Hospital nurses are increasingly faced with caring for highly complex acute patients with quickly changing healthcare needs.
Nurses’ ability to provide quality care often depends on not only their critical care experience but also what they know about current evidence-based and best practices, according to Mary Ann Christie, ACNP, MSN, an acute care nurse practitioner at UF Health Shands Hospital in Gainesville, Fla.
In fact, the majority of hospital beds today are critical care beds, said Christie, who is certified in critical care and progressive care and is a speaker for the our Critical Care Review course, which prepares nurses for critical care and progressive care (CCRN and PCCN) certification exams.
“The American Association of Critical-Care Nurses defines critical care on a continuum from acutely ill to critically ill, which includes patients found in ICUs, EDs, progressive care areas, step down, and remote telemetry,” Christie said. “All are taking care of such sick adults.”
Adult patients admitted to progressive care today were admitted to the ICU at most hospitals just a few years ago.
“They’re acutely ill,” she said. “They need very specialized nurses who are specially trained, not just in telemetry, but in identifying critical illnesses and acute changes in patients.”
Critical care nursing is an exciting opportunity, along with a huge responsibility.
“There’s a lot of knowledge base that needs to be undertaken, and that’s why certification is such a great idea,” said Christie, who became CCRN-certified in 1972.
The CCRN and PCCN exams are well-validated, comprehensive, and difficult exams. For nurses who work only in coronary care, the neurological part of the CCRN exam might be daunting, for example. Even nurses who have the comprehensive experience have to be up to date on evidence-based and best practices, according to Christie.
What’s new? Pretty much everything
Christie has practiced nursing for 48 years and remains at the bedside today as an NP. But Christie said her experience alone isn’t enough to help her pass the critical care certification exam.
“Nurses who have the most experience don’t always do the best on the test,” she said. Sometimes, that’s because the nurses have learned how to do things but not the physiology behind why they do things that way. Or maybe nurses with a lot of experience only have worked at one hospital and haven’t been exposed to many current practice changes, according to Christie.
Everything in nursing has changed, said Christie, including the way nurses look at blood pressures or do invasive or noninvasive monitoring.
“For example, when I was taking the exam, when somebody came in and had a [myocardial infarction], they were admitted to the hospital for seven days in the ICU,” she said. “No hot, no cold, no back rubs, you didn’t get them out of bed, and you monitored them.”
In 1972, patients didn’t go to the catheterization laboratory for six weeks.
“Oh my goodness, look now,” she said. “People come in with a STEMI (ST-elevation myocardial infarction) and don’t even come to the ICU. They go right to the cath lab, they get a stent, they go to step down and go home.”
Her recommendation to the more mature nurse is to take a review course. “You do not know everything there is to know about critical care unless you’ve kept up to date,” Christie said.
Newer nurses who have been in practice for five years or less have recently learned evidence-based and best practices, which gives them an advantage in critical care despite the lack of experience, according to Christie.
“They have a much better base in research than if you graduated in the ’70s, ’80s or even the ’90s,” she said. “And they’ve just taken the NCLEX and are used to taking an exam on the computer.”
Newer nurses are in an ideal position to take the certification exam once they’ve gained a couple of years of experience.
“We really think that in critical care it takes two years to get the big picture,” Christie said.
When certification is critical
The CCRN exam tackles critical care for all body systems. Examples include acute STEMI, acute pneumonia and acute ventilator changes. Critical care isn’t the patient who comes in with a chronic obstructive pulmonary disease exacerbation who is hemodynamically stable, Christie said.
The PCCN exam is for nurses who care for patients on the acutely ill end of the critical care continuum, in progressive care areas such as telemetry, step-down, intermediate care, transitional care and EDs.
Today’s critical care nurse might encounter a scenario such as a male patient who is admitted with severe acute pancreatitis, has blood sugars in the 1,000 range, becomes very hemodynamically unstable, has to be intubated and volume resuscitated.
So, he comes to the ICU on a ventilator and goes into acute respiratory distress syndrome. He has a hyperglycemic crisis, respiratory failure and even with fluid resuscitation, gets acute kidney injury.
Nurses have to pick up the changes right away, not only with labs, but by urine output, blood pressure and looking at drugs the patient is getting, according to Christie.
Then, the 70-year-old male has a stroke. He’s on a ventilator and might have had sedation on the vent, she said.
The nurse has to be able to pick up that stroke by the change of mental status, Christie said. In today’s algorithm for critical care, nurses must do some quick assessments and call for a stroke alert, she said.
“Before that stroke alert team gets there, that nurse is responsible for checking the oxygenation, glucose, electrolytes, [and consider] could this patient be septic?” she said. ““We’d expect nurses at the bedside to begin the differential, begin the identification,” she said.
Certification could soon be required
While critical care and other certifications aren’t mandatory at most hospitals and facilities now, they could become mandatory in the near future.
“Many hospitals are going toward certain criteria for their nurses,” Christie said. “One is that they have to have a BSN. It’s also becoming standard that once you’ve worked in a hospital’s intensive care, progressive care or step-down unit for two years, you should be certified. Right now, that’s not mandatory.”
Take these courses to learn more about critical care:
Critical Care Review (CCRN®/PCCN®)
(10 contact hrs)
Critical care and progressive care nurses require specialized knowledge on several fronts, including cardiovascular, endocrinology, pulmonary and renal care in the ICU and PCU. This specialized course will help prepare you for the national certification examination.
Alarm Fatigue Can Endanger Patients
(1 contact hr)
Over time, hospital clinicians become used to hearing an extensive number of alarms and tend to become desensitized to them, which leads to a lack of or delay in response. This module provides nurses with information about the safety concerns associated with alarm fatigue and evidence-based strategies to reduce it.
Rapid Response Teams Can Rescue Patients from Inhospital Cardiac Arrest
(1 contact hr)
RRTs reported in the literature have comprised various combinations of team members. This module details the history of the RRT movement, the evidence supporting the use of RRTs, and recent studies that have challenged the efficacy of RRTs.