Nurses can go into so many different areas in the field, cardiovascular nursing being just one of them. But as with all career choices, nurses need to have the right information to determine if this area is right for them.
We interviewed Jill Price, PhD, MSN, RN, senior director of Chamberlain University’s College of Nursing Post-Licensure programs. Price has nearly two decades of experience in Critical Care and Cardiovascular Nursing, and trained nurses at the first cardiac care center in the U.S. Virgin Islands—St. Croix—in critical care and cardiovascular care. Previously, Price worked as an advanced cardiac life support instructor and pediatric advance life support instructor.
What are the different types of nurses used in cardiovascular care? What do their jobs entail?
For nurses who don’t have any sort of critical care experience and want to go into cardiovascular nursing, I would first recommend the nurse seek out a critical care training course and then either a job in a critical care step down unit or an intensive care unit. Some hospitals require a year of medical-surgical nursing experience first before seeking a position in a critical care unit, so the nurse would need to check with the institution on what their requirements entail.
The different types of nurses who pursue cardiovascular care are those who love taking care of very sick patients with several comorbidities. These nurses are a unique group in that they like to help patients with complex medical problems, often times requiring advanced technology to maintain their heart rate. Cardiovascular nurses have advanced critical thinking skills.
If nurses want to pursue a job in cardiovascular care, what additional training or certifications do they need?
In terms of certification, I would recommend getting certified as a critical care nurse with the American Association of Critical-Care Nurses (AACN) organization. Additionally, they should seek out advanced cardiac life support (ACLS) and advanced pediatric life support (PALS) certifications.
What are the biggest challenges of being a cardiovascular nurse?
Since cardiovascular disease—which includes heart attacks—is the leading cause of death in the United States, nurses working in cardiovascular care, inclusive of interventional cardiovascular laboratories, are on call often. This requires not only working during the week at normal scheduled hours, but also being on call after normal working hours. And when a nurse is called in, they have less than 30 minutes to drop whatever they are doing to get to the hospital and save a patient’s life. Cardiovascular nurses are dedicated and committed to their job and time away from families can be challenging for some.
What are the greatest rewards?
Resuscitating a patient back from being in full blown cardiac arrest and seeing them walk out of the hospital like they were never sick. Or witnessing a patient whose limb was blue from an arterial vascular occlusion and working to open the occlusion and save the person’s limb by witnessing the blood flow restoration in the limb.
What were some of the most important things you learned while doing that kind of work?
I learned that with new devices and drugs consistently being developed, the cardiovascular nurse must stay abreast on all the latest technology and innovation in order to advocate for the patients’ best interests and choice in health care. Also, timing is everything, from saving the heart to the brain. You have to essentially dedicate your life to this kind of nursing, and even if you make a difference in one person’s life—but there will be many—you will feel proud knowing all that dedication and rushing to their care was worth it.
If nurses are interested in becoming a cardiovascular nurse, what advice would you give them?
Be prepared to devote time away from your family in return for helping save lives. Work in telemetry or acute care settings right out of nursing school and enroll in a critical care course, with the goal of becoming a certified critical care nurse, as soon as possible.
With advance research always being conducted on how to help decrease, prevent, and treat cardiovascular disease, you will get to learn something new every day.
Nursing can be stressful, no matter what area of the field you’re working in. But working in the Emergency Room (ER) or Emergency Department (ED) carries with it its own kind of stressors. Silver Powell, RN, at the University of Maryland Medical Center Midtown Campus Emergency Department, took to time answer our questions about what nurses regularly deal with in the ER/ED.
What follows is an edited version of our interview.
As a nurse in the ER/ED, what does your job entail? What do you do on a daily basis?
As an ED nurse, my duties tend to change. The majority of the time I circulate as either the charge nurse or the triage nurse. On a typical day as the charge nurse, the shift starts with taking reports from the night shift nurse on all the patients in the department, including the patients that are roomed as well as in the waiting area, and issuing assignments to the nurses circulating on the unit. From there, both charge nurses count the narcotics in the medication room and reconcile any pending discrepancies.
