Critical Care Nursing

My Specialty

Critical Care Nursing

Preparing for the unpredictability of acutely ill patients

By Elizabeth Hanink, RN, BSN, PHN
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Some days, it can be exciting and on the cutting edge. Other days, it can settle into a calm routine, but not often. Critical care nursing by its nature involves the care of patients who are acutely ill with multiple system challenges. Complex assessment and interventions prevail, and there is often the need to monitor and adjust very complicated equipment to changing conditions. The one thing that is predictable is, well, the unpredictability.

Add in the emotional needs of compromised patients and their families and a 12-hour shift seems very long. Still, some nurses thrive for years in this atmosphere, challenging themselves to maintain sharp, up-to-date skills as well as their own emotional equilibrium. In exchange for their demanding work, they receive kudos from their fellow nurses, increased pay and the elusive reward of satisfaction.

Do You Have What It Takes?    

Like many careers in nursing, the critical care option involves a great deal of self-selection. Do you perform well in a constantly changing atmosphere? Can you make judgments that are both quick and good? Do you want to be in circumstances where minutes and precision count and sometimes nothing helps? Can you rise to the occasion more often than not and respond to patients and families whose lives now include the major stress of a heart attack, car accident or transplant? If your answer is yes, maybe critical care is for you.
New Grad Immersion

Although the American Association of Critical-Care Nurses (AACN) and the American Nurses Association grant certification to those who seek it, their recognition is not necessary, and many nurses learn right on the job. Usually telemetry training and advanced cardiac life support (ACLS) are prerequisites, but some hospitals will allow a new hire to acquire these skills during orientation. Experience is definitely something many hospitals like to see before hiring a critical care nurse. After all, it takes time to polish basic skills and get comfortable in the role of “nurse” — and to stop visualizing someone to rescue you.

“It is not experience in nursing, in and of itself, that prepares” the new ICU nurse, says Ramon Lavandero, RN, MSN and AACN’s director of communications. What really counts is the type of support, mentoring and clinical learning that hospitals provide, often based on standardized curricula established by AACN or Versant and using multiple modalities provided by companies like Medical Education Technologies.

Other hospitals welcome new graduates and maintain specific programs for them. Dianna Sepulveda, RN, BSN, from Long Beach Memorial Medical Center, explained that her institution has an innovative program in conjunction with Cal State Long Beach and Long Beach City College. The hospital provides tuition support, books and the opportunity to work in the ICU while receiving school credit. Participants spend 160-180 hours during the semester in computer-based learning, skills practice and case studies. They receive mentoring from experienced staff nurses, often earlier graduates from their own school. In exchange, students commit to two years of employment with the hospital. This arrangement is ideal for nurses who want to start in critical care and who have shown they will succeed.
For the Experienced Nurse

Many hospitals, including Long Beach, offer similar programs to experienced RNs who want to transition to high-acuity nursing.

Marilou Fregil-Cunanan, nurse, critical careMarilou Fregil-Cunanan, RN, BSN, received that initiation 30 years ago when she entered the specialty. More intensive than regular orientation and lasting about 16 weeks, these programs offer nurses a chance to learn before counting as a regular staff member, which is very important preparation for this specialty. The ICU is a 31-bed unit that accepts medical, surgical, respiratory, trauma and neurological cases. Every nurse must be ready to work with a wide spectrum of patients, including being able to assist in the ER with trauma care.

“You have to be on top of everything all the time,” Ms. Cunanan points out. “You need quick reactions, quick thinking, and the basic nursing education has to be very strong. It is a challenge always to face that situation where quick reaction could matter to a patient’s life.”

So what attracts her to critical care? After reviewing the traits a nurse needs in such a high-intensity environment, she explains, “I see these very ill, very sick patients that require high training and competence… When you see them come back after they have been through all these hard times, and they come back walking and talking after we were all thinking, ‘Is this guy going to make it?’ you know you have contributed some to that.”

Alma De Belen, RN, CCRN, also started out with a critical care orientation. While her employer, White Memorial Medical Center, does not offer a complete critical care course to nurses starting in the specialty, it does support prep classes for anyone interested in certification through AACN. Most new hires already have ICU experience. New grads in their Versant program rotate to the ICU where they care for patients under preceptors and encounter the wide variety of cases that the 19-bed unit houses: med-surg, cardiac (including open heart), and even some maternity and behavioral patients with medical problems. “You need to be well-versed in every system here,” Ms. De Belen says.

A feature of her job, one she finds very satisfying, is her placement on the Rapid Response Team. Along with a respiratory therapist, she responds to any nursing unit that has a patient who is becoming unstable. She makes a rapid but thorough assessment and then institutes interventions and contact with the physician. This system, sort of a pre-Code response, allows for prompt care without the need to wait for a physician to respond or until the patient is in full-blown arrest.

And what is hardest about being an ICU nurse? “If I have a patient that I know I did my very best for, but they don’t make it… You go home feeling very tired, not physically but mentally,” she said. “Sometimes it really breaks my heart.”

Ms. De Belen’s feeling capture an increasing dilemma that faces many critical care nurses, according to Mr. Lavandero. And that is, “how to provide critical care in the context of end-of-life care.”

Getting Certified

Formal recognition as a certified critical care registered nurse (CCRN) comes through the American Association of Critical Care Nurses. The preparation is rigorous, as are the renewal requirements.

A candidate must first work at least 1,750 hours in the previous two years in qualified patient care; then there follows a 150-question test, including both clinical judgment and nursing ethics; and you may need to provide a reference. Fees range from $220 for AACN members to $325 for nonmembers, with different options leading to recertification.

All include a substantial amount of continuing education and working at least 432 hours within the previous three-year period in direct bedside care of critically ill patients. One path also includes retaking the CCRN exam. Renewal fees also need consideration since many hospitals do not pay a differential for this achievement.

The AACN offers separate certification for clinical nurse specialists and nurse practitioners, and it increasingly recognizes that acutely ill patients are not just lying on beds in the ICU; they can also dwell in the ER and in step-down or transitional units, telemetry floors…all over the hospital, really. Nurses who work in these areas can qualify for progressive critical care nurse designation (PCCN), which acknowledges the acuity of the patient rather than their geographic location. It can even include home health nurses.

California leads the nation in CCRNs — 5,521 at last count — with a healthy number of progressive care nurses as well. Ideally, AACN would like to see a 65 percent ratio of certified nurses to reflect, as their test does, the critical nature of the care given.

If you think this specialty is for you, start your action plan. Look for a hospital that offers a comprehensive course or start gathering skills on your own. Most hospitals offer at least telemetry instruction. ACLS is a little different and can be expensive; you might have to wait until you start working at a site. If certification is a goal, study on your own. The AACN offers books and courses that you can use independently.

Knowing that your nursing skills were instrumental in saving a patient’s life is deeply satisfying. Even if the patient does not survive, knowing that they received the best that nursing has to offer can be a wonderful consolation.   


For More Information About This Specialty:


American Association of Critical Care Nurses:
CCRN (includes neonatal). CCNS, PCCN (progressive), ACNPC, CMC (medical cardiac), CSC (surgical cardiac)

American Nurses Credentialing Center:
Acute care nurse practitioner

Critical Care Advanced Practice Sources

Acute care, CNS and NP, and dual

University of California, San Francisco
Acute and critical care, CNS and NP

San Francisco State
Critical care, CNS

San Diego State
Acute and critical care, CNS and NP

Elizabeth Hanink RN, BSN, PHN, is a freelance writer with extensive hospital and community-based nursing experience.

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