In the early 1970s, advertisements were placed in Heart and Lung by major medical
center recruiters for both critical care and progressive care nurses. Initially,
progressive care units were used to house post myocardial infarction patients
who needed cardiac monitoring but who did not require intensive care and
observation. As the health care environment began to change, the acuity of
patients admitted to the hospital steadily increased and with it the demand for
critical care beds also increased. With an increased demand for and decreased
availability of critical care beds, patients were often transferred from critical
care units while still requiring an increased level of nursing care and vigilance.
Patients who were admitted to critical care units five years ago are now routinely
admitted to progressive care.
Progressive care is the term the American Association of Critical-Care
Nurses (AACN) uses to collectively describe areas that are also referred
to as Intermediate Care Units, Direct Observation Units, Step-down Units,
Telemetry Units, or Transitional Care Units as well as to define a specific
level of patient care. AACN recognizes the need to define and identify the
special needs of progressive care nurses. In 2001, a task force and advisory
panel were created to define the progressive care environment and patient
populations served, as well as the core competencies and basic knowledge and
skill requirements of progressive care nurses.
The American Association of Critical-Care Nurses recognizes progressive care
as part of the continuum of critical care. AACN's vision is dedicated to
creating a healthcare system driven by the needs of patients and families
where critical care nurses make their optimal contribution. The AACN Synergy
Model for Patient Care is the conceptual framework that actualizes the vision.
It defines nursing practice based on the needs of the patient and the
characteristics of the nurse to attain optimal patient outcomes.
Progressive care defines the care that is delivered to patients whose needs
fall along the less acute end of that continuum. Progressive care patients
are moderately stable with less complexity, require moderate resources and
require intermittent nursing vigilance or are stable with a high potential
for becoming unstable and require increased intensity of care and vigilance.
Characteristics of progressive care patients include: a decreased risk of a
life-threatening event, a decreased need for invasive monitoring, increased
stability, and an increased ability to participate in their care.
Progressive Care Patient Location
Using AACN's Synergy Model will assist in defining the progressive care patient.
The Synergy Model identifies patients based on the characteristics and needs
that they present and not on the location of the bed they occupy. As in
critical care, the geographic domain of progressive care is expanding.
Care provided to progressive care patients is not limited by geography but
is based on the needs and required interventions of the patient.
While specific progressive care units can be identified, patients
requiring progressive care nursing can be located throughout the hospital.
Progressive care can be very specialized, with care focused on a specific
system such as cardiac, or more generalized, as in the care of patients with
Progressive care nursing has expanded beyond the basic cardiac telemetry
that marked its beginning and now encompasses many of the same technologies
and therapies that were once limited to critical care units. To meet the
changing needs of the patient, nurses caring for progressive care patients
must demonstrate competencies that are influenced by ever changing technology.
Progressive care nurses must demonstrate the following core competencies:
- Dysrhythmia monitoring techniques
- Basic & advanced life support
- Basic dysrhythmia interpretation and treatment
- Drug dosage calculation, continuous medication infusion administration, and patient monitoring for medication effects (i.e., non-titrated vasoactive agents, platelet inhibitors, anti-arrhythmic agents, and insulin)
- Patient monitoring using standardized procedures for pre, intra, and post procedures (i.e.; cardioversion, TEE, cardiac catheterization with PCI, bronchoscopy, EGD, PEG placement, chest tube insertion)
- Hemodynamic monitoring including equipment setup and troubleshooting, monitoring and recognition of signs and symptoms of patient instability
- Recognition of the signs and symptoms of cardiopulmonary emergencies and initiation of standardized interventions to stabilize the patient awaiting transfer to critical care
- Interpretation of ABGs and communication of findings
- Recognition of indications for and management of patients requiring non-invasive O2 delivery systems including oral airways, bipap, and nasal CPAP
- Assessment of the ventilated patient to assure delivery of the prescribed treatment and patient response
- Assessment and understanding of long term mechanical ventilation and weaning
- Recognition of the indications for and complications of enteral and parental nutrition
- Assessment, monitoring and management of patients requiring renal therapeutic interventions; For example hemodialysis, peritoneal dialysis, stents, continuous bladder irrigation, and urostomies
- Recognition of and evaluation of the family's need for enhanced involvement in care to facilitate the transition from hospital to home
According to the Synergy Model, stability, complexity, vulnerability, resiliency,
predictability, resource availability, participation in care and participation in
decision making are the patient characteristics that describe patient function.
The nurse characteristics that typically represent comprehensive nursing practice
include clinical judgment, advocacy, caring practices, collaboration, systems thinking,
response to diversity, clinical inquiry and learning facilitator. The framework
therefore takes into account the unpredictability of the progressive care patient,
and based on the patient and family's needs the competencies of the progressive
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