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Journal of Critical Care (2013) 28, 315.e13–315.

e21

Motivation and job satisfaction of Tele-ICU nurses☆


Peter L.T. Hoonakker PhD a,⁎, Pascale Carayon PhD a,b , Kerry McGuire PhD c ,
Adjhaporn Khunlertkit PhD d , Douglas A. Wiegmann PhD a,b , Bashar Alyousef MS a,b ,
Anping Xie MS a,b , Kenneth E. Wood DO e
a
Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, 53706, USA
b
Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, 53706, USA
c
National Aeronautics and Space Administration, Johnson Space Center, Houston, TX 77052, USA
d
Quality and Safety Research Group, Department of Anesthesiology and Critical Care Medicine,
the Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA
e
Geisinger Health System, Danville, PA, 17822, USA

Keywords:
Abstract
Intensive Care Unit;
Introduction: Although the first tele-ICU has been in existence for more than 12 years, little is known
Tele-nursing;
about the work of tele-ICU nurses. This study examines sources of motivation and satisfaction of tele-
Organization and
ICU nurses.
administration
Methods: A 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.
Results: Nurses 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.
Conclusion: Most 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.
© 2013 Elsevier Inc. All rights reserved.


Author contributions: Peter Hoonakker: Concept and design, data collection, data analysis, draft of paper, revising and final approval. Pascale Carayon:
Concept and design, data collection, draft of paper, revising and final approval. Kerry McGuire: Data collection, data analysis, draft of paper, revising and final
approval. Adjhaporn Khunlertkit: Data collection, data analysis, draft of paper, revising and final approval. Doug Wiegmann: Concept and design, data
collection, data analysis, draft of paper, revising and final approval. Bashar Alyousef: Data analysis, draft of paper, revising and final approval. Anping Xie: Data
analysis, draft of paper, revising and final approval. Ken Wood: Concept and design, pilot study, draft of paper, revising and final approval.
⁎ Corresponding author. Center for Quality and Productivity Improvement (CQPI), University of Wisconsin-Madison, Madison, WI, 53706, USA. Tel.: +1
608 263 2520, +1 608 658 0837(cell).
E-mail address: phoonakker@cqpi.engr.wisc.edu (P.L.T. Hoonakker).

0883-9441/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jcrc.2012.10.001
315.e14 P.L.T. Hoonakker et al.

