Critical Careers

Ronnie Ursin, BSN, RN, BS, figured there would be a lot to learn when he moved from his nursing job on a medical/surgical floor to a cardiac intensive care unit–and he was right. “It was like night and day,” he says. “It had been described to me as going through nursing school all over again, and that’s exactly what it was like.”

Ronnie Ursin, BSN, RN, BSRonnie Ursin, BSN, RN, BS

On the med/surg unit, Ursin took care of half a dozen patients at once, who for the most part could walk and talk and be left alone for periods of time. In the ICU, he cared for only one, maybe two, patients during each shift, but these patients were the most vulnerable of any in the hospital. Hooked up to multiple high-tech machines, they required vigilant monitoring and assessment, and their complex conditions could change in a blink of an eye.

Critical care nursing is one of the most intense specialties nursing has to offer. But for nurses who thrive in the practice, it also is one of the most rewarding.

“You can see these patients who are very sick and three days later you’re able to see them get better and send them off the unit,” says Ursin, a board member of the National Black Nurses Association. “You know you played a part [in their recovery]. That’s the most rewarding thing of all.”

After gaining experience in cardiac intensive care, Ursin became director of the Acute Medical Unit at Washington Hospital Center in Washington, D.C. He says his critical care experience helped broaden and deepen his medical knowledge, which has assisted him in his current position.

A great benefit of working in critical care is autonomy, Ursin adds. “Because the critical care nurse is at the patient’s bedside more than the doctors, the doctors really value the nurse’s opinion. There are some things we catch that the doctor doesn’t catch.”

The Human Touch in a High-Tech Setting

The concept of critical care is relatively new. Hospitals developed the first intensive care units in the 1950s to care for very sick patients, such as polio victims. Patient survival rates rose and more ICUs were added, with the first cardiac care units developed in the 1960s.

Today critical care nurses care for the most seriously ill and severely injured patients in a variety of settings: on emergency transport teams, in intensive care units, pediatric ICUs, neonatal ICUs, cardiac care units, cardiac catheter labs, telemetry units, progressive care units, emergency departments and recovery rooms. Smaller hospitals typically have a general intensive care unit for any patient in critical condition and perhaps a cardiac care unit. Large university medical centers often have 20 or more specialized critical care units.

In addition, today’s critical care nurses increasingly work in home health care, managed care organizations, outpatient surgery centers and clinics, according to the American Association of Critical-Care Nurses (AACN), headquartered in Aliso Viejo, California.

Martha Baker, PhD, RN, director of the BSN program at Southwest Baptist University in Bolivar, Mo., worked in critical care for more than three decades as a staff nurse, charge nurse and educator, as well as in staff development. She says she found the specialty exciting and she particularly enjoyed the opportunity to learn about new medical technology. Friends described her as an “adrenaline junkie,” but the most rewarding part of her critical care experience, she says, was providing the human touch in a high-tech environment.

In fact, Baker cautions, one thing critical care nurses have to guard against is getting too caught up in the mechanics. “Amid the multiple machines, you have to remember there is a person in the bed. You’re not taking care of the monitor, the ventilator and the balloon pump. You’re taking care of a human being.”

Cultural Critical Care

From the time in high school when he worked as a volunteer in an emergency room, Ramon Lavandero, MSN, RN, MA, FAAN, has been drawn to critical care. Lavandero has worked as a staff nurse, directed critical care at a university medical center and taught critical care nursing. In his work at hospitals, he enjoyed the team camaraderie as well as the intellectual stimulation of caring for patients with complex conditions.

Ramon Lavandero, MSN, RN, MA, FAANRamon Lavandero, MSN, RN, MA, FAAN

“When a person is dealing with a life-threatening illness, every aspect of that individual is potentially affected,” he explains. “There are interactions of the different body systems and between the body and mind, and also with the family and social systems. You can’t be thinking in narrow boxes.”

Lavandero, who is now director of development and strategic alliances for AACN, says he found deep meaning in his work with patients and their loved ones. “I found the families were really fellow caregivers.”

“You’re there to keep the patient comfortable, but you also need to be there for the family,” Baker agrees.

This is one of the reasons why understanding and respecting cultural differences is so important in critical care, and why culturally knowledgeable minority nurses are so urgently needed in this specialty. Critical care nurses are advocates for their patients, respecting their rights, values and beliefs and intervening whenever the patients’ best interests are in question. They act as liaisons between the patient, family and other nurses and doctors, often bridging communication gaps that can develop under such stressful conditions. When end-of-life decisions must be made, critical care nurses are right there on the front lines.

Baker, who is president-elect of the National Alaska Native American Indian Nurses Association, often served as a resource for other hospital staff members who wanted to learn about traditional Indian customs to better serve their patients. At the request of families, she helped arrange smudging ceremonies and traditional drumming and singing for patients who were in intensive care. “It takes some creativity, but you can make those accommodations on the unit if you work at it,” she says.

