Virtual wards: benefits, challenges and required skills

Introduction

A virtual ward is an alternative to secondary bedded care, which brings hospital-level care into a patient’s usual place of residence. Through technology, this allows patients to:

• Be monitored and cared for safely at home;
• Return home sooner from a hospital environment than they otherwise could.

Virtual wards generally combine remote monitoring and face-to-face treatment, depending on a patient’s needs (NHS, 2022).

Patients admitted to hospital may experience “multiple adverse environmental factors in the ward (‘hospital stressors’)” (Schattner, 2023). Additionally, 68% of adults aged ≥65 years in England are expected to be living with multimorbidity by 2035, and life expectancy is increasing (Kingston et al, 2018); these two factors mean an increasing number of patients are susceptible to hospital-acquired infections and deconditioning (Schattner, 2023). In addition to helping to overcome these factors, virtual wards enhance patient choice by enabling those who are reluctant to become inpatients to access hospital-level care (Healthcare Excellence Through Technology (HETT), 2022).

Emergency hospital care is “the most expensive element of the NHS” (Deeny et al, 2018). Virtual wards aim to reduce the number of emergency department visits, emergency admissions and bed days by providing a safe and effective alternative. Few studies have identified that they reduce admissions, although more research is needed (Steventon et al, 2018).

The potential positives of virtual wards for both patients and financial resources are clear. This article explores:

• Their benefits and challenges for nurses;
• The key nursing skills needed for them to work successfully for patients and staff;
• Their impact on practice.

Benefits and challenges for nurses

The NHS’s (2022) guidance instructed integrated care systems (ICSs) to develop virtual ward capacity equivalent to 40-50 ‘beds’ per 100,000 of the population; a minimum of two pathways (acute respiratory infections and frailty) were stipulated. Some organisations are already expanding the scope from these pathways into areas such as paediatrics, for example at Blackpool Teaching Hospitals NHS Foundation Trust, University Hospitals Dorset NHS Foundation Trust, and The Dudley Group NHS Foundation Trust (NHS England, 2023a). Patients are typically admitted to acute virtual wards for a short period of time – often less than two weeks – although this can vary depending on a patient’s condition (Sheasby, 2023a).

Additionally, Severn Hospice has launched a virtual ward pilot overseen by a palliative care consultant (Hospice UK, 2023). This involved discussions with local hospitals and community trust partners and, due to its success, the hospice intends to increase its virtual ward capacity and monitor the impact it is having on traditional inpatient beds. However, it is important to note that virtual wards are not intended as a means of delivering social care to patients (NHS England, 2023b).

The range of roles and bands available in virtual wards differs, depending on the ward’s specialty and the trust or ICS that is responsible for it. In most settings, there is a core base of band 5, 6 and 7 nurses. However, in some areas, there are unregistered band 4 staff; in others, there are band 8 staff, who are often responsible for the virtual pathway itself, interdepartmental relationships and case management (Sheasby, 2023b).

Virtual wards provide a vital link between secondary and community care. There “is an ageing workforce” in community nursing (Swift and Punshon, 2019), and including virtual wards as part of rotational training for newly registered staff and students could encourage younger nurses to work in community care.

Virtual wards could also help to showcase the range of careers and specialisms in nursing, which staff working in a hospital setting may not experience. Including virtual wards in rotational working would also expand staff members’ awareness of them; in turn, this would promote uptake of virtual solutions, thereby increasing new skills in remote care. Rotational posts for all bands of nurses would also prevent the degradation of clinical skills for those on virtual wards, as this is a concern for staff who no longer provide face-to-face patient care (Sheasby, 2023a).

Virtual wards offer nursing staff the chance to develop new skills. This can help futureproof nursing careers, ensuring individuals adapt to the use of technology in clinical settings (Booth et al, 2021). Reflective of this, NHS England (2023c) identified “technological advancement” and delivering care “closer to home” as actions it plans to take.

Nursing roles on virtual wards already exist for qualified nurses, which could present a retention opportunity (NHS, 2022), for example, for staff who are considering early retirement, returning from sickness or on light duties. Therefore, despite the NHS’s high level of nursing vacancies, virtual wards have the advantage that they are not always recruiting from the same pool of staff.

