tele-ICU Nurses Research Articles

The Lived Experiences of Telemedicine Intensive Care Unit Nurses.

Although nurses are the primary clinicians in telemedicine intensive care units (tele-ICUs), their experiences remain underresearched. To describe and interpret the lived experiences of tele-ICU nurses. A qualitative, hermeneutical, phenomenological approach based on van Manen's methodology was used to collect and interpret interview data. In-depth interviews were conducted with 11 tele-ICU nurses affiliated with a health system in the northeastern United States. The interviews were intended to elicit direct reports of specific incidents to capture the phenomenological experience. Field observations of the practice setting were conducted to enhance data richness. The participants were primarily female, aged 34 to 67 years, with 11 to 45 years of nursing experience. The following 4 major themes and 12 subthemes were identified: (1) watching intensively and panoptically, with subthemes (a) affirming unremitting diligence, (b) uncovering virtual knowing, and (c) easing perceptions of intrusion; (2) transcending complex boundaries, with subthemes (a) building trustful collaboration, (b) discerning vigilant interventions, and (c) exercising skillful investigation; (3) transforming nursing practice, with subthemes (a) mastering tact, (b) delineating the critical wholeness, and (c) augmenting safety and quality of care; and (4) developing an e-identity, with subthemes (a) tempering feelings of working in shadows, (b) evolving to the enhanced specialist role, and (c) achieving professional gratification. Tele-ICU nurses play a transformative role in nursing practice. These findings have implications for nursing practice, education, health policy, enhancement of the current American Association of Critical-Care Nurses (AACN) Tele-ICU Nursing Practice Model, and future research on ICU telemedicine.

Communication and role clarity inform TeleICU use: a qualitative analysis of opportunities and barriers in an established program using AACN framework

BackgroundUnderstanding the use of tele-intensive care unit (ICU) services is an essential component in evaluating current practice and informing future use as the adoption and application of teleICU services expands. We sought to explore if novel ways to utilize teleICU services can emerge within an established, consulting-style teleICU model considering the program’s flexible, provider-driven operation.MethodsThis was a qualitative study of one teleICU/hospital dyad using semi-structured interviews from a convenience sample of ICU (n = 19) and teleICU (n = 13) nurses. Interviews were analyzed using directed content analysis to identify themes that describe their experiences with teleICU using a deductive codebook developed from an expert consensus (American Association of Critical Care Nurses) AACN statement on teleICU nursing.ResultsThree themes were identified through the qualitative content analysis: [1] nurses described unique teleICU knowledge, including systems thinking and technological skills, [2] the teleICU partnership supported quality improvement initiatives, and [3] elements of the work environment influenced perceptions of teleICU and its use. When elements of the work environment, such as effective communication and role clarity, were not present, teleICU use was variable.ConclusionsFlexible, provider-driven approaches for integrating teleICU services into daily practice may help define the future use of the teleICU model’s applicability. Future work should focus on the importance of effective communication and role clarity in integrating the emerging teleICU services into teleICU/ICU practice.

Answering the Call: Impact of Tele-ICU Nurses During the COVID-19 Pandemic.

The coronavirus disease 2019 pandemic has exacerbated staffing challenges already facing critical care nurses in intensive care units. Many intensive care units have been understaffed and the majority of nurses working in these units have little experience. To describe how the skilled tele-intensive care unit nurses in our health system quickly changed from a patient-focused strategy to a clinician-focused approach during the coronavirus disease 2019 crisis. We modified workflows, deployed home workstations, and changed staffing models with the goal of providing additional clinical support to bedside colleagues while reducing exposure time and conserving personal protective equipment for those caring for this highly contagious patient population. The unit changed focus and granted more than 300 clinicians access to technology that enabled them to care for patients remotely, added nearly 200 mobile carts, and allowed more than 20 tele-intensive care unit nurses to work from home. Tele-intensive care unit nursing provided clinical knowledge to the nurses covering current and expanded critical care units. Using technology, virtual rounding, and increased collaboration with nurses, tele-intensive care unit nursing minimized the risk to bedside nurses while maintaining a high level of care for patients. Tele-intensive care unit nurses provided a proactive, holistic approach to caring for critically ill patients via camera as part of their routine workflow. In addition, during the coronavirus disease 2019 pandemic, these nurses created a new strategy in virtual health care to be implemented during a crisis.

