Critical Need

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An unprecedented shortage of nurses with specialized critical care skills and experience is opening up a wealth of rewarding new opportunities for minority nurses

By Pam Chwedyk

Do you enjoy working one on one with extremely sick patients? Can you cope with a hectic, fast-paced environment where there’s always another crisis around the corner? Do you have top-notch observation, assessment and critical thinking skills—an almost intuitive ability to quickly sense what’s wrong with a patient and immediately take the right corrective action? If so, the critical care nursing profession needs you—urgently.

Since the mid 1990s, this nursing specialty that focuses on the care of patients in crisis has been experiencing a Code Blue emergency of its own. Within today’s much-publicized nursing shortage, critical care is the one area where the need is most acute. Across the country, hospital intensive care units (ICUs), telemetry/step-down units, emergency rooms, operating rooms, post-operative units, burn and trauma units—and even nursing homes and home-care programs—are all scrambling to recruit enough nurses with the specialized skills to meet the needs of an ever-growing influx of critically ill patients who are far sicker than their counterparts of a decade ago.

The greatest need is in the most technologically complex and highly specialized areas, such as cardiovascular ICUs, open heart recovery units, pediatric and neonatal critical care units (PICUs and NICUs), and cardiac cath labs. In response, hospitals are increasingly employing creative strategies to recruit more critical care nurses—from offering hefty sign-on bonuses to reviving long-dormant in-house training programs.

AACN According to the American Association of Critical-Care Nurses (AACN), what started as a scattered regional shortage has become a widespread phenomenon. The association reports that the number of requests for temporary and traveling critical care nurses to fill staffing gaps has skyrocketed in every part of the United States over the past year—including increases of 45% for adult critical care units, 50% for PICUs/NICUs, and 140% for ERs.

The only good thing about the shortfall is that it is creating unprecedented opportunities for minority nurses to enter one of the most fulfilling career specialties in health care and make an important contribution toward meeting this critical staffing need. Critical care nursing is a field that offers exceptional rewards—not just an abundance of readily available jobs but also the special satisfaction of helping the most seriously ill patients in the entire medical system recover from life-or-death crises.

Is Critical Care Nursing Right for You?

Experts blame the critical care nursing shortage on a variety of factors, including the impact of managed care, the expansion of acute care beyond traditional ICU settings, and an apparent failure to cultivate enough highly skilled new specialists to replace today’s aging critical care nurse population, whose ranks are rapidly thinning due to retirement. “The problem isn’t that there aren’t enough nurses out there,” explains Justine Medina, R.N., M.S., clinical practice specialist for the AACN. “This is a specialty nursing shortage—a lack of nurses with the specific critical care experience and expertise to transition into these specialized roles.”

But having the requisite education and experience may not be enough to ensure a successful career in this specialty. Critical care nursing also requires a special type of personality. Be warned: This field is not for everybody.

“Even though nurse-to-patient ratios in ICUs are much lower than in regular Med/Surg units, those patients are really, really sick,” says Franklin Shaffer, R.N., Ed.D., a former critical care nurse who is now vice president of education and professional development for traveling nurse agency Cross Country Staffing of Boca Raton, Fla. “Often they have multiple system failures and they have a tube in every orifice, plus some type of apparatus monitoring all their vital signs. So you’re not just taking care of the patient, you’re also taking care of all this sophisticated equipment. It’s a high-tech, high-stress area where you’re constantly bombarded with changes in the patient’s condition and all the parameters can shift very rapidly.”

Because one-to-one ratios, and even two-nurses-to-one-patient ratios, are not uncommon in ICUs, critical care nurses are constantly busy at their patients’ bedsides and are under never-ending pressure.

“You’re just moving, moving, moving and you’ve got no time to think, no time to look things up—you just have to know,” says Kay Jelton, R.N., nursing resources director for Sutter Roseville Medical Center in the Sacramento, Calif. area, which had to temporarily convert one of its two ICUs into a step-down unit in 1997 because of a nursing staff shortage. “You have to have very strong assessment skills, know when something’s wrong with the patient or the equipment and troubleshoot it immediately—and enjoy that.

“It’s a very intense environment,” she continues. “You have to be comfortable with conflict and able to accept constantly changing priorities. There are some nurses who just aren’t going to be comfortable with this, ever. But there are other nurses who rally with that and love that environment.”

One minority nurse who thrives in this challenging atmosphere is Mona Steele, R.N. “On a regular nursing floor, where you may have five to seven patients during an eight-hour shift, there isn’t enough time to get closely involved with your patient,” says Steele, a traveling critical care nurse for Cross Country Staffing who specializes in open heart ICUs. “In critical care, you get to concentrate totally on the whole patient in a holistic healing process. I like that closeness—I’m a real patient-care person. And there’s always something new every day. It’s a fast pace, but you learn so much. It really challenges your curiosity.”

Reynaldo Rivera, CCRN, CNAA, director of critical care nursing for New York City’s Brooklyn Hospital, also feels strongly that the positive aspects of this career far outweigh the downside. “Even though it’s stressful, critical care nursing is rewarding, because you save lives every day,” he maintains. “When people ask me what I do for a living, I tell them, ‘I save lives.’”

