September 1, 2024 • 13 mins
A Realistic View Into Nursing Areas: Step Down
In this episode, I focus on the Step Down unit as a part of the five-part series that gives you an idea of what different areas of nursing are like. Each episode will challenge you to think about whether that particular area would be a good fit for you. I share both my positive and my negative experiences with the goal of helping you find your 'fit' in the nursing field. The reality is that everything doesn't fit everybody.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Some of my paramedic to RN friends were talking about how we didn't have an accurate view
(00:10):
of nursing before we became nurses.
And we all moved around to different units before finding our fit.
Some of us still haven't found it.
For me, I have experienced, because I've moved around to the ED, step down, critical care,
surgical services, endoscopy care, coordination, and case management.
So over the next several podcasts, what I'm doing is sharing with you the workflow environment,
(00:35):
the hours, and also the positives and negatives of the areas I've worked from my experience
as being a paramedic.
And I think that's the most important.
So welcome to my podcast.
In school, I recognized that a lot of the nursing assistants or people who had experience
(01:02):
in the hospitals, they already knew exactly where they wanted to go, but we didn't.
And that led me to kind of move around.
And one of the first jobs I got was in a step down unit.
And I think I mentioned this in previous podcasts that, you know, when doing your last semester
of nursing school, is when you want to kind of start locking down your new grad position,
(01:26):
your new grad residency.
And I interviewed with several EDs and I didn't get a position.
And well, I ain't going to say I didn't get a position because I had an ED I could
go to, but the problem was it was where I was doing my clinicals at, which was like
an hour and a half from my house.
But I live, you know, where I live, there's like three hospital systems and three level
(01:51):
one trauma centers within a 45 minute drive of each other.
So I kind of felt like it wouldn't be too hard to get an ED position here, but that
just wasn't the case being a new grad.
Even though I was a paramedic with new grad experience, I mean, being a new grad with
paramedic experience, it just didn't, my car didn't play out.
(02:13):
So I really took the first job that I could get and it wound up being a cardiac step down
unit.
So I wanted to kind of talk about my experience on that unit because I didn't stay there
long at all.
I really figured out that it wasn't really a good fit for me.
But I will tell you my experience on that unit and it may be a good fit for you.
(02:36):
But like I said, it was my first nursing job.
And so what is a step down unit and relevance into, you know, the hospital system?
So you got three types of acuity.
You usually have low acuity, medium acuity, and you have high acuity.
So you probably heard the term med search.
(02:58):
Med search stands for medical surgical unit.
And the medical surgical unit is low acuity and the patients are there usually either
inpatient or observation status.
And observation status mean they probably being watched overnight and may DC the next
day or the next couple of days.
Inpatient mean they're going to have a little longer stay.
(03:19):
So there's certain criteria to fit observation, certain criteria that you have for inpatient.
But the main thing you need to understand is that these patients are not critically
ill, meaning they have a low acuity.
Now if they get sicker, they can upgrade to either step down unit or to the ICU.
So the ICU is really the critical.
(03:41):
That's the critical care.
That's the critically ill, which we call high acuity patients.
So usually what happens is sometimes you may get a patient that may be ICU status and maybe
to get a change of condition, they start to get better.
Then they may bring them down to a step down unit or they may even just admit them to what
(04:01):
we call a floor unit, which is a med search.
So the step down unit is the difference between the med search and the ICU, meaning they don't
have the highest security and they don't have the lowest security.
They're kind of like in the middle.
For example, they may be on a PCA pump or they may be telemetry, meaning they're kind
(04:24):
of monitoring the EKG rhythm, their heart rhythm, or they may be on certain cardiac
drips, which may cause them to be stepped down status.
But typically they won't be on any pressures.
Well, they won't be on the pressures if they own step down unit.
If they own any pressures, they would have to be ICU status.
So what was my workflow?
Well, my workflow kind of vary.
(04:47):
Usually it's fast pace, slow pace, then fast pace.
Again, it really just depends on the mixture of patients you have.