My next responsibility is to ensure that the nurses circulating have the support and supplies they need to properly care for the patients. This may include delegating tasks to other nurses or techs or being a liaison between the nurses and the physicians on the unit or the nurses on the other units. Responsibilities also include triaging patients that are brought in by ambulances and assigning rooms to all triaged patients. Often, the rooms fill quickly, yet it’s pertinent to initiate a work up on patients that are not roomed to eliminate any delays in process of the patient’s care.
In the meantime, I am also responsible for ensuring the cleanliness and the safety of the department.
As the triage nurse, my responsibilities start with checking the functionality and presence of the emergency equipment. The next priority is to triage all patients that come through the main ED waiting area. The charge nurse relies heavily on the triage nurse for support; therefore, I am responsible for aiding the charge nurse with all duties whenever possible.
Why did you choose to work in the ER/ED? How long have you worked there? What prepared you to be able to work in such a stressful environment?
While in nursing school, I applied for a student nurse position here in the ED at Midtown and fell in love with the excitement of the department. I immediately connected with the staff and felt honored when I was offered a position right after graduation. I gladly accepted and have been working here at Midtown in the ED for 5 years. Although working in the ED is very stressful at times, my student nurse position prepared me well. I made a strong connection between what I was learning in school in my critical care course and put it into action.
How do you keep yourself from bringing the stress of the job home? What do you do to relieve your stress?
Many times, after having a stressful day, some of the other staff and I get together after the shift and have a debriefing. This allows us to express what we think contributed to the stress of the day and discuss what we could do differently in the future—so we can possibly alleviate having to face some of the same stress repeatedly.
What are the biggest challenges of your job?
With so much autonomy as an ED nurse, one of the biggest challenges of the job is being able to recognize the priority problem for each patient and being able to meet their needs. With the population that we serve, patients often are experiencing multiple priority problems, which at times can make it difficult to meet all of their needs.
What are the greatest rewards of working in the ER/ED?
The greatest reward of my job is to know that I have helped someone, no matter how large or small their problem may be.
What would you say to someone considering this type of nursing work? What kind of training or background should he or she get?
I would tell anyone that is considering working in an ER/ED that although stressful, it is a very rewarding job. Each day is different, and there are so many things to see and to learn. In my opinion, there is no definitive training that completely prepares one for life in the ED, yet taking as many critical care courses in as many different areas as possible is always a plus.
Working in an ED entails working closely with many people from so many different areas of the health care spectrum; team work is incredibly important. We rely on others from all specialties to aid us in the care of patients to ensure optimal patient outcomes.
In the age of smart phones, there’s an application for most everything and everyone. Nursing is no exception. Nurses, accustomed to their pocket references, have a slew of new electronic resources to choose from, including a nursing education application for the iPhone and iPod Touch created by critical care nurses at Shands at the University of Florida.
Designed especially for critical care nurses providing post-operative pediatric congenital cardiac care, two Shands nurses developed the app as a digital reference tool when treating children and infants after their heart surgeries. Users can also bookmark pages and make notes. One of the developers had field tested his own paperback pocket reference, and also on post-operative pediatric congenital cardiac care. He applied his experience to the digital content, and the application draws its evidence-based data from varied websites, journals, and textbooks. Though it’s not a free app ($9.99 at the Apple Store), proceeds benefit nursing education, research, and professional development at the hospital and its Center of Nursing Innovation.
For many African Americans and other racial and ethnic minorities, the intensive care unit is the end of the line. According to a 2006 study by researchers at the University of Pittsburgh, a greater proportion of African Americans in particular receive treatment in the ICU at the end of their lives compared to Caucasian Americans. And overall, critical care patients in general are so seriously ill that one in five will die in the ICU or shortly thereafter.
Critical care nurses need to pay particular attention to the care of minority patients, especially African Americans, because many of these patients have seen a world of health troubles by the time they arrive in the ICU, says Alvin Thomas, MD, a critical care physician at Howard University Hospital in Washington, D.C.
Speaking at an education session at the American Association of Critical-Care Nurses’ 2008 National Teaching Institute last May in Chicago, Thomas noted that in the case of several critical conditions found in the ICU, such as severe sepsis and organ failure, African American patients are often more seriously ill than whites—no matter how high the quality of care the ICU provides. The problem, he emphasized, is not that black patients receive inferior care in the ICU compared to whites; rather, it’s that they have had less access to quality health care and have had poorer health outcomes throughout their lives, before they are even admitted to the ICU.
