In the past, physical and chemical restraints had been used routinely to keep patients safe in healthcare settings, however harm caused by restraints has led to the development of state and federal regulations deterring their use.1 This change prompted the use of observers or one-to-one sitters (referred to as observers moving forward) to manage patients with psychiatric conditions, and others at risk for self-harm and falling, especially those with delirium. In the United States, more than 50 percent of hospitalized older adults are affected by delirium.2
In recent years, a number of contributing factors have led to the increase in observer use. Fewer mental health facilities and an increased aging population have contributed to substantially higher numbers of hospitalized patients requiring constant observation to keep them safe.3 Also, patient falls, defined as “unplanned descent to a lower level when a staff member was not with the patient” (p. 137)3, are prevalent within healthcare settings. Falls within the hospital are said to be one of the most preventable adverse events in healthcare; and each year approximately 11,000 patients die from injuries associated with falls4. The Agency for Healthcare Research and Quality (AHRQ) reports that 700,000 to 1 million patients fall per year while hospitalized, with at least one-third of those being preventable.5,6
Self-harm events also contribute to a rising observer use. These are defined as any patient actions that have the potential to cause harm or those that cause actual harm.3 These events occur when patients self-medicate, adjust their intravenous fluid or medication rates, or that exhibit suicidal gestures.3 Each year, there are 8.7 million hospital admissions for suicidal ideation or suicide attempts and 1500 suicides occur while in the hospital.7 Thus, the Joint Commission recommends ongoing monitoring for prevention of injury.
Patients who are at risk for injury must have measures in place to protect them. Hospitals are utilizing observers to help protect these at-risk patients. However, there is little to no reimbursement from government or commercial payers for one-to-one care.7 As a result, the recent surge in observer use has crippled nursing budgets, as labor costs have escalated to over a million dollars annually per hospital.6
Many hospitals have employed observer alternatives, such as the telesitter or continuous virtual monitoring (CVM). This technology uses technicians (staff members) to monitor patients virtually through a video monitoring system utilizing a two-way speaker system and an infrared, live stream video camera. The technicians communicate with the patients and maintain safety by redirecting patients from potentially harmful or impulsive behaviors or by utilizing a remote alarm feature in an emergent situation.3,8 However, while CVM has been deemed a promising new technology, the receptivity of healthcare providers has been variable, warranting further investigation of potential barriers and facilitators to CVM.
Purpose
The purpose of this qualitative study was to identify potential barriers and facilitators in the implementation of continuous virtual monitoring (CVM) at a large urban academic medical center in the northeast. The aims of the study were to understand current perceptions of registered nurses (RNs) related to CVM for hospitalized patients, identify barriers to safe implementation of CVM that may require additional education, and to identify facilitators that will aid in successful implementation of CVM.
Study Procedure
Sample. A convenience sample of 32 RNs who practice in various intermediate units (medical, surgical, cardiology, and oncology specialties, and the emergency room) and the intensive care units participated in the focus groups.
Setting. The focus groups were held onsite at a large urban academic medical center in the northeast in various conference rooms during meal breaks. The sessions were held on both day and night shifts, allowing for participation by RNs on all shifts.
Procedures. A nurse facilitator with no supervisory responsibilities led the focus groups utilizing a semi structured interview guide. Focus groups were audiotaped utilizing two separate audio recorders in case one failed. The goal was to conduct 4-5 separate focus group sessions and more if needed to achieve data saturation.
Consenting participants committed to spending between 30 to 60 minutes with the nurse facilitator to share their perceptions of the CVM program. The nurse facilitator obtained verbal consent from all participants before commencement of the focus groups. The project lead transcribed audio recordings verbatim and any identifying information of participants was deleted.
Data Collection. When conducting each of the focus groups, the nurse facilitator utilized a semi structured interview guide with the following questions:
- Please describe your current perception and experience surrounding the CVM program,
- How do you currently determine which patients will be a good candidate for virtual monitoring?
- What criteria should be looked at before utilizing CVM for patients?
- How do you determine when a patient is no longer a good candidate for virtual monitoring?
- What does the current communication look like between the monitor technicians and the patients’ nurse to maintain safety? and
- How can communication be improved between the monitor technicians and the RNs caring for the patients?
The questions were open ended for discussion and participants were encouraged to reflect and respond with peers in the group. The nurse facilitator utilized clarifying and summarizing statements to ensure feedback was clearly heard and understood.
Data Analysis Plan
Data were analyzed utilizing a conventional content analysis method. The project lead shared the de-identified transcripts with members of the project team for analysis. The verbatim transcripts were read several times by the project lead along with members of her scholarly project team, first for content and then to identify themes. Key concepts were pulled from the transcripts, coded, and categorized. Cross checking of codes by the research team was done to furnish alternative interpretations of the data. The relationship between key concepts and subcategories was identified.
Results
Six focus group sessions with a total 32 participants were held on meal breaks, 3 on the day shift, 2 on the evening shift, and 1 on the night shift. The RNs provided varying perceptions and experiences related to the use of CVM. Qualitative analysis of the focus groups led to the emergence of 5 themes from the focus groups: “patient specific”, “redirectable”, “resource utilization”, “knowledge deficit”, and “opportunities for improved communication”.
Conclusion and Implications for Practice
This study identified 5 major themes hospital leaders should consider when implementing a CVM system within their institutions. According to the RN participants it is important to define which patient populations are best suited for CVM (patient specific), and redirectable). Also, while CVM has the ability to serve as a fiscally safe solution (resource utilization) in many patient care situations it requires thorough, ongoing staff education. Furthermore, policies need to be in place when implementing CVM, that identify technician and RN responsibilities for receiving and responding to calls and for standardize communication during handoff of care (“opportunities for improved communication”). Recommendations for future research and quality improvement studies related to CVM should be focused on these important patient care considerations.
See more of: Invited Posters