Finding your niche in nursing can come naturally or may take years.
You may even find that regular changes among today’s nearly 100 nursing specialty areas suit you best to decrease burnout.
If you are considering the step-down unit versus the ICU, read on for expert advice, tips, and encouragement.
What Is a Step-Down Unit?
Defining a step-down unit can actually be quite difficult because numerous hospitals treat these units differently
Different hospitals will allow different levels of patient acuity on the floor and call these units a variety of names.
For example, you may hear a step-down unit referred to as cardiac progressive care, the telemetry unit or intermediate care unit among others.
However, the similarity among all of them is that they cater to patients who are not quite sick enough to be in the intensive care unit (ICU) but who are not well enough to be on a general medical-surgical floor.
In fact, studies have shown that certain high-risk patients experience better outcomes from transferring from the ICU to the step-down unit rather than directly to the floor.
Patients in these units may still be on intravenous drips, ventilators, cardiac monitoring and frequent assessments, but they do not require as much close observation as ICU patients do.
In addition, settings on their ventilators and medication drips do not have to be titrated so frequently.
Patients may be admitted to this floor from surgery or the emergency room, and they may even be discharged from a step-down unit if they recover quickly.
However, numerous patients progress through the step-down unit on the way to or from a medical-surgical or ICU floor.
What Is an Intensive Care Unit?
A hospital’s intensive care unit provides the most critical level of care available to patients.
Even small hospitals tend to have an ICU area with at least a couple beds although these units must typically transfer their sickest patients to larger hospitals with more ICU experience and resources.
On the other hand, the largest metropolitan hospitals have multiple intensive care units catering to a wide variety of patient needs. Some of the top examples include the following:
- Medical ICU
- Surgical ICU
- Trauma Unit
- Burn Unit
- Cardiac ICU
- Neonatal ICU
- Pediatric ICU
- Long-term ICU
Related: Medical ICU vs Surgical ICU
Patients in any type of ICU need more specialized care than do those on a step-down unit.
Therefore, the nurse-to-patient ratio is lower.
Patients may also be admitted to the ICU from the emergency room or operating room or may be placed in ICU after their health deteriorates on a regular medical floor or step-down unit.
Typical Job Duties in Each Unit
Many job duties for nurses working on step-down units are similar to those necessary for ICU nurses to accomplish each shift.
The primary difference between the two lies in the acuity of patients typically seen on each unit.
Step-Down Unit Job Duties
As with all nurses, step-down unit nurses provide acute care to sick or injured patients.
This includes monitoring vital signs and other aspects of patient symptoms, communicating with doctors and other members of the health care team, creating nursing care plans, educating patients and family members and implementing doctors’ orders.
Depending on the hospital, these nurses may also be required to work with some of the following:
- Ventilators
- Trach tubes
- Intravenous Drips
- CPAP
- Telemetry
- EKG Machines
- Sedation
- Chest tubes
ICU Job Duties
An ICU nurse’s job duties are similar in many ways to the step-down unit nurse as they care for the sickest patients in the hospital, but they are generally required to work with more medical machinery and intravenous drips.
In addition, while drips and ventilator settings typically remain close to constant on the step-down unit, they are frequently titrated in the ICU.
Many patients are sedated, and nurses are required to regularly check neurological status while also providing continuous bedside monitoring of blood pressure, oxygen saturation, temperature and other vital signs.
Many specific types of diagnostic and treatment equipment are used only in the ICU and are not allowed on any other units in the hospital. These include the following among others.
- Arterial lines
- Swan-Ganz catheters
- Intracranial pressure monitors
- Ventricular assist devices
- Intra-aortic balloon pumps
Nurses will also remain in much closer contact with doctors and the patients’ family members about changes in each patient’s condition.
These nurses must be ready for the unexpected at all times and are required to have Advanced Cardiopulmonary Life Support (ACLS) certification.
Unlike the step-down unit, patients are rarely if ever discharged home directly from the ICU.
Typical Salary for Nurses in Each Unit
In the ICU, all nurses must be registered nurses. However, some health care organizations allow LPNs to work under RNs in step-down units.
In these cases, the LPN will make less than the RN by virtue of his or her training.
On the step-down unit, the national average annual salary for the RN is $120,065, with an hourly wage of $58.
Only 25% of step-down unit registered nurse jobs in the United States fall lower than $76,000 per year. New York, Idaho, and California pay the highest amounts on average.