1. Introduction working in various ICUs, in multiple hospitals, simulta-


neously. Despite the many reported successes of the tele-ICU
The work of Intensive Care Unit (ICU) nurses can be organization, research on tele-ICUs is limited; in particular
physically, psychologically and emotionally demanding and nursing issues related to tele-ICU have been overlooked [18].
stressful. There is significant burnout and turnover among Little is known about the work of nurses in the tele-ICU. Tang
ICU nurses, which deprives the country from well-qualified, et al. [8] conducted an observational study of nurses and
rare sources of expertise in critical care [1-3]. The emergence physicians in one tele-ICU. A total of 49 hours of observation
of the tele-ICU may provide an opportunity for highly skilled were performed for physicians and 41 hours for nurses.Re-
and experienced ICU nurses to continue using and sults of the study showed that nurses and physicians in the
developing their critical care knowledge and skills in a tele-ICU performed the same types of tasks: patient
high quality work environment. In addition, tele-ICU nurses monitoring (overseeing remote patients by using clinical
may provide support to ICU nurses when dealing with high information obtained from various resources), collaboration
demands and stress. This study examines the sources of job (interactions between remote monitoring staff), system
satisfaction and dissatisfaction in a group of 50 tele-ICU maintenance (tasks related to computer and technology
nurses and their reason for choosing to work in a tele-ICU. use), patients’ health record maintenance and other tasks
such as administrative, social or personal tasks. But
physicians spent considerably more time on patient monitor-
2. Background ing and nurses spent more time on maintaining patient's
health records. This study provides some limited information
Tele-Intensive Care Units (tele-ICUs) are units where about the work of tele-ICU nurses, but does not examine the
intensivists and ICU nurses provide 24/7 care, support and viewpoint of tele-ICU nurses regarding their work. The
advice from a distance to remote ICUs; various forms of objective of this study is to examine what motivates tele-ICU
health Information Technology (IT) are used to support the nurses in their work and what aspects of their work they are
sharing of information between the tele-ICU and the ICUs. satisfied and dissatisfied with. We used the Balance theory
Technologies allow intensivists and nurses in the tele-ICU to and the work system model [19-21] as a conceptual
monitor patients, to observe patients and medical devices in framework to identify sources of satisfaction and dissatisfac-
the patient room though a camera, and to communicate with tion experienced by tele-ICU nurses (see Fig. 1). A major
ICU nurses and providers. Several papers provide a detailed strength of the work system model is the inclusion of all work
description of the evolution of the tele-ICU, the tele-ICU characteristics that can affect work motivation and job
organization, and tele-ICU nurses’ activities [4-8]. Tele-ICUs satisfaction [20]. Therefore, the work system model provided
are a relatively new phenomenon, but the “oldest” tele-ICU the basis for a systematic approach to identify sources of work
has been in existence for more than 12 years. Nearly 10% of motivation and satisfaction among tele-ICU nurses. Accord-
all ICU patients are currently monitored by tele-ICUs [5]. ing to the work system model, tele-ICU nurses may
There are several reasons for the expansion of tele-ICUs. experience satisfaction or dissatisfaction related to their
In recent years, due to medical advances and population individual preferences and characteristics, their tasks, the
aging, there has been an increase in patients that need physical environment, the various tools and technologies
intensive care, creating an acute need for ICU nurses and used, and the organizational environment [19-21].
physicians [7]. Furthermore, not only patients are aging,
nurses are aging as well: projections show that between 2010
and 2020 over 40% of the registered nurses workforce will
be over 50 years and many older nurses are expected to retire.
3. Methods
In the next decades there will be a shortage especially of
registered nurses [9-13]. Tele-ICUs offer a solution to this 3.1. Study design
problem by enabling a relatively small number of intensivists
and nurses to oversee the care of a large number of ICU We conducted interviews with nurses in 5 different tele-
patients. Some studies show improvements in care processes ICUs. These interviews were part of a larger study that
and quality of care after implementation of the tele-ICU, such examines the challenges faced by tele-ICU nurses when dealing
as decreased mortality and length of stay (LOS) [14-16]. with multiple ICUs (http://cqpi.engr.wisc.edu/vicu_home). The
Tele-ICUs can provide supplementary resources and help interview guide was tested in a pilot study at the tele-ICU of the
to the ICU team at the bedside. One tele-ICU can for example University of Wisconsin-Madison Hospital. The study was
monitor 16 ICUs in 12 different hospitals. A tele-ICU nurse approved by the IRBs of the university and the tele-ICUs.
can monitor up to 50 patients in several different ICUs (the
national average is about 35 patients), and a tele-ICU 3.2. Setting
intensivist may monitor up to 150 patients. This environment
poses unique challenges [17]. For instance, a tele-ICU nurse The 5 tele-ICUs differ by region, size, number of years in
collaborates with many nurses and other healthcare providers existence, number of hospitals and ICUs connected, and
Motivation and job satisfaction of Tele-ICU nurses 315.e15

Fig. 1 Work system model [19-21].

number of tele-ICU nurses and intensivists employed. zation) were covered. Two or three interviewers performed
Table 1 summarizes the characteristics of the tele-ICUs the interviews. All but two interviews were audio-taped,
that participated in the project. transcribed and made anonymous to protect confidentiality
of the interviewees. For the two interviews that were not
3.3. Sample audio-taped, researchers took handwritten notes, which were
then transcribed.
We interviewed 10 tele-ICU nurses in each of the 5 tele-
ICUs; we conducted more than 70 hours of interviews with a 3.5. Data analysis
total of 50 tele-ICU nurses. Interviews lasted on average 70
minutes (range: 42-139 minutes). The interviews were the We used a mix of qualitative and quantitative methods to
longest in tele-ICU #2 (average duration per interview 91 analyze the data. First, all parts of the interview transcripts
minutes vs. 70 minutes total). Ninety percent of the that contained the responses to the three open-ended
interviewed tele-ICU nurses are women. On average they questions (see above) were read by the research team
have 3½ years of experience in the tele-ICU (range 0- members, and the responses were categorized according to
8 years). On average, they have been a nurse for nearly 21 the main elements of the work system model (See Fig. 1:
years (range 3-28 years). All nurses work in 12-hour shifts: person, tasks, organization, environment, and tools and
about half in the night shift and half in the day shift. On technologies). Only if consensus was achieved among all
average, the tele-ICU nurses monitor 4-5 ICUs and 38 beds team members was a category accepted. Once the different
during a shift. Nearly half (44%) of the nurses have a part- categories were defined, all interviews were coded by two
time job in the tele-ICU; the rest work full time in the tele- team members, using these categories. Finally, we counted
ICU (3 12-hours shifts). Forty-two percent of the nurses how often a certain category was mentioned in each
work also as a bedside nurse. interview: if a nurse mentioned a certain category several
times during an interview, it was counted as one occurrence.
3.4. Data collection instrument This procedure makes it possible to count how many nurses
mentioned a certain category. We only included responses
We used a semi-structured interview to collect data about in the results if they were mentioned by at least two tele-
different aspects of the work of tele-ICU nurses. See http:// ICU nurses.
cqpi.engr.wisc.edu/vicu_tools for the interview guide. The
interview guide was used to gather information about tele-
ICU nurses’ background, activities, work organization,
sources of job satisfaction and dissatisfaction and their 4. Results
motivation to work in the tele-ICU. We asked the tele-ICU
nurses the following questions: “Why did you decide to 4.1. Motivation
work in the tele-ICU?”; “What is it about your job at the
tele-ICU that you like?” and “What is it about your job at The 50 tele-ICU nurses had different reasons to work in
the tele-ICU that you dislike”? Probes were used to ensure the tele-ICU. They mention a total of 90 reasons (on average
that all aspects of the work system (individual, tasks, 1.8 reasons per tele-ICU nurse). The different reasons were
physical environment, tools and technologies, and organi- distributed across nine categories (see Table 2).
315.e16 P.L.T. Hoonakker et al.

