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
1. Introduction
The work of Intensive Care Unit (ICU) nurses can be
physically, psychologically and emotionally demanding and
stressful. There is significant burnout and turnover among
ICU nurses, which deprives the country from well-qualified,
rare sources of expertise in critical care [1-3]. The emergence
of the tele-ICU may provide an opportunity for highly skilled
and experienced ICU nurses to continue using and
developing their critical care knowledge and skills in a
high quality work environment. In addition, tele-ICU nurses
may provide support to ICU nurses when dealing with high
demands and stress. This study examines the sources of job
satisfaction and dissatisfaction in a group of 50 tele-ICU
nurses and their reason for choosing to work in a tele-ICU.
2. Background
Tele-Intensive Care Units (tele-ICUs) are units where
intensivists and ICU nurses provide 24/7 care, support and
advice from a distance to remote ICUs; various forms of
health Information Technology (IT) are used to support the
sharing of information between the tele-ICU and the ICUs.
Technologies allow intensivists and nurses in the tele-ICU to
monitor patients, to observe patients and medical devices in
the patient room though a camera, and to communicate with
ICU nurses and providers. Several papers provide a detailed
description of the evolution of the tele-ICU, the tele-ICU
organization, and tele-ICU nurses’ activities [4-8]. Tele-ICUs
are a relatively new phenomenon, but the “oldest” tele-ICU
has been in existence for more than 12 years. Nearly 10% of
all ICU patients are currently monitored by tele-ICUs [5].
There are several reasons for the expansion of tele-ICUs.
In recent years, due to medical advances and population
aging, there has been an increase in patients that need
intensive care, creating an acute need for ICU nurses and
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.
In the next decades there will be a shortage especially of
registered nurses [9-13]. Tele-ICUs offer a solution to this
problem by enabling a relatively small number of intensivists
and nurses to oversee the care of a large number of ICU
patients. Some studies show improvements in care processes
and quality of care after implementation of the tele-ICU, such
as decreased mortality and length of stay (LOS) [14-16].
Tele-ICUs can provide supplementary resources and help
to the ICU team at the bedside. One tele-ICU can for example
monitor 16 ICUs in 12 different hospitals. A tele-ICU nurse
can monitor up to 50 patients in several different ICUs (the
national average is about 35 patients), and a tele-ICU
intensivist may monitor up to 150 patients. This environment
poses unique challenges [17]. For instance, a tele-ICU nurse
collaborates with many nurses and other healthcare providers
P.L.T. Hoonakker et al.
working in various ICUs, in multiple hospitals, simulta-
neously. Despite the many reported successes of the tele-ICU
organization, research on tele-ICUs is limited; in particular
nursing issues related to tele-ICU have been overlooked [18].
Little is known about the work of nurses in the tele-ICU. Tang
et al. [8] conducted an observational study of nurses and
physicians in one tele-ICU. A total of 49 hours of observation
were performed for physicians and 41 hours for nurses.Re-
sults of the study showed that nurses and physicians in the
tele-ICU performed the same types of tasks: patient
monitoring (overseeing remote patients by using clinical
information obtained from various resources), collaboration
(interactions between remote monitoring staff), system
maintenance (tasks related to computer and technology
use), patients’ health record maintenance and other tasks
such as administrative, social or personal tasks. But
physicians spent considerably more time on patient monitor-
ing and nurses spent more time on maintaining patient's
health records. This study provides some limited information
about the work of tele-ICU nurses, but does not examine the
viewpoint of tele-ICU nurses regarding their work. The
objective of this study is to examine what motivates tele-ICU
nurses in their work and what aspects of their work they are
satisfied and dissatisfied with. We used the Balance theory
and the work system model [19-21] as a conceptual
framework to identify sources of satisfaction and dissatisfac-
tion experienced by tele-ICU nurses (see Fig. 1). A major
strength of the work system model is the inclusion of all work
characteristics that can affect work motivation and job
satisfaction [20]. Therefore, the work system model provided
the basis for a systematic approach to identify sources of work
motivation and satisfaction among tele-ICU nurses. Accord-
ing to the work system model, tele-ICU nurses may
experience satisfaction or dissatisfaction related to their
individual preferences and characteristics, their tasks, the
physical environment, the various tools and technologies
used, and the organizational environment [19-21].
3. Methods
3.1. Study design
We conducted interviews with nurses in 5 different tele-
ICUs. These interviews were part of a larger study that
examines the challenges faced by tele-ICU nurses when dealing
with multiple ICUs (http://cqpi.engr.wisc.edu/vicu_home). The
interview guide was tested in a pilot study at the tele-ICU of the
University of Wisconsin-Madison Hospital. The study was
approved by the IRBs of the university and the tele-ICUs.
