Stepdown or PACU for pre-ACNP school experience

[NurseNelly24, BSN]

Hello all,

So I've been a nurse for about 5 years, worked in ER, Tele, Ambulatory PACU, etc. I'm in the middle of interviewing for per-diem positions (in addition to my part-time job in the ER) and I want to choose the best specialty that will prepare me for Acute Care NP school. I'm inspired to be an ACNP specifically as a Hospitalist or in a specialty group (Ortho, GI, Cardiac Surg, etc.)

The three interviews were 2 for an inpatient PACU position, and other one a Stepdown position.

The Stepdown unit is basically tele portion with a PCU portion; get trachs, vents, central lines, gtts, etc; Stepdown section patient-nurse ratio 1:4-5, and 1:3 in PCU.

As for the PACU positions are both inpatient, with potential for ICU overflow, and apart from Open Heart Surgery patients, every other post-op patient comes there.

I know most of you will say go to the ICU, but my current ER job pays me very very well (higher than the state average) and I'd be taking a pay-cut if I go to the ICU part-time, and I wouldn't even think about working work ICU per-diem.

I've already looked into a few ACNP programs where they state acute care/critical care experience is required and while I already have acute care experience with working in the ER, I would like to see more critical cases that I may not always see in the ER.

If you were to choose do you think Stepdown experience or PACU? I'm torn because while I know you see a lot of critical cases in the PACU, you are more likely to see a continuum of care in the Stepdown.

Any tips would be helpful, thanks for the input!

[Corey Narry, MSN, RN, NP]

Well, just based on the hospital where I work, I have a bias against PACU because although that area is considered "critical care", I feel like a lot of critical care really happens in the ICU.

PACU nurses are good at managing post-anesthesia complications or recovery, if you will, in patients who are slated to transfer to non-ICU settings after surgery They are good at monitoring airway, managing pain, and post-op nausea. They may titrate a vasopressor or see a freshly extubated patient who is still quite drowsy but these are consequences of the patient's anesthesia rather than a true multi-organ dysfunction that is managed in the ICU.

Step down, to me, will offer you a more well rounded idea of how non-ICU patient's are managed on a day to day basis. You may actually interact with Hospitalists in this setting and have a better sense of their thought process in managing their patients. It might be tough though since you're only going to pick up Per Diem hours. It is also a busier unit and depending on where you work, some step-down patients in certain hospitals are considered ICU patients in another.

[NurseNelly24, BSN]

On 12/13/2019 at 1:45 PM, juan de la cruz said:

PACU nurses are good at managing post-anesthesia complications or recovery, if you will, in patients who are slated to transfer to non-ICU settings after surgery They are good at monitoring airway, managing pain, and post-op nausea. They may titrate a vasopressor or see a freshly extubated patient who is still quite drowsy but these are consequences of the patient's anesthesia rather than a true multi-organ dysfunction that is managed in the ICU.

Thank you for this perspective! I really never thought of it like that regarding taking care of critical patients that are waking up from anesthesia v multiorgan dysfunction.

I’m pretty confident in working with critical patients from working ER trauma, so i hope that will help with working stepdown on a per diem basis. Since we would often get overnight icu/stepdown holds. But as you said it will be a more well rounded experience when I’m working on the unit; and i also I intend to pick up extra at least 1-2x a week just to not feel like I’m starting anew every shift lol thanks again!

[ghillbert, MSN, NP]

Having done ACNP, I would not consider it without ICU experience.

[NurseNelly24, BSN]

I can see myself pursuing an ICU job at some while I’m in the program, but I also personally don’t have much of a desire to work in an ICU setting as an NP. Being a Hospitalist in IM is end goal.

The programs I’ve looked into so far consider ER/ICU Experience for the program.

And on top of that I work in a level 1 trauma in an inner city area, so on a typical shift I end up taking care of at least 1 CICU, MICU, SICU, or CTICU patient in the ER. It’s just the continuum of care I haven’t been exposed to.

[ghillbert, MSN, NP]

Just answering your question as someone who has completed the program. I would not consider either stepdown or PACU as adequate experience, which I thought is what you were asking.

[NurseNelly24, BSN]

1 hour ago, ghillbert said:

Just answering your question as someone who has completed the program. I would not consider either stepdown or PACU as adequate experience, which I thought is what you were asking.

I appreciate your answer, so i don’t want you to take offense.

It’s just that right now it wouldn’t be possible for me to do ICU full time because my current position pays more and paying my way through school is going to be essential; Plus I would never do ICU per diem.

So if there are part time ICU positions available i can consider, but in my area most of the positions are full time it per diem which is why i was considering stepdown and pacu. But since you’re saying neither would be sufficient I’ll look into other options.