Culturally Competent Critical Care

Because their specialty involves caring for exceptionally sick people, some of whom may be dying, critical care nurses must also be adept at caring for the emotional needs of patients’ families and be able to handle end-of-life issues sensitively. It is here that minority nurses can ultimately make their most significant contribution to critical care practice.

“A minority nurse caring for a critically ill minority patient is so much more attuned to the patient’s needs than someone who has never experienced that culture,” Shaffer believes. “For example, their special knowledge of the culture’s values and belief systems can help them guide a dying patient toward a more peaceful death. Then there are the culturally diverse dietary and nutritional issues, which are important when you’re caring for patients holistically.”

The AACN’s Medina agrees that when patients are this seriously ill, the need for culturally competent care becomes more important than ever. “In critical care, the specific needs of the individual patient must drive the practice,” she says. “If you have a minority patient with unique cultural needs, the nurse should be competent to recognize and discuss those needs. From my own experience as a Hispanic nurse, I think minority and ethnic nurses who have very strong ties with their communities can really help educate other members of the critical care team who don’t have that unique perspective.”

Experience Preferred—But Not Necessary

While minorities are estimated to currently make up only about 10% of the critical care nurse population (see Who are Today’s Critical Care Nurses?), the crucial need for more of these specialists is opening the door for nurses of diverse races and backgrounds to make inroads into the field. In fact, there’s never been a better time for new or career-changing minority nurses to get into critical care.

Traditionally, most hospitals have preferred to hire nurses with prior critical care experience—a Catch-22 that often made it difficult for newcomers to land their first jobs. But today, many facilities are so eager to fill critical care staffing shortages that they are welcoming promising new graduates and helping them acquire the necessary expertise by providing internships, externships and other training programs.

Sutter Roseville, for example, now offers an intensive training regimen for its critical care new hires. Says Jelton, “Although we do prefer some sort of relevant background so that they know what they’re getting into and that they really like this type of nursing, we will train nurses with no critical care experience. We put them through a three-day basic cardiac monitoring course, where they learn how to read the rhythm strips, how to intervene, and how to work with pacemakers.

“Then they go into a six-week full-time critical care training program, plus a three- or four-month orientation. This training is individualized, based on the needs of each nurse—some people progress very quickly while others need more time.”

At other facilities, such as Brooklyn Hospital, where budget cuts have severely limited training resources, newcomers who can show a strong proactive commitment to acquiring critical care skills on their own have a definite edge.

“When I interview a new grad, I want people who show they have initiative—people who have already taken some classes in basic cardiac life support, advanced cardiac life support, IV and EKG,” says Rivera. “I also look for people with good technology skills, because everything in critical care is going to computerization. Being proactive means knowing what skills are necessary.”

He points out, however, that the experience-vs.-training debate remains controversial. “My feeling is that you can’t just put a new person into the ICU right away—you need to start them in a step-down unit first. It takes a while to develop the critical thinking skills that are necessary in acute care. You can’t convert a Med/Surg nurse to an ICU nurse with just an orientation.”

Still, the more critical care education and knowledge an inexperienced candidate can bring to the table in advance, the better. “If a person is still in nursing school, they should take advantage of any opportunities they can to learn about critical care and acquire those skills,” emphasizes Dr. Laura Kimble, coordinator of the critical care graduate-level nursing program at Emory University in Atlanta. “For example, Emory has a critical care elective that our students take between their junior and senior year. They get to work in actual critical care settings, and it has been an excellent way of helping our new graduates transition into positions in the field.”

In addition to the specialized classes mentioned above, Kimble also advises potential critical care nurses to take courses on physiology and pathophysiology. “This is important because you have to really understand the rationale for your decisions and why you’re doing the type of interventions you’re doing,” she explains. “Areas like hemodynamics, hemodynamic modeling and mechanical ventilation would also be good technical things to learn.”

Critical Resources

From continuing education programs and professional certifications to mentorships and networking, other resources to help nurses develop themselves into specialized critical care experts abound (see Resources).

“Many cities, particularly the larger ones, have critical care consortiums and local AACN chapters,” Kimble says. “Both students and current nurses who want to move into the field could be involved in that chapter and take continuing education courses. So when they go to apply for their first job, they can demonstrate their interest in critical care and their knowledge of the current issues.”

Melody Hopkins, R.N., a burn unit critical care nurse at Parkland Health and Hospital Systems in Dallas, recommends reading critical care journals to keep up with the latest technological issues and best practices. “There are some good specialized magazines that focus on critical care, just like ER nursing has its own journals.”

Networking with experienced critical care nurses and learning from their expertise is something Medina can’t recommend highly enough. “AACN doesn’t have a specific mentoring program, but some of our chapters do,” she notes. “There are lots of ways to communicate with other nurses—discussion databases, listservs. Even practicing critical care nurses are looking for ways to help new people enter the field—so they can retire.”

She also offers some insider’s advice of her own: “If you’re sure this is what you want to do, then go after it—because the opportunities will be everywhere. Critical care nursing comes in every flavor imaginable—neuro, renal, trauma, transplant, etc. If the jobs are not happening at one particular hospital, just open up a newspaper and you’ll see hundreds of jobs. The shortage is not going to go away and experienced people are hard to find.”

Pam Chwedyk is editor of Minority Nurse. E-mail her at pam.chwedyk@casscom.com.