3.2. Setting
The 5 tele-ICUs differ by region, size, number of years in
existence, number of hospitals and ICUs connected, and
Motivation and job satisfaction of Tele-ICU nurses
Fig. 1 Work system model [19-21].
number of tele-ICU nurses and intensivists employed.
Table 1 summarizes the characteristics of the tele-ICUs
that participated in the project.
3.3. Sample
We interviewed 10 tele-ICU nurses in each of the 5 tele-
ICUs; we conducted more than 70 hours of interviews with a
total of 50 tele-ICU nurses. Interviews lasted on average 70
minutes (range: 42-139 minutes). The interviews were the
longest in tele-ICU #2 (average duration per interview 91
minutes vs. 70 minutes total). Ninety percent of the
interviewed tele-ICU nurses are women. On average they
have 3½ years of experience in the tele-ICU (range 0-
8 years). On average, they have been a nurse for nearly 21
years (range 3-28 years). All nurses work in 12-hour shifts:
about half in the night shift and half in the day shift. On
average, the tele-ICU nurses monitor 4-5 ICUs and 38 beds
during a shift. Nearly half (44%) of the nurses have a part-
time job in the tele-ICU; the rest work full time in the tele-
ICU (3 12-hours shifts). Forty-two percent of the nurses
work also as a bedside nurse.
3.4. Data collection instrument
We used a semi-structured interview to collect data about
different aspects of the work of tele-ICU nurses. See http://
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
motivation to work in the tele-ICU. We asked the tele-ICU
nurses the following questions: “Why did you decide to
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 tele-ICU that you dislike”? Probes were used to ensure
that all aspects of the work system (individual, tasks,
physical environment, tools and technologies, and organi-
315.e15
zation) were covered. Two or three interviewers performed
the interviews. All but two interviews were audio-taped,
transcribed and made anonymous to protect confidentiality
of the interviewees. For the two interviews that were not
audio-taped, researchers took handwritten notes, which were
then transcribed.
3.5. Data analysis
We used a mix of qualitative and quantitative methods to
analyze the data. First, all parts of the interview transcripts
that contained the responses to the three open-ended
questions (see above) were read by the research team
members, and the responses were categorized according to
the main elements of the work system model (See Fig. 1:
person, tasks, organization, environment, and tools and
technologies). Only if consensus was achieved among all
team members was a category accepted. Once the different
categories were defined, all interviews were coded by two
team members, using these categories. Finally, we counted
how often a certain category was mentioned in each
interview: if a nurse mentioned a certain category several
times during an interview, it was counted as one occurrence.
This procedure makes it possible to count how many nurses
mentioned a certain category. We only included responses
in the results if they were mentioned by at least two tele-
ICU nurses.
4. Results
4.1. Motivation
The 50 tele-ICU nurses had different reasons to work in
the tele-ICU. They mention a total of 90 reasons (on average
1.8 reasons per tele-ICU nurse). The different reasons were
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
nurses to work in the tele-ICU was curiosity or the challenge.
As one tele-ICU nurse explained: “So through the course of
my career, I've needed to find different avenues that I need to
feel challenged. And this [the tele-ICU] does it”. A second
reason to work in the tele-ICU was the job opportunity, either
as an effect of active recruitment by the tele-ICUs or the
nurses applying for the jobs (“Well, matter of fact, when I
first came here, I came here as an agency employee, and I did
a three-month assignment, and I just loved what we were
doing”). Health reasons were a third important reason to
work in the tele-ICU: “I had a back injury. Was told by the
neurosurgeon that unless I wanted to have real problems and
have surgery, I had to get away from the bedside and find
something quiet to do. He suggested a nice, quiet doctor's
office. Well, you take an ICU nurse and put them in there,
you're going to kill them with boredom”. Health reasons are
often linked to the next category: the demanding working
conditions in the ICU. Many nurses were tired of working in
the ICU (“I really enjoy my bedside work, and, but as I get
older, I realize that it's getting harder and harder to do three
or four shifts at the bedside”), and have either physical
complaints (back, shoulders, knees) (“I think it was a factor
of being in medicine for as long as I've been in it. A physical
aspect of my job is that this, my brain still works very, very
Table 2 Motivation of nurses to work in the tele-ICU
Total
Curiosity/ Learning /Challenge/ Potential for growth / 23
Critical thinking
Job opportunity 19
Health reasons 15
Tired of bedside and working conditions in ICU 13
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
well, my body does not.”) or are burned out by their work in
the ICUs (“But, then after that, you know, working at the
bedside is a very challenging job, I mean, it's very stressful, I
mean, physically, emotionally”). Teaching and helping
smaller ICUs and the nurses who work in the ICUs is
another reason for nurses to work in the tele-ICU: “So, that's
my biggest interest in this, is how I see it helping smaller
hospitals, and the nurses at the bedside and the patients at the
small hospitals”. Finally, some nurses are drawn by the
technology (“I love this, because I love technology” and “I
saw it as high tech, and the future of nursing, and I wanted to
know more about it. And then I came and I came to look at it,
I fell in love with it, and signed on”).
