Virtual Nursing Playbook: Nursing Execs Explain the Keys to Success

By Delaney Rebernik

With nursing tech disruption at a fever pitch, savvy CNOs and CNIOs are putting their heads together to ensure their investments make real impact. And there’s one place in particular where they’re setting their sights.

“I think virtual nursing is definitely on the mind of every CNO, or it should be,” says Natalie Nicholson, DNP, MBA, RN, CENP, NEA-BC, associate chief nursing officer at Denver Health, which has more than 8,000 employees across its main hospital and nearly 40 additional care locations. The organization identified a virtual nursing vendor through an RFP process and plans to roll out its program this year.

Nicholson and her team are not alone. Two-thirds of U.S. chief nursing officers are already interested in, researching, or deploying virtual nursing, says Bonnie Clipper, DNP, MA, MBA, RN, CENP, FACHE, FAAN, founder and CEO of Innovation Advantage, a healthcare innovation consultancy specializing in the model.

Driving the trend is an aging population who’s requiring more care and a shortage of clinicians to provide it.

“It’s no surprise that nursing has taken a major hit with COVID in terms of staffing,” says Kathi Zarubi, DNP, MBA, RN, senior vice president and chief nursing officer at HonorHealth, which has six hospitals and more than 70 additional care locations throughout Arizona. “All hospitals in the country are trying to figure out how to safely staff.”

Zarubi sees virtual nursing as a key part of the solution, and she has led her organization in launching a pilot at one of their Phoenix medical centers in December.

Denver Health and HonorHealth’s CNO-CNIO teams share what it takes to stand up and evolve a virtual nursing program that fosters quality care and human connection from both sides of the screen.

On team nursing 2.0

In virtual nursing, a remote clinician can handle administrative duties that, though essential, could take time and energy away from bedside care. Zarubi says these duties often include admission or discharge documentation, as well as patient education about things like a new medication’s side effects. It’s the power of two nurses, one at the bedside and the other on the screen, combining brain power and bandwidth to better patient care.

Virtual nursing could represent the next evolution of team nursing, CNOs and CNIOs say. The context has changed significantly since the model emerged in the 1950s.

“What’s old is new again, but with a flavor of technology,” says Candice Larson, MSN, RN, NI-BC, ITILv3, HonorHealth’s chief nursing informatics officer.

On charting the course

When deciding whether and how to implement virtual nursing, center your north star, CNOs and CNIOs say. Hint: It should involve high-quality care and safety.

Other objectives may include nurse recruitment, retention, and efficiency, as well as cost.

“Health systems across the nation are in financial burdens right now,” Nicholson says.

From there, Zarubi says, be sure to ask the right questions, such as “How do I retain these very precious nurses, and how do we make the work enjoyable and not a burden?”

With these big-picture considerations in mind, look to prospective end-users—both nurses and patients—to shape strategy.

With five of its six hospitals Magnet-recognized, HonorHealth already had a framework in place for sourcing input on its pilot plans, Zarubi says.

“Magnet is really a structure that supports the individual bedside nurse having a large say in how things function and the governance of care,” she says.

At HonorHealth, that looks like a transformation office that Larson co-leads with nursing colleagues to create technology solutions that support organizational strategy. Outputs flow monthly to a nursing informatics council, where, in any given meeting, about 50–60 frontline staff, clinical directors, and CNOs across care settings and locations weigh options and make decisions. For larger-scale initiatives, Larson taps a clinical technology experience council, another multidisciplinary body that brings physicians, nurses, and other clinicians to the table to help decide whether solutions under consideration should move forward.

“We really want it to work for the organization, and not just today, but in the long haul,” Zarubi says. “So these kinds of councils allow us to take a look at those technologies from that standpoint and get all the users at the table to provide their input.”

The same goes for gathering input from patients and their loved ones through a dedicated advisory council, which has been a fixture “for many years,” she says.

“Measuring the patient perspective, and the actual patient and family experience with any new technology, to me, is very important,” she says.

