When it comes to nursing specializations, there is a veritable smorgasbord of options available.
The nursing profession occupies one of the most fundamental positions in the healthcare delivery system, and as such, nurses can be found working in almost every setting.
Some settings require nurses to be more generalized and deal with less acute patients, while others require dedicated specialization that can take years to master.
But what if you’re looking for something in between?
The step-down unit lies somewhere between highly advanced specialties, such as intensive care units, and broad knowledge because it requires a deeper understanding of an expansive range of semi-critical patient conditions and treatments.
Is the step-down unit a fit for you?
That’s what this guide is for. Read on to explore what types of patients receive care in a step-down unit, what purpose a step-down unit serves, what step-down nurses do, how much they can earn, and more.
What Is a Step-Down Unit?
A step-down unit (SDU) has an interdisciplinary team of healthcare professionals providing an intermediate level of care for hospital patients. It is neither as high in acuity as the Intensive Care Unit (ICU) nor as low as the Medical Surgical (med-surg) ward.
The step-down unit concept first appeared in 1968 as a proposed solution for cardiac patients not yet ready for discharge to a med-surg floor but stable enough to no longer need the level of acuity provided in the ICU. Since then, the presence of SDUs in hospitals has expanded.
Stepdown units help mitigate patient congestion in the ICU by providing a transitional point on a continuum of care in the hospital. These units free up ICU beds for patients who urgently need them without overwhelming med-surg floors. SDUs are typically located next to or very near the ICU.
Why Is It Called a Step-Down Unit?
The name step-down unit is, in this case, quite literal. If you imagine the ICU, SDU, and med-surg as rungs on a ladder, you would see the ICU on top, followed by the SDU and the med-surg unit.
Depending on the hospital or health system (or country), the SDU may have a different name, such as any of the following:
- Transitional Care Unit
- Intermediate Care Unit (IMCU)
- High-Dependency Care Unit (HDU)
- Semi-Critical Care Unit
Is a Step-Down Unit and a PCU the Same Thing?
Progressive Care Units (PCUs) are often found in smaller hospitals without critical care or ICUs. PCUs allow these hospitals to provide care at a higher level of acuity than the general med-surg floor.
Step-down units are primarily found in large hospitals and trauma centers that require transitional advanced care for patients. The size and dynamics of an SDU depend on the hospital it is in. You may find specialized step-down units such as respiratory SDUs, step-down ICUs, surgical SDUs, or cardiac SDUs.
How Many Patients Does a Step-Down Nurse Have?
The patient-to-nurse ratio in a step-down unit may vary slightly but is typically three to four patients for one nurse.
Who Works in a Step-Down Unit?
Much like any other hospital unit, wing, or ward, a step-down unit has a multidisciplinary team of healthcare professionals coordinating and collaborating to provide customized care for each patient. Although each hospital staffs and organizes its units according to its specific procedures, regulations, and strategies, the following healthcare clinicians are likely to be found in a step-down unit:
- Physicians
- Registered nurses
- Occupational therapists
- Respiratory therapists
- Social workers
Types of Patients in a Step-Down Unit
The types of patients treated in a step-down unit cover a broad range of conditions. While some hospitals use the SDU only for patients transitioning from the ICU, others are set up to allow patients to flow from other units as needed.
Guidelines for patient admission to a step-down unit depend on the hospital, health system, and geographic location. However, the main considerations for whether or not a patient is appropriate for admission to the SDU are their acuity level and the anticipated workload that their condition will require.