With a diverse nursing staff, “everyone brings something different to nurture one another and support one another,” says Regina Cullen, senior nurse recruiter at Brigham and Women’s Hospital in Boston, which provides intensive in-house critical care training programs for both new and experienced nurses. The hospital has a minority mentorship fellowship for students in their junior year, and in many cases hires those nurses once they graduate.

Diversity goes beyond ethnicity, however, says Lavandero, a native of Puerto Rico. Diversity of religious beliefs, gender, geographical and educational background is important, too, to produce a staff with a variety of cultural perspectives. A patient’s needs may be overlooked if the perspective is too narrow, he warns.

Making the Move to Critical Care

Opportunities abound for minority nurses interested in working in critical care, a specialty that has been hit especially hard by the nursing shortage. Many experienced nurses are nearing retirement age at a time when hospitals are expanding their critical care units. According to a 2004 survey by the American Association of Critical-Care Nurses, 27% of the nation’s critical care units reported increases in the number of budgeted positions. Progressive care areas have a larger number of unfilled positions than intensive care units. The AACN survey found that it took an average of 62 days to fill a nursing position in intensive care versus 90 days in progressive care.

Baker tells her students to get at least six months of experience on a regular hospital floor before going into critical care. Nurses entering critical care must not only adjust to the intense pace, but they also have to master all the high-tech medical equipment, which can be overwhelming for brand new graduates.

“You have to be alert and on task because small changes [in a patient’s condition] make a big difference,” says Baker. “It’s very difficult to do that right out of school because you’re also learning to be a nurse.”

Brigham and Women’s Hospital, a teaching hospital for Harvard Medical School, focuses on growing its own critical care nursing staff from within by helping intermediate care nurses interested in critical care move into working in ICUs. Cullen says this makes for a highly successful transition because the nurses are already familiar with the hospital. They can focus all their attention on the critical care program without having to worry about adjusting to a new work environment as well.

The hospital also hires ten new graduates a year for critical care, but they must first spend six months working in intermediate care before moving into an intensive care unit. To be eligible, the nurses must also have completed a senior practicum in an ICU and worked as a student nurse or patient care assistant at the hospital. Initially the hospital tried hiring these nurses directly into critical care after four months of orientation. But, Cullen says, “We found they needed the basic nursing foundation first.”

Do You Have What It Takes?

What does it take to work in critical care? First of all, critical care nurses should have solid clinical skills. “When you listen to the heart or chest, you have to know what you’re hearing and be able to detect small changes,” Baker says. “You have to be able to be organized, prioritize decision making and be detail-oriented so you can monitor everything.”

An ability to think and act quickly is essential. “Things happen so fast, you constantly have to be on top of all the signs,” says Ursin. “You can’t just say, ‘okay, I’ll deal with that in five minutes.’”

Today’s critical care patients are sicker than ever before, and many would not have survived a generation ago. New treatments and technology are being developed every year, making patient care even more complex. Critical care nurses must stay on top of the latest information and constantly update their skills to keep pace.

Critical care is not for everyone, Baker says, and nurses must consider carefully whether the specialty is right for them. “For me, nobody is less of a nurse because they don’t like critical care,” she emphasizes. “Everybody’s gift in nursing is not the same, and that’s the beauty of nursing.”

For instance, nurses who get the greatest rewards from getting to know their patients personally are probably not best suited for critical care units, where patients are too ill to engage with others and are heavily medicated, which blurs their recall of the events in ICU and the nurses who cared for them. Patients often spend only short periods in the ICU before moving to units with less-intensive care.

But if this fast-paced, challenging career with its own unique rewards does sound exciting to you, the demand is there and the need for more culturally diverse nurses in the specialty is creating unprecedented opportunities. To learn more about what a career in critical care is like, Lavandero suggests talking to other critical care nurses and spending some time in an intensive care unit. Check with the educator for that unit, and seek out nurses with a variety of experience levels in critical care to get a good feel for the specialty, he advises.

For More Information

American Association of Critical-Care Nurses

Established in 1969, the American Association of Critical-Care Nurses (AACN) is the largest specialty nursing organization in the world, with more than 400,000 members. The association publishes a monthly newsletter, a scientific research journal, a clinical magazine for practicing nurses, a quarterly series for advanced practice nurses and an annual Career Guide. The association’s annual National Teaching Institute and Critical Care Exposition attracts more than 6,000 participants and exhibitors, providing nurses with a wealth of education and career information. AACN also offers scholarships to AACN members who are RNs completing a baccalaureate or graduate degree program in nursing. The association’s Web site features information about certification, clinical practice, education, public policy, research and more.

AACN Certification Corporation

The AACN Certification Corporation provides credentialing for nurses who maintain standards of excellence in acute and critical care nursing. The corporation administers the CCRN, CCNS (for clinical nurse specialists) and PCCN (progressive care) specialty credentials and the CMC (cardiac medicine) and CSC (cardiac surgery) subspecialty credentials. Its Web site provides information about each of these credentials, online exam registration and renewal, and information about exam review courses.