Table 1 Characteristics of participating tele-ICUs


Tele-ICU Tele-ICU Tele-ICU Tele-ICU Tele-ICU
#1 #2 #3 #4 #5
How long has the tele-ICU existed (years)? 4 4 10 6 7
How many hospitals are connected to the tele-ICU? 12 9 5 8 14
How many ICUs are connected to the tele-ICU? 14 13 7 15 24
How many beds are monitored by the tele-ICU? 153 120 103 260 236
How many nurses work in the tele-ICU? 29 28 14 42 32
How many tele-ICU nurses also work at the bedside 18 (62%) 14 (64%) 5 (31%) 7 (17%) 24 (75%)
in the ICUs monitored by the tele-ICU?
How many beds does a tele-ICU nurse monitor? 30-40 30 50 37-52 30-50
How many physicians work in the tele-ICU? 17 23 15 20 27
How many beds does a physician monitor? 153 120 103 130-260 65–135

One of the most often mentioned reasons for tele-ICU well, my body does not.”) or are burned out by their work in
nurses to work in the tele-ICU was curiosity or the challenge. the ICUs (“But, then after that, you know, working at the
As one tele-ICU nurse explained: “So through the course of bedside is a very challenging job, I mean, it's very stressful, I
my career, I've needed to find different avenues that I need to mean, physically, emotionally”). Teaching and helping
feel challenged. And this [the tele-ICU] does it”. A second smaller ICUs and the nurses who work in the ICUs is
reason to work in the tele-ICU was the job opportunity, either another reason for nurses to work in the tele-ICU: “So, that's
as an effect of active recruitment by the tele-ICUs or the my biggest interest in this, is how I see it helping smaller
nurses applying for the jobs (“Well, matter of fact, when I hospitals, and the nurses at the bedside and the patients at the
first came here, I came here as an agency employee, and I did small hospitals”. Finally, some nurses are drawn by the
a three-month assignment, and I just loved what we were technology (“I love this, because I love technology” and “I
doing”). Health reasons were a third important reason to saw it as high tech, and the future of nursing, and I wanted to
work in the tele-ICU: “I had a back injury. Was told by the know more about it. And then I came and I came to look at it,
neurosurgeon that unless I wanted to have real problems and I fell in love with it, and signed on”).
have surgery, I had to get away from the bedside and find
something quiet to do. He suggested a nice, quiet doctor's 4.2. Satisfiers
office. Well, you take an ICU nurse and put them in there,
you're going to kill them with boredom”. Health reasons are Tele-ICU nurses made a total of 228 comments about
often linked to the next category: the demanding working aspects of their work that they like. Results in Table 3 show
conditions in the ICU. Many nurses were tired of working in that tele-ICU nurses like the job content and particularly the
the ICU (“I really enjoy my bedside work, and, but as I get challenges in their work (64 times mentioned): “Well, what
older, I realize that it's getting harder and harder to do three I like about it is that it's a constant challenge. It's a
or four shifts at the bedside”), and have either physical challenge of just dealing with lots of different systems, lots
complaints (back, shoulders, knees) (“I think it was a factor of different people. You're having to triage a lot of things in
of being in medicine for as long as I've been in it. A physical your mind and, you know, multitask, and, you know,
aspect of my job is that this, my brain still works very, very prioritize and triage”.
Tele-ICU nurses especially like learning from the variety
Table 2 Motivation of nurses to work in the tele-ICU of patients and from interacting with their colleagues in the
tele-ICU and the ICUs (64 times mentioned). As one tele-
Total
ICU nurse explains: “The other thing I love about it is the
Curiosity/ Learning /Challenge/ Potential for growth / 23 challenge of me learning something new every day. You
Critical thinking know, I come across a diagnosis that I've never heard of
Job opportunity 19 before, that I wouldn't be exposed to if I wasn't exposed to
Health reasons 15
30 to 40 patients”. They also mentioned the positive impact
Tired of bedside and working conditions in ICU 13
on patient outcomes: “I would say for those that I've helped
Teaching / helping other nurses / hospitals 8
Cutting edge technology 6 that maybe don't have the higher level of experience and it
Teamwork in tele-ICU/ tele-ICU manager 4 helped improve patient outcome, that would be a satisfaction,
(Physical) working conditions in tele-ICU 1 because you're there, and you know you've helped
Value of tele-ICU, future of nursing 1 somebody towards the same goal”and working on the
Total 90 cutting edge with the latest high technology: “So I think it
is the wave of the future, and I wanted to be involved in that”.
Motivation and job satisfaction of Tele-ICU nurses 315.e17

