A rapid realist review of practices for assigning remote telemetry responsibilities to new critical care nurses
Brandi Vanderspank-Wright, PhD, RN, CNCC(C), Michelle Lalonde, PhD, RN, Amanda Ross-White, BA, MLIS, Sarah Crowe, MN, PMD-NP(F), NP, CNCC(C), Carley Alexander, BScN, RN, Rosalin Awad-Maglieri, BScN, RN, and Natalie Bourgeois, BScN, RN.
Background: Registered nurses in critical care units may have a variety of responsibilities in addition to direct patient care. Assuming roles over and above their patient assignment can be challenging for nurses new to critical care. Even though additional roles may include similar skill sets (e.g., electrocardiography), the demands of learning multiple new roles and responsibilities occur during a larger transition into specialty practice.
Aim: To identify and summarize literature that helps provide guidance and best-practice(s) regarding assigning telemetry to new critical care nurses.
Methods: Rapid realist review. Databases searched were Medline (Ovid), CINAHL (Ebsco), Nursing & Allied Health (Proquest), and Web of Science Core Collection. Inclusion criteria include new graduate nurses, new critical care nurses in adult settings, assignment of telemetry monitoring, and all study designs. Grey literature, dissertations, and studies with experienced nurses were excluded. The search was conducted on January 25, 2022.
Findings: A total of four manuscripts met the criteria. Three provided a detailed program overview; one reported on a qualitative study. All were from the United States.
Conclusion: Limited evidence is available to provide a substantive solution to this clinical problem – further research and/or quality improvement is merited.
Implications for Nursing
- Rapid review methodology provides a pragmatic solution to immediate clinical needs
- The state of science on remote telemetry training for new critical care nurses merits further exploration
- Regardless of similarity of skill set, additional responsibilities while also providing direct patient care may be challenging for critical care nurses, particularly those who are a novice
Registered nurses (RN) who are hired into critical care units have various responsibilities in addition to direct patient care within the intensive care unit (ICU) itself. Often, they will be required to assume roles and responsibilities over and above their patient assignment. Some examples include responding to cardiac arrests on inpatient units and being part of rapid response/critical care response teams (Pattison et al., 2014; Topple et al., 2016; Williams et al., 2019). An additional responsibility in some hospital critical care settings (e.g., rural, community) is remote telemetry monitoring of inpatients admitted to medical and surgical floors. Staffing can be challenging in urban and rural critical care units. Shortages, both new and previously existing, necessitate the hiring of RNs with limited or no previous critical care experience (i.e., new graduate nurses and nurses new to critical care) (Elias & Day, 2020; Innes & Calleja, 2018). As a result, new hires are faced with acquiring the necessary knowledge, skills, and judgement (i.e., competence) to provide care to critically ill patients and their families, including working within a complex interdisciplinary critical care team – but they are also required to learn additional roles (Elias & Day, 2000; Innes & Calleja, 2018; Lalonde et al., 2021; Vanderspank-Wright et al., 2019). Even though these additional roles may include similar skill sets (e.g., electrocardiography), the demands of learning multiple new roles and responsibilities occur during a more significant transition into specialty practice. Extant literature reminds us that transition into critical care is challenging for novices (i.e., new graduate nurses and nurses new to intensive care); theoretical understandings of transition deepen our understanding that proficient and competent practice can take two to three years to develop (Benner, 1982; Duchscher, 2008, 2009).
The aim of this rapid realist review, which is both pragmatic and practical in design, was to identify and summarize literature that helps provide guidance and best-practice(s) regarding assigning telemetry to nurses who are new to critical care, including newly hired nurses with limited critical care experience and/or new graduate nurses.
Methodology and Review Design
Rapid reviews are “a form of knowledge synthesis that accelerates the process of conducting a traditional systematic review through streamlining or omitting specific methods to produce evidence for stakeholders in a resource-efficient manner” (Garrity et al., 2021, p. 15). Rapid realist reviews are similar but are often conducted within shorter timeframes to answer clinical questions. This review was modelled on methods articulated by Saul et al. (2013). Data extraction tables are available upon request to the primary author.