Patients in a step-down unit may have cardiac, pulmonary, neurological, gastrointestinal, endocrine, and surgical conditions such as the following:
- Patients transferred post-op for nursing care and observation in case of complications
- Patients transferred from the emergency room (ER) due to severe illness or injury that require close monitoring and nursing care
- Patients who are stable yet require organ system support
- Patients recovering from organ transplant surgery
- Patients with traumatic brain injury who require repositioning, suctioning, and/or monitoring for deterioration
- Patients recovering from or stabilizing after a stroke
- Patients who require noninvasive ventilation support
- Patients who require ventilation or vasopressor weaning
- Patients who are stable yet pose a high risk of becoming unstable
- Patients who require noninvasive but frequent monitoring and nursing interventions
- Patients with sepsis
- Patients recovering from a drug overdose
Step-Down Unit vs. ICU
As mentioned, the step-down unit provides care to patients with a lower acuity level than those in the ICU. At least in part, this is what the name “step-down” refers to. It serves as a transition space for patients discharged from the more expensive—and often congested—ICU who are not yet stable enough for the general floor.
Patient-to-nurse ratios in the ICU are typically lower than in the SDU, with one nurse providing care to one or two patients only.
Step-Down vs. Med-Surg
In terms of patient acuity and needs, the step-down unit is considered a step above med-surg. Patients in med-surg are stable, and although their conditions, injuries, or illnesses require hospitalization, they are not severe enough to necessitate intermediate care.
The difference in acuity between step-down and med-surg is also reflected in nurse-to-patient ratios. Patient-to-nurse ratios for a med surg unit may be as high as six to seven patients to one nurse, whereas the ratio in an SDU is lower.
What Is a Step-Down Nurse?
A step-down nurse is a registered nurse with the knowledge and training necessary to provide enhanced nursing care to patients requiring semi-acute or semi-critical care. These nurses must discern when intervention is needed and closely monitor vitals and equipment providing organ or respiratory support.
What Do Nurses Do in a Step-Down Unit?
The duties of a step-down nurse may include the following:
- Continuous monitoring and observation of patient vitals and condition, watching for improvements or deterioration
- Frequent neurological assessments
- Intravenous medication administration, line management, and titration
- Management and analysis of patient equipment
- Surgical and complex wound care
- Drainage management
- Bedside cardioversions
- Stroke scale assessments
- Turning, repositioning, lifting patients
- Suctioning
- Communication with the interdisciplinary team regarding patient condition and needs
- Collaboration with the rest of the healthcare team to implement the care plan
- Documentation for patient logs and unit systems
- Providing patient and/or patient family education
What Skills Do SDU Nurses Need?
Specialized stepdown units may require in-depth knowledge and skills pertaining to either respiratory, cardiac, endocrine, neurological, or gastrointestinal disorders. Nevertheless, some skills are broadly required for nurses in the SDU setting, including the following:
- Basic electrocardiogram (ECG) knowledge
- Competency in operating monitoring equipment and machines used in the SDU (airway delivery devices such as C-pap, Bipap, mechanical ventilation, etc.)
- Competency in arrhythmia and ABG interpretations
- Physical strength for turning, repositioning, and lifting patients
- Observational skills utilizing senses of smell, sight, depth perception, and hearing
- Ability to notice details and an understanding that subtle changes can have serious implications
- A solid understanding of the medicines, assessments, and patient conditions that are specific to high-acuity care in order to work autonomously
- Critical thinking and decision-making skills, which enable nurses to quickly discern when and how to intervene
- Thorough and concise patient documentation
- Dexterity to perform necessary patient care
- Communication skills to appropriately educate families, coordinate with other healthcare professionals, and complete effective shift handoff reports
- Organization to keep track of specific needs, monitoring, and documentation for patients with various conditions and/or illnesses
- Adaptability to unique patient needs
Step-Down Nurse Salary
Nurse salaries for the step-down unit vary widely. Industry research shows an annual income ranging from $77,000 to $106,000 can be expected. This variance can largely be attributed to the fact that cost of living, demand, location, and subspecialization all impact what a hospital system offers for these positions.
Step-Down Nursing Career Outlook
Patient length of stay (LOS) continues to be a serious metric of focus for hospitals looking to improve ICU efficiency and thereby reduce LOS within the ICU. Not only are ICUs expensive for patients and healthcare insurance companies, but they are also costly for hospitals to staff, certify, and maintain. As healthcare costs continue to rise and pressure to reduce operational costs increases, hospitals will likely continue utilizing SDUs to streamline patient flow from specialty units to med-surg and ultimately to discharge.
