probably wouldn’t be seeing a patient with this type of complaint, and I took a lot of time preparing the types of questions I wanted to ask him related to his depression, which is not something I’ve had to do before, so it was good practice.” When asked about mental health learning needs, the students felt that, in general, mental health topics were covered sufficiently in their curriculum to prepare them for their future roles. “I think we do see delirium, substance abuse withdrawing, depression, psychosis in the ICU quite a bit, with the different patient populations…. I did a neuro ICU rotation and definitely became a lot more exposed to those things. I did ER prior to that and saw all of the schizophrenia and bipolar patients, but again it’s so acute and they’re in that acute phase that my management was based on just safety of the patient and the people around, and I think we cover what the acute track needs.” She added that one aspect of care that she was uncertain about was assessment for suicide, determining risk, and making appropriate referrals. “I couldn’t find it in my notes, so that was one thing I was trying to figure out. I wasn’t really comfortable when the patient responded a certain way; I’m like, man should he be admitted, like is he a harm to himself? So, getting that information would be useful because that’s something I feel like we’ll see in an acute care setting, and it is important to assess to make sure that the patient is not harm to themselves or others.” In response to an inquiry about ways to improve the instructional experience, the students in the focus group suggested the incorporation of additional virtual encounters in the curriculum. “Maybe having another encounter towards the beginning of the semester to get feedback on things you could improve on in the visit as well as the SOAP note and getting a second chance to practice it again to see if you were able to take those recommendations and improve.” Another student thought that more encounters could help with the transition from an RN mindset to a provider mindset: “Incorporating it more throughout the other classes too, I think this is a great tool to help get our minds in that mode, and just the learning. I think it’s a really good way to learn without having to actually see a real patient or even before you see a real patient.” This student cited other learning experiences that she had missed due to COVID-19 restrictions or delays.

4. Discussion

The telehealth instructional initiative was easily integrated within the second and third of four core specialty courses, increasing the likelihood that incorporating this content will be sustainable following the completion of the grant period. Because this encounter includes practice with virtual delivery of care, it could be placed at any convenient time point in a semester without students needing to be in person on campus. AGACNP students participate in the virtual encounter around the semester’s midpoint. An additional experience could be incorporated into their end-of-semester immersion experience or subsequent courses using existing faculty and SAEL resources.

While the AGACNP students were receptive and generally positive about the telehealth experience, feedback about the mental health context was mixed. Focus group participants were uncomfortable with conducting a mental health assessment but recognized its value to their education and overall competency. Other survey comments indicated that some students felt that it was irrelevant to their role. This feedback is consistent with what is often seen in practice. Many acute care providers are not comfortable addressing even a simple suicide screening with a patient for fear of doing it incorrectly or not knowing how to do it. They choose instead to refer that patient to a mental health or primary care provider. However, it is critical that AGACNPs perform mental health screenings and understand when referrals are warranted, particularly those related to direct patient safety. AGACNPs are often a patient’s only provider, as many of them serve roles in Internal Medicine, urgent care, and other inpatient specialties. While these patients might not have a primary diagnosis of a mental health concern, such as the patient in our scenario, it is critical that all aspects of care be managed. Students receive information about suicide risk assessment early in their core program, but since it is not routinely used in their clinical instruction, additional information about suicide assessment and management would be a valuable addition to the preparatory work for a scenario that allows them the opportunity to practice this assessment in a safe environment. In addition, reinforcement of this information followed by opportunities to demonstrate their skills throughout the program would be beneficial in building skills competency and provider confidence.

Exposing students to activities involving observation of their performance may be anxiety-inducing, especially when introducing a new delivery format. A pass/fail grading strategy, except for a numerical grade for the post-encounter SOAP note, may have reduced most students’ anxiety about a new experience. A limitation of this formative activity was our use of RedCap to collect evaluation data, which functioned well for analysis purposes but resulted in our inability to determine whether students had completed the anonymous surveys. We had a 35% response rate for the didactic activity and a 75% response rate for the simulation activity, which, while not ideal, reflected increased engagement following the experiential component of the instructional activity. Reminders and faculty encouragement increased the response rate of subsequent cohorts over time.

Multiple students indicated that the opportunity to engage in another virtual encounter, either in this course or other courses, would increase their comfort level with the use of telehealth and with patient assessment. Program faculty are exploring whether this is feasible given current resources and curriculum demands. The integration of additional practice experiences could potentially allow a more focused evaluation of performance, provide hands-on practice with situations that students may not commonly experience with preceptors, or even include opportunities for collaboration with students from other specialty areas or health professions to teach care coordination, such as psychiatric referral for mental health concerns. The incorporation of telehealth delivery content in the AGACNP program is consistent with national accreditation standards and recommendations for graduate nurse instruction. Virtual encounters with SPs that simulate telehealth visits provide flexibility for online programs and prove particularly useful for the continuity of learning during the COVID-19 pandemic. They are an acceptable and relatively cost-effective way to develop student competencies. Mental health screening, assessment, and referral are essential competencies for all providers, given the prevalence of mental health problems and their impact on all domains of health. These skills can be incorporated into a broader specialty-specific instructional series to prepare students to address mental health risks in their future roles. In the College’s graduate program, a scenario involving both physical and mental health assessment, better reflecting the scope of AGACNP practice, would provide an opportunity for students to recognize and respond to depressive cues in the context of responding to a physiological complaint. Other opportunities could include collaborative assessment and treatment planning with psychiatric mental health nurse practitioner students, which would enrich the clinical component of both programs.