Key nursing skills

There are no specific clinical skills needed to work on virtual wards. However, the need for particular ‘soft’ nursing skills is enhanced in the virtual ward environment (NHS England, no date; Skills for Health, 2022), and nurses new to the service will have to consider how they adapt their clinical practice.

Virtual wards can offer nurses unparalleled insight into a patient’s life, which requires knowledge about safeguarding arrangements in case a referral needs to be made (NHS England, 2023b). Concerns about patients on virtual wards may present differently from those about patients on physical hospital wards. It is, therefore, important that the scope of virtual wards is clearly defined to ensure nurses understand the types of patient they will be caring for, and the boundaries of that care, along with inclusion and exclusion criteria.

Virtual ward nurses can have a positive impact on patients’ quality of life by identifying those vulnerable to social isolation and referring them to appropriate support services (Skills for Health, 2022). This is also a preventative measure to help patients stay as well as possible. Knowledge of organisations and services is key to improving patient outcomes (University of Kent, no date). This knowledge should be used to manage transitions between care providers and pathways (Skills for Health, 2022), including navigating the challenges that virtual wards can present.

On virtual wards, there is increased communication with patients and families, meaning it is important to build a rapport quickly (Skills for Health, 2022). Professional communication is also needed, as the success of virtual wards depends on multidisciplinary teams working together and sharing information effectively. There are concerns about the flow of critical information and communication levels between multidisciplinary teams; it is important that the right information is available at the right time (Engers et al, 2022).

Nurses on virtual wards need to have technical skills and to be familiar with the monitoring equipment that is used. This equipment can differ depending on the type of ward and the region in which it operates. However, in our opinion, most nurses should recognise all the technology and have no difficulties in becoming adept at using it.

Impact on practice

A benefit of virtual wards is that they can lead to the provision of uniquely personalised care. Nurses are more able to concentrate on one patient at a time without interruptions, improving care and eventual outcomes (Shepperd et al, 2021). This also benefits staff, by removing the pressure of balancing multiple demands on a physical ward (HETT, 2022). To work successfully, virtual wards need nurses to practise autonomously. Decisions must be made confidently and sometimes without the immediate support of other staff, unlike on physical wards. A clear escalation process should be in place, based on clearly defined roles of what to do if a patient’s condition deteriorates (Skills for Health, 2022).

Where possible, health professionals should empower patients to manage their conditions and be central to any decision making (Deeny et al, 2018). As virtual wards are still relatively new and many patients are unfamiliar with how they work, it is even more important to ensure the patient understands these processes. Fig 1 shows the results of a study into the views of both the general public and NHS staff about virtual wards.

Having clear processes in place can help allay patients’ reservations about virtual wards. By displaying their own confidence about virtual wards, nurses can help to instil this in patients. A study by Deeny et al (2018) found that patients who felt more confident about self-managing their conditions presented at emergency departments less and were less likely to become inpatients, without detriment to their overall outcomes.

Another element that is crucial to the success of virtual wards is identifying suitable patients: ostensibly, these wards work best when there is a clear diagnosis and the clinicians involved have access to a patient’s medical history (Hutchings and Edwards, 2023). The decision to use a virtual ward could be a way of:

• Avoiding admission to a secondary care facility;
• Discharging early from secondary care.

For the latter, enabling earlier discharge nurses are key. They may need to liaise with community teams who have been supporting the patient. Physical examinations and non-medical prescribing can help assess a patient’s suitability for a virtual ward. Planning discharges before admissions, where possible, ensures everything is in place for patients to be transferred to a virtual ward. In some areas, these wards are used as step-up and step-down ‘beds’ for patients who would otherwise remain in hospital unnecessarily (Chappell et al, 2024).

Other nurses who provide care in patients’ homes – such as community nursing teams and those from private providers – are vital for virtual wards. They are likely to already have:

• Local knowledge;
• Knowledge of some patients and their home lives;
• A rapport with social care teams.

Due to this, some professionals suggest investing in community teams, rather than building completely new teams to staff virtual wards. Whichever route is taken, acute hospitals and secondary care need to be involved in the process (Hunter, 2022).