Furthermore, studies have shown that using SDUs has been associated with better patient outcomes, lower patient readmissions to the ICU, and reduced mortality rates. However, many journal authors cite the need for further study of SDUs and standardization of terms and admission guidelines.
These factors suggest a positive career outlook for nursing in a step-down unit. This career will likely see growth and transformation as the functioning, efficiency, outcomes, and cost continue to be studied, leveraged, and refined.
Advantages and Disadvantages of Being a Step-Down Nurse
Working in a step-down unit is unlikely to be boring or monotonous. Despite the fact that patients in the SDU are more stable than those in an ICU, this is not a setting where nurses become complacent or lax. The advantages and disadvantages of being a step-down nurse are often closely related and depend on a nurse’s mental fortitude and personality. Consider the following:
- Skill and knowledge growth vs. complexity: Nurses who appreciate the challenge to their critical thinking skills brought on by caring for patients with varying conditions and complexities can stretch, grow, and flex their clinical abilities and knowledge in the SDU. The complexity and severity of patient conditions in this unit require a steep learning curve, which can be overwhelming to some nurses.
- Low patient-to-nurse ratio: Another advantage for nurses working in a stepdown unit is the relatively low patient-to-nurse ratio. Although the patient conditions are serious and complex in this unit, the responsibility of three or four patients per nurse—albeit higher than in the ICU—is a better ratio than in many other settings.
- Mental fatigue vs. positive challenge: While the intensity is not as heightened in the SDU as in the ICU or other critical care units, the ever-present risk of patient instability can lead to mental fatigue for nurses. Alternatively, some nurses thrive in these types of settings, where the intensity pushes them to be their best.
- A sense of purpose: Making decisions and providing care that can save a patient’s life also creates a sense of purpose and satisfaction that some nurses find fulfilling.
- Impact of both positive and negative outcomes: Phrases such as “improved patient outcomes” become concrete and tangible concepts in a step-down unit when observing, assessing, and documenting the stabilization and recovery of a previously critical patient. On the other hand, patient mortality can be particularly devastating when a patient initially improves enough to step down from critical care.
- Frustration: Nurses may experience frustration when treating one condition exacerbates another.
- Potential burnout: Burnout specific to SDU nurses has yet to be widely studied. Nevertheless, studies associate high-intensity hospital settings with high rates of burnout.
- Patient demands: Patients in the SDU are often more awake and communicative than they were in the ICU, which potentially means more disruptions to nursing routines in responding to call lights.
- Relationships: Nurses can form bonds with coworkers and patients in the SDU, forged through enduring and overcoming challenges.
How to Become a Step-Down Nurse
A master’s degree or advanced education isn’t required to become a stepdown nurse. However, you must be a licensed registered nurse with either an associate degree in nursing (ADN) or a bachelor of science in nursing (BSN).
Furthermore, while some facilities will hire an ADN RN for the step-down unit, they may require the RN to agree to attain a BSN within a specified period of time.
What Experience Is Needed to Work in the Step-Down Unit?
The step-down unit has patients with a higher acuity level than general med-surg units. Therefore, brand-new RNs (even new BSN RNs) are unlikely to be assigned to work in intermediate care until they have accumulated one to two years of direct practice in a hospital setting—although there are exceptions.
Step-down units tend to prefer nurses with experience in other intermediate care settings, such as the emergency department or telemetry, subspecialty settings, such as cardiac telemetry, or high-acuity settings, such as the ICU.
Becoming a stepdown nurse means solidifying the foundational clinical knowledge and skills learned in nursing school and through direct practice experience and committing yourself to a deeper understanding of critical conditions and their treatments.
Step-Down Nurse Certifications
Generally, the BLS (basic life support) and ACLS (advanced cardiac life support) certifications are required for nursing positions in a step-down unit. If the step-down unit is in a pediatric hospital or likely to have pediatric patients, then the PALS (pediatric advanced life support) may also be required.
