Virtual nursing is gaining significant momentum as an effective way to redesign and redistribute nursing workload. Virtual models decrease the burden on nurses delivering direct bedside patient care and leverages nurses who want to continue practicing, but may not be able to practice at the bedside, by extending their nursing careers.

THE PROBLEM

"The flexibility and various practice areas and models of care may appeal to nurses considering leaving the profession and who may not be able to work in a traditional setting," said Sylvain Trepanier, RN, chief nursing officer at health system Providence. "Virtual nurses will become a new area of professional practice. The hope is that this will keep nurses in the profession, enhancing their careers and improving retention."

PROPOSAL

Since 2004, Providence has been using various telemedicine technologies and virtual care models, including Teladoc Health, to support safe, high-quality care across the organization.

"Leveraging our deep experience in telemedicine, it made sense to apply bidirectional audio/video technology to assist our nursing colleagues in addressing some of the issues we hoped to alleviate as we piloted a new model of nursing care," Trepanier said.

"The pilot development process was highly collaborative among nursing and telehealth leadership, and representatives from ancillary services," he continued. "We carefully looked at all aspects of bedside care and had substantial discussions to identify what could be completed virtually and what required direct bedside care."

In discussions with bedside staff, they identified the overwhelming number of tasks they were responsible for that pulled them away from direct patient care, which caused dissatisfaction.

"The primary nursing model is no longer sustainable with the continued healthcare staffing challenges and the aging of the population."

Sylvain Trepanier, RN, Providence

"In staff feedback sessions, direct care nurses provided numerous examples of the various tasks they were responsible for in the management of the patient, and how in attempting to complete all these tasks there were numerous opportunities for an improved patient experience, improved operational throughput, reduced interruptions, and improved workload for our bedside nurses," Trepanier explained.

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MEETING THE CHALLENGE

At Providence, virtual care is being used to supplement or enhance care for patients. While bedside nurses still care for patients by providing direct hands-on care, virtual nurses can also participate and appear in the patient's hospital room in real time on their TV, ready to assist the patient.

"Bidirectional audio and video technology was installed and configured for each of the patient rooms and interfaced with the electronic health record to enable the nurse to seamlessly video conference with the patient," Trepanier explained.

"The team developed specific roles and responsibilities for the bedside nurse, virtual nurse and ancillary staff," he continued. "Communication tools such as secure chat and wearable two-way communication devices were also leveraged to enhance live correspondence between the virtual and bedside team."

Processes were designed to share with the virtual team the attending provider contact information. Paperless downtime documentation procedures were created to support the virtual nurses' EHR workflows.

Training modules were then created in the organizational learning management system customized for various roles (bedside nurse, virtual nurse, all other caregivers and super-users). All staff were required to complete the modules, and training was supplemented with virtual and in-person skills sign-off.

Additionally, as part of onboarding for the virtual nurse, the nurse shadowed the bedside nurse virtually to observe admission, discharge and education processes.

RESULTS

"The immediate results have been incredibly promising," Trepanier noted. "Within the first week, the virtual and bedside nursing teams collaborated on new use cases for the model. The virtual nurses have also proven to be incredible advocates for their patients, creating an improved care experience. We have had overwhelmingly positive patient feedback.

"The pilot is also providing perspective and data to help us answer additional questions," he continued. "We are using the data from this program to gauge if virtual nursing helps reduce average length of stay. Additionally, we are tracking how these changes in skill mix may impact caregiver experience, patient experience, the cost of care delivery, and other nursing-sensitive quality indicators."

The initial pilot successes led to its continuation and to plans to expand.

ADVICE FOR OTHERS

"In addition to technology that enabled bidirectional communication, we also optimized our EHR to be able to better coordinate care between our virtual and bedside care teams," said Trepanier. "We also enabled and improved our usage of live synchronous communications tools – for example, on-person devices and chat applications."

But technology is only one piece of this work. He said the following are even more important to the success of a virtual nurse program:

• Change management. Work with frontline caregivers to hear their concerns and ideas and have them buy into the project before starting. Leverage those early conversations to inform and educate on the work. Identify champions.

• Outline the scope and vision. Be very clear on the outcome and changes to be made. Share with the staff what will be changing, and how, prior to implementing the workflow changes. This will allow staff members to be prepared to operationalize the various workflows and ensure that their scope is maximized, and that everyone is working at the top of their licenses. This also allows for enough time to train the staff and ensure competency with any new skills.

• Executive sponsorship/leadership. There needs to be an engaged, present leader to paint the vision and emphasize commitment to the program, staff and patient safety. They need to be on the unit and present with their staff. They need to respond to concerns, champion the program and speak to the intent of why the organization is undergoing the change.

"The primary nursing model is no longer sustainable, with the continued healthcare staffing challenges and the aging of population," said Trepanier. "We have to do something to address the nursing shortage, and we are choosing to do that by innovating and redesigning how we deliver care."

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