My ratio was one to three, and that's pretty typical of a step down unit.
Typically you won't have more than that.
Now I've seen some step down units to where maybe the ICU was kind of overcrowded and
(05:11):
they may be holding ICU patients in a step down, which if you are qualified to take care
of that patient, usually you'd be oriented to an ICU and your ratio may break down to
one to two units.
Because usually on ICU it's usually one to two or usually even one to one.
So what was my day like or how's everything set up?
(05:36):
So usually when you get in in the morning, you usually do your reporting.
So the outpatient nurse is kind of giving you a full overview of what went on the night
before the patient, why they admitted, their cold status, and anything that changed in
(05:58):
their condition overnight.
So usually you have a full assessment at eight o'clock, you do a full assessment at 12, and
you do a full assessment at four o'clock.
But in between that, you normally have a med pass in the morning and you usually have a
med pass in the afternoon.
What a med pass is, there are certain morning meds that patients take that morning and there
(06:20):
are certain medications they take usually in the afternoons and sometimes they do it
in the evening times.
This patient is different, but the majority of your meds are normally given in the morning
and then in the afternoon.
But in between that, you may have like your low onesies or two z's that you may give.
And you also have rounds.
Sometimes the rounds will be right in the right smack middle of your med pass, you may
(06:45):
have rounding, which usually in a rounding you have them with your position, you have
them with therapy, which consists of physical occupational therapy.
House nurse will be in there and also either your case coordinator, I meant your care coordinator
and your case manager.
Sometimes you may even have pharmacy or dietary may be in there depending on if you have a
(07:08):
patient to have a G-tube.
So just to kind of let you know.
Also you usually ambulate your patients every morning.
So it's a really heavy workload, but depending on how you manage your patient and depending
on how good you are with time management, you may be able to get through certain patients.
(07:33):
So the environment is hit or miss.
Just like I said earlier, you may have a good team that you work with, you may have a good
manager, a good charge nurse, a good team lead and a good crew of nurses that can help
you out.
To me, out of all the places I've seen, certain systems have really good teamwork to where
(07:55):
if you feel like you're behind and you're struggling, they will actually come in to help
you or certain places may have really good nursing assistants to where they can take
a really heavy load off you.
And so it just really kind of depends.
The hours, usually the hours of 12 hour shifts with, as I mentioned on calls, just depending
on how staffed you are, if you have more on call than not.
(08:22):
But my schedule was, I had two weeks I was on days and two weeks I was on nights.
So it was a flip flop schedule, variable, alternating schedule with sucked angle IT.
So what are some of the positives and what are some of the negatives?
I think being a paramedic working on these units.
(08:44):
One of the positives I think is if you want to go to the ICU, then this is a good place
to get your start.
So then that way you don't be overwhelmed on the ICU.
The ICU, like I'm talking about, can be really overwhelming if that's your first place you
start.
It's not because the patients are sick, it's understanding the different medications.
(09:04):
And as a street 911 paramedic, you're going to enter a whole nother realm of medical that
you may not be aware of.
Also another positive is that I was already ACLS, I was already had PALS, and I was experienced
in doing IVs where most nurses were not experienced.
(09:26):
That can kind of be a good thing and that can kind of be a bad thing because I wound
up doing IVs for a lot of nurses which took away from, which I was glad to help, but it
also took away from my time with my patients too.
Another positive is that you already have good assessment skills, but there's a caveat
(09:52):
to that.
Floor nursing takes a different type of assessment and that can kind of go until the negative
side too because floor assessments isn't the same as ED nursing paramedic assessments.
You know, when you're doing a floor nursing assessment, I mean, you're going into asking,
you know, do you have a healthcare power of attorney in place?
(10:14):
Who's your emergency contact?
What do they skin look like?
You know, you're going pretty deep into an assessment for things that we normally don't
do in emergency situations.
Also negative is family can be a big much.
Visitors can be a bit much.
(10:36):
You have to know how to navigate that, especially during the daytime.