Table 3 What nurses like about their job in the tele-ICU


Categories Topic Total
1 Job content / Challenge Personal education; see rarer/extreme and more different cases/illnesses; learn to quickly evaluate 17
(high tech, critical thinking patients; learn a lot from variety of patients; learn about different therapies
and career development) Utilizing nursing experience/critical thinking skills; mental challenge/stimulation because of more 12
and diverse patients
Positive impact on patient outcomes, seeing improvements in patient, seeing patients responding 9
to changes in care
Learn from each other/other nurses/tele-ICU physicians/patients 9
Caring for patients 5
Having all the information on a patient available and have time to put the whole picture together 4
Love the challenge of critical patients, like working with critical patients 4
Dealing with multiple patients instead of bound to few patients 2
Like dealing with numbers 2
Total job content 64
2 Working conditions Less busy/stress/frustration/interruptions than the ICU, like change of pace 15
No/less heavy lifting or physical demands 11
Like working hours/schedule/night shift/weekend 8
No blood/guts, smell, touching 5
Ergonomically correct/customizable workstations 4
Convenience and low risk 2
Flexibility of work in tele-ICU 2
No physical/verbal abuse from anyone 2
Physical location of tele-ICU 2
Total working conditions 51
3 Relationship within Enjoy and like coworkers, tele-ICU physicians 12
tele-ICU Like intimate environment, like the closer relationship between tele-ICU nurses, physicians and 9
the teamwork
Like the availability and accessibility of physicians in tele-ICU 6
Less hierarchy between physicians and nurses; on same playing field with physicians in tele-ICU, 4
respectful of each other, less fistfights with physicians
Increased understanding and appreciation of physician/nurse roles 3
Total relationship within tele-ICU 34
4 Interaction with ICUs Provide adequate help to inadequate staffing in ICU, efficient help to ICU nurses, 14
help to ICU at another level, providing support for ICUs, reducing workload of ICUs
Having more interaction with different hospitals, staff, patient and variety of ICUs work with 4
Being appreciated by ICU nurses 2
Like the interaction with ICU nurses or interaction with the hospitals 2
Total interaction with ICUs 22
5 Balance ICU and tele-ICU Like to work in both tele-ICU and ICU 12
Total balance ICU and tele-ICU 12
6 Management Like the tele-ICU management and/or manager 8
Being valued as an employee 3
Total management 11
7 Information technology Cutting edge, high tech., wave of the future, like working with technology 8
Comprehensive information on patient readily available 2
Total IT 10
8 No ICU work Break from the bedside 7
Not having to deal with patient or family 4
Total no ICU work 11
9 Nursing profession Love nurse profession, proud to be nurse, proud of professional qualification as critical care nurse 6
Getting to help people 2
Share knowledge with the bedside nurse (able to teach ICU nurses and also learn something 2
from them)
Total nursing profession 10
10 Company/Growth Seeing growth in a small, start-up tele-ICU/company 3
Total company 3
Total satisfiers 228
315.e18 P.L.T. Hoonakker et al.

