The American Nurses Association's Nursing Scope and Standards of Practice states that “nursing occurs in any environment where there is a healthcare consumer in need of care, information, or advocacy.”1 Additionally, “the ‘how’ of nursing practice is defined as the ways, means, methods, and manners that nurses use to practice professionally.”1 Given the broad scope of modern nursing, tele-ICU nurses find themselves adjusting and relearning what it means to care for patients from behind a camera.
The invention of tele-ICUs began in response to a national shortage of critical care intensivists.2 As a result of ongoing development and investment in technology, tele-ICU services became a solution for expanding localized physician expertise to a larger portion of the ICU population.2 Research publications showing the impact of the tele-ICU on clinical outcomes and operational efficiencies are growing, and emerging evidence suggests tele-ICU involvement in patient care is associated with lower mortality and hospital length of stay, as well as increased adherence to best practices.3,4
At Atrium Health, Virtual Critical Care (VCC) nurses are an elite group of experienced clinicians who deliver and manage care using state-of-the-art remote technology. This technology includes high-fidelity, two-way audio and video equipment mounted in each ICU room. Atrium Health's tele-ICU program was launched in 2013 and now serves 13 ICUs with the capacity to support over 300 critically-ill patients. It is staffed by board-certified nurses, respiratory therapists, pharmacists, and intensivists. (See Atrium Health VCC team by the numbers.) The VCC center employs 37 RNs, each with at least 4 years of recent critical care experience and requirements to maintain CCRN certification. Atrium Health's VCC nurses may also earn and maintain the CCRN-E certification, instead of the CCRN; this is a good option for those who plan to work more VCC center hours than at the bedside. The overall average critical care experience level is 14 years. The VCC was recently recognized nationally with a Bronze Beacon Award of Excellence from the American Association of Critical Care Nurses (AACN). This article examines the opportunities and challenges associated with tele-ICU nursing and provides insight into the careers of the clinicians behind the cameras through anecdotes from Atrium Health VCC nurses.
A unique work environment
A 12-hour shift in an office setting is very different from 12 or more hours in an ICU. VCC nurses work at specially designed workstations in a central operations room, or COR. Each workstation accommodates eight monitors, displaying real-time clinical information for up to 45 patients. There are no audible alerts, so all patient information is gathered by reading patient charts and monitoring vital signs on computer screens. Workstations are adjustable, giving the nurse an option to sit, stand, walk in place, or sit on a yoga ball.
Nurses spend much of their shift proactively scanning medical records, analyzing data, trending vital signs, troubleshooting complex clinical scenarios with bedside colleagues, communicating with members of the team by phone or camera, and visualizing patients by camera through routine and as-needed camera rounds. Although the work is not physically demanding, the pressure of triaging several patients' needs at once using multiple computer applications, screens, and keyboards, and responding quickly and accurately, while helping others stay calm in tense situations can be quite stressful. There are typically fewer than 10 team members in the COR, which makes the environment a generally quiet one where it is easy to lose track of time; making time for self-care is important for VCC nurses.
With leadership support, one VCC nurse leads an effort focusing on teammate health and safety related to workstation ergonomics. The nurse periodically surveys teammates on their knowledge and experience with back, shoulder, neck, and vision strain from prolonged computer use. Several interventions are in place, including inhaled aromatherapy; supported and encouraged stretch breaks or walks; sessions on stretching, yoga, and chair massage; and printed resources on stretching and exercise strategies. A healthcare ergonomics expert evaluates the workstations and provides recommendations. The nurse manager arranged for a massage therapist and yoga instructor to teach staff methods to alleviate the stress and strain that come with prolonged sitting and focusing for 12 hours.
AACN has long acknowledged that healthy work environments are vital for nurses to optimally impact patient care.5 VCC nurses embody Atrium Health's core values of caring, commitment, integrity, and teamwork. The COR follows the AACN Standards for Establishing and Sustaining Healthy Work Environments, and Atrium Health provides a variety of resources to help the COR honor its commitment to these standards.6 In the last 3 years, the COR has administered the AACN Healthy Workplace Survey to its nurses.6 After survey results are shared with staff, shared governance councils use them for action planning to improve teammate engagement through shared decision-making.