For example, many Americans of color are less likely than whites to have health insurance, a primary care physician or access to a specialist, Thomas pointed out. They are also more likely to have put off receiving care and to have higher rates of risk factors such as smoking, obesity and lack of exercise. As a result, when they are admitted to the ICU, they are much sicker than their white counterparts.
Thomas urges critical care nurses to become “champions” of population health for their patients. That means looking beyond the medical care given in the ICU and understanding the big picture of how these patients live in the outside world. How easy is it for them to purchase medications, get transportation to the doctor’s office, or even find a doctor in their neighborhood? How can their families be enlisted to help?
As an example, Thomas cited the recent case of a 37-year-old woman of color who lives in southeastern Washington, D.C., where primary care doctors are few and far between. She had labile, poorly controlled asthma but was reluctant to go to the hospital or call an ambulance. When her condition became unbearable, she took two buses to Howard University Hospital, walked into the ED, barely able to speak, and collapsed. She was sent to the medical ICU. Discharged after seven days in the hospital, she did not keep any appointments for follow-up visits in the pulmonary clinic and disappeared from the radar screen.
For Beverly George-Gay, MSN, RN, a veteran ICU nurse who is now a full-time assistant professor at Virginia Commonwealth University (VCU) School of Nursing in Richmond, Va., this story is all too familiar. “Many African Americans will wait before they seek care,” she agrees. Like the young black woman who came to VCU’s medical center with a large lump in her breast and was admitted to the ICU in an advanced stage of cancer. “She had tried a lot of home remedies before coming in,” George-Gay says.
Recent research studies confirm that minority patients, and African Americans in particular, tend to arrive in the ICU with more complicated conditions than their white counterparts. Blacks have higher rates of sepsis and severe sepsis than whites, a higher incidence of organ failure, and are signiﬁcantly more likely to develop post-operative complications that land them in intensive care. Black men have the highest adjusted in-hospital mortality rate from acute respiratory distress syndrome (ARDS) and elderly black women have the highest mortality from myocardial infarction.
Again, it must be emphasized that in most cases black patients develop these serious conditions before they are admitted to the ICU, not afterwards. Extensive research for this article failed to find any evidence that minority patients are treated differently than whites once they actually arrive in the ICU. One 2008 study, led by J. Daryl Thornton, MD, MPH, of the Case Western Reserve University Center for Reducing Health Disparities, suggests that black patients have a shorter length of stay in the ICU than whites and are less likely to be told about end-of-life issues, receive coronary artery bypass procedures or get pain medication. However, the researchers acknowledge that their study was based on analysis of less-than-recent data (from 1989-1994) and that additional research is needed before any conclusions can be drawn.
George-Gay certainly doesn’t think that African American patients receive unequal treatment in ICUs—at least not in her ICU. “Yes, some African Americans don’t get preventive care and are not [always] offered some of the cutting-edge technology,” she says. “But once they are in the ICU, I always thought we took care of all ICU patients in a colorblind fashion.”
But even though minority critical care patients are unlikely to experience overt racial discrimination in the ICU, they may still encounter unconscious bias, such as stereotyping, that can result in culturally insensitive care. George-Gay says her white colleagues sometimes surprise her with misguided conclusions about their African American patients. For example, when a black patient recently admitted to the ICU was found to have lice, George-Gay overheard a nurse commenting, “I think [black people] put something in their hair that causes lice.”
“I said, ‘WHAT?!’” George-Gay recalls. “[This nurse needed to be taught that] lice are a socio-economic phenomenon.”
The Institute of Medicine (IOM)’s landmark 2002 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care notes that “although myriad sources contribute to these disparities, some evidence suggests that bias, prejudice and stereotyping on the part of health care providers may contribute to differences in care.”
Of course, most health care professionals do not think they are treating minority patients any differently. In a 2004 study by Joseph Betancourt, MD, MPH, and Owusu Ananeh-Firempong II, BS, entitled “Not Me! Doctors, Decisions and Disparities in Health Care,” doctors were asked if some patients were treated unfairly based on race or ethnicity; 14% said “never” and 55% said “rarely.” However, the Unequal Treatment report cites a 2000 study, “The Effect of Patient Race and Socio-Economic Status on Physicians’ Perceptions of Patients,” which found that many white doctors actually believed many common negative stereotypes about black patients—e.g., that they were more likely to abuse drugs and alcohol, were less educated and even that they were less intelligent—regardless of the patient’s income, education or personality characteristics.