Virtual critical care nursing

In Brief Tele-ICU nurses provide proactive, holistic care for critically-ill patients virtually over a camera. Although tele-ICU nurses can find the role particularly rewarding, they may also encounter challenges adjusting to this remote position. Tele-ICU nurses must adapt to an office work environment that redefines their place on the healthcare team from bedside leader to a more supportive role. This article relates the experiences of tele-ICU nurses in Atrium Health's virtual critical care center and explores how tele-ICU nurses can adapt, continue to learn, and support their patients and bedside colleagues. Tele-ICU nurses provide proactive, holistic care for critically-ill patients virtually over a camera. Tele-ICU nurses must adapt to an office work environment that redefines their place on the healthcare team from bedside leader to a more supportive role. This article relates the experiences of tele-ICU nurses in Atrium Health's virtual critical care center and explores how tele-ICU nurses can adapt, continue to learn, and support their patients and bedside colleagues.

A Mixed Methods Study of Tele-ICU Nursing Interventions to Prevent Failure to Rescue of Patients in Critical Care.

Background:Failure to rescue (FTR) is a benchmark of quality care. Limited evidence exists examining the influence of telemedicine intensive care units (tele-ICU) nursing interventions in preventing FTR. The purpose of this study was to characterize tele-ICU nursing interventions and to determine which combination of documented tele-ICU nursing interventions (DTNI) best predicts prevention of FTR in ICU patients with hospital-acquired conditions (HACs).Materials and Methods:We used convergent parallel mixed methods design to conduct qualitative interviews with a purposive sample of tele-ICU nurses (n = 19) from 11 US tele-ICU centers. Quantitative data, including demographics, DTNIs, severity of illness scores, and video assessment times from January 2016 to December 2016 were retrieved for ICU patients discharged from a multihospital health system with a tele-ICU center (n = 861). Findings from both qualitative and quantitative analyses were merged, compared, and contrasted.Results:FTR patients had higher severity of illness, longer video assessment by tele-ICU nurses, and were more likely to have DTNIs related to hemodynamic instability. Four themes emerged from qualitative analysis: fundamental tele-ICU nurse attributes, proactive clinical practice, effective collaborative relationships, and strategic use of advanced technology. Mixed methods analysis revealed convergence between DTNIs and tele-ICU nurses' characterizations of their practice.Conclusions:Tele-ICU nurses' characterizations of their practice closely align with DTNIs. Tele-ICU nursing practice to prevent FTR involves systems thinking and integration of many complex factors. Tele-ICU nurses can reduce the odds of FTR with focus on support and clinical coordination interventions that avoid hemodynamic instability in ICU patients with a diagnosed HAC.

AACN TeleICU Nursing Practice: An Expert Consensus Statement Supporting High Acuity, Progressive, and Critical Care