The second most often mentioned category (51 times nurse: “I think it's our relationships that we've, you know,
mentioned) covers a range of working conditions in the ICUs built here with physicians as well and different hospitals, …
that nurses do not experience in the tele-ICU: the often when I work with a physician here, they have a different level
stressful (15 times mentioned) and physically exerting (11 of respect for us there, and I think it sort of just transcends to
times mentioned) working conditions, and the shift work nursing in general. We've never worked like this with a
schedules in the ICU (8 times mentioned): “I like that I'm not physician as a team this closely, so I think that that's made a
heavy lifting, I'm not dealing with blood and guts and family difference at the bedside as well, and I think it's a different
drama and fistfights with physicians at the bedside and all of level of acceptance for nursing, actually”. Interestingly, the
that nonsense. I like that I don't have to deal with that”. relationship and interactions with the ICUs monitored by the
The third important category of satisfiers relates to the tele-ICU is less often mentioned (22 times): “I like, when you
relationships within the tele-ICU (34 mentioned). Tele-ICU have good interaction with the other hospitals, you know,
nurses like working with their colleagues and especially with younger, less experienced nurses, where you feel that you can
tele-ICU physicians (12 times mentioned). They like the mentor and help, it was very satisfying”. But tele-ICU nurses
intimate environment, the close relationship between tele- like that they can help with staffing and workload problems in
ICU nurses and physicians and the teamwork (9 times the ICUs and that they help the ICUs to provide better care:
mentioned): “The work environment between the nurses and “We just are there to help support them, not to manage or not
physicians. We're all on the same level, not the level of to oversee or anything, and we're only there just so things
responsibility, but the same peer level. You don't get that in a don't fall through the cracks and the patient get the best care.”
hospital, not normally. There is a hierarchy. And here, it's,
you know, everybody's respectful of each other's position 4.3. Dissatisfiers
and their job, and we know we have to work as a team”, and
the availability and accessibility of tele-ICU physicians (6 Tele-ICU nurses made a total of 84 comments about
times); “The physicians here are really good about…, they aspects of their work that they dislike.
don't, you know, you can ask them questions, you can throw Results in Table 4 show that tele-ICU nurses dislike some
things at them, and they're very good at teaching, and I've of the working conditions in the tele-ICU (26 times
learned a lot just from being here”. The close relationships mentioned): “I don't like this eICU without windows and
with the physicians make them feel more appreciated as a the fluorescent lights” and “That it's hard to, sometimes you

Table 4 What nurses dislike about their job in the tele-ICU


Categories Topic Total
1 Working conditions High (mental) workload in tele-ICU; being short staffed; too many admissions at the same time 9
Too much sitting and lack of physical activity 8
Long shifts can get taxing at the end of the shift 4
Idle time in tele-ICU, difficult to stay awake, nothing to do when slow 3
Physical layout (No windows and fluorescent lights) 2
Total working conditions 26
2 Miss working in ICU Miss ICU/bedside/hospital; miss personal interactions; miss relationships with the patient/family; 13
miss interactions with families; miss the drama/ craziness/ excitement in ICU
Miss doing hands on activities in ICU; miss physical contact 5
Total Miss ICU 18
3 Relationship with ICUs Not well received by ICU staff and /or nurse 7
Not utilized by ICU as much it could be 2
The different cultures in the ICUs 2
Hard to not be in control at the bedside 2
Some hospitals call too often 2
Total relationship with ICU 15
4 Information technology IT issues (computer, servers, phones); too many logins; small monitors/screen 9
Total IT 9
5 Job content No consistency in how work is done in tele-ICU 4
Doing data collection, documentation, paper work; monotony: doing the same work week after week 3
Degradation of bedside skills 2
Total job content 9
6 Tensions in tele-ICU Stressful tensions/ lack of personal space in small room of tele-ICU 4
Annoying coworkers in tele-ICU 3
Total tensions in tele-ICU 7
Total dissatisfiers 84
Motivation and job satisfaction of Tele-ICU nurses 315.e19

