Welcome to the latest in a series of interviews conducted by the AMSN Digital Content Committee with session presenters from the 2024 AMSN Annual Convention. Marie Mullins, BSN, RN, CMSRN, a member of the AMSN Board of Directors, talks with Emily Schmidt, BSN, RN, CAVRN, SANE, about her convention session, “MSNCB Presents…CAVRN.” Learn about the development of the Certified Acute-Care Virtual Registered Nurse (CAVRN) certification program, the skills needed to become a virtual nurse, how the field is evolving, and the benefits of the CAVRN credential.

Marie Mullins: Can you talk me through the early stages of creating the CAVRN credential, and what were some of the key considerations that you wanted to take on for this job?

Emily Schmidt: We began by taking a deep dive, defining the essential functions and responsibilities that a virtual nurse would encounter on a daily basis, drawing from those real-world experiences, and applying that across different virtual nursing environments. While virtual nursing is still relatively new, there are a lot of different areas of virtual nursing, whether you're doing the inpatient hospital at home or monitoring a triage line or a chat line. So, we wanted to make sure that this credentialing was going to cover all aspects of virtual nursing.

One of the key considerations was identifying specialized skills and competencies that would differentiate a virtual nurse from your traditional bedside in-person nurse, and that meant focusing on things like advanced communication, digital literacy, and critical thinking within a remote setting because there are significant differences when providing care behind a computer screen. Virtual nurses really need to be able to excel in assessing patients through technology and interpreting that data without having the benefit of direct physical observation of these patients. In the early stages of developing the credential, collaborating with subject matter experts to understand those tasks and challenges was really helpful, setting a good foundation for the exam.

Patient safety and quality of care also were top considerations, as were skills such as recognizing the early warning signs of patient deterioration, rapid response, and mastering the art of communicating with patients and bedside staff through those virtual technologies. I think they did a really good job of developing this credential because it sets a robust, forward-thinking standard for virtual nursing professionals.

Mullins: I appreciate that you took all these different things into account because virtual nursing is still developing and there are so many unknowns. I think you even said in your presentation that you're building the plane while you're flying. There are different care settings, different ways you care for patients, so how does the CAVRN certification standardize virtual nursing?

Schmidt: The CAVRN provides a good structure and validated framework that defines virtual nursing across different scopes and different practices. It creates a baseline of high-quality, consistent care that virtual nurses should be expected to provide no matter where or how they are interacting with patients or bedside staff. The standardization also offers a lot of reassurance to healthcare organizations and leaders who may be considering expanding into the virtual nursing program.

I've had a couple people reach out to me lately who are really interested in jump-starting with virtual nursing. I always try to guide them to have these CAVRN-certified nurses, because you can feel confident that these nurses have that verified skill set that's going to align with best practices, and it just ensures a good continuity of care, trust, and a good relationship that potentially could lead to increased adoption of virtual nursing.

I think I'm a really good advocate to speak to how important it is to make sure that staff are well-educated about the program, that patients feel safe using it, and that bedside staff feel comfortable using it. CAVRN-certified nurses step in and help alleviate any of that uncertainty around virtual nursing. I think that by establishing these standardized practices, it'll really help weave virtual nursing into traditional nursing. It won't be so much as a secondary thought; it'll be, “Hey, let's call the virtual nurse for this admission.”

Mullins: I really appreciate that you've taken into consideration how it's going to fit into the acute-care setting. How do you see the role evolving to meet patient care and team needs? How do you see that evolving in the future?

Schmidt: It's already evolving. Things change daily. You may come into work one day and be following one workflow, then the next day you come in, and it's something completely different.  Because of the advancement of technology, patient and community needs, staff needs, things change very rapidly in virtual nursing. I think virtual medicine is already redefining accessibility and effective patient care, but I think we're going to see it really start to expand and cover even more areas. 

For example, virtual nurses can staff triage or advice lines with insurance companies or be chat nurses with your doctor’s office, where you can electronically send a chat to your care team. There's just so many areas, and I think we're going to see that continually expand. We're going to start seeing more remote patient monitoring devices, where patients are wearing biometric equipment at home. The virtual nurse is monitoring that, interpreting the data, and they see a patient’s vital signs start to decline and try to intervene early; I think we're going to start to see that grow as well.

I also think virtual medicine has the potential to ease staffing shortages and increase support for bedside teams. When these bedside nurses feel like they're supported in their role, they might feel less stressed and not overworked, which ultimately will lead to improved retention rates. That is such a huge return on investment for these organizations. I think virtual nurses are going to start to adopt more technology and take on a broader range of responsibilities, maybe providing more follow-up, patient discharge, health coaching for chronic conditions, and managing complex care plans. 

We might see more artificial intelligence (AI) being utilized. I'm a firm believer that if used properly, AI could be a huge benefit to healthcare staff, especially virtual nursing, because it can help create personalized care plans, help with charting, and improve diagnostic accuracy. I think that as patients become more informed about virtual nursing and get more involved in their care, it's going to expand even more. There are great things on the horizon for virtual nursing. It's just in its early stages right now.