The following certifications and training may be preferred by hospital administrators and, therefore, may be of interest to some nurses in specific step-down settings:
- PCCN Adult–Direct Care Pathway: This certification offered by the American Association of Critical-Care Nurses (AACCN) is specifically aimed at nurses who work in intermediate care settings such as step-down units, telemetry, emergency rooms, and other transitional departments. This certification has a clinical practice hour requirement—at least 1,750 hours in acute care direct practice—that must be met before the certification can be pursued. Once obtained, it can be renewed every two or five years as long as the coinciding practice hour requirements are met.
- NIH Stroke Scale: Developed by the National Institute of Health (NIH) and the National Institute of Neurological Disorders and Stroke (NINDS), the NIH Stroke Scale assesses a person’s neurological functioning. The American Heart Association (ANA) offers NIH Stroke Scale training courses over a time continuum so that healthcare professionals can gradually attain mastery of the skill.
- Essentials of Critical Care Orientation (ECCO): The AACNN offers these training courses, which are available for individual nurse purchase. The modules focus on different specialties, such as cardiovascular, endocrine, gastrointestinal, neurological, and hematological disorders. The trainings are all targeted at nurses working in intensive or intermediate care settings.
Is Working as a Step-Down Nurse Hard?
Yes, it is hard work, but that doesn’t mean it isn’t satisfying and rewarding. The patients a step-down nurse cares for have quite literally survived conditions and circumstances that could have ended their lives, and yet, through the dedicated efforts and collaboration of healthcare professionals, they have stabilized.
Many aspiring nurses choose nursing specifically because they want to make a difference, and in the step-down unit, that desire can be validated. Unlike nurses in the ICU or the emergency room who witness a patient at their worst, a step-down nurse is uniquely positioned to witness and assist the patient’s transition from critical to lower acuity. Those opportunities can be powerful motivators and sources of inspiration for nurses.
Tips for New Step-Down Nurses
Are you preparing to make a transition of your own from med-surg to step-down? Here are a few tips:
- Ask to shadow: Before officially starting, ask if you can shadow for a shift or two. Shadowing will help you tune into the feel and flow of the dynamics in the unit. This can help you set reasonable expectations for work and consider whether the setting will be a good fit.
- Ask about common conditions: Every SDU differs from the others, even SDUs that aren’t tied to a specific specialty. Ask the nurses about common patient conditions they encounter. What would they suggest you study?
- Study: Experience is a great teacher, but studying on your own time will help you feel more confident. Brush up on your assessment skills and understanding of critical conditions and comorbidities (circulatory and respiratory disorders are common).
- Pamper your feet: If you haven’t already, invest in quality nursing shoes that will care for your feet so you can manage the shifts with your mind entirely focused on the job.
- Go in with the right attitude: Step into the step-down unit ready to listen, learn, and prove you have what it takes. Whatever your previous experience is, it’s helped you get this far, but we’re never truly done learning.
- Prioritize self-care: Make a habit of scheduling time for self-care activities such as meditation, yoga, fitness, hiking, cooking, etc. Get your hair done, join a book club, or purchase tickets to the ball game on your day off. Find activities that have nothing to do with work and that replenish your mental energy.
- Sleep: Ensure you are routinely getting enough sleep. A rested body and mind can help you better focus and manage stressful situations and emotions.
- Consider therapy: If you’re struggling with patient mortality or other issues, don’t wait until you dread going to work and eventually burn out. Talking to other step-down nurses may help you feel less alone, but that isn’t a complete replacement for the benefits of individual therapy.
Find Local Nursing Jobs in Step-Down Units near You
Stepdown nurses bridge the gap between critical care and medical-surgical nursing. This level of care is an essential link along the continuum of hospital services that helps to transition patients out of critical care safely.
Are you already a step-down nurse? The demand for your skills is high, but not all SDU nurse jobs are long-term commitments. Nursa’s PRN RN jobs offer competitive hourly pay rates for single shifts, so you can pick up work when it works for you. Explore PRN RN shifts in step-down units near you when you sign up with Nursa.
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