get involved in something and you sit for so long and you important predictors of nurse turnover, such as a high
stand up and you're stiff, I feel like I sat for too long. That's workload, stress, burnout, and poor inter-personal relation-
the part that I don't like”. They do not like the extensive ships and collaboration. For example, our results partly
sitting and the lack of physical activity (8 times mentioned), support the study by Cartledge [3] who interviewed ICU
the high (mental) workload in tele-ICU: “Sure, yeah, it's nurses who had left their job. This study showed that the
easier on your back and your legs and … Mentally, it's a little main reasons for leaving were: stress; inadequate opportu-
more challenging sometimes, I think, because you have so nities for professional development; (lack of) recognition and
many more patients, you're not just caring for your team, respect of others (including the relationship with medical
you're caring for a lot more patients”, and the long (12-hour) staff); and the implications of shift work. The results of this
shifts that can be taxing toward the end of the shift (4 times study show why nurses leave the ICU, and may be motivated
mentioned): “The workload sometimes is a little more than, to work in the tele-ICU (as compared to working in ICUs).
that makes me feel comfortable. I can't get all my work done The tele-ICU may, therefore, be a mechanism for retaining
or maybe I feel a little bit stressed about having so much to nurses and dealing with the nursing shortage.
monitor at once”. The second aspect of the tele-ICU work
that tele-ICU nurses dislike is not being in the ICU (18 times
5.1. Motivation
mentioned). They miss being physically at the bedside, the
personal interactions, and the relationship with the patient/
Nurses decided to work in the tele-ICU for multiple
family (13 times mentioned): “The one thing that I do miss is
reasons; broadly, we can distinguish three different groups.
the interaction with patients and family and that compassion
Nurses in the first group talked about the tele-ICU providing
that I can offer them.” They also miss the hands-on activities
a job opportunity. Some of these nurses were actively
in the ICU and the physical contact (5 times mentioned):
recruited to come and work in the tele-ICU, for instance,
“Actually, doing the physical exam, and actually laying my
because the tele-ICU nurse manager knew them. The second
hands on a patient, and kind of getting in there in the thick of
group of nurses was motivated to work in the tele-ICU more
it, I do miss that sometimes”. The third aspect of the tele-ICU
as a reaction to the ICU. For several reasons (age, health
work the nurses do not like is the relationship with the ICUs
problems, burnout), these nurses did not want to continue
(15 times mentioned); they do not always feel well received
working as a bedside nurse. They were looking for an
by ICU staff /nurses (mentioned 7 times), and feel sometimes
environment that was better adapted to their particular
underutilized (2 times mentioned): “It's uncomfortable if
needs. The third group of nurses was attracted by the
there's a hospital or if there's a nurse that doesn't want
concept of the tele-ICU because of the potential for growth
anything to do with you and you still have to make contact
and learning, or because of the ability to help patients and
with that person. You know, that's an awkward time. I don't
nurses at the bedside.
enjoy, you know, having to do that. So I don't enjoy it, you
know, when we're not well-received, it's not enjoyable”.
5.2. Sources of satisfaction and dissatisfaction

5. Discussion Sources of satisfaction and dissatisfaction reported by


tele-ICU nurses cover all elements of the work system (see
In this study we examined the motivation and satisfaction Fig. 2). With regard to their tasks, they describe job content
of nurses working in a range of tele-ICUs. Research on tele- as both a source of satisfaction and a source of dissatisfac-
ICUs is limited; in particular nursing issues related to tele- tion. Nurses are most satisfied with challenges that working
ICUs have been overlooked. Little is known about the work in the tele-ICU offer. They have the opportunity to learn new
of tele-ICU nurses; what motivates them, and what they like things through interactions with tele-ICU physicians and
and dislike about their work. Motivation and job (dis) other nurses, and through exposure to a large variety of
satisfaction are important predictors of nurse turnover and patients. Many ICU nurses have worked for years in specific
well-being; therefore, understanding work characteristics ICUs (e.g., cardiac ICU, neuro-ICU) but in the tele-ICU
that motivate and satisfy tele-ICU nurses can help tele-ICUs nurses have to deal with all kinds of different ICU patients.
in attracting and retaining nurses. All nurses who participated On the dissatisfaction side, nurses talk about the low job
in this study had previous experience as an ICU nurse. Many content of some tele-ICU tasks. Tele-ICU nurses talk about
nurses in our study still work part-time in the ICU. Other not doing ICU tasks as a major source of satisfaction, but
nurses have left the ICU environment and work full-time in some also report missing being at the bedside. Overall, more
the tele-ICU. Their experience as ICU nurses adds an extra nurses report positive task aspects as sources of satisfaction.
dimension to the results of this study: the tele-ICU nurses are The work environment in the tele-ICU was mentioned as
in a unique position to compare working in the ICU with a source of satisfaction because of the quietness, flexibility
working in the tele-ICU. Many nurses in our study and the absence of many physical stressors found in working
mentioned reasons for leaving the ICU and working in the at the bedside. A major reason for nurses to work in the tele-
tele-ICU; many of these reasons have been identified as ICU is that they no longer can cope with the often stressful
315.e20 P.L.T. Hoonakker et al.