4.2. Satisfiers
Tele-ICU nurses made a total of 228 comments about
aspects of their work that they like. Results in Table 3 show
that tele-ICU nurses like the job content and particularly the
challenges in their work (64 times mentioned): “Well, what
I like about it is that it's a constant challenge. It's a
challenge of just dealing with lots of different systems, lots
of different people. You're having to triage a lot of things in
your mind and, you know, multitask, and, you know,
prioritize and triage”.
Tele-ICU nurses especially like learning from the variety
of patients and from interacting with their colleagues in the
tele-ICU and the ICUs (64 times mentioned). As one tele-
ICU nurse explains: “The other thing I love about it is the
challenge of me learning something new every day. You
know, I come across a diagnosis that I've never heard of
before, that I wouldn't be exposed to if I wasn't exposed to
30 to 40 patients”. They also mentioned the positive impact
on patient outcomes: “I would say for those that I've helped
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
mentioned) covers a range of working conditions in the ICUs
that nurses do not experience in the tele-ICU: the often
stressful (15 times mentioned) and physically exerting (11
times mentioned) working conditions, and the shift work
schedules in the ICU (8 times mentioned): “I like that I'm not
heavy lifting, I'm not dealing with blood and guts and family
drama and fistfights with physicians at the bedside and all of
that nonsense. I like that I don't have to deal with that”.
The third important category of satisfiers relates to the
relationships within the tele-ICU (34 mentioned). Tele-ICU
nurses like working with their colleagues and especially with
tele-ICU physicians (12 times mentioned). They like the
intimate environment, the close relationship between tele-
ICU nurses and physicians and the teamwork (9 times
mentioned): “The work environment between the nurses and
physicians. We're all on the same level, not the level of
responsibility, but the same peer level. You don't get that in a
hospital, not normally. There is a hierarchy. And here, it's,
you know, everybody's respectful of each other's position
and their job, and we know we have to work as a team”, and
the availability and accessibility of tele-ICU physicians (6
times); “The physicians here are really good about…, they
don't, you know, you can ask them questions, you can throw
things at them, and they're very good at teaching, and I've
learned a lot just from being here”. The close relationships
with the physicians make them feel more appreciated as a
nurse: “I think it's our relationships that we've, you know,
built here with physicians as well and different hospitals, …
when I work with a physician here, they have a different level
of respect for us there, and I think it sort of just transcends to
nursing in general. We've never worked like this with a
physician as a team this closely, so I think that that's made a
difference at the bedside as well, and I think it's a different
level of acceptance for nursing, actually”. Interestingly, the
relationship and interactions with the ICUs monitored by the
tele-ICU is less often mentioned (22 times): “I like, when you
have good interaction with the other hospitals, you know,
younger, less experienced nurses, where you feel that you can
mentor and help, it was very satisfying”. But tele-ICU nurses
like that they can help with staffing and workload problems in
the ICUs and that they help the ICUs to provide better care:
“We just are there to help support them, not to manage or not
to oversee or anything, and we're only there just so things
don't fall through the cracks and the patient get the best care.”
4.3. Dissatisfiers
Tele-ICU nurses made a total of 84 comments about
aspects of their work that they dislike.
