More health systems are developing virtual nursing teams to augment their workforce and close care gaps.
Nurses in remote positions tend to take on many administrative responsibilities, freeing up their in-person colleagues to provide hands-on care and spend more time with patients.
Health systems are experimenting to determine which technology solutions and workflows are most effective, while unions raise concerns about patient safety and push for in-person hiring instead.
Augmenting services
Several provider organizations have announced virtual nursing programs over the past year, largely in acute-care settings. Trinity Health, based in Livonia, Michigan, announced in January it plans to launch a virtual nursing model across 88 hospitals in 26 states following a year of pilot programs. In June, Renton, Washington-headquartered Providence announced it was implementing the model at eight hospitals in Texas.
Such programs require upfront expenses for recruitment and technology. When hiring, health systems often look for nurses with years of in-person experience to work exclusively in a virtual capacity. After being trained on telehealth technology, the clinicians are typically stationed at an on-site “command center” to handle admissions documentation, discharge planning and transfers, medical histories and assessment of current symptoms, though some work from their homes. The nurses also monitor patients from afar, educate them on medications and treatment, coordinate care with and advise the in-person clinical team and schedule calls with family members.
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Patient rooms are equipped with cameras, video screens, electronic alert buttons and telemetry devices that monitor their vitals and send data to care teams and the healthcare organization’s electronic health record. Patients and in-person clinicians can use screens set up in the room to interact with a virtual nurse.
At Stafford Hospital in Virginia, part of Mary Washington Healthcare, Associate Vice President of Hospital Operations Debra Marinari proposed virtual nursing as a way to augment care and address loss of clinical expertise after three years of the COVID-19 pandemic. The program began in May after six months of preparation.
“It was quickly recognized that we were not going to be able to continue nursing and the model of care that we had,” Marinari said. “Something had to change. What we were doing was not sustainable.”
The hospital tracks nurse turnover rates, infection and readmission rates and patient experience metrics to determine the program’s success, Marinari said. In-person and virtual team members provide feedback to nursing leadership about workflows and collaborative processes.
Having virtual nurses handle more of the administrative work boosts capacity, Marinari said. Because the virtual nurses tend to have more experience, Stafford Hospital set their pay at a slightly higher level than regular staff nurses working with critical-care patients.
The organization hopes to hire enough virtual nurses to remotely monitor patients 24/7, with Mary Washington aiming to expand the program to other facilities, Marinari said.
Provider organizations say that virtual nurses can effectively act as a support team for bedside nurses, potentially reducing burnout. The programs are also being used as an employee engagement tool to retain and attract clinicians. Having a remote option allowed Lexington, Kentucky-based CHI Saint Joseph Health to keep an employee on staff even after they moved hundreds of miles away, said CEO Anthony Houston.
“We didn’t have to backfill that person with, perhaps, an expensive temporary nurse while we searched for someone,” Houston said.
CHI Saint Joseph, which started an integrated virtual nursing program in 2022 using technology developed and patented by its parent company CommonSpirit Health, sees the clinicians as leaders in the front-line care process, who usually take on more responsibilities than their bedside counterparts, said Chief Operating Officer and Chief Nursing Executive Melissa Bennett. They need to be familiar with all the pieces that go into care, from how nutrition trays are delivered to where patients should be placed, she said.
In addition, the hospital expects virtual nurses to lead communication on patient safety, reporting any issues between shifts, sending messages to pharmacists and physicians, and hosting a daily quality huddle on any processes that need to change.
To make sure there are no gaps or delays in care, virtual nurses cover for each other on remote patient monitoring and administrative tasks, Bennett said. She said virtual nurses at CHI Saint Joseph are paid comparably to those doing in-person work.
“This [model] certainly doesn’t ever replace the bedside nurse. It augments and supports the bedside nurse,” Bennett said.
Unions voice concerns
Some unions representing nurses have expressed concerns about having clinicians providing care remotely, particularly when it comes to monitoring patients from afar. Rather than hire fully virtual nurses, the organizations say providers should bring on more in-person staff.
