From virtual care solutions to enhanced interprofessional collaboration, many new approaches to care delivery seek to improve patient outcomes and experience, while also improving workflows and the work environment and experience for nurses and clinicians. But how effective are these solutions in achieving their goals?
That’s what five nurse-led teams around the country explored through a pilot program from the Institute for Healthcare Improvement and Johnson & Johnson Foundation, called the Transforming Healthcare through Innovative Nurse-Led Care Delivery Learning and Action Network. With senior-level support and engagement, acute care bedside nurse teams piloted care delivery solutions that attract, support, and strengthen a thriving nurse workforce. The pilots leveraged ‘rapid cycle testing,’ which means instead of testing complex approaches over long periods of time, the teams implemented small changes over very short periods – days or weeks – to generate learnings faster and more efficiently.
It’s all about ‘failing fast’ and learning quickly. “We see bumps as expected and accepted,” said Patricia A. McGaffigan, RN, MS, CPPS, Vice President, Institute for Healthcare Improvement. “That is where a lot of the learning really occurs. We want to learn from and celebrate what goes well, and we also want to learn from doesn’t work, so we take time to celebrate and acknowledge that too.”
Each site set a particular project aim, and pilot units were measured against their objectives as well as “thriving metrics,” or the number of nurses who reported agreeing with statements like “I love my job,” “I can easily manage the demands of my job,” and “I have adequate control over the pace of my work,” among others. Aggregated data from the five pilot sites showed average increases of agreement with the above questions of 7.8%, 5.6% and 11.3%, respectively. Site-specific measures were also used to align with key project focus areas.
Further, the pilot programs demonstrated some of the key elements needed in a workplace where nurses thrive, such as consistent engagement of nurse executives, more time to do work that matters, the support needed to practice at the top of their licenses, flexibility, opportunities to use and build new skills, reduce moral distress through positive patient improvements, and feel more involved in critical decisions.
Below, learn more about each pilot program.
Boston Children’s Hospital
Project Aim
Improve nurse thriving by introducing a virtual nurse role to handle 20% of the direct and indirect care tasks from bedside RNs, as well as providing support to newer nurses.
Results
Before starting the pilot, the Boston Children’s analytics and nursing teams reviewed task lists and discovered that 36% of inpatient tasks could be handled by a virtual RN. By May 2024, virtual RNs were taking care of 22% of the total tasks.
The Boston Children’s team has found that virtual nurses have moved from primarily supporting nurses at the bedside to actively taking on some of their care duties, leading to better outcomes, particularly in terms of patient safety, time savings for bedside nurses.
“Feedback from both our nurses and the families of our patients has been overwhelmingly positive,” said Laura J. Wood, DNP, RN, NEA-BC, FAAN, EP Patient Care Operations & System CNO. “We started this virtual care journey to improve how we operate, but I’ve come to see how much joy and satisfaction it brings to our nurses as they find creative ways to enhance care delivery.”
What’s Next
The team is planning to expand the virtual RN role from the two pilot units to all med/surg units, as well as increase the number of days virtual RNs are available and focus on improving quality objectives during admissions.
Inova Fairfax
Project Aim
By June 30, 2024, improve nurse satisfaction by 5% through testing solutions to broaden the scope of virtual care.
Results
While the Inova team first assumed the pilot would focus exclusively on virtual primary nursing, it was expanded to virtual care support for nurse case managers and wound care nurses.
For case manager nurses, virtual camera consults cut down on the time spent commuting between units and patients, allowing for more patient interactions per shift.
Using wound care photography for all wound consults saved 11 hours of commuting time per week, and 35-45% of all wound care consults were done virtually.
Adding more tasks to the virtual nursing workflow, like virtual pain reassessments, also helped bedside nurses by saving time and increasing the number of pain reassessments completed by virtual nurses each month.
Nurses reported more time for patient care, education and family updates, timeliness of care, positive patient feedback, smoother medication administration and discharges, and an improvement of timely completion of their work, including leaving work on time.