Results in Table 4 show that tele-ICU nurses dislike some
of the working conditions in the tele-ICU (26 times
mentioned): “I don't like this eICU without windows and
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
get involved in something and you sit for so long and you
stand up and you're stiff, I feel like I sat for too long. That's
the part that I don't like”. They do not like the extensive
sitting and the lack of physical activity (8 times mentioned),
the high (mental) workload in tele-ICU: “Sure, yeah, it's
easier on your back and your legs and … Mentally, it's a little
more challenging sometimes, I think, because you have so
many more patients, you're not just caring for your team,
you're caring for a lot more patients”, and the long (12-hour)
shifts that can be taxing toward the end of the shift (4 times
mentioned): “The workload sometimes is a little more than,
that makes me feel comfortable. I can't get all my work done
or maybe I feel a little bit stressed about having so much to
monitor at once”. The second aspect of the tele-ICU work
that tele-ICU nurses dislike is not being in the ICU (18 times
mentioned). They miss being physically at the bedside, the
personal interactions, and the relationship with the patient/
family (13 times mentioned): “The one thing that I do miss is
the interaction with patients and family and that compassion
that I can offer them.” They also miss the hands-on activities
in the ICU and the physical contact (5 times mentioned):
“Actually, doing the physical exam, and actually laying my
hands on a patient, and kind of getting in there in the thick of
it, I do miss that sometimes”. The third aspect of the tele-ICU
work the nurses do not like is the relationship with the ICUs
(15 times mentioned); they do not always feel well received
by ICU staff /nurses (mentioned 7 times), and feel sometimes
underutilized (2 times mentioned): “It's uncomfortable if
there's a hospital or if there's a nurse that doesn't want
anything to do with you and you still have to make contact
with that person. You know, that's an awkward time. I don't
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. Discussion
In this study we examined the motivation and satisfaction
of nurses working in a range of tele-ICUs. Research on tele-
ICUs is limited; in particular nursing issues related to tele-
ICUs have been overlooked. Little is known about the work
of tele-ICU nurses; what motivates them, and what they like
and dislike about their work. Motivation and job (dis)
satisfaction are important predictors of nurse turnover and
well-being; therefore, understanding work characteristics
that motivate and satisfy tele-ICU nurses can help tele-ICUs
in attracting and retaining nurses. All nurses who participated
in this study had previous experience as an ICU nurse. Many
nurses in our study still work part-time in the ICU. Other
nurses have left the ICU environment and work full-time in
the tele-ICU. Their experience as ICU nurses adds an extra
dimension to the results of this study: the tele-ICU nurses are
in a unique position to compare working in the ICU with
working in the tele-ICU. Many nurses in our study
mentioned reasons for leaving the ICU and working in the
tele-ICU; many of these reasons have been identified as
315.e19
important predictors of nurse turnover, such as a high
workload, stress, burnout, and poor inter-personal relation-
ships and collaboration. For example, our results partly
support the study by Cartledge [3] who interviewed ICU
nurses who had left their job. This study showed that the
main reasons for leaving were: stress; inadequate opportu-
nities for professional development; (lack of) recognition and
respect of others (including the relationship with medical
staff); and the implications of shift work. The results of this
study show why nurses leave the ICU, and may be motivated
to work in the tele-ICU (as compared to working in ICUs).
The tele-ICU may, therefore, be a mechanism for retaining
nurses and dealing with the nursing shortage.
5.1. Motivation
Nurses decided to work in the tele-ICU for multiple
reasons; broadly, we can distinguish three different groups.
Nurses in the first group talked about the tele-ICU providing
a job opportunity. Some of these nurses were actively
recruited to come and work in the tele-ICU, for instance,
because the tele-ICU nurse manager knew them. The second
group of nurses was motivated to work in the tele-ICU more
as a reaction to the ICU. For several reasons (age, health
problems, burnout), these nurses did not want to continue
working as a bedside nurse. They were looking for an
environment that was better adapted to their particular
needs. The third group of nurses was attracted by the
concept of the tele-ICU because of the potential for growth
and learning, or because of the ability to help patients and
nurses at the bedside.
5.2. Sources of satisfaction and dissatisfaction
Sources of satisfaction and dissatisfaction reported by
tele-ICU nurses cover all elements of the work system (see
Fig. 2). With regard to their tasks, they describe job content
as both a source of satisfaction and a source of dissatisfac-
tion. Nurses are most satisfied with challenges that working
in the tele-ICU offer. They have the opportunity to learn new
things through interactions with tele-ICU physicians and
other nurses, and through exposure to a large variety of
patients. Many ICU nurses have worked for years in specific
ICUs (e.g., cardiac ICU, neuro-ICU) but in the tele-ICU
nurses have to deal with all kinds of different ICU patients.
On the dissatisfaction side, nurses talk about the low job
content of some tele-ICU tasks. Tele-ICU nurses talk about
not doing ICU tasks as a major source of satisfaction, but
some also report missing being at the bedside. Overall, more
nurses report positive task aspects as sources of satisfaction.