Fig. 2 Work system satisfiers and dissatisfiers experienced by tele-ICU nurses.

and physically demanding working conditions, and the shift patient needs a different set of eyes, whereas on the negative
work schedules in the ICU. As mentioned above, numerous side, nurses talk about challenges related to acceptance of the
nurses chose to work in the tele-ICU for health reasons often tele-ICU. Tele-ICU nurses sometimes face difficulties
related to the stressful and demanding ICU work environ- establishing good working relationships with the ICUs.
ment. But tele-ICU nurses also reported a range of negative Nurses and especially physicians in the ICUs do not always
working conditions, in particular the extensive sitting and welcome the tele-ICU because they may sometimes have a
computer work. feeling of “Big Brother watching them”.
Information technology was not frequently mentioned, Some tele-ICU nurses like the ability to balance their
but when mentioned, it was as often a source of work in the tele-ICU with work at the bedside. Other sources
dissatisfaction, because of various problems with computers of satisfaction include the tele-ICU management and the
and servers, as a source of satisfaction. company and its future growth.
With regard to the individual element of the work system, Overall, each element of tele-ICU nurses' work system
tele-ICU nurses talk about their role as a nurse as a source of contains both positive and negative characteristics (see
satisfaction. Being in the tele-ICU allows nurses to help Fig. 2). For instance, the organization element includes 5
others (e.g., patients in small ICUs, and ICU nurses). positive elements (relationship within tele-ICU; interactions
The organizational element of the work system was very with ICUs; balance between tele-ICU and ICU; tele-ICU
often mentioned by tele-ICU nurses, in particular the management; and company) and 2 negative elements
relationships within the tele-ICU. Tele-ICU nurses like (relationship with ICUs, and tensions in the tele-ICU).
working in a team with their colleagues and especially with Tele-ICU nurses mentioned positive work system character-
tele-ICU physicians, which can be more difficult in the ICU. istics more frequently than negative characteristics. This
Tele-ICU nurses mentioned that they learn much from the may be an indication that their work system is well-balanced
close interactions with the tele-ICU physicians; this with more sources of satisfaction, in particular with the
teamwork contributes to the positive job content described tasks being performed and the organizational environment.
earlier. A few nurses mentioned tensions in the tele-ICU as a This is an example of compensatory balance as described
source of dissatisfaction, but this was mentioned much less by the Balance Theory [20]. The Balance Theory uses the
frequently than the positive relationships within the tele-ICU work system model to identify positive and negative
(7 versus 34 mentions). In contrast, the relationship and work characteristics and suggests that a ‘balanced’ work
interactions with ICUs monitored by tele-ICU nurses are system can be achieved through combinations of work
about equally sources of satisfaction and dissatisfaction. On characteristics. Future research could explore whether this
the positive side, tele-ICU nurses mention the help provided compensatory balance in the work system of tele-ICU nurses
to ICUs, especially when the workload is high or when a leads to positive outcomes for nurses as well as for patients.
Motivation and job satisfaction of Tele-ICU nurses 315.e21