The recently updated expert consensus statement on tele-intensive care unit (tele-ICU) nursing, AACN TeleICU Nursing Practice, conveys the essential elements for implementing, evaluating, and improving tele-ICU nursing practice. AACN TeleICU Nursing Practice includes revised practice definitions, a refined practice model, and vignettes that demonstrate the impact of tele-ICU.Practice definitions have been updated and expanded to reflect the current state of tele-ICU nursing practice, which reaches 18% of all ICU patients. In addition, this updated document more clearly describes the roles of the tele-ICU nurse, the nurse leader, and the health care organization. The individual responsibilities of these roles are no longer combined. Revised recommendations (previously labeled practice guidelines) are presented by role, with each role individually defined and responsibilities described. The focus of the revised recommendations is on the application of a healthy work environment, the development of proficiency in tele-ICU knowledge, skills and abilities, and the need to support and engage in research.New vignettes provide powerful testimony to the impact of tele-ICU nursing. Each vignette is written as a demonstration of how tele-ICU nursing can fulfill the 3 consensus recommendations. Vignettes include help provided by a tele-ICU nurse to a family practice physician managing a cardiac arrest at a remote Alaska critical access hospital, support provided during recent natural disasters to hospitals requiring evacuation, and coaching the staff of a small rural hospital in the application of a hypothermia protocol for a patient resuscitated after cardiac arrest.The AACN TeleICU Nursing Practice Model was also given a new look in AACN TeleICU Nursing Practice. This model is supported by both the AACN Synergy Model for Patient Care and AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence, 2nd edition. The updated TeleICU Nursing Practice Model demonstrates how the key concepts of true collaboration, practice excellence, and skilled communication enhance patient care when combined with the optimized use of technology and the application of authentic leadership.AACN TeleICU Nursing Practice also includes a name change. This updated document has been classified as an expert consensus statement instead of a guide-line to reflect that the body of evidence to support tele-ICU nursing is still developing. The task force recommended the name change and included an acknowledgment that further research, both quantitative and qualitative, are needed to support tele-ICU nursing and to ensure optimal patient outcomes for the future. Among the task force’s recommendations for future research are inquiry into appropriate staffing models, optimal communication methods, nursing interventions, mentoring, retention, moral distress, return on investment, and the impact of the Tele-ICU Nursing Practice Model on patients and families.

An introduction to nursing surveillance in the tele-ICU

An introduction to nursing surveillance in the tele-ICU

Virtual collaboration, satisfaction, and trust between nurses in the tele-ICU and ICUs: Results of a multilevel analysis

PurposeThe purpose of the study was to examine how tele–intensive care unit (tele-ICU) nurse characteristics and organizational characteristics influence tele-ICU nurses' trust and satisfaction of monitored bedside ICU nurses, and whether these influences are mediated by communication. Materials and methodsData of tele-ICU characteristics and characteristics of the ICUs they monitored were collected at 5 tele-ICUs located throughout the country. One hundred ten tele-ICU nurses at those tele-ICUs completed a questionnaire containing items related to their characteristics and their trust, satisfaction, and perceived communication with monitored bedside nurses. We analyzed the data using a hierarchical path model, with communication variables entered as mediators. ResultsMany of the tele-ICU nurse characteristics (age, currently or previously worked at the monitored ICU, hours worked per week, and years as a ICU nurse) had statistically significant direct effects on perception of communication timeliness, accuracy, and openness, as well as trust and satisfaction with monitored bedside ICU nurses. Communication openness mediated the relationships of both working at a monitored ICU and being older (≥55) on satisfaction. Communication accuracy mediated the relationships of both a specialized monitored ICU and working at a monitored ICU on trust. ConclusionsTele-ICUs and monitored ICUs should work to optimize communication so that trust can be established among the nurses.

Thinking Inside The Box: The Tele–Intensive Care Unit as a New Clinical Site

The tele-intensive care unit (ICU) offers students an opportunity to observe the decision-making process of nurses working in consultative teams in a high-acuity environment, providing a unique opportunity for novices to "see" into the thinking and the communication of expert nurses. Students are often overwhelmed by the physical environment of an ICU--specifically, its noise, technology, and pace--and often are relegated to the sidelines when a patient becomes unstable. Clinical education in the tele-ICU allows students to participate safely in the care of complex, unstable patients. Nurse educators, as experienced tele-ICU nurses, can help students to process complex information and can model intradisciplinary and interdisciplinary communication about patient concerns. The experience moves the students from engagement in tasks and a linear process of thinking to engagement in decision making and a more complex understanding of the nurse's role in patient care.

Motivation and job satisfaction of Tele-ICU nurses

IntroductionAlthough the first tele-ICU has been in existence for more than 12 years, little is known about the work of tele-ICU nurses. This study examines sources of motivation and satisfaction of tele-ICU nurses. MethodsA total of 50 nurses in 5 tele-ICUs were interviewed about reasons for working as a tele-ICU nurse and sources of satisfaction and dissatisfaction in their job. ResultsNurses have different motivations to work in the tele-ICU, including the challenges and opportunities for new learning that occur while interacting with clinicians in the tele-ICU and the various ICUs being monitored. Tele-ICU nurses also appreciate the opportunities for teamwork with tele-ICU physicians and nurses. The relationship and interactions with the ICUs is sometimes mentioned as a dissatisfier. Some nurses miss being physically at the bedside, as well as interacting with patients and families. ConclusionMost tele-ICU nurses are satisfied with their job. They like the challenge in their work and the opportunity to learn. For some nurses, the transition from a bedside caregiver to an information manager can be difficult. Other nurses have found a balance by working part-time in the tele-ICU and part-time in the ICU.

