The United States nursing workforce is in dire straits. Struggling to recover from a once-in-a-century pandemic that significantly worsened existing challenges, nurses urgently need support. Increasingly, health systems are providing that support through virtual nursing programs.
Research reveals that nurses experience burnout at higher rates than their healthcare worker peers. A 2023 cross-sectional study shows that 91.1% of nurses experienced high levels of burnout, compared to 79.9% of other healthcare workers. Additionally, 61% of nurses experienced low levels of job satisfaction versus 38.8% of other healthcare workers.
Nursing shortages -- a decades-old problem -- drive the vicious cycle of burnout. According to the American Association of Colleges of Nursing, research shows that the total supply of registered nurses (RNs) decreased by more than 100,000 from 2020 to 2021, representing the largest drop in nurses over the past four decades. Additionally, more than 610,000 registered nurses said they intend to leave the workforce by 2027 due to burnout, stress, and retirement.
Virtual nursing programs are becoming a popular strategy to curb burnout and increase retention within the nursing workforce. A 2023 survey showed that a majority of healthcare professionals (66%) believe virtual nursing will become integral to acute care delivery models. About 75% also noted that a potential benefit of virtual nursing is the opportunity to recruit nurses who are unable or unwilling to work at the bedside.
Advocate Health and St. Francis Health System are two of many healthcare provider organizations that turned to virtual nursing to combat nursing workforce challenges. As they implemented their respective programs, the organizations overcame several barriers, giving leaders critical insights into the best practices and missteps to avoid.
How health systems are using virtual nursing
Advocate Health and Saint Francis Health System launched virtual nursing programs during the COVID-19 pandemic. At this time, workforce shortages had become commonplace as healthcare workers sought to move to less stressful healthcare settings or exit the industry altogether.
"We had a lot of nurses that were migrating out of acute care," said Patricia Mook, senior vice president of nursing operations and professional development at Charlotte, North Carolina-based Advocate Health, in an interview with Virtual Healthcare. "We [also] had a lot of nurses that were at the time unable to work at the bedside for a variety of reasons but still wanted to work."
The exodus of nurses led to missed care in the health system as nurses struggled to fill the workforce gaps. This led Mook to sit down with the health system's nursing leaders to implement a strategy to alleviate the above issues. That strategy evolved into the health system's virtual nursing program.
"We started originally with bedside baby monitors," said Mook, who leads the virtual nursing program. "Very quickly, within 10 days to two weeks through brainstorming and quick initiatives, we were able to pull technology that we already had ... and we put them on a particular unit that was completely pulmonary and all pretty much COVID patients who were very, very sick. And we were able to put up a version of 24/7 virtual care within 10 days."
Today, more than 20 hospitals in the Advocate Health network use virtual nurses to manage admissions and discharges. Virtual nurses also consult with less experienced nurses at the bedside to enhance care. They initially worked from an area in the hospital but can now work from home.
Further, the program allows the nurses from the bedside to rotate in and out of virtual nursing, working two shifts at the bedside and one virtually. This helps alleviate the stressors of in-person work.
"They're using different muscles and [are] able to have a little bit of respite from the physicality of the work that they do at the bedside," Mook explained.
The virtual nursing option is particularly helpful for nurses experiencing health issues who do not want to give up their jobs. For instance, Mook noted that a nurse with immune deficiencies who could not work at the bedside could continue providing care through virtual nursing.
We wanted to focus on virtual nursing because, coming out of the pandemic, we reached the highest turnover rate that this organization has had in history at 19%.
Cynthia LeathersVice president and chief nursing officer, Saint Francis Health System
"So [virtual nursing] allows us to really retain nurses in caring for patients and support patient care at the same time," she said.
Similarly, Saint Francis Health System, based in Tulsa, Oklahoma, implemented virtual nursing due to high turnover.
"We wanted to focus on virtual nursing because, coming out of the pandemic, we reached the highest turnover rate that this organization has had in history at 19%," said Cynthia Leathers, the health system's vice president and chief nursing officer, in an interview with Virtual Healthcare.
Before the health system could deploy virtual nursing, the various virtual care services launched across the system during the pandemic needed to be standardized. To do that, the organization created a task force to vet companies offering virtual care platforms, eventually selecting Teladoc Health.
"Once we identified what platform we were going to go with, then we knew that virtual nursing was one of the first services that we wanted to launch," Leathers said.
The health system began its virtual nursing efforts with its medical-surgical (med-surg) units, launching an 81-bed pilot. The virtual nurses work in a hub on the main campus, offering remote support at the bedside via cameras installed in patient rooms.
Three virtual nurses work on the day shift, focusing on admissions and discharges and patient education. One nurse works the night shift, conducting 24-hour chart checks for the units.
Leathers also noted that virtual nurses can only 'enter' a room once they have the patient's permission. Following a virtual "knock" via the audiovisual equipment in the patient rooms, patients must provide permission before a virtual nurse can appear on the screen.
The benefits of virtual nursing have been apparent in both health systems. According to Leathers, the nurse turnover rate in the units using virtual nurses declined significantly, and the program has supported nurse recruitment.