The volume of patients seen daily requires VCC nurses to process emotions differently than their colleagues at the bedside. “Because you are reading physician notes on so many patients, it is depressing to hear of tragic stories of people who were up and living and are now in traumatic situations,” says VCC nurse C.B. Atrium Health provides support with a Code Lavender program that offers emotional and spiritual support to staff in times of need. Other healthy workplace strategies include disconnecting from technology devices during time off, using the Employee Assistance Program benefits, participating in pet therapy visits to the COR, and receiving chair massages.
Making the transition
The transition from bedside to VCC nursing can be challenging for high-performing critical care nurses. It often takes several months to adjust to the virtual nursing office setting. VCC nurses must take all the knowledge they previously used to physically care for their patients and refine their communication skills to deliver that message to their bedside colleagues. VCC nurse M.H. said the transition to VCC nursing was not easy. “You have to restructure your thinking from a bedside nurse to a resource nurse,” she said. M.H. explained that while it is sometimes difficult to decipher clinical boundaries and how far to intervene in patient care, a positive aspect of the new role definition is that “you don't feel like you have to be everything to everyone.” M.H. said she experiences less stress in the COR than she did as a clinical nurse. M.H. believes the overall transition to virtual care is allowing her to become more autonomous in her role in patient care, and she appreciates the reduced exposure to potential injury and illness that can result from bedside work.
Relationships and collaboration
Successfully integrating a tele-ICU into the care team requires shared knowledge, goals, and respect.3 However, VCC nurse C.B. says, “people forget about us. They forget about where we are from and what our experience is. We are thought of as just a face in a box. We realize this is the nature of the business, but we have a lot of experience to share.”
Bedside acceptance of virtual care instructions did not come easily. As a result, the COR established a robust shared governance outreach council to develop, maintain, and foster bedside relationships. The Ambassador Program, eMentor Program, nursing school clinical rotations, and Collaborative Group meetings are a few of the outreach programs developed by this council to improve the relationship with bedside clinicians.
The ePharmacists and virtual respiratory therapists (VRTs) work closely with VCC nurses to provide holistic patient care. ePharmacist D.K. says the VCC nurses are “higher caliber and seen as a resource—especially to the new nurses—and can sense when something is about to go wrong.” She believes there is positive communication that extends back to the bedside, which relies on nurses for peer-to-peer support. The VRTs have observed how nurses assess patients using their clinical judgment. VRT J.S. likes how they collaborate before escalating issues to intensivists.
The collaboration of the interdisciplinary team has helped VCC teammates provide optimal patient care and experience. This partnership occurs externally as well. The Collaborative Group, which consists of nurses from the COR and all the bedside ICUs within Atrium Health, meets quarterly to discuss new workflows and to develop and maintain vital relationships. During these meetings, the group discusses what is working well and what is not working so well to collaboratively reach new solutions. This ensures unity and helps break the technology/virtual barrier. This group also shares tips and tricks of critical care and develops relationships across the units in the health system.
How assessment skills differ
The American Telemedicine Association (ATA) has created practice guidelines for telemedicine to “advance the science and to assure the uniform quality of service to patients.”7 To provide care via camera, the VCC nurses at Atrium Health must have proficient assessment skills and be able to translate their visual assessment into a holistic picture. Along with ATA guidelines for telemedicine, the AACN has developed practice guidelines for the tele-ICU nurse.8 These guidelines focus on true collaboration, skilled communication, and practice excellence to provide optimal patient care and outcomes.8 VCC nurse J.L., who balances her shifts between bedside and VCC nursing, says the bedside nurses are so busy, “they don't often get a chance to take an in-depth look into the chart to pull everything together.” Some of the perceived challenges faced by virtual nurses have contributed to bolstering their strongest attributes. According to J.L., “I am not able to touch my patients, but I can use my critical thinking skills without being exhausted. Being removed from the physical stress allows me to see the big picture a lot sooner than I would if I were in the thick of it.”
Benefits of a tele-ICU nurse
In the current healthcare environment, nurses are being asked to do more for their patients, often with fewer resources. VCC nurses at Atrium Health advocate for both their patients and their colleagues at the bedside. This is often one of the most rewarding parts of the job. The physical demands of nursing and the current state of workplace violence in hospitals across the country are parts of the profession that can distract from complete attention to the patient.5 “Assessing patients and families who may pose a personal threat to my safety isn't an issue anymore. I don't miss people trying to slap, punch, or kick me,” says VCC nurse L.C.
