In conversations about virtual, team-based nursing services, the term "nurse-to-patient ratios" is an anachronism, according to nursing leaders at Providence and Trinity Health.
Within the traditional primary nursing model, a virtual mountain of research demonstrates low nurse-to-patient ratios bolster safety and quality of care. However, as new virtual programs emerge and pick up steam, new research indicates that virtual nursing models improve communication, safety and quality — all without assigning a ratio.
Cynthia Salisbury, MSN, RN, executive director of nursing operations at Renton, Wash.-based Providence, likened jamming the term "ratio" in virtual nursing conversations to applying the "miles per gallon" metric to electric vehicles. Both terms apply to things becoming obsolete: primary nurse-led care and gasoline-fueled cars.
Primary models also run the risk of missed nursing care, or tasks that are delayed, partially completed or never completed. Well-resourced and -staffed collaborative care teams can mitigate this risk, according to Ms. Salisbury.
With an increase in high-acuity cases, capacity strains, emergency department boarding, patient throughput issues, an increasingly large elderly population and a growing deficit of nurses, the historical care delivery model isn't cutting it.
"Ratios were developed to ensure safe care delivery for patients and nurses," Ms. Salisbury said. "This goal remains essential. As we evolve from primary nursing, patient ratios based on this model of care delivery are proving a barrier to innovation. … In this new environment of innovation, we must come together as leaders aligned on a common goal to develop an approach that allows us to break free of the restraint imposed by ratios, while enhancing care delivery and allowing our profession to thrive."
Rather than using ratios, Gay Landstrom, PhD, RN, senior vice president and CNO of Trinity Health, prefers what she calls the correct "dosage" of nursing staff per unit.
Trinity's virtual nursing program, called TogetherTeam, incorporates three employees — an in-person RN, a virtual RN with years of experience and a nursing aide, such as a licensed practical nurse or a certified nursing assistant.
To determine whether to apply the hybrid nursing model to a unit, Trinity first examines the type of patients a unit cares for — such as those with respiratory issues or those undergoing kidney transplants, for instance. If hands-on physical care is needed, a CNA is assigned. If medication support and someone with more training is needed, an LPN is chosen.
To address day-to-day or shift-to-shift changes, the unit's charge nurse reassigns the virtual and in-person staff.
"So we plan well, but we also know that day to day, our charge nurse has to have the flexibility and be empowered to shift the assignments," Dr. Landstrom said. "I'm a strong advocate for that, that charge nurse who is there on the unit seeing specifically what the patients need. They're the best ones to make that call."
The 93-hospital system has about 400 virtual nurses. As of November 2024, the program is live at 26 hospitals across 11 states, and it is on track to cover about 6,500 beds across 26 states by mid-2026.
Several Trinity hospitals have reopened beds and units that were closed because TogetherTeam has ensured registered nurses are practicing at the top of their license, Dr. Landstrom said.
At Providence, its Co-Caring model has virtual nurses help with tasks such as admission, discharge preparation, pre-procedural checklists and medication reconciliation. With two RNs and support staff caring for patients, Ms. Salisbury said patients and their families say they feel more comfortable and safe.
The system has not changed its staffing model, as Washington requires hospitals to use staffing matrices and submit those plans to the state's health department. Currently, day virtual nurses care for 15 to 20 patients, and night virtual nurses care for 30 to 50.
For other health systems investigating their own virtual nurse programs, Providence's nursing leader recommends tailoring staffing plans specific to each hospital's and unit's needs rather than relying solely on ratios.
"Having a number to start off with, I understand," Ms. Salisbury said, "but I would encourage nursing leaders that are entering into these models of care not to be afraid to create your own model based on what that role looks like and your patient population. Do you need a starting point? Absolutely. I get that. But don't be afraid to deviate from that as you create your model and just make it make sense for what you are asking the virtual nurse to do and the care needs of those patients."