Before a virtual ward can be identified as suitable for a patient, health professionals must ascertain the patient’s living conditions and family support. They must also consider whether the patient’s carers can provide the mental and physical support needed, as virtual wards create an “increased carer… burden” compared with hospital wards (Chappell et al, 2024). Clinical risk must be managed too, as there could be issues with the patient’s living environment. Equipment may be needed to ensure safety, or it may not be possible to make the home suitable for the patient’s care needs.

Managing risk is something with which nurses of all levels should be familiar and is not drastically different on a virtual ward. However, when assessing a patient’s suitability for virtual ward care, nurses should consider whether transferring the patient to a virtual ward will negatively affect their condition, as well as the likelihood that they will be admitted to secondary care.

One key difference between virtual and traditional wards in risk management is the fact that patients’ vital signs are measured continuously in a virtual ward, for example, by an oximeter. This helps mitigate the risk of not being in a hospital, as deterioration can be identified quickly. Another advantage of having access to digitally enabled patient observations is that clinical decisions can potentially be made more quickly. Consequently, evaluations of existing virtual wards have shown no impact on patient mortality compared with traditional wards (Hutchings and Edwards, 2023). However, it must be noted that there is currently a lack of nationwide data regarding clinical outcomes.

Small-scale surveys have shown high levels of patient satisfaction with virtual wards. As an example, Norfolk and Norwich University Hospital launched a virtual ward in 2021, and feedback from patients and caregivers was favourable: 100% said they would recommend virtual wards to family and friends (Wells et al, 2022).

Care must be taken to not exclude patient groups from virtual wards and increase health inequalities. Giving patients technical equipment means those without smartphones or tablets are not excluded. Some digital solutions also have an in-built router, meaning a broadband connection is not necessary. Staff should work with patients and carers to find solutions to accessibility issues related to the technology and/or the need for equipment to ensure a patient’s residence is safe and suitable. In some trusts, a band 3 role of digital support worker has been introduced to help patients navigate the digital side of the service (HETT, 2022). However, even in services where this role is available, nurses need an awareness of how technology can impact health inequalities and work to reduce this (Honeyman et al, 2020).

Nevertheless, technology cannot solve societal problems; for example, people who are subject to health inequalities are more likely to live in poor housing with low levels of financial security (Local Democracy and Health, 2022). This, coupled with the current cost-of-living crisis, would affect decision making about whether a virtual ward is the best option for a patient whose housing conditions are not conducive to a recovery.

Next steps

Virtual wards present a new way of working that will be expanded if NHS England’s (2023c) ambitions are met. Some trusts have already seen a reduction in the number of bed days since commencing virtual ward projects, and it is hoped this will reduce the workload of nurses on acute hospital wards (Hunter, 2022). However, provision of virtual wards varies greatly across the UK: some services are just getting started, whereas others have been operating successfully for years (HETT, 2022). The services are not universal and, although lots of useful resources and case studies are available on NHS England’s website, there is no singular way to set up or staff a virtual ward.

There is a lack of nationwide data on the the benefits of virtual wards for both staff and patients, as there are currently no national reporting metrics. There is anecdotal evidence in individual virtual wards that they improve patient satisfaction and reduce nurse workloads compared with traditional wards (Hunter, 2022); however, wider data gathering and analysis are needed. Data sharing is also key and needs to be integrated between systems including social care, community care, hospitals, NHS 111 and 999 (Hutchings and Edwards, 2023).

Looking forward, “no ringfenced recurrent funding” is available for virtual wards from 2024/25 onwards. Therefore, they need to be self-funded and fall under existing budgets (NHS, 2022); this could be within current pathways or inpatient care. We have also observed staff on virtual wards suggest that some could be disbanded, with the staff redeployed within community teams or acute hospitals. However, it is important to be aware that this could stymie their expansion, thereby limiting the opportunities for nurses outlined in this article.

Conclusion

Virtual wards offer nurses opportunities to develop digital skills and be exposed to certain career specialisms. They have the potential to keep nurses practising who may otherwise have left healthcare. Successful virtual wards require multidisciplinary work and the sharing of information; currently their use is inconsistent across the country.