The IOM report suggests that care providers tend to latch on to racial stereotypes when they cannot come up with a logical explanation for a minority patient’s health problem. “If the provider has difficulty understanding the symptoms, then he/she will operate with prior beliefs about the likelihood of patients’ conditions,” the report states.
Understanding the Barriers
For critical care nurses, the first step in providing culturally sensitive care to patients of color, especially low-income and immigrant patients, is becoming thoroughly knowledgeable about how health disparities and cultural issues may have contributed to the patient’s critical condition. For example, consider the impact of factors such as:
• Lack of primary care physicians. The IOM report cites a study that found a huge gap in the ratio of physicians to population between wealthy and impoverished communities—respectively, one physician per 300 residents versus one physician per 10,000 or even 15,000 residents.
• Lack of health insurance. Currently, some 47 million Americans do not have health coverage. Latinos are the hardest hit: 25.8% of this population is uninsured.
• Language barriers. Patients who speak little or no English are less likely to understand their diagnosis, prescribed medications, discharge instructions and plans for follow-up care.
• Behavioral and cultural risk factors. These can include not seeking preventive or routine care, not keeping follow-up appointments, obesity and smoking.
Minority critical care nurses interviewed for this article agree that cultural attitudes are often to blame for some of the poor health conditions they see in patients of color once they arrive in the ICU.
“Many African Americans don’t like being in the hospital; they just can’t stand it,” says Kim Staten, RN, an ICU nurse at Saint Barnabas Medical Center in Livingston, N.J. Consequently, they may put off seeking care for a medical problem until it becomes a crisis. “The thinking goes: ‘If I can walk, talk, breathe and go to my job, there’s nothing wrong with me,’” Staten explains.
A variety of factors lie behind this reluctance to seek routine care, including lack of financial resources and lack of convenient access to affordable health care services. In addition, this attitude suggests a great deal of mistrust of the medical system. A recent survey by the Kaiser Family Foundation found that 65% of African Americans and 58% of Hispanics—compared to only 22% of whites—were afraid of being treated unfairly when accessing health care services.
Unfortunately, the longer these patients postpone getting routine care, the bigger their problems will be when they finally have to be brought to the ICU, says Melissa Douglas, BSN, RN, a critical care nurse who works in the medical ICU at Georgetown University Hospital in Washington, D.C. They will be much sicker and the costs of their care will be far higher, she notes. Recently an African American woman was admitted to Georgetown’s ICU with kidney failure because she didn’t have a car to get to the dialysis unit. “She could have gotten a ride,” Douglas says, “but she didn’t think it was a priority.”
Once the immediate symptoms go away, she continues, many black patients stop taking their medications and have to be readmitted to the ICU. Douglas says this is a particularly common problem with heart failure meds, because they are expensive and the patient may not understand the need for constant medication to control their condition.
Traditional cultural beliefs and misperceptions about health and illness can also create barriers to seeking care, particularly among older persons of color, and even some younger African Americans in parts of the rural South. When Joyce Walker, RN, an ICU nurse at Gottlieb Memorial Hospital in Melrose Park, Ill., visits relatives in Shaw, Miss., she hears many examples of folk beliefs that are also kept alive among older generations of black Americans in her Chicago suburb. For example, some older patients resist surgery for cancer because they believe it will spread the tumor, or because they believe that they can control the disease through faith or will power.
Meeting Families’ Needs
In addition to being particularly vigilant when caring for minority patients in the ICU, critical care nurses also need to be knowledgeable about the cultural needs of patients’ families, especially if the patient is at the end of life. For example, different cultures have different ways of making family decisions about the care of a relative who is critically ill. Nurses also need to be sensitive to traditional cultural beliefs and customs about death and dying, such as a family’s wish to perform prayers or rituals they believe will help guide the patient to a more peaceful death.
Cynthia L. Russell, PhD, RN, an ICU nurse at the University of Missouri-Columbia’s Sinclair School of Nursing, believes nurses should encourage family members to give support and comfort to the patient. Some hospitals, such as the Medical College of Virginia Hospital, have opened up some of their ICUs to families 24 hours a day, seven days a week, George-Gay adds. Family members may be asked to rub lotion onto the patient or pull a pneumatic stocking onto the patient’s foot.
