Virtual Nursing: A New Care Delivery Model

A New Way to Give Care

The recent pandemic presented an array of barriers and complexities in the delivery of healthcare to patients. However, no one expected a solution to be the mass acceptance of virtual nursing and virtual care. While we now find ourselves on the frontier between virtual and traditional care models, we are seeing how this virtual shift has the potential to influence everything from nurse retention and the efficiency and quality of care to how hospital rooms are designed and built. In the face of post-COVID-19 staffing challenges and overwhelmed medical facilities, healthcare leaders are realizing virtual care may be the way of the future.

A virtual nursing care delivery model is a healthcare approach that leverages technology with remote observation and communication to provide patient care, monitoring, and support. The virtual nurse is a licensed nurse serving in a remote location in support of the nurse at the bedside. The two work in collaboration to deliver patient care and monitor the care environment.

Successful Implementation

The key to the success of virtual care models appears to be shared decision making and building the virtual care concept from the staff level. Patricia Mook, MSN, RN, NEA-BC, CAHIMS, FAONL (personal communication, August 24, 2023), Senior Vice President of Nursing Operations, Education, and Professional Development at Advocate Health, explains that her team has three units continuously up and running, and they will be adding 12 additional units soon. Because they are setting up a repeatable structure, they have been able to create a playbook and can duplicate it over and over with lessons learned and improvements made along the way.

Patricia Mook is calling the new care delivery model, Nursing 3.0. The model features a nurse stationed remotely behind a camera who can perform nursing assessments, admissions, discharges, purposeful rounding, patient and family education, and encouraging patients to turn and ambulate. Working in partnership with on-site nurses, these virtual nurses can amplify the work of the nurse at the bedside, advising and documenting on-site care. Research by Patricia Mook and her team has shown a decrease in length of stay, fall reduction, and improved patient satisfaction.

In a recent article by Beckers Healthcare, Bari Dean (2023, August 18) shares another example of a successful deployment at Saint Luke’s Health System in Kansas City, KS. Jennifer Ball, Director of Virtual Care for the Health System, conveys how virtual nursing is a forward-thinking model of care that will help nurses as well as patients. Data have shown a decrease in the time it takes to discharge a patient by 2 hr.

Family and Patient Buy-In

More research will be required to fully assess the patient and family perspective of the new virtual nurse care environment. Some healthcare systems will allow the patient to opt out of being remotely cared for, while others describe the workflow as their new way to deliver care with no opt out possibilities. For patient satisfaction and privacy, a component of the technology enables a digital door knock feature. Before anyone virtually enters the room, a bell sound or door knock notifies the patient when someone is waiting to virtually enter. The patient must give permission for this care experience.

Rosemary Kennedy, PhD, RN, FAAN, Chief Health Informatics Office at Connect America, and Susan C. Hull, MSN, RN-BC, NEA-BC, FAMIA, Principal, Consumer Health Informatics at MITRE (personal communication, August 24, 2023) were also in the conversation with Patricia Mook. With their work in the home health environment and nursing informatics, they agree that the promise of the connected care environment from the hospital to the home can be accomplished.

Nurse Recruitment and Retention

Using virtual care models, Patricia Mook has seen improvements in nursing recruitment and retention. The model allows new graduate nurses to get experience on-site and then, after a year, become a virtual nurse. The nurses work on both sides of the camera—on the floor and in the virtual setting—and now the role is a sought-after position with improved job satisfaction. Data and research reflect how nurses are adopting and enjoying the care delivery model with a desire to work in both areas.

According to Jennifer Ball at Saint Lukes’s Health System, virtual nurses work in remote centers with videoconferencing technology to observe and reduce the burden of the bedside nurse.

An article by the Agency for Healthcare Research and Quality (2023) shared a recent interview conducted by Sara Mossburg with Kathy Sanford, Chief Nursing Officer at CommonSpirit Health; and Sue Schuelke, Assistant Professor at the University of Nebraska Medical Center. Kathy describes the virtual playbook for the virtual care model as the Virtually Integrated Care (VIC) model. The VIC is different from other virtual programs as it operates 24 hr a day. The process for the virtual nurse to enter the room features a doorbell ring alert. The virtual nurse can make rounds with the physician, answer questions, and be a liaison between the onsite team and the family. CommonSpirit also uses virtual nurses to support and guide new nurse graduates, augmenting faculty, and clinical expertise for their Nursing Residency Program. Often, telehealth or telemedicine focuses more on technology than a care delivery model, but pharmacists and other care team members are now showing interest in the use of the care delivery model. Sanford shares ways this care delivery model may be differ by state as each state has unique nursing scope of practice laws for nurses and other licensed healthcare professionals.