During the nighttime, because the patient would sleep, visitors would sleep or not in
there, you really didn't have too much problems at night.
Besides the elderly having sundown episodes or demented trying to get out of bed because
the many patients, they don't sleep well at night.
They typically can be a handful.
(10:58):
So another negative is I felt a bit overqualified and not in my element.
As a paramedic, I was used for a different type of flow.
Even though not a lot of patients we picked up were necessarily critical, I still had
a critical mindset to catch if they were to decompensate.
(11:19):
Usually on the floor, you're so overwhelmed that you kind of feel like you're not in your
element because you're too busy running back and forth.
You may be getting a soda for this patient.
You may be trying to do a blood sugar check.
You know, you're late to do a blood sugar check on another patient.
You have to get a Tylenol for one patient.
(11:40):
Physical therapy may be in a room with another patient and just finish and now your patient
needs his pain medication.
So you can be a bit much and you can be running around in circles.
But for me, I think one of the biggest negatives is the med passes.
You know, I'll tell you a little story I have.
(12:00):
So one patient can have 13 meds.
And I remember one time I had a patient, patients that would normally after I scan all the medications
and take them out of the package and put them in a cup to give them, they will literally
take medications out of the cups.
I have no idea what they take them out of the cups.
I have to literally go back, look into the pixels and pull every med and try to compare
(12:21):
it to see which one they didn't take.
And I've had several times where I've given them the cup, the hands shaking, I'm checking
with the patient, hey, would you like for me to give you the meds?
They say, no, let me take them myself.
And they literally go to take the medications and half of it was spilled out onto the bed,
onto the floor.
(12:42):
And it's four in their mouth.
I don't know which four they took because the rest are either in the bed or on the floor.
And this is after I've already scanned them and discarded the package.
So I figured out real quick that that just wasn't for me.
So I just wanted to kind of give you an idea of what it is like working on a nursing step-down
(13:06):
unit.
And hopefully I didn't put too much of my biases in it and you can see if it's for you
or if it's not, but just want to kind of give you a good look.
But thank you guys for joining.
And again, I'll see you guys next episode.
Take care.
(13:27):
As always, hey, make sure you guys follow me on Instagram at paramedic2rnfo.
And I'll see you guys next episode number two.
Some of my paramedic to RN friends were talking about how we didn't have an accurate view
(00:10):
of nursing before we became nurses.
And we all moved around to different units before finding our fit.
Some of us still haven't found it.
For me, I have experienced, because I've moved around to the ED, step down, critical care,
surgical services, endoscopy care, coordination, and case management.
So over the next several podcasts, what I'm doing is sharing with you the workflow environment,
(00:35):
the hours, and also the positives and negatives of the areas I've worked from my experience
as being a paramedic.
And I think that's the most important.
So welcome to my podcast.
In school, I recognized that a lot of the nursing assistants or people who had experience
(01:02):
in the hospitals, they already knew exactly where they wanted to go, but we didn't.
And that led me to kind of move around.
And one of the first jobs I got was in a step down unit.
And I think I mentioned this in previous podcasts that, you know, when doing your last semester
of nursing school, is when you want to kind of start locking down your new grad position,
(01:26):
your new grad residency.
And I interviewed with several EDs and I didn't get a position.
And well, I ain't going to say I didn't get a position because I had an ED I could
go to, but the problem was it was where I was doing my clinicals at, which was like
an hour and a half from my house.
But I live, you know, where I live, there's like three hospital systems and three level
(01:51):
one trauma centers within a 45 minute drive of each other.
So I kind of felt like it wouldn't be too hard to get an ED position here, but that
just wasn't the case being a new grad.
Even though I was a paramedic with new grad experience, I mean, being a new grad with
paramedic experience, it just didn't, my car didn't play out.
(02:13):
So I really took the first job that I could get and it wound up being a cardiac step down
unit.
So I wanted to kind of talk about my experience on that unit because I didn't stay there
long at all.
I really figured out that it wasn't really a good fit for me.
But I will tell you my experience on that unit and it may be a good fit for you.
