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Leslie Hampton, RN, nurse manager (right), and Addie Lewis, RN, examine an EKG printout in the progressive care unit at University of Washington Medical Center in Seattle.

They’re neither med/surg nor ICU/CCU nurses. Like the misperceived middle children, progressive care nurses often feel like they're in a no-man's land. They bristle at the buzz--that they work in patient holding areas and provide lesser care.

So who are these progressive care nurses? What is their unique contribution to patient care?

Maggie White, RN, BSN, remembers 1982 as the year that surgeons at Methodist Dallas Medical Center requested a separate area staffed with skilled surgical nurses to monitor patients with cardiac arrhythmias. She and another nurse, Peggy Miller, “recruited nurses from wherever we could, educated them, and got the group up to speed,’’ White says. So began the hospital's surgical telemetry unit, where White is nurse manager.

‘’The way our unit developed parallels the birth of progressive care units (PCUs) and nursing in the early ‘70s across the country,’’ she says.

With critical care beds at a premium, step-down units embraced patients as they migrated outside the traditional walls of the ICU. ‘’Patients’ need for a new level of care pushed open progressive care doors,’’ says Juan (Ray) Quintero, RN, CCRN, a staff nurse in the neuroscience unit at the VCU Medical Center in Richmond, Va. ‘’Today, any new ICU is almost never considered without a PCU,’’ he says.

Today’s venue

Typically, hospital organizational charts place progressive care with medical/surgical nursing, but the care environment is different, says Karen Harvey, RN, MSN, a certification specialist with the AACN Certification Corp. in Aliso Viejo, Calif.

Progressive care units can be extremely specialized, with patient care focused on a specific system, such as cardiac, or broader based, such as in a medical intermediate care unit. ‘’A high turnover of patients and a faster pace than med/surg are the facts of life in PCUs,’’ says Kathleen Dooney, RN, MSN, director of nursing education at Winthrop-University Hospital in Minneola, N.Y.

Some potential PCU patients include those with low-probability MI, hemodynamically stable MI, dysrhythmia or pacemaker, mild to moderate heart failure, and hypertensive urgency with no evidence of end organ damage.¹ ‘’In our telemetry unit, we care for cardiac patients, some with comorbidities, who can be up and about connected to monitors,’’ Dooney says. ‘’These patients can participate in their care more than those in ICU.’’

PCU care is more high tech and includes treatments that require more intense care and monitoring than those on med/surg units. ‘’What makes the difference in our telemetry patients is their need for high-frequency monitoring for cardiac changes and interventions often the result of medications not administered on medical/surgical floors,’’ says Leslie Hampton, RN, BSN, nurse manager on the telemetry unit at the University of Washington Medical Center in Seattle.

PCU nurses perform vital signs, blood gases, and patient assessments more frequently than on med/surg floors but less often than in the ICU, a reflection of the patient's condition, says Diane Salipante, APRN, MS, CCRN, nurse practitioner, Pulmonary Critical Care (on the pulmonary critical care unit at), University of Rochester (N.Y.)-Strong Memorial Hospital.

‘’Though PCU patients are stable, they are also acutely and critically ill and at risk for rapid status change,’’ Salipante says. ‘’Patients have one foot in progressive care and one foot in critical care. There’s a revolving door for patients whose degree of need for vigilance escalates from intermittent to continuous.’’

Defining parameters

Four years ago, the American Association of Critical-Care Nurses created the Progressive Care Task Force to discuss the impact of this expanding patient care management component. ‘’We agreed to set the direction of progressive care and its vision to give progressive care nurses a sense of who they are and the required skills they use when caring for high-acuity patients outside ICUs,’’ says Quintero, an AACN task force member.

Today, the AACN recognizes progressive care as part of the continuum of critical care. According to the AACN-developed Synergy Model, a framework for practice, patient needs drive nurse competencies, and when characteristics and competencies synergize, outcomes for the patient, the nurse, and the system are optimal.² Progressive care nurses practice the same standard of nursing as critical care nurses and require the same level of education as nurses who work in the ICU, except with respect to invasive technologies.