At our healthcare system, our patients are our number one priority. That perspective keeps us thinking about new ways to deliver care, including those that allow our caregivers to put their knowledge, skills, and focus to the best use. The development and ongoing evolution of our homegrown virtual acute care nursing (VACN) program is one way we are making sure our caregivers are working at the highest levels to care for our patients.

Our VACN program allows experienced, registered nurses (RNs) to practice virtually in another location. These virtual RNs help nurses at the bedside by documenting patient health information such as medication histories, providing patient education, functioning as a clinical coach, monitoring patient diagnostic test results, completing patient admission documents, or helping with discharge planning and care coordination, amongst other responsibilities. Through virtual nursing practice, virtual nurses help remove a documentation burden for our clinical staff while also improving our patient outcomes.

Background: Starting a VACN Program

In 2022, VACN was first piloted on one medical and one surgical unit at our healthcare system, and now, has expanded to over 20 units and 600 inpatient beds. To change our care delivery model, everyone had to be prepared for a ride on the “VACN Express,” and our nursing professional development (NPD) specialists were our conductors.

To implement a successful program, it was important to educate staff early and often. Leadership teams on each pilot unit, including the nurse manager (NM), assistant nurse manager (ANM), and NPD practitioners, discussed which RNs would likely excel in the VACN role. Our main criteria for the role were years of clinical RN experience on the unit, familiarity with our computer systems, and a willingness to be a pioneer in this care delivery innovation. Charge RNs and preceptors were at the top of the list.

Once the VACN RNs were chosen, we started formulating the role description and daily task list for the new role, making sure to receive plenty of input from clinical staff and the chosen VACNs. The nurses who were to become VACN RNs were an integral part of developing the role and responsibilities throughout the pilot program. Once a version of the role and responsibilities was finalized, we made sure to educate the bedside staff, including nurses and patient care technicians, on how it would improve their workflow and patient experience. A flyer was developed by the NPD team for bedside staff and another for patients/families on the program's purpose and functionality. To ensure adequate communication and understanding, we also discussed this information at unit huddles twice daily, staff meetings, individual face-to-face conversations, and via leadership email communications.

In addition to educating the VACNs and bedside nurses, we contacted leadership from multiple departments involved in the care of our patients. These included providers, case management, dietary, environmental services (EVS), patient escort, and multiple therapies. We developed a flyer for each of these disciplines to distribute to their respective care areas with key information that pertained to their department.

The education for the VACNs themselves was much more in depth. They each went to shadow a virtual nurse from our “Hospital Care @ Home” program to visualize what virtual nursing care could look like. They each completed web lessons detailing how to properly use virtual technology and principles of virtual healthcare. We worked with the virtual nurses and program developers to create a virtual nursing environment that would best serve our needs. While developing that environment, we had multiple sessions on how to use the technology and to test the new upgrades.

Our VACN Pilot & Its Results

Our pilot began with five inpatient beds on each pilot unit and impacted the patients that were placed in that bed assignment. The pilot steer selected nurses engaged and readied to provide virtual care and ensured bedside staff were knowledgeable about the program. Once a streamlined workflow was established with the five patients per virtual nurse, we slowly increased the number of patients virtual nursing covered, learning new efficiencies and practices along the way. We worked with the VACNs and bedside staff to improve the workflow as the pilot expanded to include the entire patient population of each pilot unit.

During and after the pilot, we evaluated data and found an improvement in organizational outcomes such as length of stay (LOS) and 30-day readmissions, in addition to patient experience (PX) metrics, directly related to the program. Based on the success of the pilot units, other medical and surgical units were chosen to expand. Orientation checklists were developed prior to the expansion and materials were provided to expansion units to educate the VACNs and bedside staff.

Program Expansion

One of the first units to expand the virtual nursing care delivery model after the pilot period was a 40-bed medical stepdown unit. The leadership team, including the NM, ANM, and NPDs, chose their first virtual nurses based on the criteria above. These nurses were already engaged on the unit as charge nurses, preceptors, and mentors. As virtual nurses, the plan was for them to rotate between bedside clinical shifts and virtual nursing shifts. As early adopters of change, they were quick to recognize the impact the virtual nurse role would have on their patients, family members, peers, and the unit's overall success.

Prior to the expansion of VACNs to additional units, unit education was created and initiated by the pilot units' NPDs, tailored to be unit specific. Additionally, a presentation was created with up-to-date information for staff that reviewed details about virtual nursing and its positive impact on patient and caregiver experience. In addition to small group in-services, discussions were held at staff meetings and huddles. Disseminated flyers also included written communication and education. We arranged for the VACNs to be paired with experienced VACNs from the pilot units for a 12-hour shift to learn and observe virtual nurse best practices. Job aides on how to get started using the VACN software, documents that reviewed workflow and process, and the virtual acute care nursing website were shared with the virtual nurses. Binders with unit specific information related to virtual nursing were created and made available in the virtual nurse workspace.

During the go-live period, VACN RNs shared lessons learned frequently, participating in daily huddles to relay any feedback regarding any technology issues or recommendations for improvement. Bedside nurses followed the established workflows based on their patient assignments. Unit leadership rounded often on the unit and in the virtual nurse work area to gather information and encourage use. Frequent updates and reminders were shared with staff at huddles, staff meetings, and via email as the process evolved. 

Program Implementation Results

Overall, the initial three-month implementation period was successful; bedside nurse documentation burden was decreased and patient experience scores increased, particularly in the realm of improved communications and teach-back. Initially, some staff were hesitant to utilize the VACN. During this time, we continued to educate staff and in collaboration with unit leadership, rounded frequently, performed ongoing evaluation, and made occasional adjustments to the workflows of both the VACN and bedside staff based on their feedback. As the virtual nurses spent time in the virtual role and on the unit in a patient care assignment, they evolved as role models for their peers as they became proficient in utilization of the virtual nurse role, and over time, bedside nurses began to incorporate use of the virtual nurse into their daily workflow. Many nurses will now tell you that use of the role is part of their shift routine and that they consider the VACN an integral part of the care team. In addition, many state that they complete more hands-on patient care when the admissions, discharges, and other documentation and/or tasks are being handled by the VACN.

NPD is a nursing practice specialty that improves the professional practice and role competence of nurses and other healthcare personnel by facilitating ongoing learning, change, and role competence and growth with the intention of improving population health through indirect care (Harper et al., 2022). With any change in the organization, our NPD team is integral for education, awareness, troubleshooting, and support as we serve as change agents and partners in practice transitions. As technological advances in healthcare continue to evolve, so do the expectations and responsibilities of the NPDs. Using many different resources and modalities, our NPDs successfully steer our teams to success on the “VACN Express.”     

References

Harper, M. G., & Maloney, P. L. (2022). Nursing professional development: Scope and standards of Practice (4th ed.). Association for Nursing Professional Development.