(02:36):
But like I said, it was my first nursing job.
And so what is a step down unit and relevance into, you know, the hospital system?
So you got three types of acuity.
You usually have low acuity, medium acuity, and you have high acuity.
So you probably heard the term med search.
(02:58):
Med search stands for medical surgical unit.
And the medical surgical unit is low acuity and the patients are there usually either
inpatient or observation status.
And observation status mean they probably being watched overnight and may DC the next
day or the next couple of days.
Inpatient mean they're going to have a little longer stay.
(03:19):
So there's certain criteria to fit observation, certain criteria that you have for inpatient.
But the main thing you need to understand is that these patients are not critically
ill, meaning they have a low acuity.
Now if they get sicker, they can upgrade to either step down unit or to the ICU.
So the ICU is really the critical.
(03:41):
That's the critical care.
That's the critically ill, which we call high acuity patients.
So usually what happens is sometimes you may get a patient that may be ICU status and maybe
to get a change of condition, they start to get better.
Then they may bring them down to a step down unit or they may even just admit them to what
(04:01):
we call a floor unit, which is a med search.
So the step down unit is the difference between the med search and the ICU, meaning they don't
have the highest security and they don't have the lowest security.
They're kind of like in the middle.
For example, they may be on a PCA pump or they may be telemetry, meaning they're kind
(04:24):
of monitoring the EKG rhythm, their heart rhythm, or they may be on certain cardiac
drips, which may cause them to be stepped down status.
But typically they won't be on any pressures.
Well, they won't be on the pressures if they own step down unit.
If they own any pressures, they would have to be ICU status.
So what was my workflow?
Well, my workflow kind of vary.
(04:47):
Usually it's fast pace, slow pace, then fast pace.
Again, it really just depends on the mixture of patients you have.
My ratio was one to three, and that's pretty typical of a step down unit.
Typically you won't have more than that.
Now I've seen some step down units to where maybe the ICU was kind of overcrowded and
(05:11):
they may be holding ICU patients in a step down, which if you are qualified to take care
of that patient, usually you'd be oriented to an ICU and your ratio may break down to
one to two units.
Because usually on ICU it's usually one to two or usually even one to one.
So what was my day like or how's everything set up?
(05:36):
So usually when you get in in the morning, you usually do your reporting.
So the outpatient nurse is kind of giving you a full overview of what went on the night
before the patient, why they admitted, their cold status, and anything that changed in
(05:58):
their condition overnight.
So usually you have a full assessment at eight o'clock, you do a full assessment at 12, and
you do a full assessment at four o'clock.
But in between that, you normally have a med pass in the morning and you usually have a
med pass in the afternoon.
What a med pass is, there are certain morning meds that patients take that morning and there
(06:20):
are certain medications they take usually in the afternoons and sometimes they do it
in the evening times.
This patient is different, but the majority of your meds are normally given in the morning
and then in the afternoon.
But in between that, you may have like your low onesies or two z's that you may give.
And you also have rounds.
Sometimes the rounds will be right in the right smack middle of your med pass, you may
(06:45):
have rounding, which usually in a rounding you have them with your position, you have
them with therapy, which consists of physical occupational therapy.
House nurse will be in there and also either your case coordinator, I meant your care coordinator
and your case manager.
Sometimes you may even have pharmacy or dietary may be in there depending on if you have a
(07:08):
patient to have a G-tube.
So just to kind of let you know.
Also you usually ambulate your patients every morning.
So it's a really heavy workload, but depending on how you manage your patient and depending
on how good you are with time management, you may be able to get through certain patients.
(07:33):
So the environment is hit or miss.
Just like I said earlier, you may have a good team that you work with, you may have a good
manager, a good charge nurse, a good team lead and a good crew of nurses that can help
you out.
To me, out of all the places I've seen, certain systems have really good teamwork to where
(07:55):
if you feel like you're behind and you're struggling, they will actually come in to help
you or certain places may have really good nursing assistants to where they can take
a really heavy load off you.