Professional Accountability in the Tele-ICU

The American Association of Critical-Care Nurses (AACN) is the world's largest specialty nursing organization. The AACN Certification Corporation provides credentialing to validate nursing practice in acute and critical care. The advent of tele-ICU nursing added a challenge to the application of certification in a new specialty area. Nurses working in a tele-ICU have many years of experience in hands-on acute or critical care nursing at the bedside. In their role as tele-ICU nurses, these skills are applied to the assessment, evaluation, and decision support of care for critically ill patients in various acute and critical care units from remote locations connected directly to the ICU through high-speed audio and video technology. This article outlines the journey of the advent of the CCRN-E (registered nurse in critical care) credential and its place in the new specialty of tele-ICU nursing practice.

Using Nursing Expertise and Telemedicine to Increase Nursing Collaboration and Improve Patient Outcomes

To examine the impact of the first nurse-implemented tele-intensive care unit (tele-ICU) staffing model, with the intent that shared nursing vigilance and collaboration can decrease patient complications potentially impacting patient outcomes. A quantitative study used a pre-post program design of 90 staff nurses in the Adult Critical Care Unit, 10 tele-ICU nurses, and 1,308 patient participants at Providence Alaska Medical Center (Anchorage, AK). Twelve months of baseline data were collected: Acute Physiology and Chronic Health Evaluation severity-adjusted ICU length of stay (LOS), ICU mortality, protocols for the prevention of ventilator-associated pneumonia (VAP), ventilator bundle compliance (stress ulcer and venous thrombosis prophylaxis), and glucose control. Follow-up data were obtained using the same outcomes examined for baseline: 9 months for the nurse and only an additional 3 months with the addition of physician monitoring services. Data demonstrated post-tele-ICU implementation improvements as follows: severity-adjusted LOS decrease, 15% (222 patient-days saved); severity-adjusted ICU mortality decrease, 14% (20 lives saved); compliance improvement of "at-risk" patients, restraint documentation 26% improvement; ventilator bundle compliance, 6% increase; and VAP, 13% decrease in patient-days. Collaboration between bedside and remote nurses in conjunction with the use of tele-ICU program technology positively impacts critical care patient outcomes. Effective nursing collaboration and communication and improved patient outcomes can be attained through nursing vigilance and attention to best practices or health system protocols and the use of smart technology such as the population management tools in the tele-ICU program.

Making the Move: From Bedside to Camera-Side

The tele-intensive care unit (tele-ICU) uses sophisticated telemedicine technology and a remote team of critical care experts, including nurses, to provide continuous monitoring, assessment, and interventional services to a large number of patients across multiple ICUs. This new practice environment offers experienced critical care nurses an opportunity for career and knowledge expansion while reducing some of the physical and emotional risks encountered at the bedside. The role of the tele-ICU is still evolving but focuses on 4 areas of responsibility: performing virtual rounds, managing patient alerts, providing ICU support, and coaching or providing teaching moments. The transition from the bedside into the tele-ICU role can be complex as tele-ICU nurses encounter ICU acceptance barriers and a lack of or a change in professional identity. A formal orientation program focused on competency is necessary for the successful transition from bedside nurse to tele-ICU nurse.

The effects of health information technology change over time: a study of Tele-ICU functions.

