After a grueling few years responding to the COVID-19 pandemic, turnover, burnout, and hospital vacancy rates have all increased among nurses. With hospitals drowning under a sea of patients due in part to an earlier than usual surge in respiratory illnesses, a problem compounded by staffing challenges, some experts argue a change is needed. Can virtual nursing help?
Virtual nursing has been around since the early 2000s, and MedPage Today spoke with a handful of experts in the field who argued that now more than ever, integrating virtual nurses in hospitals can help keep new nurses practicing safely and prevent more experienced nurses from leaving the field entirely.
Turnover for registered nurses (RNs) rose by about 8% in 2021 and now stands at roughly 27%, according to a survey from NSI Nursing Solutions. That same survey reported RN vacancy rates of 17.1%. What's more, two-thirds of nurses say they plan to leave the profession in the next 3 years, according to a recent survey in the journal Critical Care Nurse.
One of the biggest impacts of the increased turnover in nursing and current vacancies is the loss of experienced nurses, because it creates a knowledge gap, said Teresa Rincon, RN, PhD, a senior telehealth consultant for Blue Cirrus Consulting. The Critical Care Nurse survey found that of the roughly 9,000 respondents, only 24% said their units had the right number of nurses with the right level of skills and knowledge more than 75% of the time.
The knowledge gap "is where virtual nursing comes in," Rincon said. There's a subset of nurses who may not be able to work 12-hour shifts on their feet. They may have a bad back or a bad knee, or they may be immunocompromised and worry about being exposed to infection in a hospital setting, said Wendy Deibert, MBA, BSN, senior vice president of clinical solutions for Caregility, a virtual care platform company in Eatontown, New Jersey. These nurses, many of them with years -- even decades -- of experience, represent an untapped resource, and under the right circumstances they might not leave the profession, she explained.
Three core benefits of integrating virtual nurses into care, experts say, include coaching or precepting nurses; relieving bedside nurses of time-consuming tasks; and surveillance. In addition, "it's a great way to bring more nurses back into the field," said Ashley VonNida, DNP, MSN, chief nursing officer for Equum Medical, an acute care telehealth staffing firm in Nashville, Tennessee. A lot of the virtual nurses currently working for Equum Medical retired from healthcare but miss the interaction with the patients and still want to provide care, she said. As for the functions virtual nurses can serve, "anything that a bedside nurse does that doesn't require hands on a patient, we provide that using AV [audio-visual] technology."
VonNida stressed that she doesn't see virtual nursing replacing bedside nurses; instead, she views the virtual nursing as a "hybrid" approach and a "redistribution" of the workforce. "So instead of having six bedside nurses on a unit, you have five bedside nurses on a unit and a virtual nurse," she said.
Coaching, Precepting New Nurses
New nurses coming onto the floor of a hospital for the first time are "scared to death" of making a mistake, said Deibert. "They're thrown into a world ... with not a lot of experience behind them," she said. "So having a button on the wall where you can push ... at a moment's notice and get a nurse in that room to assist" virtually is a huge help.
For example, she can guide a nurse through putting in a chest tube or another procedure that may be routine, but requires practice. "I can zoom in to [see] exactly what they're doing and give direction and support, so that they don't feel like they're out there on a limb by themselves," she said. "Not only does that boost their confidence, but it also really stops that turnover, because if they get too scared and do not feel supported, they're not going to stay there."
And the system she works in has two-way audio-video capability as well as the ability to zoom in to either 20× or 30×, Deibert told MedPage Today. "I can read an IV pump. I can see [a patient's] pupil. I can see their wound -- how deep that wound is ... I can zoom up, zoom out, go left, right, up, down ... look all around the room," she said. Earlier in her career, Deibert wasn't able to assess heart sounds and lung sounds, but now with Bluetooth stethoscopes, that gap is closing too, she noted. The nurse and the patient can also see her on a monitor, unless she "goes in quietly," which she said she makes it a habit to do when a patient is sleeping.
Relieving the Burden on the Bedside
Another core benefit of this "hybrid model" is that the virtual nurse can take some of the weight off the bedside nurses by managing tasks that don't require a nurse's physical presence. Virtual nurses can manage admissions and help educate patients about their plan of care, Rincon explained. Virtual nurses can also help with patient education, documentation, family conferences, and discharging patients.
"I can't start an IV. I can't put a tube in ... or do those dressing changes that can be pretty elaborate," Deibert said. But any time a bedside nurse is giving one patient a bath, for example, that's when that nurse can tap the virtual nurse, and she can then "round" on the bedside nurses' other patients, and ensure their needs are met.
"A lot of times the virtual nurses can document things to save the nurse at the bedside time... So it doesn't tie their hands up... when they could be doing something that's physically helping the patient" such as administering a medication, said Fiona Winterbottom, CNS, a clinical nurse specialist who has been working in virtual nursing for the last decade.
Surveillance, Screening
Another area where virtual nurses can support those at the bedside is through monitoring and surveillance. While bedside nurses are trying to juggle seeing five or six patients, a virtual nurse can be doing remote screening, explained Winterbottom.
Virtual nurses see trends differently than nurses at the bedside because they have fewer distractions, Winterbottom said. Virtual nurses are gathering data -- watching patient's vital signs, looking at physiological lab data, being attuned to algorithms and clinical decision support alerts, while also actively rounding on patients, Rincon said. As they do all this, they're deciding whether a patient is beginning to stabilize or moving toward deterioration.
This kind of constant screening and leveraging of clinical decision support systems allows for virtual nurses to zero in on patients within the floors they are virtually responsible for, and help avoid a code or a rapid response team from being called, added Deibert.
"When you have small groups of people taking care of large amounts of patients within a quiet, non-distracting environment, they can really do protocolized care very well," said Corey Scurlock, MD, MBA, founder and CEO of Equum Medical.
Choosing Virtual Nursing
Virtual nurses, depending on their specialty need at least 1 to 3 years' experience, said Deibert, and to work in critical care at Equum requires 10 years.
For those who choose to precept or coach nurses new to the field, they must be both patient and experienced, Winterbottom said. "It's far easier ... to do something myself than talk somebody through something, because it takes me three times as long. So, if you don't have the patience, the coaching abilities ... [and] you can't do it at the bedside, you're probably not going to be able to do it through a camera."
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