To provide important context for the consideration of generalizability and/or transferability (note, both terms are used purposefully given the methodological variety of the included studies) of the review findings, we have provided important context that provides not only the reader an understanding of the clinical context, but also provides a rationale for the use of a realist rapid review protocol.
The critical care unit is a 12-bed Level 3, Advanced critical care unit in the province of Ontario, Canada. Additional responsibilities of nurses include remote telemetry monitoring and code blue response. New graduate nurses and nurses with no prior critical care experience are hired in this unit. The current practice is to begin independent remote telemetry monitoring at approximately six months post-hire into the unit.
The associated PICO is elaborated in Table 1, and Inclusion/Exclusion criteria in Table 2.
|Nurses new to critical care *newly hired *new graduate nurses||Being assigned to monitor remote telemetry||Levels 2 and 3, Adult, Critical Care Unit/Intensive Care Unit/Intensive Treatment, Unit/Progressive Care Unit/High Acuity Unit/Step-Down Unit|
|Nurses new to critical care *newly hired *new graduate nurses||Experienced critical care nurses defined as >2 years in any critical care setting.|
|Telemetry assignment/monitoring||Standard cardiac monitoring practice in critical care|
|Adult ICU/Critical Care||All non-adult critical care settings.|
|Studies of all types and publications that provide a detailed description of the program overview||Grey literature, theses, dissertations.|
In consultation with an experienced medical information specialist, a search strategy was developed in Medline. While the search was not formally peer-reviewed by a second librarian, the search was reviewed by members of the review team who have experience with systematic reviews and/or are experts in critical care nursing practice. The search strategy was then translated into the remaining databases Medline (Ovid), CINAHL (Ebsco), Nursing & Allied Health (Proquest), and Web of Science Core Collection and executed. Initially, a date limit of five years (January 1, 2016, to December 31, 2021) was placed on the search, but given the lack of returns, no limits were applied. Inclusions were limited to English language publications. An example of the search strategy is detailed in Figure 1. All searches are available as a supplemental file on request to the authors.
Example of Search Strategy – Medline
Citations retrieved from the search were then uploaded into Covidence for screening. Duplicates were removed. We then used a two-step screening process completed by one reviewer who is an expert in content and review methodology. Inclusion and exclusion were based on a priori (see Table 2). First, the title and abstracts were screened. Then, a full-text screening was completed. Inclusions were shared amongst the review team to ensure agreement, given that a two-screener process was not used. Reference lists of the included manuscripts were also reviewed as part of the hand-searching process. A PRISMA flow-diagram details the screening process (see Figure 2). No additional inclusions resulted from hand-searching.
We did not conduct a quality appraisal because the majority of the manuscripts were program overviews and not empirical research.
Extraction templates were created in Microsoft Word. Extraction was completed by one member of the review team with experience in review methodology (BVW). A second reviewer verified extraction tables.
For data synthesis, we describe practices through synthesis tables where possible and narrative summaries. Results have been reported as per a modified PRISMA 2020 (Page et al., 2021) to maintain consistency with the rapid aspect of this review. Based on the reported data, it was impossible to conduct meta-analyses.
This rapid realist review aimed to identify and summarize literature that helps provide guidance and best-practice(s) regarding assigning remote telemetry to nurses new to critical care, including newly hired nurses with limited critical care experience and new graduate nurses. A total of four manuscripts were included. Three of the included manuscripts provided a detailed program overview, and one reports empirical findings from a qualitative study. All the manuscripts were from the United States. All reported settings, sample demographics, and research designs are included in Table 3.
