By Dorothy Brooks
There has been considerable discussion about all the ways telemedicine has enabled patients to access care in new and more convenient ways. However, the same technology also is enabling healthcare administrators to push the envelope regarding staffing.
Across the United States, health systems are experimenting with programs that enable nurses, working remotely, to handle tasks that usually are handled by in-person, bedside nurses. These virtual nurses are managing everything from purposeful rounding to handling administrative tasks that often keep bedside nurses from spending more time on patient care.
At least one aim of virtual nursing is to address a critical workforce shortage, as burnout from the pandemic, along with other factors, has led to an exodus of nurses from the profession. To that end, many of these programs are focused on alleviating some of the burdens on frontline clinicians in the ED, thereby affording nurses a better work-life balance.
Further, while many of these programs are just starting, administrators see vast potential in leveraging the approach to give new options to veteran nurses who might otherwise leave the profession, along with their valuable knowledge and expertise.
AdventHealth, which operates more than 50 hospitals in nine states, began a program in 2022 to leverage virtual nurses in three of its Florida facilities. The initiative is part of a larger, comprehensive effort aimed improving the overall nursing experience in the health system, explains Michele Johnson, MSN, vice president and chief nursing officer at Fish Memorial in Orange City, FL.
While AdventHealth hospitals in DeLand and Daytona Beach, FL, are using virtual nurses on inpatient units, Johnson says virtual nurses at Fish Memorial were deployed to support bedside nurses in the ED. The pilot has expanded to the hospital’s progressive care inpatient unit. “Just like an in-person nurse would knock on your hospital room door, a virtual nurse — a registered nurse working offsite — asks if [he or she] can turn on the webcam and then appears on the TV monitor in front of a patient’s bed,” Johnson explains. “In some cases, the bedside nurse will introduce the patient to the virtual nurse.”
In the pilot phase at Fish Memorial, virtual nurses in the ED were focused on reconciling medication history and obtaining general admission information. “Nurses often spend a lot of time on this, researching a patient’s medical history by calling family members and other medical providers, tracking down prescriptions, and more,” Johnson says. “With the help of the virtual nurses, our bedside nurses can spend more time providing hands-on clinical care.”
The results have been promising. Johnson notes administrators are excited about the prospect of further leveraging the technology to make an even bigger dent on workload intensity. She also envisions using virtual nurses to help onboard novice nurses, improve patient education, and elevate patient safety.
“Additionally, virtual nursing has the potential to serve as a valuable retention pathway, allowing experienced and knowledgeable nurses to continue practicing in the profession for a longer duration,” Johnson says. “We recognize that our population of baby boomers is growing. As a result, many of our nurses are also aging. Virtual nursing offers an alternative for experienced, veteran nurses who may prefer not to be on their feet for 12-hour shifts. It provides them with the option to leverage their expertise in a remote setting.”
While concerns about work-life balance were present even before COVID-19, this became a critical problem amid the mounting burdens of the pandemic. “Our ED, like many others across the U.S., experienced high patient volumes and significant burnout among our teams, leading to a high turnover rate,” Johnson says. “We focused on improving workload intensity, providing more support for our novice nurses, and creating a more sustainable and supporting environment.”
These efforts, including the virtual nurse pilot, have begun to deliver measurable outcomes. Johnson reports Fish Memorial has seen its monthly turnover rate of nurses drop from 46% during the surge in cases related to the omicron variant to around 11% today. “Virtual nurses can provide a second set of eyes for bedside nurses and help with admissions and discharges, reducing the workload on the onsite care teams and allowing them to work more closely with high-acuity patients,” Johnson observes.
Further, even when deploying virtual nurses specifically in the ED, Johnson stresses the impact can be far-reaching, extending into the inpatient area — particularly during the admissions process. “When the virtual nurse in the ED completes the medication history and general admission [process], it greatly assists the inpatient admission nurse,” Johnson says. “This streamlined process reduces admission time and has been highly appreciated by our inpatient RNs. [It also] helps them manage consecutive admissions from the ED.”
Workforce-related issues were top of mind when administrators at Philadelphia-based Jefferson Health decided to go forward with a virtual nurse pilot in March 2023, explains Colleen Mallozzi, MBA, RN, senior vice president and chief informatics nursing officer at Jefferson Health. “There was a lot of discussion around how [we could] do things differently,” she says. “We have to figure out ways to evolve the team in a way to support nurses [so they can] manage what they’re dealing with on a daily basis.”
The first phase of the virtual nurse pilot began in two observation units at Jefferson Abington Hospital in Abington, PA. “Nurses in these units take care of patients who are supposed to be short-stay, but [the units] do also include some inpatients,” notes Laura Gartner, DNP, MS, RN, NEA-BC, division director of clinical informatics at Jefferson Health Abington. “It’s a med-surge level of care with a pretty high turnover, [and] the unit we want to expand to is also a med-surge.”
Gartner notes virtual nurses can handle tasks that do not require touch. “The focus of our virtual nurses has been on admission history, documentation, and discharge education,” Gartner reports. “They are also doing purposeful rounding,” which typically involves checking in on each patient, asking about pain levels and any other symptoms or issues of concern. “The virtual nurses also help with some miscellaneous things that we have found very helpful, such as checklists that need to be completed before procedures [and] patient education,” Gartner adds.
Mallozzi says Jefferson Health is excited about involving virtual nurses in mentoring newer-to-practice nurses. “We have a lot of onboarding going on right now across the country with new nurses coming in. There is an opportunity for virtual nurses to offer support to those nurses as they try out new tasks and as they learn to have those thoughtful conversations with patients,” Mallozzi shares.