VCC nurse H.R. said this is the best critical care job for her. “I needed a break from the trenches, but wanted to continue to critically think,” she said. VCC nurse D.H. says, “ensuring the bedside nurse has the tools he or she needs to provide care to the patient is one of my favorite parts of the job.” VCC nurse L.C. agrees, adding, “Everyone here has spent enough time at the bedside to know what it is like on the other side of the camera and we want to make things easier for them, to be a resource for them.”
Tele-ICU nurse challenges
Although state-of-the-art technology has made this innovative type of care delivery possible, VCC nursing comes with a unique set of challenges. The inability to physically place hands on a patient and help in an emergency or when the bedside is overstressed is an obvious limitation. Effectively making the transition from bedside to virtual nursing is critical to the process.
It can be difficult for VCC nurses to watch events unfold over the camera and feel the need to do more to assist the bedside team with patient care. VCC nurse T.R. had one such interaction. A patient went into cardiac arrest, and CPR was initiated. The COR was alerted to the event just before the code blue was called and a VCC intensivist was brought in to help. T.R. helped the bedside team by offering suggestions on bagging and monitoring CPR cycles during the chaos of the situation. The bedside team spent the better half of an hour putting all their efforts into resuscitating the patient, and all the while, T.R. offered help. However, she felt quite helpless in that moment. “I watched from afar and felt like there was absolutely nothing more that I could do,” she said. “My hands, which have helped so many patients, were now useless. That feeling of helplessness is what has stayed with me when I look back on that day.”
VCC nurse D.W. points out, “there are a lot of changes happening at the bedside, and we need to be mindful of what has changed since we've been away from the bedside.” Some VCC nurses continue to work at the bedside along with their VCC shifts, but many do not. Annual competencies are tailored to assess the knowledge and customer service skills needed for the role of the virtual nurse. The unit's Professional Development Council is continually finding new and innovative ways to ensure the team remains current in its knowledge and skill. Newly required 4-hour bedside shifts help VCC nurses refamiliarize with bedside nursing workflows, routines, and work environments, as well as foster face-to-face relationships with bedside colleagues.
Maintaining knowledge and skill is important to gaining bedside nurses' trust. When the COR started, staff assumed the bedside team would be excited about the new resource, but the bedside team members were slow to accept their virtual colleagues; many thought the VCC team was intrusive, overbearing, or interfering. This misperception has improved with time but is a continued challenge.
Many initiatives have been developed to help increase integration, such as an active Ambassador Program. VCC ambassadors make monthly site visits to the units to foster relationships, provide education about VCC, and service recovery if needed. In addition to the VCC ambassador, each bedside unit has a designated ambassador to ensure the VCC nurses are up to date on any unit issues or projects. Staff turnover in the ICU makes it important to ensure all teammates understand the purpose of the VCC team and how to use the technology to help care for their patients. Ambassadors help close the gap in education for new staff, resource staff, and travelers.
Looking to the future
This type of nursing has led to discoveries of more options for professional advancement. “I am looking more at my education and what other skills I can master that do not involve direct patient care,” said VCC nurse T.R. VCC nurse J.L. finds herself seeking new knowledge about different specialty clinical areas that she encounters virtually. “I had to up my game with some of the specialties like neurology, hematology, and oncology,” she said. “It's a huge learning curve!” This spark in learning has pushed several VCC nurses toward advanced degree programs for nursing informatics, education, legal consulting, and administration for program management.
Because there is no blueprint for tele-ICUs, the COR can flex and provide units with the individualized support they need. Meanwhile, the system's Critical Care Network is working to align all the organizations' critical care units in standard practice and the VCC is an important tool central to supporting this work. With the current push on the Society of Critical Care Medicine (SCCM) ICU Liberation initiative, VCC nurses have a bird's-eye view of how each unit performs against national benchmarks and can focus attention where it is needed.9
Bedside clinicians need the experience that tele-ICU nursing offers. History shows critical care units face challenges recruiting and retaining nurses.10 Turnover and nursing vacancies negatively affect work environments, which in turn negatively affect patient outcomes.11 Currently, Atrium Health has a well-performing Transition to Practice (TTP) residency program for new graduate nurses. TTP is an accredited Practice Transition Program with Distinction through the American Nurses Credentialing Center. Both the TTP nurses and local nursing school students attend clinical rotations in the COR. This exposure to tele-ICU as additional support to those new to the profession and the implementation of a successful eMentor program have the potential to positively impact patient care. The experience the VCC nurses bring to professional development through mentoring over camera and through an eMentor program is a very rewarding part of the job.