The work environment in the tele-ICU was mentioned as
a source of satisfaction because of the quietness, flexibility
and the absence of many physical stressors found in working
at the bedside. A major reason for nurses to work in the tele-
ICU is that they no longer can cope with the often stressful
315.e20
Fig. 2 Work system satisfiers and dissatisfiers experienced by tele-ICU nurses.
and physically demanding working conditions, and the shift
work schedules in the ICU. As mentioned above, numerous
nurses chose to work in the tele-ICU for health reasons often
related to the stressful and demanding ICU work environ-
ment. But tele-ICU nurses also reported a range of negative
working conditions, in particular the extensive sitting and
computer work.
Information technology was not frequently mentioned,
but when mentioned, it was as often a source of
dissatisfaction, because of various problems with computers
and servers, as a source of satisfaction.
With regard to the individual element of the work system,
tele-ICU nurses talk about their role as a nurse as a source of
satisfaction. Being in the tele-ICU allows nurses to help
others (e.g., patients in small ICUs, and ICU nurses).
The organizational element of the work system was very
often mentioned by tele-ICU nurses, in particular the
relationships within the tele-ICU. Tele-ICU nurses like
working in a team with their colleagues and especially with
tele-ICU physicians, which can be more difficult in the ICU.
Tele-ICU nurses mentioned that they learn much from the
close interactions with the tele-ICU physicians; this
teamwork contributes to the positive job content described
earlier. A few nurses mentioned tensions in the tele-ICU as a
source of dissatisfaction, but this was mentioned much less
frequently than the positive relationships within the tele-ICU
(7 versus 34 mentions). In contrast, the relationship and
interactions with ICUs monitored by tele-ICU nurses are
about equally sources of satisfaction and dissatisfaction. On
the positive side, tele-ICU nurses mention the help provided
to ICUs, especially when the workload is high or when a
P.L.T. Hoonakker et al.
patient needs a different set of eyes, whereas on the negative
side, nurses talk about challenges related to acceptance of the
tele-ICU. Tele-ICU nurses sometimes face difficulties
establishing good working relationships with the ICUs.
Nurses and especially physicians in the ICUs do not always
welcome the tele-ICU because they may sometimes have a
feeling of “Big Brother watching them”.
Some tele-ICU nurses like the ability to balance their
work in the tele-ICU with work at the bedside. Other sources
of satisfaction include the tele-ICU management and the
company and its future growth.
Overall, each element of tele-ICU nurses' work system
contains both positive and negative characteristics (see
Fig. 2). For instance, the organization element includes 5
positive elements (relationship within tele-ICU; interactions
with ICUs; balance between tele-ICU and ICU; tele-ICU
management; and company) and 2 negative elements
(relationship with ICUs, and tensions in the tele-ICU).
Tele-ICU nurses mentioned positive work system character-
istics more frequently than negative characteristics. This
may be an indication that their work system is well-balanced
with more sources of satisfaction, in particular with the
tasks being performed and the organizational environment.
This is an example of compensatory balance as described
by the Balance Theory [20]. The Balance Theory uses the
work system model to identify positive and negative
work characteristics and suggests that a ‘balanced’ work
system can be achieved through combinations of work
characteristics. Future research could explore whether this
compensatory balance in the work system of tele-ICU nurses
leads to positive outcomes for nurses as well as for patients.
Motivation and job satisfaction of Tele-ICU nurses
5.3. Study limitations
Although we conducted a large number of interviews with
tele-ICU nurses (total of 50 interviews), the results cannot be
generalized to all tele-ICU nurses. However, we compared
results of the interviews across the 5 tele-ICUs and did not
find differences in the motivations to work in the tele-ICU, as
well as the satisfiers and the dissatisfiers (these data are
available upon request from the first author).
6. Conclusion
Nurses have different motivations to work in the tele-
ICU. One of the most important reasons to work in the
tele-ICU is the challenge, the opportunities for learning
and critical thinking. Other nurses started working in the
tele-ICU because they had the opportunity, for health
reasons and/or they were tired of working at the bedside.
Results of our study show that most tele-ICU nurses are
satisfied with their job. They especially like the challenges
in their work and the opportunities to learn. For some
nurses, the transition from a bedside caregiver to an
information manager can be difficult, and they miss the
bedside. Other nurses have found a balance by working
part-time in the tele-ICU and part-time in the ICU.
Acknowledgments
This study was made possible with support from the
National Science Foundation (NSF Grant #: OCI-0838513,
Carayon: PI; Brown, Hoonakker, Wiegmann and Wood, co-
PIs) and the cooperation from the 5 tele-ICUs, and their
managers and the nurses who work there.
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