Sue Schuelke refers to virtual nursing as interprofessional integration. The care delivery is not episodic but rather, the virtual nurses are part of the care team. Sue refers to several barriers to virtual nursing. Change management is often a barrier, however, greater acceptance was found with Licensed Practical Nurses and new hires because of the nurse mentor available at all times. Another barrier noted was the float pool staff were unfamiliar with the model. She also commented on how physicians were using the virtual care delivery model to make virtual rounds. The model is expanding to pre-op for education, oncology nurse navigators, and into the home.

Change management and education are components of setting up a virtual care program. The cognitive impact of transitioning from traditional care to virtual care is an important concept to follow and understand. As the care delivery model is more widely adopted, nurses are becoming champions and leaders in developing the scope and standards for nursing practice in the virtual world.

American Academy of Nursing (AAN)

The AAN represents nursing’s most accomplished leaders in policy, research, administration, practice, and academia. Academy Fellows collectively are charged to share innovative ideas, develop new strategies for nursing, and transform healthcare.

One of the major contributors to policy and improvement comes from the Academy’s expert panels. The expert panels advance evidence-based innovation in healthcare delivery to address the health needs of the population. At the recent AAN 2023 Policy Conference, the Building Healthcare System of Excellence panel discussed the growing adoption of Virtual Nursing. A working committee was formed to tackle and discuss the impacts to nursing scope and standards, nursing practice, and safety and quality. Over the next year, the committee will scan the nation for evidence best practices, evidenced-based design, stories of success, and lessons learned.

Design Implications

As part of the architecture, engineering, and construction (AEC) community, how will the new care delivery model impact the design of the healthcare environment? It is important to advocate for a true understanding of the vision, road map, and time line for the health systems strategy and implementation. Several important questions to ask include:

Will the delivery model expand across the organization as an enterprise model?

What is the strategy of the model? (Staff retention and recruitment, patient quality and safety, coordination of care, etc.)

Are there policies and procedures in place for regulating patient privacy and patient experience?

Architectural Impact

The implementation of a virtual care delivery model impacts two areas of the patient room from an architectural and design standpoint—the footwall and ceiling. A digital footwall is often a term used to describe the large monitor at the footwall as well as the possibility of a digital care board. Sometimes, these technologies can be combined with a segregated screen for multiple purposes. A video camera will be mounted on the footwall or can be mounted on the ceiling. One will need to take into consideration the placement of ceiling speakers and microphones. The form factor of these elements is in an ever-changing state, so it is best to account for the following in some form or fashion:

Large monitor at the footwall

Camera

Speakers

Microphone

The challenge with the design of the digital footwall is flexibility and adaptability. As with all technology, the size and shapes of these elements are not going to stay the same over time. As technology continues to advance, all-in-one products are being developed as well as continual improvements in quality and clarity. Designing a custom footwall may not be the solution desired for flexibility but rather a “footwall canvas” allowing a plug and play modality to flex for these changes and upgrades.

Engineering Impact

Planning for the technology infrastructure and the future of a virtual care delivery environment requires a multidisciplinary approach. Coordination of the location of these components as well as the functional requirements must include clinical staff, information technology, informatics, patient experience, architecture, interior design, electrical engineering, and vendor partners. Including the right stakeholders at the right time and documenting the decisions will be an important way to communicate the functional requirements necessary to support the model of care. Creating a test environment for exploring functionality, form factors, and interoperability during the initial stages of design is a valuable way to discuss the implications of decisions made and make changes quickly in the design process.

Construction Impact

While prefabrication is often a desired outcome for headwalls and footwalls, the changing landscape of technology often creates limitations and a difficult decision. Involving the electrical contractor, lighting contractor, and low voltage designer in collaborative conversations early is the ideal planning strategy. Planning early and preparing a fully functioning mock-up room are an investment well spent. Ideally, the location of the mock-up room should be easily accessible to all team members, especially for clinical staff to easily find and attend meetings. Creating additional space adjacent to the mock-up room for collaborative meetings and dialogue is optimal and will help bring decisions more quickly. Ideally, creating an environment that provides a separate network for testing technology, as well as electrical, lighting, finishes, and furnishings, will ensure the most optimal planning space. If possible, close restrooms for use for ongoing meetings would be a plus. While the construction site will have limitations for the ideal mock-up room setting, one might consider a location within the current hospital should one be an option.

Conclusion

While still in the preliminary stages of virtual care, the potential benefits are hard to ignore. Over the next few years, it can be anticipated that healthcare providers will be looking to technology to advance care models as both nurses and patients begin to seek out virtual care options.