During the recent COVID-19 pandemic, organizations developed a number of innovations to maintain services while protecting staff from unnecessary exposure risk. The most common innovation was the use of virtual staffing models that utilized various forms of technology to support and maintain staff engagement with work. While the risk of exposure to COVID-19 has greatly subsided, the concepts and lessons learned with virtual staffing are being leveraged as a solution to the challenges with current nursing staff shortages. Even though initial use shows great promise with increasing patient monitoring, staffing options and safety, its use poses some considerations regarding regulatory compliance that organizations should keep in mind.
Determining the Organization’s Virtual Nurse Staffing Model
Virtual nursing has opened up numerous opportunities when it comes to optimizing staff in the care of patients. However, it presents some potential vulnerabilities in delivering safe patient care. These opportunities are varied and based on the virtual nurse staffing model an organization has defined for use. Does virtual nursing mean you will employ part-time support for your unit-based healthcare teams? Or will the model provide an accessible nursing mentor who is available to address staff concerns with patient care?
Including virtual nursing as part of an organization’s care model will be extremely challenging as it can present a tremendous change in staffing concepts for nurses to navigate. The Senior Nurse Executive (SNE) will be instrumental in providing support during model design and implementation. This will be critical for front-line staff to gain their understanding, support, and enthusiasm for embracing the virtual nursing model. The SNE is also responsible for ensuring adequate nurse staffing to support safe patient care and must be engaged as the ultimate executive sponsor on behalf of the entire nursing enterprise. They will need to ensure that considerations for patient safety remain paramount from design to performance measurement.
As organizations design the virtual nursing model, they should ensure the roles and responsibilities of the virtual nurse are clearly defined and that work center staff and supervisors understand these responsibilities and, most importantly, their limitations. This may include:
- Defining how staff and patients contact the virtual nursing staff. This will depend on the technology used in the model. The organization should ensure that the process is clearly communicated to staff and patients alike. Expectations should be placed on response times when virtual nurses are contacted and procedures for when there is a lack of response.
- Designating communication responsibilities and processes between the virtual nurse, the on-site nurse, the patient, the Provider, and the support staff. How will communication flow between stakeholders with virtual nursing? Will virtual nurses be expected to participate in rounding with the healthcare team? If the virtual nurse notes a change in the patient's condition, how is that communicated to the provider? Who does the provider respond to with interventions?
- Establishing processes for the virtual nurse to notify staff during patient emergencies. If the virtual nurse observes a cardiac arrest or a patient fall, who do they notify to activate the appropriate response? How do they participate during the response to provide information to the care team?
- Determining how virtual nurses will document care and communication. The documentation process in the medical record by virtual nurses will depend on their role in providing patient care and access to the medical record. Will they be able to access the electronic record, or will their documentation be in hard copy format?
- Developing backup plans in the event of technology interruptions. If technology interruptions occur, how will the organization flex if the virtual nurse is no longer able to support the healthcare team?
Determining your organization’s virtual nursing staffing model will depend on your organization’s needs and how the virtual nurse will be employed in patient care at your facility. Telehealth.HHS.gov has excellent resources to guide organizations in the use of telehealth monitoring, including initial steps, developing patient monitoring strategy, billing considerations, patient preparation, etc. The Best Practices page provides some considerations for organizations regarding the use of synchronous and asynchronous monitoring that may align more with virtual nursing practice models. (Link: https://telehealth.hhs.gov/providers).
Technology Will be Instrumental…. and a Vulnerability
The use of virtual nursing will require some form of a technological bridge between the patient and/or staff and the virtual nurse. However, this will bring the potential for vulnerabilities with unauthorized access to patient information and potential hacking risks. Many organizations invest in robust audio/video systems that allow virtual nurses to access patient rooms to permit interactions with patients and families. Designing the use of this technology in the virtual nursing model will require considerations such as:
- Ensuring patient rights are supported. Will the organization obtain a signed "consent for video monitoring" from the patient or their designated representative, giving the healthcare facility permission to use/record video footage of them? Does the consent explain that video monitoring will be used only when necessary and with proper privacy protections and clearly outline the reasons for monitoring? Will it explain where cameras are located, who can access the footage, and the patient's right to withdraw consent at any time? Does your state or local authority have more stringent regulations regarding video access to patients that must be considered?
- Addressing patient privacy concerns. Will there be a process where the nurse “requests” virtual access from the patient before activating the camera? Will there be an indication of when the virtual nurse has access to the camera (such as a red light) so the patient is aware of when they are being observed? How has the organization ensured that the patient’s concerns for privacy have been addressed? How does the patient address their privacy concerns?
- Preparing patients for the use of virtual nurses. Patients may not be used to interacting with a virtual nurse. What is the process for educating the patient and/or their designated representative on using virtual nurses, including how to contact them and their role in providing care? Will this education be documented in the patient care record? Will all patients be supported by virtual nursing staff or only those who may be appropriate for this staffing model? What if the patient declines the use of virtual nursing in their care?
- Healthcare Information Privacy. Will the virtual nurse be able to access the electronic health record from their remote location? Will access be on an organization-provided device or their personal computer? How will the organization address cyber-security with virtual nursing to protect patient information? Will access to data/video be encrypted to prevent unauthorized access?
Recognize the capabilities (and limitations) of the technology that your organization will use with virtual nursing. Incorporate established safeguards for privacy and cybersecurity and ensure staff are trained to recognize potential vulnerabilities.
Measure Performance
As you incorporate virtual nursing in your staffing model, it is essential that data is used to assess performance and impact. Organizations should establish the goals they wish to achieve with the use of virtual nurses:
- Are you looking to decrease the workload intensity of your direct care nursing staff?
- Are you attempting to decrease staff turnover, the use of overtime, over-reliance on contracted labor, and overall labor costs?
- Do you want to decrease the length of stay?
- Are you attempting to improve patient satisfaction?
- Are you attempting to improve nursing satisfaction?
- Are there specific quality goals you wish to improve upon?
Develop your quality measurement strategy prior to rolling out your virtual nursing program so you can gather baseline data to demonstrate any change. A Nurse Executive leader may be unable to demonstrate to the governing body that a virtual nursing investment made an impact because output data was either not clear at the start of the initiative, or data monitoring was insufficient. Incorporate process metrics to monitor performance and ensure the identification of potential patient safety vulnerabilities.
Conclusion
As virtual nursing continues to expand to support strained nurse staffing models nationwide, organizations must recognize and address potential regulatory issues this innovation approach may present. Accrediting organizations and regulatory bodies will expect leaders to be engaged in addressing patient safety concerns and regulatory requirements.
For questions or to learn more contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