A summative program description is provided for each of the included manuscripts. Costanzo et al. (2013) describe a blended program that was developed through a collaborative process between academic and content experts from the involved hospital. The program consists of online learning modules with requisite quizzes and resources and a review session to consolidate learning. A final evaluation includes an identified passing grade requirement of 85%. A remediation process is also detailed in the program description.
Poteet and Touloukia (1992) described an 8-week orientation facilitated by a group of preceptors from the Cardiac ICU. Content was provided on self-identified needs of new graduate nurses (e.g., IV equipment and procedures, blood administration, nasogastric tubes, and the use of emergency equipment (p. 96D) through formal teaching. A clinical practicum was also put in place where the new nurses were gradually exposed to increasingly complex patients. Supports were readily available during clinical shifts. All shifts were 10 hours long and comprised two hours of didactic content, with the remaining eight hours focused on patient care. New graduate nurses were formally welcomed into the unit during a “welcome breakfast” as a means of facilitating their socialization into the unit (p. 96D).
Robins et al. (1995) described the process of needing to orient nurses to two critical care areas, cardiology and neurosurgery. Based on the aim of this review, we only reported on cardiac-specific content. Two main components of their cardiac orientation were described. All new hires were provided with a general orientation in addition to a lecture series. All new hires were also offered preceptor experience. Special attention was paid to cardiac-specific skills, including dysrhythmia identification, pacemakers, cardiovertor-defibrillators, and cardiac pharmacology, including the administration of vasoactive medications.
Reported Outcomes of Programs
Manuscripts that reported on program overviews did provide some insight into the evaluation of their programs. While not formally described as the effectiveness of interventions, the following were reported and are highlighted in Table 4.
Narrative Summary of Evaluation Reported
|Study||Reported Evaluation of Program|
|Costanzo et al.||Post remediation benefits evident High mean passing score (94.5%). Shorter timeframe to complete compared to course model. Cost savings Increased learner comfort with technology|
|Poteet & Touloukia||Solution for staffing shortage. Excellent clinical performance noted in learners. High team spirit among staff. They are now the preceptors for their shift. Quick progression to independent practice. Perpetuated mentorship. Costs of program reported as justifiable.|
|Robins et al.||Cost analysis indicated program was not sustainable as designed. No program or patient outcomes were provided.|
Summary of Qualitative Findings
Qualitative findings from the study by Nickasch et al. (2016) suggest an overarching theme of confusion and uncertainty. Participants in their study described not knowing what to do and when to do it regarding ECG abnormalities. They also described needing to rely heavily on others, like telemetry technicians, and therefore never felt autonomous or independent in their practice. While they expressed having had training (e.g., Advanced Cardiac Life Support), they reported not using this skill, lacking consolidation into practice, and therefore losing this skill. It was also reported that they did not identify as cardiac nurses. Examples of supporting quotes are included in Table 5.