"This past May of 2024, we have hired more med-surg nurses than we have in our history," Leathers said. "I do think that virtual nursing has been a key part of that."
At Advocate Health, virtual nursing has been popular among recently graduated nurses.
"We found that they thoroughly enjoyed their orientation," said Mook. "They always had an experienced nurse over their shoulder."
Having a more experienced nurse guide them also reduced care delays, as new grads could get the support they needed virtually, she added.
Implementation do's and don'ts
The success of virtual nursing at Advocate Health and Saint Francis Health System is primarily due to a considered implementation process. Looking back, Mook and Leathers can pinpoint the strategies that worked well and those that didn't.
We learned that we really needed to include more stakeholders to create an optimal model.
Patricia MookSenior vice president of nursing operations and professional development, Advocate Health
Implementing the virtual nursing program at Saint Francis Health System involved overcoming several hurdles, but technology was not one of them.
"We did not have any issues with the technology at all," Leathers noted. "It was seamless as far as the technology [was concerned]. The development of the workflow was time-consuming because we thought it was really important to have a collaborative decision-making process on those workflows."
The health system created task forces that met weekly for about 90 days to discuss and establish the new workflows. Multi-department collaboration was vital to this process's success; thus, the task forces included members from the nursing, IT, and virtual services teams.
Once the workflows were developed, the leaders shared them with the nursing teams. However, they made one mistake: they didn't share them with the in-person care nurses soon enough.
"When we went live, there were boots-on-the-ground nurses that weren't familiar with what the workflow needed to be," Leathers said.
Health system leaders are now working to ensure the workflows are standardized as the virtual nursing program is scaled across units.
Creating and implementing workflows was one issue. Health system leaders also noted communication gaps between the virtual nurses and the nurses in the unit during the implementation.
"There were some boots-on-the-ground nurses that really didn't want to delegate and give up that control on the discharge process or the admission process," Leathers said. "They wanted to just do it themselves."
Strengthening the relationship between the virtual and on-the-ground nurses is critical. Saint Francis Health System accomplished this by conducting listening sessions with the nursing workforce to understand the challenges of the new protocols and collaborative care model. Leathers noted that they made changes to workflows based on nurse feedback.
And it's not just the relationship between the nurses. Collaboration between clinical leaders is also essential, so health system leaders worked to foster trusting relationships between the clinical manager overseeing the virtual nurses and those heading individual units.
Mook echoed these sentiments, stating that shared governance was also critical to the success of virtual nursing implementation at Advocate Health. The health system created a culture of shared governance through unit practice councils, which are multidisciplinary teams that meet monthly.
"We learned that we really needed to include more stakeholders to create an optimal model," Mook said. "And as we spread this across our enterprise ... we've learned that decision-making needs to be made at the practice level. And we have incorporated all stakeholders, not just our nursing stakeholders, but our physician stakeholders, our social work stakeholders, our discharge planning stakeholders."
The health system also created patient focus groups to address patient concerns regarding the implementation.
Like Saint Francis, Advocate Health had to foster relationships between virtual nurses and those caring for patients in person. Mook noted that nurses expressed concerns about being replaced and a lack of patient privacy, but leaders were able to dispel those concerns during education and training sessions.
Another critical factor in ensuring a successful implementation was gaining and maintaining buy-in from the organization's CFO.
"It's important to really show what the ROI is going to be for this large investment," Mook said. "And really to have them see what the benefits are in terms of recruitment retention, which is so very costly right now."
Virtual nursing can help reduce nurse vacancy rates and patient lengths of stay while improving patient experience, which can positively affect the organization's bottom line, she added.
Another misstep Leathers mentioned was the staggered-phase approach to implementation. The decision to stagger the go-live process was to ensure enough time to install the technology; however, it led to some operational inefficiencies.
"We implemented one unit on one day, and then two weeks later, we implemented a second unit, and then two weeks later, we implemented a third unit," she said. "Looking back, we probably should have just waited and implemented all three units at the same time because the virtual nurses had to go back to a new group every two weeks. And so that was six weeks of new people learning the process."
Advocate Health leaders learned that they needed to understand existing workflows before creating and implementing new ones. Mook explained that virtual nursing implementation hit several roadblocks during the deployment in the first unit because they didn't do their due diligence to understand the workflows in place and how that would impact new workflows. Establishing the unit practice councils helped the health system mitigate this issue as they continued deployments in other units.
Now that the virtual nursing programs have successfully been deployed, the health systems want to expand them.
Advocate Health will deploy the program in two more hospitals soon, and any new hospital construction will already include the capacity to implement virtual care technology, like cameras in patient rooms. Meanwhile, Saint Francis Health System plans to expand the program to three hospitals and nine units by the end of the year. After that, they want to scale the program to cover all med-surg beds systemwide.
These plans to expand virtual nursing point to the enduring advantages of the model. Still, as with any new technology-based approach, thoughtful deployment is one of the most vital drivers of success.
Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring, and digital therapeutics.