Mullins: You have a lot of experience around virtual nursing, and you have a background that is in virtual nursing. How did your specific experiences shape your contributions to the CAVRN credential development?

Schmidt: My journey with virtual nursing, including the hands-on role with inpatient virtual nursing, was extremely helpful. The hospital-at-home programs and remote patient monitoring gave me a unique and well-rounded perspective on the different areas within the world of virtual nursing; there's a lot of other areas where it can be utilized. My experience with workflow development, policy creation, and content design allowed me to easily identify gaps and necessary improvements within virtual nursing. 

For the credentialing exam, I give credit to my background in emergency medicine. I really think it gave me a strong foundation for this role. To be proficient in virtual nursing, you need a good, solid foundation of clinical knowledge. When you're working remotely, it's a lot different. You must be able to pick up on cues from patients and make quick decisions in high-stress situations. I think emergency medicine contributed to that because it taught me how to make rapid, accurate clinical decisions at the flip of a switch. I learned to identify those subtle signs that can lead to worse outcomes, even with limited information.

That's one of the things I like to tell people about virtual nursing. Sometimes, with remote patient monitoring, you're like the FBI. You get a patient who’ll call your hotline, and they'll give you a vague symptom or a vague complaint, and it is your job to complete an assessment and try to pry some more detailed information out of them. Which is where having hands-on clinical experience comes into play. When we began developing the CAVRN credential, I drew heavily from those insights in making sure the exam was practical and included real-world challenges, focusing on the technical competencies and communication to make a successful virtual nurse.

Mullins: You hit a little bit on the fact that you need to have some background before you go into virtual nursing. You want to have some basic knowledge and be able to understand some of the patient cues, like you said. So, what unique skills or competencies are you looking for when you're looking at someone in a virtual nursing role, and how does CAVRN help prepare nurses for that?

Schmidt: Virtual nurses need to have several core attributes to be able to blend their clinical expertise with technology. A good, solid foundation of clinical knowledge and experience is important to be able to provide high-quality care and education. We do a lot of patient education at the time of discharge, a lot of diabetes education, a lot of new diagnoses like heart failure, COPD, etc. It’s important to have a good clinical background and strong communication skills as well, because it can be difficult to communicate when you're behind a computer screen. When you're interacting with these digital platforms, you have to be able to speak clearly and empathetically without that physical presence. It requires a fine-tuned ability to pick up on subtle cues with words or voices or descriptions to be able to provide effective care for the patient.

I also think mastering technology is imperative. We rely so much on different telehealth platforms, remote patient monitoring, and electronic medical record systems, and you need to be able to navigate these tools seamlessly to provide accurate care for the patient. Even if it's just changing a Wi-Fi setting or your camera freezes or your computer system locks up, you must be able to quickly identify and resolve the problem because you're not always going to have IT right there with you to help.

Virtual nurses also must understand the protocols for virtual patient assessment and monitoring. I think the CAVRN certification does a really good job in emphasizing regulatory, legal, and ethical considerations. With virtual nursing, there's a whole different world of legal and ethical considerations, making sure the patient's information is safeguarded and that we're not going to be breaking any HIPAA rules with providing remote care. The exam does a good job focusing on that, as well as demonstrating to hospitals, patients, and the community that these nurses can provide high-quality care in a virtual environment.

Mullins: Could you also speak about the feedback you received at the AMSN Annual Convention on your presentation?

Schmidt: I had a lot of good feedback. It was so nice after the convention, having people coming up to me saying how much they loved the idea of virtual nursing. I received a lot of emails and a lot of LinkedIn messages from people asking about the CAVRN credential and how they could volunteer to help with the CAVRN certification in the future.

I think we're going to continue to see virtual nursing expand within a few years. A lot of people don't know about it right now, and there's a lot of misconceptions out there about it, and I try to dispel those misconceptions on my LinkedIn profile. A lot of people think it's going to replace the bedside nurse or it's going to make their staffing ratios unsafe, and that's not it at all.

Virtual nursing is meant to complement and help bedside nurses, and it should not affect patient-to-nurse ratios. I think organizations are slowly starting to realize that virtual nursing has a good return on investment when you look at the overall picture.

Mullins: Is there anything else you want our readers to know about virtual nursing?

Schmidt: If you're interested in virtual nursing, just keep trying. It's a very high-demand area right now; everybody wants to do it. Don't be afraid to stick your neck out there. I was fortunate enough to get my position just by reaching out to someone on LinkedIn who was associated with a virtual nursing program. So that's one thing that I tell people who are interested in virtual nursing: Make those connections. Reach out to people who know things about virtual nursing and are associated with it. Worst case scenario, they're going to say, “I'm sorry, I don't have any control over hiring,” or “We don't have anything right now,” but in the best case scenario, you can make a great connection for the future or even land a job and get to speak at the AMSN Annual Convention in Toronto about virtual nursing like I did. So don't be afraid to take those leaps and make those connections. There are opportunities out there; just don't be too scared to pursue them.