Nurses have been in high demand for years, and especially since the pandemic. As baby boomers continue to age, the demand for bedside nursing continues to increase. In fact, 50% of the current RN workforce is over the age of 50.

THE PROBLEM

"There is a gap between the number of available jobs and the number of new RN graduates," said Julie Firman, DNP, RN, system chief nurse executive at Baptist Health, a health system based in Montgomery, Alabama. "Even before the pandemic, we knew we had to do something radically different to meet care requirements.

"We knew we could not apply ancient solutions and expect new or different results," she continued. "There had to be a shift to an alternative care delivery model, one that takes the burden off our bedside caregivers to the extent possible."

Exacerbated by the pandemic, Baptist Health was taxed with capacity issues due to staffing constraints, as well as just generally higher acuity than the organization was historically accustomed to. Staff members were forced to answer the question: How do we continue to keep patients safe and provide high-quality care with fewer resources?

PROPOSAL

As Baptist Health conceptualized this new care delivery model, the general premise surrounding virtual nursing was to use this unique labor source for three overarching goals: 

• Increase capacity to keep patients safe via continuous observation from virtual safety companions.
• Reduce the burden of documentation on bedside nurses so they can spend more time with their patients.
• Increase efficiency by supplementing care delivery through shared roles and responsibilities between virtual staff and bedside staff.

"Additionally, we felt nurses providing care in a virtual setting could enhance real-time patient monitoring of clinical indicators such as sepsis recognition," said Joseph Cook, DNP, RN-BC, system chief nursing informatics officer. 

"Our thought process was similar to an eICU model but in a med-surg setting, where virtual nurses could recognize, assess and evaluate, and then quickly notify bedside caregivers of changes or downward trends in patient status."

Baptist Health started with the vision that creating a team approach to nursing through shared roles and responsibilities between bedside staff and virtual staff would benefit both nurses and patients.

"By removing the administrative and documentation burden from our bedside caregivers and shifting it to virtual staff, we felt our nurses would be able to spend more time with their patients, leave work on time, and create a generally healthier and improved work environment," Firman said.

"Furthermore, we thought this model would be an opportunity to increase the number of caregiver touchpoints with patients and better involve families in updates to their loved ones’ conditions using our virtual staff," she continued. "We tried to build our model around the notion that each patient will now have two nurses coordinating their care."

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MEETING THE CHALLENGE

For virtual nursing, Baptist Health in part turned to health IT vendor Banyan Medical Systems, which offers a technology platform to effectuate virtual services, virtual staff to augment and supplement the care model, and change management consulting.

"From a technology perspective, we installed two cameras – a 180-degree panning camera and a 20x zoom camera – in each of our inpatient rooms," Cook explained. "We have a software platform that allows permission-based access to each of the cameras that our virtual nurses use to interact with our patients.

"Within the software application, we have a task-management dashboard for viewing assigned and completed patient care tasks between the virtual nurses and the bedside nurses," he continued. "All of this infrastructure is integrated to our registration and scheduling system via an ADT feed so that it contains up-to-date census by unit and room number, as well as patient identifiers."

After configuring and installing the platform, staff turned the focus to establishing a clear delineation of roles and responsibilities between the bedside nurse and the virtual nurse.

"To accomplish this, we granulated all possible patient assessments and interventions and used our Professional Practice Council to formulate standard work and determine what can realistically be completed virtually, as well as what should or should not be done virtually," Cook explained.

"Through our shared governance model we also sought feedback and ideas from our bedside staff for what would provide the most value to them and how we would operationalize communication and care coordination," he continued.

Currently, virtual nurses are able to autonomously perform admission history documentation, medication-history documentation, interdisciplinary plans of care initiation, daily disease-process-specific education, and to complete the discharge process.

"Overall, our virtual nurses and virtual safety companions offer additional support to bedside nurses to keep patients safe and decrease the burden of administrative tasks," Firman noted. "They are able to assume the parts of care delivery that do not require hands-on intervention, which allows bedside nurses to spend more time with their patients.

"In addition to the standard work that our virtual nurses perform, we have implemented some innovative workflows that came directly from feedback from our bedside staff including leveraging the virtual nurse as the second RN witness for high-risk medication administration and utilizing the virtual nurse as the second set of eyes for assessing and documenting wounds upon admission," she added.