“Patients’ families need to stay involved,” says Walker. “If the family doesn’t visit, the patient’s health deteriorates.”
Cultural attitudes can sometimes impede patient care, such as when a patient’s family refuses to approve a do-not-resuscitate (DNR) order or an amputation. “They’ll reject DNR and say, ‘We’re going to leave it in God’s hands,’” Staten says. “They want to do everything possible for the patient who is a frail old lady or little old man.” So she paints them a picture of what it would be like for their loved one. “I tell them it means pounding on his chest, which is going to give him a lot of pain,” she says.
There are many tools and resources available to help critical care nurses increase their knowledge of minority health and cultural competency issues. For example, the Culturally Competent Nursing Modules (CCNMs), developed with support from the Office of Minority Health, are a popular online continuing education course designed to help nurses understand issues related to cultural competency in nursing practice, become more self-aware about biases and beliefs that may influence the care they provide, and enhance their skills in providing care to patients from diverse cultures.
To learn more about this course, visit the Web site www.thinkculturalhealth.org.
In the growing sea of nursing specialties, critical care is actually one of the oldest. It was established in the 1950s and 1960s as the specialized care provided for the first intensive and cardiac care units. Seriously ill patients with complex health issues needed qualified nurses with unique skill sets. The same remains true today.
Critically ill patients who were once mostly cared for in ICUs can now be found throughout health care facilities, in emergency departments, post-anesthesia recovery units, interventional radiology, cardiac catheter labs, pediatric and neonatal intensive care units, burn units, progressive care units such as step-down and telemetry units, and even inpatient general care areas.
“The needs of the patients and their families determine whether they require a critical care nurse. It’s not based on the name of the unit or its location,” says Reynaldo Rivera, D.N.P., R.N., C.C.R.N., N.E.A.-B.C., A.N.P. Among his responsibilities as Director of Nursing in Medicine Services at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York, Rivera works with recent nursing graduates as they transition into their first professional role. “People are admitted into the hospital with more serious conditions and complex co-morbidities than patients in the past. The role of the critical care nurse continues to adapt to meet the challenges of a changing health care system,” he says.
More than half a million acute and critical care nurses comprise this specialty, which continues to grow. These nurses also teach, research, manage departments, and lead in the quest to create a health care system that is driven by the needs of patients and families.
A career in critical care has taken Cuban-born and U.S.-educated Maria Shirey, Ph.D., M.B.A., R.N., N.E.A.-B.C., F.A.C.H.E., from an internship program for new nurses at the Baptist Hospital of Miami to educator, manager, and executive positions in Florida, Texas, Louisiana, and Indiana. She is now an associate professor in the Doctor of Nursing Practice program at the University of Southern Indiana‘s College of Nursing and Health Professions in Evansville. “I have been a nurse for 33 years, and the skills gained at the bedside have been useful at every stage of my career,” she says. “Critical care nurses must make quick decisions constantly, and those decisions need to be based on evidence and data. You have someone’s life in your hands, and that’s not a responsibility to be taken lightly.”
Nurses may enter critical care immediately after licensure, or they transition into the specialty after gaining experience in other areas. Patients depend on these highly knowledgeable and skilled nurses to make accurate assessments, prioritize needs, and recognize the difference between an exception and a problem.
Linda Martinez, M.S.N., R.N., A.C.N.S.-B.C.-C.M.C., says critical care nurses begin with the basics, but soon realize textbook cases exist only in the classroom. A critical care nurse for 31 years, she works as a clinical nurse specialist for Presbyterian Heart Group at Presbyterian Hospital in Albuquerque, New Mexico. “First you learn the basics. Then, you learn the exceptions. As nurses gain experience, they start to individualize normal by putting into context what’s going on with each patient,” she says. “Assessment skills have to be very sharp in critical care. You have to be able to quickly assess a patient’s situation in case there’s a life-threatening change. You put everything you’ve learned into context.”