In the ICU as a whole, the average registered nurse makes a $121,963 salary per year, which equates to an hourly wage of $59. Only 25% of ICU nurses in the United States make less than $80,000 per year.
Typical Work Flow for Nurses in Each Unit
Both step-down units and ICUs are busy floors where nurses will rarely find themselves sitting at the nurses’ station with nothing to do.
However, the reason for each unit’s busyness differs based on nurse-to-patient ratio and patient acuity.
Step-Down Unit Workflow
In the step-down unit, nurses will find that they are kept busy throughout their shifts.
Most well-staffed step-down units assign three to four patients to each nurse although understaffed units may make this number higher, especially during night shifts.
Depending on the unit, shifts may last 8 or 12 hours.
While the patient acuity on the step-down unit is lower than what you would find in the ICU, most nurses share that they feel just as busy because they have a larger patient load.
In addition, the majority of patients here are able to talk, and many are able to get out of bed and walk.
This actually creates more work for the step-down nurse when compared to the ICU nurse whose patients are often sedated, on ventilators or unable to get out of bed.
Patients here will need assessments completed and vital signs checked at least every eight hours. Some may require every four hour assessments or hourly vital signs.
Nurses will also spend time passing oral medications, providing intravenous medications, connecting with other members of the health care team, checking telemetry units for heart rhythms, and documenting what happened during their shift for each patient.
ICU Workflow
The ICU is equally busy even though nurses here only have one to two patients.
The number of patients assigned to each nurse depends on the type of monitoring and the amount of intravenous medication titration the patient needs.
In very severe cases, you may see two or three nurses working with a single patient although this does not happen frequently.
Nurses in the ICU will spend more time with each of their patients than they would on the step-down unit.
Physical assessments often take longer, vital signs must be performed more frequently and bedside monitors must be watched carefully, especially for unstable patients or those recently returned from surgery.
Full assessments and vital sign documentation must be completed every four hours at minimum.
However, patients who are on certain intravenous medications, such as for blood pressure, will need their vital signs documented up to every 10 to 15 minutes or along with each dosage adjustment.
Documentation also takes longer with these more involved patients.
While some shifts in the ICU may feel slower than others, nurses must always be ready to jump into action because these are the most unstable patients in the hospital.
Therefore, many nurses stay close to their patients’ rooms or constantly monitor vital signs at the nurses’ station.
Typical Work Environment in Each Unit
Because of the acuity differences between these patients, most step-down units are set up differently from intensive care units.
Step-Down Unit Work Environment
Many step-down units are designed to look much like medical-surgical units with patient rooms located down long hallways and one or two nurses’ stations located between them.
There may also be smaller nurses’ stations in a couple spots depending on the size of the unit to allow nurses quiet places to chart.
However, the main nurses’ station will usually have the telemetry center that is manned by a telemetry nurse who keeps an eye on all the patients’ heart rhythms.
There are usually more visitors on these floors than there are in the ICU because visiting hours are not as stringent.
This can make the step-down unit a noisy place during the daytime.
ICU Work Environment
On the other hand, an intensive care unit usually has a large nurses’ station located in the center of the floor with patient rooms forming a circular shape around the station.
This keeps every patient close to the nurses for quick interventions. There are usually more windows in patient rooms here with some hospitals opting for completely glass-fronted rooms to allow nurses to glance quickly at their patients while charting.
Bedside monitors are mirrored to monitors at the nurses’ station.
In some ICUs, you will also find pull-down desks or small cubby-like desks next to each patient room for nurses’ who need to stay even closer to their sickest patients.
Many ICUs have strict visiting hours with locked doors, preventing family and friends from coming and going at whim.
This can keep the unit a bit quieter except in emergencies when the atmosphere is all hands on deck.
| Step-Down Unit | Intensive Care Unit | |
|---|---|---|
| Types of Nurses | RNs and LPNs | RNs |
| Number of Patients | 3 to 4 | 1 to 2 |
| Type of Patients | Serious but stable | Critical |
| Average Salary | $120,065 | $121,963 |
Both the Step-Down and ICU Are Fulfilling
Both step-down units and ICUs can be equally busy yet equally fulfilling for confident nurses.
In many hospitals, new graduates with no experience as well as experienced nurses looking for a change can find jobs on these units.
Check out our job board to apply for a new position now.