Reported themes and examples of a supporting participant quote
|Reported Theme||Participant Quotation|
|Confusion and uncertainty: What should I do next? (p. 420)||“Yeah, if somebody would come to me … and say this patient had whatever abnormal rhythm … I would honestly not know the answer … my first thing would be to call the doctor because I don’t know.” (p. 420)|
|Subtheme 1: Use it or Lose it (p. 421)||“The class was fine, but to be proficient, you have to use it, and on my unit, we never use it.” (p. 421)|
|Subtheme 2: Losing My Independence: Relying on Unlicensed Telemetry Technicians (p. 421)||“I trust them (the telemetry technician) a lot more than I would trust myself to know what the heck they’re talking about … they see it every day.” (p. 4121)|
|Subtheme 3: Help: I am Out of My Comfort Zone (p. 421)||“Not being a cardiac nurse, the minute RNs (on medical-surgical unit) hear the patient should go, it’s like, let’s just go, let’s get them off the floor, because I don’t want something to go wrong.” (p. 421)|
Limited evidence has provided direction on what might constitute best practices for transitioning new critical care nurses into the additional role of telemetry monitoring. Given the lack of included studies and no meaningful way to engage with quality across the reported findings, we preface the reporting of results with caution. Evidentially, this is an area of inquiry that requires further study to determine best practice(s). It is established that a multi-component approach that includes cardiac educational content and a preceptor experience is essential. Future work on this topic may consider the following conceptual considerations and how new critical care nurses perceive additional roles that are primarily outside the physical structure of the ICU. In an ethnographic study by Scholtz et al. (2016) on the culture of nurses in a critical care unit, the authors reported that critical care nurses place the utmost importance on the care of patients stating that “[m]any nurses have mentioned “the patient” to be the only, most important, and most rewarding side to their work” (p.4). This finding is particularly interesting when considering the physical presence of patients admitted to an ICU. They are directly observable compared to patients monitored remotely via telemetry where no substantive therapeutic relationship is possible. It is also important to consider the implications of monitoring patients outside of ICU but being situated in an environment (i.e., the ICU) where alarm fatigue is a clinical reality and arguably further impacted by remote telemetry alarms. The overarching risk is sentinel events whereby, for example, a perceived nuisance alarm (i.e., artifact) is considered an emergency requiring attention (Funk et al., 2014).
Existing literature on the transition into critical care highlights the complexity of the role and the experiences that new nurses have. While no theoretical frameworks specific to transition were evident in the included manuscripts, their importance merits attention. Given the known skill and task-oriented nature of new nurses and new graduates in particular (Benner, 1982; Duchscher, 2008, 2009), it merits further investigation into how these additional skills are incorporated into role transition and acquisition supported and experienced. Further, when considering the practical and pragmatic nature of this research, quality improvement methodology may be advantageous because many designs incorporate real-time feedback, evaluation, and modification of processes.
Limitations of this review include screening and extraction by one reviewer. To mitigate this, all authors were provided access to the Covidence files; where the screener and extractor were not certain, concerns were brought forward to the team for consideration and consensus. No quality appraisal was complete, given the lack of empirical research retrieved. The evidence included may be limited due to a single country context and the publication dates.
Further research is merited to understand and evaluate processes inherent in training, including patient care assignment and assigning additional roles to nurses working in critical care units. Quality improvement designs may be beneficial for developing and evaluating processes specific to role readiness for remote telemetry monitoring as an additional RN responsibility. Some direction is provided from the descriptions of the program overviews retrieved and the experiences articulated in a qualitative study.
Brandi Vanderspank-Wright PhD RN CNCC(C), School of Nursing, University of Ottawa, Ottawa, Ontario and Critical Care Unit, Cornwall Community Hospital, Cornwall, Ontario.
Michelle Lalonde, PhD, RN School of Nursing, University of Ottawa, Ottawa, Ontario, Institut du Savoir Montfort, Hôpital Montfort, Ottawa, Ontario.
Amanda Ross-White, BA, LIS, Queen’s University, Kingston, Ontario.
Sarah Crowe, MN, PMD-NP(F), NP, CNCC(C), Fraser Health Authority, Langley, British Columbia.
Carley Alexander, BScN, RN, Critical Care Unit, Cornwall Community Hospital, Cornwall, Ontario.
Rosalin Awad-Maglieri, BScN, RN, Critical Care Unit, Cornwall Community Hospital, Cornwall, Ontario.
Natalie Bourgeois, BScN, RN, Critical Care Unit, Cornwall Community Hospital, Cornwall, Ontario.
Brandi Vanderspank-Wright, Associate Professor, School of Nursing, University of Ottawa, Ottawa, ON & Nurse Mentor, Critical Care Unit, Cornwall Community Hospital, Cornwall, ON
Funding and Conflict of Interest:
The authors have no funding or conflicts of interest to declare.
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 Critical Care Services Ontario Levels of Care definitions are available at: https://criticalcareontario.ca/wp-content/uploads/2020/11/Adult-LoC-Guidance-Document-Final.pdf
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