Jaime Houtchens is a registered nurse at a Gig Harbor hospital. But she normally works from her home in Centralia.
As a virtual nurse, she looks after her patients through a screen and a video camera.
She has a three-screen workstation both at St. Anthony Hospital and at home, where she can easily access her patients’ charts, tests and lab results, as well as doctor notes.
Each of the roughly 25 patients she sees per day can also see her through a screen in their own room when their camera is on.
“Hello, this is Jaime. I’m your virtual nurse,” Houtchens, a seven-year bedside caregiver, often says when first “entering” a patient’s room. “Is it OK if I turn on the camera and say hello?”
If her patient says yes, she’ll remotely tilt the hospital room camera up — generally on the opposite wall from the bed — and her patient’s screen will turn on. It’s not unlike joining a Zoom meeting, she said.
Houtchens is one of the first health care providers in Washington to try out this new type of nursing. It’s a role hospitals hope can help with staff retention as the pinch for bedside nurses grows tighter and health care system budgets continue to be strained.
Houtchens and her co-workers are called enhanced care registered nurses, or ECRNs, according to leaders at Virginia Mason Franciscan Health, which is affiliated with Chicago-based health care giant CommonSpirit Health.
Virginia Mason Franciscan Health rolled out the ECRN program at St. Anthony earlier this year and launched it at St. Anne Hospital in Burien last month. There are currently 21 ECRNs at St. Anthony and 17 at St. Anne.
Hospital leaders say the program was also created, in part, to try to reduce staff burnout.
“We asked our front-line team what was important to them,” said Dianne Aroh, VMFH’s chief nursing officer. “And resoundingly, they’ve talked about needing to have more control of their personal life and wanting to have that flexibility.”
She and other hospital leaders around the state are quick to add that these virtual nursing roles are not replacements for the in-person, bedside caregivers that have staffed hospitals for centuries. Instead, they’re meant to offload some duties that often take up much of a bedside nurse’s time, like discharging patients or talking them through lengthy medication regimens.
“Hospitals will still continue to exist,” Aroh said. “But more and more patients can actually be taken care of very differently.”
Life of a virtual nurse
At St. Anthony, an ECRN’s typical day shift starts with a night-shift report and a 7 a.m. bedside nurse huddle, which ECRNs join via Zoom. Then it’s time to check in with patients.
Houtchens, who took the virtual job earlier this year, generally visits with each of her patients twice during her 12-hour shift — once in the morning and again in the afternoon, unlike the more frequent, hourly rounds bedside nurses make.
She keeps it brief if there aren’t major updates or questions.
If a patient isn’t comfortable with the camera or wants privacy, ECRNs can note it and let bedside nurses follow up, said registered nurse Jordan Tremper, CommonSpirit’s director of virtually integrated care.
“After implementing this program, every inpatient at St. Anthony’s is now touched by some form of virtual care,” he said.
Houtchens and the hospital’s other ECRNs largely focus on patient education and take time to go through a patient’s home medicine list, care plan and discharge details — things that don’t necessarily need to be done in-person, Houtchens said.
Bedside nurses still prioritize physical exams of patients, but ECRNs can also use the cameras to make sure IVs are set up correctly and bed alarms are on, for example, Houtchens said.
While she still loves aspects of bedside caregiving, the virtual role feels much more well-balanced and requires less physical demand and emotional burden, she said.
“[Bedside nursing] does wear on you,” Houtchens said. “This is like taking a step back, but I’m able to still be involved, talk to patients, and use my skills. … It’s more sustainable.”
Growth of telemedicine
The idea of virtual care isn’t new.
Rural communities have long used methods of telemedicine for long-distance diagnoses and chronic disease management.
In the late 1950s and early 1960s, research started growing around hospital-based telemedicine, eventually leading to the creation of the tele-ICU, which still exists and staffs critical care nurses and specialists who work remotely with front-line providers.
Over the past decade, opportunities for telemedicine have grown, said Darcy Jaffe, senior vice president of safety and quality at the Washington State Hospital Association. Health care systems have increasingly involved technology to help providers see patient results, do research and communicate among staffers, among other tasks, she added.
During the worst of the COVID-19 pandemic, telehealth appointments boomed.
“We know the pandemic gave us the opportunity to push ourselves into areas maybe we would have been slower to get to,” Jaffe said. “Now we’re seeing an acceleration to provide more access to people.”
Over the past year, health care systems in Washington have introduced a new range of hospital-based telemedicine options to support their in-person operations. It’s a strategy health care leaders say is here to stay.
At MultiCare hospitals in Spokane and Tacoma, robot assistants named Moxi started helping staffers deliver lab specimens and retrieve supplies. The hospital system also runs a virtual nurse program, similar to the one at Virginia Mason, where nurses remotely handle admission screenings, home medication lists and discharge education.
“We anticipate that there will be future expansion of their roles,” said Jennifer Graham, MultiCare’s chief nurse executive. “We’re just getting started with them.”
At Providence Swedish, providers frequently use telehealth options for specialist care, connecting primary care physicians in community hospitals with specialists around the region. The hospital system also runs a tele-ICU and a tele-sitter program, for patients who might need constant, but not necessarily in-person, supervision.
“Things like virtual nursing, having specialists help physicians — that helps relieve the stress that our health care workers are facing,” said Dr. Arooj Simmonds, chief medical officer at Providence Swedish. “By trying all these different ways of accessing technology, we’re hopefully bringing some joy back in caring for patients and getting rid of some of the mundane tasks.”
While technological advancements can mean exciting ways to improve access to care, it’s important not to “get ahead of ourselves,” Jaffe added. It’s also still too early to know how cost of care might be impacted, she said.
“We want to balance the innovation and increases to access but make sure it’s still safe and still provide that same quality of care,” Jaffe said.
She added that hospitals must also “think about equity and that we’re not leaving behind various populations who maybe don’t have access to the kinds of technology available.”
Emerging from a ‘learning laboratory’
For new ECRN Becky Musgrove, the role has lengthened her career.
Musgrove, now 64, worked as a Portland-area nurse for nearly 40 years before moving to Washington in 2014. She staffed the night shift until December 2020.
“I was just like, ‘I can’t do this anymore. It might be time for me to step away from the bedside,’” she said. “So I did.”
At the time, Musgrove couldn’t retire and found work at clinics and doing triage nursing over the phone until she heard about an ECRN position.
Now, Musgrove says she’s “probably at the top of [her] licensure in this position.”
“I have more time, and my body is not on the constant go,” she said, remembering how much her feet, hands and back ached at the end of an in-person shift. “My mind is able to take over to do multitasking, nursing judgment and anticipation of needs. This is a bit of a liberty for me to be able to just use my brain.”
There will likely always be limitations to what providers can do virtually, said Jaffe of Washington State Hospital Association. Surgeries, injections or certain visual consultations, for example, still require hands-on care.
But technology can play a larger role in supporting existing health care, Jaffe said.
“We had a learning laboratory during the pandemic,” she said. “It seems like it would be wrong not to take advantage of that.”
Musgrove, when asked if she missed anything about bedside nursing, thought for a moment.
At this stage in her life, she said, not much.
“I definitely see being able to do this job kind of indefinitely,” she said.