Longitudinal studies exploring the evolution of health information technology functions provide valuable information about how technology systems are integrated and exploited in situ. This study reports changes in the distribution of functions for a specific health information technology, the tele-ICU, over time. The studied tele-ICU provided care to six remote ICUs within a local geographic region in the same state and had nursing staff around the clock. The intervention logs of tele-ICU nurses were collected during two discrete times and coded into nine emergent functional categories, who initiated the intervention and, if required, subsequent escalation. All coded functional categories were investigated for significant changes over time in the nursing logged interventions. A total of 1927 interventions were coded into the nine emergent functional categories. Seven of the nine categories (78%) were significantly different between 2005 and 2007. The functions of the tele-ICU system continue to change and develop over time. These findings suggest that the tele-ICU increased support when ICU nurses were off the unit, inter-hospital coordinating and adherence to best practices, while simultaneously decreasing real-time support for ICU nurses. This research suggests that sustaining safety features in a new technology over time have post-conditions after implementation.

A New View: Tele–Intensive Care Unit Competencies

BACKGROUND Many hospitals have well-planned nursing competency assessment programs, but these are meant to measure competency in traditional bedside roles, not in tele-intensive care unit (tele-ICU) nurses practicing remotely. OBJECTIVE To determine whether current tele-ICU programs have a formal competency assessment program and to determine when and how competency of tele-ICU nurses is assessed. Method A 20-question survey was provided to a convenience sample of the 44 known tele-ICU programs nationally. RESULTS Of the surveys distributed, 75% were completed and returned. A formal competency assessment policy for assessing nurses' competency at the time of hire, during orientation, and ongoing was in place at the workplaces of 85% of respondents. The most common methods for competency validation were performance appraisal and observation, although peer review and self-assessment also were used. Respondents identified the following competencies as the highest priorities for defining tele-ICU nurse practice: effective listening, prioritization, collaboration, and effective use of tele-ICU application tools. CONCLUSION Although awaiting development of professional practice standards, many tele-ICU programs currently measure the competence of tele-ICU nurses through competency programs.

Standardizing Sepsis Screening and Management via a Tele-ICU Program Improves Patient Care

This article evaluates the feasibility of a tele-intensive care unit (ICU) nurse-driven early identification and treatment process for severe sepsis patients in improving compliance to evidence-based practice. Florence Nightingale identified that by using science, logic, and compassion to manipulate the patient care environment nurses could create the best possible conditions for healing to occur. Nurses in a tele-ICU used this premise to initiate a standardized screening and data collection program using a custom-built document sharing application that conformed to the Surviving Sepsis Campaign (SSC) criteria for identification and treatment of severe sepsis. The tele-ICU nurses performed 89,921 screens on 36,353 ICU admissions to 161 ICU beds across a geographical range of 500 miles. Between January 1, 2006 and December 31, 2008, tele-ICU nurses identified 5,437 patients as meeting the criteria for severe sepsis. Statistically significant increases in compliance with SSC's bundled care recommendations were realized during this study period with four initial elements: antibiotic administration increased from 55% in 2006 to 74% in 2008 (p=0.001), serum lactate measurement increased from 50% to 66% (p=0.001), the initial fluid bolus of ≥ 20 mL/kg increased from 23% to 70% (p=0.001), and central line placement increased from 33% to 50% (p=0.001). A tele-ICU nurse-driven process can prompt earlier identification and improve compliance to evidence-based practice bundles for complex disease states such as severe sepsis.

Communication in the tele-ICU

Objective: To systematically describe communication between tele-ICU (Intensive Care Unit) nurses and bedside nurses in multiple ICUs, the strengths and weaknesses of communication in the tele-ICU and possible solutions for improving communication. Background: Nurses in tele-ICUs function in virtual teams whose configuration and membership is constantly and rapidly changing. This research examines communication and technological support for communication in the multiple virtual teams formed by tele-ICU nurses and ICU nurses. Methods: A case study research approach using mixed data collection methods. One tele-ICU that monitors 16 ICUs in 12 hospitals across the US participated in this study. Results: Tele-ICU nurses spend 26% of their time in communication-related activities. Fifteen percent of tele-ICU nurses surveyed reported getting incorrect information from ICU nurses and 40% reported that they are not informed in a timely manner about a change in patient status. Frequency of communication between tele-ICU and ICU nurses depends on several factors such as time of day and intensivist coverage in the ICU. Tele-ICU nurses develop and employ unique strategies for communicating with ICU nurses. Conclusion: Tele-ICU nurses use many approaches and techniques when communicating with multiple ICUs. Additional research needs to generalize these findings.