“We strongly oppose this proposal from the industry to descale and degrade nursing care, and to remove registered nurses away from our patients and into large command centers, where we will be taking care of patients remotely when they actually need us there by their side,” said Michelle Mahon, assistant director of nursing practice with National Nurses United.
Relying on pulse oximetry devices and other technology that can malfunction and give inaccurate readings is dangerous, Mahon said.
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“It’s not enough to just have somebody there remotely,” Mahon said. “You need the people who have the skills, knowledge and training to recognize subtle signs, things that technology isn’t picking up.”
While virtual patient monitoring has the potential to relieve stressed-out workforces and ensure appropriate resource allocation, it may also make care processes and structures more complex, said Stephanie Mercado, CEO and executive director of the National Association for Healthcare Quality.
“Challenges include availability and utility of remote patient monitoring tools and technology, and ongoing maintenance to ensure that these do not fail,” she said. “Careful consideration would need to be given to supervision of remote staff and quality controls to ensure that the staff were effective in meeting patient needs.”
Health systems should think through their workflows and outline backup plans, said Oriana Beaudet, vice president of innovation with the American Nursing Association.
“There’s a due diligence that has to happen with organizations when they’re deploying these technologies and these resources to make sure that those nurses are still supported,” Beaudet said.
Provider organizations with virtual nursing programs say they have fail-safes in place.
At Stafford Hospital, team members can use replacement tools in isolated cases, such as a faulty camera. On a larger scale—if there is a power outage or internet disruption, for instance—virtual nurses may be tapped to back up bedside clinicians in person.
In the short time that Stafford Hospital has been running its virtual nursing program, remote nurses have prevented adverse safety events, Marinari said.
“They’re just going to be those extra eyes and ears for the nursing team and the physicians,” she said. “The communication between the providers and the virtual nurses has been really seamless.”
Leaders at Chicago-based CommonSpirit Health say it has offered forms of virtual nursing services for more than a decade, including its recent model at CHI Saint Joseph, without major hitches when it comes to patient safety and care quality.
“We are actually finding that our patients are safer with that additional virtual person,” said Kathleen Sanford, executive vice president and chief nursing officer. “Having people who are not being interrupted all the time—the way that nurses often are on the floor—[is] adding to our safety.”
Representatives from Stafford, CHI Saint Joseph and CommonSpirit said they had not experienced pushback from unions about their virtual nursing programs.
Certification and expansion
As virtual nursing grows, industry stakeholders are conceptualizing ways to formalize the pipeline.
In March, a task force of 15 executives from 10 healthcare organizations convened by the Academy of Medical-Surgical Nurses and the Medical-Surgical Nursing Certification Board announced a forthcoming virtual nursing certification program. The certification will define the necessary skills to become a remote nurse, outlining educational requirements in domains of quality and safety, technology and collaboration.
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Other industry leaders have worked to improve their model as they expand it to additional facilities and use cases. CommonSpirit constantly reviews the effectiveness of its virtual nursing units using key performance units such as patient safety scores and staff satisfaction surveys, Sanford said. The health system compares virtual nursing units with those without remote nurses across subsidiary hospitals to determine the success of its virtually integrated care model, she said.
The health system has shifted care team makeups so all clinicians involved can work at the top of their license, although individual hospitals can adjust the model based on need and staff availability, Sanford said.
“What we are finding early on is that when you have virtual nurses, your falls go down, turnover goes down, patient experience goes up and the nurse experience goes up,” Sanford said.
Over the past few months, CommonSpirit has started rolling out a virtual home health program. As provider organizations look to widen virtual nurses’ reach, they should stay focused on improving patient outcomes, the clinical work environment and operations, Sanford said.
Sanford said leaders should ask themselves, “How are we going to make it better for our communities? How are we going to make it better for all the people that take care of the patients?”