By introducing these new nurses to the technology and their VCC teammates early in their program, they become familiar with how the COR can help as they evolve in their nursing careers. As a result of this interaction, the VCC nurses gain early acceptance with their bedside teammates. The VCC has been included in clinical rotations in four local nursing schools with the hope of not only educating nursing students about the new technology but also gaining acceptance once they graduate and move into their new careers. VCC nurse J.L. said, “I've realized how much I love educating and helping new nurses understand. The collaboration that happens between the bedside and COR is like no other type of collaboration I've been a part of.” This is an advantage with recruitment and retention of nurses.
Despite the occasional barriers, there are many stories of amazing collaboration and patient and family interaction. During a night shift, VCC nurse S.B. assisted the bedside team at one of Atrium Health's hospitals with a newly admitted patient who was in septic shock and respiratory failure. As the patient's condition worsened, the bedside nurse began calling the VCC, reporting increasing vasopressor requirements, hypotension, increased lactic acid, and multiple other issues. The VCC nurse was able to coordinate the plan of care between the tele-intensivist and the bedside nurse, which included the use of high-dose insulin euglycemic therapy (HIET)—a complicated and not often used therapy. The tele-intensivist called the bedside nurse to discuss the protocol one-on-one. He then worked with the VCC nurse to explain the purpose of the protocol and its methodology, so she could continue to support the bedside team and serve as “an extra set of eyes.” The VCC nurse connected the tele-intensivist with the bedside interdisciplinary team including the hospital's pharmacist and hospitalists. S.B. described her night as “a privilege to serve as the coordinator for all of this communication and support between the VCC and bedside team at the hospital.” Seamless care was provided, thanks to the support and direction of the VCC team.
VCC nurse S.K. cared for a patient with an admitting diagnosis of chronic obstructive pulmonary disease exacerbation. During routine daily camera rounds, she was able to speak directly to the patient. He confided in her that he gets anxious easily at home and drinks and smokes heavily to cope. During their conversation, he started getting anxious again and stated that it was hard for him to breathe. He was in tears at this point, and S.K. told him to slowly breathe in and out through the mouth and did it with him. As he began to calm down, he described how he feels that no one cares about him. S.K. spoke to the patient at length. He told her he was scared and needed to make changes to improve his life. S.K. said, “I wanted to jump through the camera to talk to him in person but made the most of the situation and used the extra time I had as a virtual nurse to spend with him.” S.K. continued, “This was a powerful conversation for both of us, and he appreciated the time and care I showed him. It makes me feel good when I can make a difference to someone, and the camera does not prevent me from being right there with my patients.”
VCC nurse S.T. helped care for a critically-ill patient who needed to be transferred from a rural hospital to Atrium Health's main hospital for emergent interventions. The patient required massive blood transfusions at the referring hospital that was continued while in transport. The patient went into cardiac arrest multiple times in route, and the transport team decided to stop at the closest ED, as the patient was too unstable to keep going. The patient was unable to complete the transfer and admitted to that facility. S.T. was able to give a complete report to the receiving nurse as she had seen him in the referring facility. The VCC nurse was able to provide continuity of care since they were involved in both the referring and receiving hospitals. S.T. said, “Even though I was not there, I felt like a part of the care team and was able to help manage the chaos from a distance as the bedside provided the urgent care.”
During routine camera rounds, a bedside nurse reached out to one of the VCC nurses. She said, “Today is the patient's birthday. She has been here for weeks and very little, if any, family has come to visit. Is there any way you can sing happy birthday to her with me?” The VCC nurse did not hesitate. She went into the room via camera, and after introducing herself, gathered other VCC nurses who began to sing “Happy Birthday” to the patient with the bedside team. The patient was so thankful; it was an emotional and tearful moment for the entire care team.
As the evolving healthcare landscape offers innovative ways for patients to seek and receive care, traditional acute care delivery models are rapidly changing. Health systems and expert clinicians are moving their scarce resources to meet patients and families where needs are the greatest, using technology at a rapid pace. This shift in care delivery offers nurses options to extend the length of their careers and opportunities to practice in nontraditional environments while positively impacting their professional lives and patient health outcomes.