On winning hearts and minds

Beyond empowering end users to define priorities and make decisions, CNOs and CNIOs can set programs up for success by addressing concerns head on.

“We’re not eliminating nurses by any means,” Zarubi says. “That is not the goal. The goal is to supplement the care and provide an even better experience for our patients.”

It’s also important to find champions to reinforce this message.

“It’s a win, and we’ve experienced that over the years with any new technology or any new piece of equipment,” Nicholson says. Some of Denver Health’s nurses also work at a nearby hospital that’s implemented virtual nursing and have been singing that program’s praises.

“Those nurses are like, ‘It’s amazing, you’ll love it,’ ” she says.

The good news is that the state of nursing today means fear of the unknown is often tempered with such excitement.

“Because the nurse market is so positive, I don’t think nurses are as fearful for their positions as they probably would be for other positions,” says Nicole Myers, MSN, RNC, associate chief nursing informatics officer at Denver Health.

On choosing the right tech

Once the vision is set, it’s time to talk tech. Myers recommends using a roadmap to visualize initiatives coming down the pike, how they roll up to organizational goals, and whether new or existing technology might enable their success through well-sequenced actions.

For virtual nursing programs, selecting the right vendor is a crucial step. Here, CNOs and CNIOs say, focus on the seamlessness of integration with current EHR software.

Denver Health, which uses Epic, closely vetted companies that responded to their RFP to ensure implementation and maintenance wouldn’t require outsized IT effort or additional personnel, Myers says. Such technical debt is not always on a CNO’s radar, but it should be, especially given the financial strain so many are feeling.

Similarly, think long and hard about which premium features are nice-to-haves, rather than day-one musts.

“We don’t truly need every bell and whistle, and I think the nurses would agree with that on the floor,” Myers says.

Also, look at the backend to ensure prospective software offers helpful analytics, Larson says.

“Does it support our processes?” she asks. “Are we getting the output in the data that we’re looking for?”

On starting small to grow sustainability

When it’s time to pilot, the prevailing advice is to start small.

That approach “allows time for change to be adapted, and to be accepted, and then start rolling it out into other areas,” Nicholson says. She and Myers plan to preempt virtual nursing services like admissions and discharges with virtual sitter services.

Zarubi and Larson are taking a similar tack. They launched their program on a single floor at one of their medical centers last month, and the laser focus has allowed them to expand quickly to all three floors earmarked for the pilot. Now, they’re refining based on early learnings and planning a full study on their nurses’ experience.

Although they’re still crunching the numbers, early signs point to improved patient experience. They’re hopeful about nurse retention, too.

“We’re trying to find that magic balance for that bedside nurse to try to get them to really enjoy their nursing experience and to home in on why they went into nursing to begin with,” Zarubi explains.

On making virtual nurses feel at home

When laying plans, don’t forget about the people behind the screen, CNOs and CNIOs advise.

Nicholson likes the requirement she’s seen for virtual nurses to have at least three years of hands-on experience.

“I think that’s fantastic; more would even be better,” she says. “There is a level of maturity and understanding when you’ve been in nursing for three to five years, and you can pick up on things that a new nurse takes a little bit more time to learn or recognize. It’s just experience. It’s just miles.”

In this way, the model also shows promise for mentorship by empowering veteran nurses who may not want or be able to work on the floor to impart wisdom to recent graduates at the bedside.

“They can present and have their clinical skills, or their clinical brains, shared with newer nurses and teach them and also be taking care of patients,” Nicholson says.

That’s why virtual nurses should be treated like part of the team. Even though HonorHealth’s remote partners are based outside Arizona, Zarubi and Larson onboard them “like they’re our own employees so they understand our goals and our values, our vision, our mission.”

That ethos carries all the way through to their virtual background, which displays the HonorHealth logo.

“It provides that seamless experience that they are one of our members of the care team,” Larson explains.

It also reinforces the humanity of it all.

“We don’t want robotic nurses,” Zarubi says. “We want real life human beings that have a human connection.”