What’s Next
The Inova team plans to expand virtual care services that align with their system priorities. These include supporting team members, easing the workload on care teams, and transforming care to improve access and patient flow.
Mercy
Project Aim
By June 19, implement an EHR workload tool to create fairer patient assignments and improve thriving in the workforce by 5%.
Results
The team made several changes, including adjusting Epic workloads, switching from paper to digital assignment spreadsheets, adding supervisor check-ins, and using workload scores, and these efforts led to better and fairer patient assignments. Surveys showed that more nurses felt they had control over their work pace, had the resources they needed, and could handle their job demands easily.
One charge nurse on the innovation unit said, “I feel like this is the first time that someone is focusing on the charge nurse role and how to make it better,” and the team highlighted that charge nurses reported a 25% improvement in time savings.
What's Next
The Mercy team will continue use of the EHR Workload Measurement Tool within the pilot unit and plans to share the tool with other Mercy facilities, including testing within an ICU. The team also plans to integrate scheduling software with the workload measurement tool.
VA San Diego
Project Aim
By July 2024, introduce an Early Mobility (EM) Nursing Assistant (NA) role to lighten the workload for Registered Nurses (RNs), with a goal of improving thriving in nursing by 1% and shift 1-hr per shift of patient mobilization time from RNs to the EM NAs.
Results
Mobilization refers to interventions such as repositioning and range of motion exercises that can improve patient outcomes. The team trained nursing assistants to use the VA Mobility Screening & Solutions Tool and identify patient mobility levels and provided RNs with tools to quickly reach Early Mobility teams for help.
The pilot successfully reduced the time RNs spent on patient mobilization. It was also associated with a 7% increase in overall thriving scores, including a 13% increase in nurses feeling they had a say in decisions affecting their work, a 14% increase in those feeling they had control over their work pace, and a 12% increase in those feeling they had the resources needed to do their job well.
What's Next
An impressive 99% of VA San Diego staff want the EM team to continue. The team plans to keep, expand, and sustain this effort by coordinating with other units throughout the hospital.
Wellspan Health
Project Aim
By July 2024, roll out virtual nursing care models across WellSpan's acute care facilities and reduce RN turnover, boost employee engagement, improve patient experience and safety, and decrease in-room, unwitnessed fall rates by 10%.
Results
The team brought virtual nurses on board to handle tasks like admissions, discharges, patient education, preoperative checklists, Epic handoffs, and documentation. The tests of change reduced fall rates and saved bedside RN time, especially with admissions, discharges, and documentation now managed by virtual nurses, and associated reductions in RN turnover.
The team also saw significant improvements in team member experience and perceptions of patient safety and quality, with 96% of respondents reporting that safety and quality had greatly improved.
One RN reported: “When I leave the end of my shift as a Virtual Nurse, I am feeling very accomplished. Knowing that I’ve impacted a nurse's day for the better is very gratifying...Overall, I feel it has significantly impacted my overall nursing stress levels. Lastly, I have more energy on my days off, which is of significance to me.”
What's Next
WellSpan is expanding their virtual care model from 5 hospital sites to 7, and plans to continue to optimize technology, work options for staff, and build a centralized department to support and scale staffing across the system.
Disseminating Results
With strong results in both patient outcomes and nurse satisfaction, the IHI team is now focused on scaling improvements by sharing learnings with health systems nationwide through a published toolkit currently in progress.
“We encourage leaders to leverage the approaches and lessons learned from these innovative sites, including the continuous testing and improvement methods to ensure that a change is leading to an improvement before widespread attempts to scale the change ideas,” McGaffigan said. “Nurses are healthcare’s indomitable innovators and improvers. When we imagine, create, and continuously improve safe, high quality, and equitable care with supportive leaders and healthy work environments, we experience joy and meaning and thrive as individuals, teams, and a profession.”
Additional information about the pilot programs and their results can be found in the June issue of Nurse Leader, the official journal of the American Organization for Nursing Leadership.
