CNOs are bullish on virtual nursing. Here's how one health system is making it work

Houston Methodist ’s ninth medical center is also its most tech-enabled.

Cypress Hospital opened its doors this past March with 100 beds and the capacity to expand to 500. The health system described the new campus as “the smart hospital of the future,” where technology will usher in new care delivery models. 

Technology is embedded in Cypress’s design — from the touchscreens in patient rooms to the wider hallways that can accommodate robots. Phones are absent and ambient listening tools help clinicians document patient encounters.

For Gail M. Vozzella , the health system’s chief nurse executive, the opening was a chance to introduce new innovations around nurse staffing. In our conversation below, we talk about one of those early initiatives: virtual nursing. 

Houston Methodist introduced virtual nursing in its intensive care units during the COVID-19 pandemic, but as the program expanded, it found that its bedside and virtual nurses largely were operating in siloes. At Cypress, virtual nurses are now embedded in the care team, attending morning huddles and following the same patients for their entire shift. 

Although the initiative is still in its pilot phase — with the health system closely tracking employee engagement surveys as well as patient safety and patient experience measures — Vozzella told me that she sees a lot of potential to expand both the number of virtual nurses as well as their responsibilities.

Cypress itself, located in one of the fastest-growing areas of the Houston metroplex, already is seeing higher patient volume than anticipated, and has been opening additional units to accommodate demand. 

Virtual nursing is one of the top five innovative care models that chief nursing officers are planning to implement, according to a survey from Wolters Kluwer Health , which found that 66% of nursing leaders identified it as a place where they plan to invest.

“Virtual nursing seemed to be a common denominator for what people were trying,” said Bethany Robertson , nurse executive for Wolters Kluwer's Health. “How they were doing it varied based on the technology that they had available.”

The survey found that virtual nursing helps reduce burnout by offering support to bedside nurses for some of their most time-consuming tasks, like admitting patients or doing post-physician follow-ups. 

“Nurses don’t want training on managing stress,” Robertson said. “Healthcare professionals want organizations to fix their inefficiencies — that’s what’s causing their burnout. And leveraging technology is one way to think about doing that.” 

Cypress’s 10 virtual nurses do two-thirds of their shifts at Houston Methodist’s virtual care center, and the rest at the bedside. The health system plans to eventually expand the initiative to its other hospitals, and is focused on Cypress as a training ground. 

Below, Vozzella and I discuss how virtual nurses are being integrated into the larger care team, the metrics that are being tracked and the results she’s seen so far.

And tell me: What experiences have you had with virtual nursing either as a patient or provider?

The following transcript has been edited for length and clarity.

LinkedIn News: What prompted you to focus on virtual nursing?

Vozzella: Unfortunately in nursing, acute care has the lowest satisfaction rate nationally. Nurses tend to have a big load of patients, larger than in the other areas, and you have to do teaching and push throughput. It was our biggest opportunity. In 2021, we started a pilot using iPads, and then we spread across all of Houston Methodist using cameras on televisions. We have been very successful at decreasing the amount of documentation the nurses did by using a ‘next up’ model of care: You would hit a button in your room, and the virtual nurse would come on and they would admit that patient, meaning they would do all of the Epic admission navigation for that patient, and then the [bedside] nurse would just have to come in and do their review and assessment. Nurses in acute care spend 40% of their time documenting, and admission and discharge are two biggies. Now it takes the virtual team 10 minutes to do their part.

LinkedIn News: How are you integrating the virtual nurses at Cypress into the care team?

Vozzella: Virtual nurses are part of the huddle in the morning and they hear reports about who's going home, who needs diabetic education — and then everything that can be done virtually is done virtually. For example, if a physician is rounding in a unit, we want that bedside nurse to be in that room too. But what we also want — which we've been able to accomplish at Cypress — is the virtual nurse to be there too. They can document the plan of care for the patient in the chart and they can put that plan on the electronic whiteboard so the patient can see it.

It's not ‘us’ and ‘them.’ It's ‘us.’ That's it. There's no ‘them.’ If you need education on a new medication, that should be done virtually. That doesn't mean our nurses aren't narrating care at the bedside. That doesn't mean that we're not talking to our patients. But our bedside nurses repeat things over and over because our patients are stressed and they need reinforcement, and it's amazing for that reinforcement not to always fall on their bedside nurse.

And with that we have shifted our ratios in acute care so they take an additional patient. Our ratios are pretty darn good here at Methodist, so it wasn't a huge stretch. But it's a change, and it's a big change for us, because any change in numbers of patients matters to nurses. But we committed to trying something new. We were upfront about it, transparent, and we said we're going to trial it and tweak it as we go. 

LinkedIn News: How many nurses are providing virtual care?

Vozzella: Cypress started with a workforce of 10 while we do the proof of concept. We also have other virtual teams covering the entire system for admissions and discharges and other things. We are even trying different things with that group too. For example, we're doing a pilot on being the double-check person for high-risk medications. Nurses will spend time looking for somebody to help do the double check — why can't virtual nurses do the double check? If they have good cameras, they can zoom in. It's not only less time walking around looking for somebody, but it's also safer because it's not your colleague who is as busy as you are. Virtual teams have the time that our bedside teams sometimes don't have in order to do it right.

LinkedIn News: Are there plans to expand beyond this 10-nurse pilot? 

Vozzella: Yes, but we want to give it the right amount of time. Overall it's been successful, but we want to be able to tweak it and then we would most likely go to another community hospital first before our quaternary medical center.

We're stable, so we have resources, and we will send people to Cypress to train and then figure out a system for what we would do next. But our focus has been Cypress.

LinkedIn News: What are the metrics you’re looking at to determine whether or not it's been successful, and whether you want to expand?

Vozzella: One is you have to get feedback from the staff. You also have to look at quality and safety. We’re very, very attentive to that: Are there more falls? Are there more central line infections? And you have to look at patient experience: Are virtual nurses clear in their instructions to elderly populations? Do we have supplemental support to make sure they understand? All of those are things we look at and keep a very, very close eye on.

LinkedIn News: The number one thing nurses say they want out of their careers is flexibility. What do you expect demand to be to fill these virtual roles?

Vozzella: Everybody is a little different. [Some nurses prefer to] connect directly with the patient and do direct care. As a bedside nurse, you're completely accountable for that patient and making sure they're getting better, not sicker, and connecting with all the subspecialty physicians. 

[But] doing that plan of care is still the hardest job. Instead of saying, ‘I'm going to move units or I'm going to leave nursing,’ maybe they’ll try to be the hybrid nurse. Right now, hybrid is primarily in our virtual care center. But eventually you probably can do more of that at home instead of commuting. 

LinkedIn News: What has the response been from nurses?

Vozzella: Turnover of staff is something that we keep a very close eye on here. At Cypress, it's too early to tell, but we want to stay very attentive. We do employee engagement surveys every year. Nurses are really helping us redesign the care of the future, and the future is right now, not ten years away.

[If you ask nurses why they went into the profession,] it’s to care for others. Not to type. Nobody says to type. Nobody says to forage for supplies. Nobody says to make 27,000 phone calls to figure out when somebody's going to a procedure or OR. But we spend a lot of our time on that, so wouldn't it be great for us to go back to what we really do and what we want to do?