And so it just really kind of depends.
The hours, usually the hours of 12 hour shifts with, as I mentioned on calls, just depending
on how staffed you are, if you have more on call than not.
(08:22):
But my schedule was, I had two weeks I was on days and two weeks I was on nights.
So it was a flip flop schedule, variable, alternating schedule with sucked angle IT.
So what are some of the positives and what are some of the negatives?
I think being a paramedic working on these units.
(08:44):
One of the positives I think is if you want to go to the ICU, then this is a good place
to get your start.
So then that way you don't be overwhelmed on the ICU.
The ICU, like I'm talking about, can be really overwhelming if that's your first place you
start.
It's not because the patients are sick, it's understanding the different medications.
(09:04):
And as a street 911 paramedic, you're going to enter a whole nother realm of medical that
you may not be aware of.
Also another positive is that I was already ACLS, I was already had PALS, and I was experienced
in doing IVs where most nurses were not experienced.
(09:26):
That can kind of be a good thing and that can kind of be a bad thing because I wound
up doing IVs for a lot of nurses which took away from, which I was glad to help, but it
also took away from my time with my patients too.
Another positive is that you already have good assessment skills, but there's a caveat
(09:52):
to that.
Floor nursing takes a different type of assessment and that can kind of go until the negative
side too because floor assessments isn't the same as ED nursing paramedic assessments.
You know, when you're doing a floor nursing assessment, I mean, you're going into asking,
you know, do you have a healthcare power of attorney in place?
(10:14):
Who's your emergency contact?
What do they skin look like?
You know, you're going pretty deep into an assessment for things that we normally don't
do in emergency situations.
Also negative is family can be a big much.
Visitors can be a bit much.
(10:36):
You have to know how to navigate that, especially during the daytime.
During the nighttime, because the patient would sleep, visitors would sleep or not in
there, you really didn't have too much problems at night.
Besides the elderly having sundown episodes or demented trying to get out of bed because
the many patients, they don't sleep well at night.
They typically can be a handful.
(10:58):
So another negative is I felt a bit overqualified and not in my element.
As a paramedic, I was used for a different type of flow.
Even though not a lot of patients we picked up were necessarily critical, I still had
a critical mindset to catch if they were to decompensate.
(11:19):
Usually on the floor, you're so overwhelmed that you kind of feel like you're not in your
element because you're too busy running back and forth.
You may be getting a soda for this patient.
You may be trying to do a blood sugar check.
You know, you're late to do a blood sugar check on another patient.
You have to get a Tylenol for one patient.
(11:40):
Physical therapy may be in a room with another patient and just finish and now your patient
needs his pain medication.
So you can be a bit much and you can be running around in circles.
But for me, I think one of the biggest negatives is the med passes.
You know, I'll tell you a little story I have.
(12:00):
So one patient can have 13 meds.
And I remember one time I had a patient, patients that would normally after I scan all the medications
and take them out of the package and put them in a cup to give them, they will literally
take medications out of the cups.
I have no idea what they take them out of the cups.
I have to literally go back, look into the pixels and pull every med and try to compare
(12:21):
it to see which one they didn't take.
And I've had several times where I've given them the cup, the hands shaking, I'm checking
with the patient, hey, would you like for me to give you the meds?
They say, no, let me take them myself.
And they literally go to take the medications and half of it was spilled out onto the bed,
onto the floor.
(12:42):
And it's four in their mouth.
I don't know which four they took because the rest are either in the bed or on the floor.
And this is after I've already scanned them and discarded the package.
So I figured out real quick that that just wasn't for me.
So I just wanted to kind of give you an idea of what it is like working on a nursing step-down
(13:06):
unit.
And hopefully I didn't put too much of my biases in it and you can see if it's for you
or if it's not, but just want to kind of give you a good look.
But thank you guys for joining.
And again, I'll see you guys next episode.
Take care.
(13:27):
As always, hey, make sure you guys follow me on Instagram at paramedic2rnfo.
And I'll see you guys next episode number two.
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