Another potential virtual nurse task that can be helpful to bedside nurses is scribing. “I, as a nurse, get to put my hands on the patients and look them in the eye while talking to my virtual nurse partner while [he or she] is doing the documentation for me,” Mallozzi explains. “It really allows the [bedside] nurse to visualize [and care for] the patient without having their back to them.”
While the virtual nurses are not working directly in the ED, they are affecting operations there. “They definitely help to decompress the ED because the virtual nurses assist the bedside nurses with admission work and things along those lines,” Gartner observes. “[Admissions staff] can pull those patients up faster from the ED. On the flip side, [virtual nurses] can help decompress the hospital unit by facilitating discharges.”
For example, Gartner explains a virtual nurse will have more time to spend with patients on education and other tasks required before discharge. “They can do everything other than pack up their bags for them,” Gartner says.
Just a few months into the pilot, administrators have observed shorter lengths of stay (LOS) for patients on the same unit with a virtual nurse vs. patients not interfacing with virtual nurses.
“Their time from discharge order to actually being discharged is shorter, their time within the observation unit is shorter, and the overall LOS for inpatients who are on these units is shorter,” Mallozzi says. “It is certainly a good thing for the efficiency of the hospital, but it’s a good thing for the patients as well. It’s less waiting on things to happen.”
While the pilot is going well thus far, Gartner acknowledges there was much work involved with implementing the virtual nurse program. For example, the hospital had to secure approval from the Pennsylvania Department of Public Health, a step that required a detailed policy explaining how the pilot would work. “We needed the workflows for the nurses, which required some changes to our electronic medical record,” Gartner explains.
Other needed steps included training virtual nurses on how they would work on the units, and training the bedside nurses on how they would coordinate with their virtual counterparts. “Further, we needed to have the equipment installed and tested on site, a step that was necessary for both the department of health as well as the training,” Gartner shares.
Mallozzi says a critical step involved managing the expectations of bedside nurses. “When we come in and say [virtual nurses] will be assuming part of their jobs, there is almost an innate [feeling of] threat that happens,” Mallozzi says. “Helping the nurses recognize that [the virtual nurse program] is designed to give them back time, enhance the work that they are doing, and enhance their interactions with patients ... was an important conversation to have.”
Fortunately, while some of the nurses did not initially grasp how the program would work, they have since fully embraced the concept and are happy to pass on many of the administrative tasks that would otherwise take them away from providing patient care.
Two nurses who have been performing virtual nurse duties thus far come from the Jefferson Health Service, Excellence, Advocacy, and Leadership (S.E.A.L.) Team, a designated group of nurses that can be deployed to work in different areas of the health system, as needed. As part of their training, these two nurses had to understand the workflows and how they would interact with patients. “It is a little bit of a different mindset,” observes Gartner, noting some have described it as “webside” manner vs. bedside manner.
The virtual nurses typically need to explain the program to patients, and they also need to understand how to respond to different patient concerns or requests. For example, Gartner notes one of the algorithms built into the program details what the virtual nurse should do in the case of an emergency — a situation during which the virtual nurse can see the patient, but cannot physically respond. The virtual nurses must understand how to escalate that situation, as well as other circumstances they may encounter.
“Figuring out the scripting with patients was an important part of the beginning of this pilot. We were present on the units, working with the virtual nurses and working with the live nurses through this initial phase,” Mallozzi says. “Also, we’ve been working with the Jefferson [College] of Nursing to figure out what the future [of this aspect] looks like here. What do we teach people about virtual nursing, and then how do we study this and educate about it?”
A major key to the success of the program has been the involvement of a supportive and engaged nurse manager. “She was open to this, she engaged her staff, and she gave us quick feedback when something wasn’t working,” Mallozzi says.
Employing virtual nurses directly in the ED is on the agenda. “Originally, when we were rolling this out, we thought about putting our devices in the ED. But because it is such a unique area, we were nervous to start there,” Mallozzi says. “We want to be there. We just want to come in with a strong plan and a really good understanding of how this technology works before we further disrupt [ED operations]. They have a lot going on in the ED, and they have a great need for support.”
Meanwhile, investigators are delving into important operational metrics to determine where the virtual nurses are making the biggest impact. For instance, compliance with documentation and great catches on medication errors are sensitive indicators. Here, the program has demonstrated value.
“On our first day, we had a patient who needed to go for a procedure for surgery, and they needed to be NPO [nothing by mouth],” Mallozzi explains. “The virtual nurse happened to be in a session with the patient when a food tray arrived.” The patient was about to eat the food, but fortunately the virtual nurse told the patient to hold off, given the upcoming procedure.
“This is important because [eating the food] would have delayed the procedure, which would have extended the patient’s length of stay, and could have prolonged the patient’s entire hospital experience and made him sicker,” Mallozzi says. “This [incident] occurred within the first few hours of the virtual nursing pilot, and it was basic. We’re going to spend some time digging in on some of the great catches — [adverse incidents] we have been able to avoid.”
As the program expands and transitions toward what Mallozzi refers to as a steady state, she will be looking to hire nurses directly into the virtual nurse roles. She also sees new opportunities for bedside nurses.
“There’s going to be the ability to create hubs, and perhaps people can take a day away from the bedside and rest and reboot, or [they can] fully move away from the bedside into this type of space and use their many years of experience to mentor others,” Mallozzi observes. “Maintaining a rapidly-turning-over workforce is expensive. If we can do things to make it easier and better to be a nurse, then that is a positive thing.”
Across the United States, health systems are experimenting with programs that enable nurses, working remotely, to handle tasks that usually are handled by in-person, bedside nurses. These virtual nurses are managing everything from purposeful rounding to handling administrative tasks that often keep bedside nurses from spending more time on patient care.
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