5.3. Study limitations and Patient Safety (HEPS 2011), Oviedo, Spain, June 22-24, 2011.
Leiden, The Netherlands: CRC Press; 2011. p. 43-6.
[5] Lilly CM, Thomas EJ. Tele-ICU: Experience To Date. J Intensive Care Med
Although we conducted a large number of interviews with 2009;25(1):16-22, http://dx.doi.org/10.1177/0885066609349216.
tele-ICU nurses (total of 50 interviews), the results cannot be [6] Stafford TB, Myers MA, Young A, Foster JG, Huber JT. Working in
generalized to all tele-ICU nurses. However, we compared an eICU unit: life in the box. Crit Care Nurs Clin North Am
results of the interviews across the 5 tele-ICUs and did not 2008;20(4):441-50.
[7] Breslow MJ. Remote ICU, care programs: current status. J Crit Care
find differences in the motivations to work in the tele-ICU, as 2007;22(1):66-76.
well as the satisfiers and the dissatisfiers (these data are [8] Tang Z, Weavind L, Mazabob J, Thomas EJ, Chu-Weininger
available upon request from the first author). MYL, Johnson TR. Workflow in intensive care unit remote
monitoring: A time-and-motion study. Crit Care Med 2007;35(9):
2057-63, http://dx.doi.org/10.1097/01.ccm.0000281516.84767.96
[PubMed PMID: ISI:000249038700007].
6. Conclusion [9] Juraschek SP, Zhang X, Ranganathan V, Lin VW. United States
Registered Nurse Workforce Report Card and Shortage Forecast. Am J
Med Qual 2012;27(3):241-9, http://dx.doi.org/10.1177/
Nurses have different motivations to work in the tele- 1062860611416634.
ICU. One of the most important reasons to work in the [10] Bureau of Labor Statistics (BLS). Table 6: The 30 occupations with the
tele-ICU is the challenge, the opportunities for learning largest projected employment growth, 2010-20: Bureau of Labor
and critical thinking. Other nurses started working in the Statistics (BLS); 2012 [cited 2012 August 1]. Available from: http://
www.bls.gov/news.release/ecopro.t06.htm.
tele-ICU because they had the opportunity, for health [11] Allen L. The nursing shortage continues as faculty shortage grows.
reasons and/or they were tired of working at the bedside. Nurs Econ 2008;26(1):35-40 PubMed PMID: 2009812506. Language:
Results of our study show that most tele-ICU nurses are English. Entry Date: 20080328. Revision Date: 20090220. Publication
satisfied with their job. They especially like the challenges Type: journal article.
[12] Stechmiller JK. The Nursing Shortage in Acute and Critical Care
in their work and the opportunities to learn. For some
Settings. AACN Adv Crit Care 2002;13(4):577-84.
nurses, the transition from a bedside caregiver to an [13] Stone PW, Larson EL, Mooney-Kane C, Smolowitz J, Lin SX, Dick
information manager can be difficult, and they miss the AW. Organizational climate and intensive care unit nurses' intention
bedside. Other nurses have found a balance by working to leave. Crit Care Med 2006;34(7):1907-12, http://dx.doi.org/
part-time in the tele-ICU and part-time in the ICU. 10.1097/01.CCM.0000218411.53557.29.
[14] Breslow MJ, Rosenfeld BA, Doerfler M, Burke G, Yates G, Stone DJ,
et al. Effect of a multiple-site intensive care unit telemedicine program
on clinical and economic outcomes: An alternative paradigm for
Acknowledgments intensivist staffing. Crit Care Med 2004;32(1):31-8.
[15] Rosenfeld BA, Dorman T, Breslow MJ, Pronovost P, Jenckes M,
Zhang N, et al. Intensive care unit telemedicine: alternate paradigm for
This study was made possible with support from the providing continuous intensivist care. Crit Care Med 2000;28(12):
National Science Foundation (NSF Grant #: OCI-0838513, 3925-31.
Carayon: PI; Brown, Hoonakker, Wiegmann and Wood, co- [16] Lilly CM, Cody S, Zhao H, Landry K, Baker SP, McIlwaine J, et al.
Hospital Mortality, Length of Stay, and Preventable Complications
PIs) and the cooperation from the 5 tele-ICUs, and their
Among Critically Ill Patients Before and After Tele-ICU Reengi-
managers and the nurses who work there. neering of Critical Care Processes. JAMA 2011;305(21):2175-83,
http://dx.doi.org/10.1001/jama.2011.697.
[17] Hoonakker PLT, McGuire K, Carayon P. Sociotechnical Issues of Tele-
References ICU Technology. In: Haftor DM, Mirijamdotter A, editors. Information
and Communication Technologies, Society and Human Beings: Theory
[1] Bakker AB, Le Blanc PM, Schaufeli WB. Burnout contagion and Framework. Hershey, PA: IGI Global; 2011. p. 225-40.
among intensive care nurses. J Adv Nurs 2005;51(3):276-87, [18] Cummings J, Krsek C, Vermoch K, Matuszewski K. Intensive
http://dx.doi.org/10.1111/j.1365-2648.2005.03494.x. care unit telemedicine: Review and consensus recommendations.
[2] Hayes LJ, O'Brien-Pallas L, Duffield C, Shamian J, Buchan J, Hughes Am J Med Qual 2007;22(4):239-50, http://dx.doi.org/10.1177/
F, et al. Nurse turnover: A literature review. Int J Nurs Stud 1062860607302777 [PubMed PMID: ISI:000248326400003].
2006;43(2):237-63. [19] Carayon P, Alvarado CJ, Hundt AS. Work system design in healthcare.
[3] Cartledge S. Factors influencing the turnover of intensive care nurses. In: Carayon P, editor. Handbook of Human Factors and Ergonomics in
Intensive Crit Care Nurs 2001;17(6):348-55. Healthcare and Patient Safety. Mahwah (NJ): Lawrence Erlbaum
[4] Hoonakker PLT, Khunlertkit A, Mcguire K, Wiegmann D, Carayon P, Associates; 2007. p. 61-78.
Wood K. A day in life of a tele-Intensive Care Unit nurse. In: Albolino [20] Smith MJ, Carayon-Sainfort P. A balance theory of job design for
S, Bagnara S, Bellandi T, Llaneza J, Rosal G, Tartaglia R, editors. stress reduction. Int J Ind Ergon 1989;4:67-79.
Healthcare Systems Ergonomics and Patient Safety 2011: Proceedings [21] Carayon P. The balance theory and the work system model…twenty
on the International Conference on Healthcare Systems Ergonomics years later. Int J Hum Comput Interact 2009;25(5):313-27.