Virtual nurses are able to round on patients in a more efficient and timely manner, and can notify bedside nurses of the need for patient intervention.

"Our virtual safety companions provide continuous observation of patients deemed high risk for falls, and are tasked with redirecting these patients or quickly notifying bedside staff to intervene," Firman said.

"Our virtual nursing program has proven to be an innovative way to support our nursing team and improve efficiencies," she continued. "The virtual nurses assist the bedside team with such elements as patient admissions, patient teaching, and discharge preparation and documentation, to name a few."

The technology has been beneficial in keeping patients safe during the pandemic, as there is always an RN readily available to lay eyes on the patient or to answer questions in a timely manner, she added.

"Virtual nurses also have played a key role keeping patients' families updated during this difficult time of restricted visitation," she said. "It has been embraced by patients and their families, physicians and most certainly the nursing team."

RESULTS

From a clinical-quality perspective, Baptist Health's biggest win in virtual nursing has been in fall prevention.

"The expanded attribution of continuous observation by our virtual safety companions, coupled with the increased frequency of virtual nurse rounding, has allowed us the opportunity to monitor more patients at risk for falls than prior to implementation," Firman reported.

"We utilize the Johns Hopkins Fall Risk Assessment Tool to objectively stratify our highest-risk patients, and we assign a virtual safety companion to monitor these patients as part of our existing bundle of interventions," she continued. "In calendar year 2022, we saw a 24% reduction in falls with injury compared to calendar year 2021, which aligns with when we completed implementation of our virtual nursing services."

The staff was very interested to understand what impact this model would have on patient satisfaction scores.

"We specifically looked at three HCAHPS questions we thought aligned with the work our virtual nurses were performing and measured six months pre- and post-implementation of virtual services," Cook explained. "We achieved a 7% improvement in nurse communication, 5% improvement in responsiveness of staff and 4% improvement discharge instructions explained.

"As we continue to expand and refine our virtual nursing model, we are hopeful to see even more improvements in these areas," he continued. "Additionally, from an efficiency standpoint, we continue to look for ways to quantify the value add related to reducing bedside documentation."

For example, the med-surg admission history takes approximately 25 minutes to complete. During fiscal year 2023 to date, the organization has had just under 9,000 admissions. Virtual nurses were able to complete 83% of all admission-history documentation. The process saved bedside nurses over 3,000 hours of documentation time so far this year.

"We are currently working on expanding this analysis to additional areas of care with which our virtual nurses are participatory," Cook added.

ADVICE FOR OTHERS

"We are very early to the virtual nursing space, and especially at our large scope we have had a lot of lessons learned since we began in 2020," Cook noted. "First, creating a standardized manner in which to orient the patient to the virtual nursing platform is paramount.

"We did not want to create a scenario where our patients were unfamiliar within the program or were startled by an interaction with a virtual team member," he continued. "We have mitigated this by having our bedside team explain and orient exactly what they can expect, prior to any interaction with our virtual nurses."

Second, having clearly defined standard work roles and responsibilities between bedside and virtual nurses was vital to ensure there were no delays in care or missed care, he added.

"Last, from an informatics perspective, we had to change our mindset that this was not just another IT application to support," he said. "There is a fundamental need to maintain continuity and continuous uptime, as this is a core nursing labor source that we are now reliant on for the care of our patients, just as important as our bedside team in providing care."

Treating the virtual caregivers the same as bedside caregivers was very important, Firman advised.

"We treat them just like our own nurses who happen to be practicing nursing from a virtual hospital," she said. "Since our virtual nurses are geographically disparate, a standardized communication and handoff model is imperative.

"We created standard work around shift handoff, intra-shift communication via our secure text messaging application, and report for patients’ post-admission history documentation, and for new additions to virtual safety companion services," she continued.

Also, the staff learned early on that there were advantages to involving other non-nursing disciplines in leveraging the platform.

"We now have physician staff, wound care nurses and pastoral care services using the platform to increase their capacity and efficiency as well," she reported. "Finally, and maybe the best thing that we did during implementation, do not be afraid to try new workflows and use cases based on the feedback of your staff.

"Virtual nursing is still an emerging technology, and collectively we will continue to refine and improve as the concept and technology expands and becomes more ubiquitous," she concluded.

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Email the writer: bsiwicki@himss.org
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