Rivera serves as president of the Philippine Nurses Association of America, where he advocates for diversity in the workforce, ethical recruitment practices, and professional development and standards. “Nurses in high acuity and critical care must have the competencies and requisite skills to do the job with an underlying sense of compassion and sensitivity. It’s the combination of all these attributes that inspire patients and their families to trust us,” Rivera says. “We practice as whole persons, using our hearts, the mind, and the hands. It’s also the soul of who we are.”
Shirey and Martinez have also become national leaders in nursing and critical care. Martinez serves on the national board of the American Association of Critical-Care Nurses (AACN), the world’s largest specialty nursing organization, representing the interests of more than 500,000 nurses who care for acutely and critically ill patients. Shirey chairs the AACN Certification Corporation, the association’s credentialing arm that certifies bedside and advanced practice nurses in high acuity and critical care. It also certifies nurse managers in a joint program with the American Organization of Nurse Executives.
Desire to learn
Shirey cites complex patient conditions, the fast pace, and pressure-packed environment as reasons why critical care nurses must commit to continuing professional development. “Things happen so quickly that you don’t have time to always research before acting. I either need to know it or know where to turn for help,” she says.
Shirey says she first joined AACN because of her desire to take better care of patients and their families. “I started studying the AACN core curriculum to hone my skills. I then joined AACN so I could receive the journals and earn my CCRN certification. All so I could be the best nurse for my patients.”
Armenian-born Anna Dermenchyan, B.S.N., B.S., R.N., C.C.R.N., agrees. She’s a clinical nurse in the cardiothoracic ICU at the Ronald Reagan UCLA Medical Center and an adjunct instructor at Mount St. Mary’s College, both in Los Angeles. “If we’re not learning, we’re not moving forward. Outdated skills affect patient care, especially with new medications and technology, changing policies, and procedures,” she says. “We have to be the best for our patients. We learn the most from them. Each case presents lessons for the next case.”
Ryan Cavada, R.N., a staff nurse at the UCLA Medical Center Santa Monica campus, says nurses in critical care need strong critical-thinking skills, the ability to work under pressure in a fast-paced environment, and a continual desire to learn. “Critical care is at the forefront of evidence-based nursing practice where we apply new medical research, adapt ever-changing procedures, and use the latest technology. Our patients can’t afford care that doesn’t meet this benchmark standard,” he says.
Advocate for the patient
Patient advocacy is a vital responsibility of critical care nurses, as acutely and critically ill patients often can’t express how they feel or what they need. “As a nurse, I am the main representative for my patients and their families,” Dermenchyan says. “Many times, patients can’t communicate for themselves, describe symptoms, or tell me something is wrong. I need to be on the lookout on their behalf and communicate their needs to the ICU team.”
Martinez adds, “Critical care nurses must hone their communication skills, because a lack of understanding or miscommunication can have life or death implications.” She recalls the night she realized the importance of good communication. “I was speaking with the intern on call about a patient in pain and it hit me that I am the voice of this patient. My role as a patient advocate became crystal clear. If I couldn’t communicate what was needed, that patient would suffer through the night.”
Working as a team
Critical care nurses collaborate with other nurses and health professionals with a single focus on caring for the patient. Filipino-American nurse Cavada points to critical care’s unique intimacy. “We really get to know our patients,” he said. “Nurses are more than an active part of a team. We become the team’s hub. Doctors, nutritionists, respiratory therapists, everyone involved in a patient’s care come to us for the most current information.” He says competent critical care nurses are concerned about their own patients and stand ready to assist their colleagues. “Good teamwork allows more to be done for the patient in less time. In critical care, that can make a big difference; time is of the essence.”
“When we get patients who are extremely sick, we all have to work together. It’s our patient, not my patient. We all want good outcomes,” Dermenchyan says. “Collaboration is key, or patients suffer.” Critical care nursing demands a healthy work environment and true collaboration, in which each professional’s knowledge and abilities are respected.
Collaboration in critical care also goes beyond health care professionals. “Family members are an important element to caring for the patient,” Shirey says. “Critical care nurses learn to integrate them into the care, keep them informed, and we know how to be sensitive to changes in the patient’s condition that might cause turmoil in the family.”
The willingness to work collaboratively toward a common goal has benefits beyond the bedside.
Nurses learn early on how to work well in teams,” Martinez says. “And teams are vital to improving the system of health care, not just in the delivery of care.”