1. Culleiton, Alicia L. RN, MSN, CNE
  2. Shellenbarger, Teresa RN, CNE, DNSc
  3. Stoker, Amy RN, MSN


More nursing students than ever before are beginning their careers in highly specialized critical care settings.


Article Content

A mentally challenged 40-year-old male patient was transferred to the surgical intensive care unit (SICU) postoperatively following a partial bowel resection. The patient ingested repeated doses of aspirin for multiple days in hopes of treating severe abdominal and back pain. He subsequently developed a severe lower gastrointestinal (GI) bleed. The patient initially presented to the emergency department experiencing hypovolemic shock and renal and liver failure. He required massive blood products and fluid administration. Ten days postoperatively, the patient was diagnosed with acute respiratory distress syndrome and was being evaluated for sepsis.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

In the SICU, the patient is hemodynamically monitored via a central venous pressure and arterial line, mechanically ventilated, and sedated on propofol (Diprivan). Norepinephrine bitartrate (Levophed) is titrated to maintain a mean arterial pressure above 60 mm Hg. Total parenteral nutrition and continuous venovenous hemofiltration therapy has also been initiated, and the patient is ordered to receive 3 units of fresh frozen plasma.


A valuable component

Nursing students are assigned for a clinical experience in the SICU. Nursing staff, as well as nursing faculty, may question if this is an appropriate patient assignment for a nursing student. The answer is simply yes. It's imperative that nurse educators and nursing staff recognize the importance of nursing students having acute, complex clinical experiences as a valuable component of nursing education. Clinical experiences in critical care settings provide nursing students with an excellent opportunity to build upon their nursing skills and use advanced knowledge and critical thinking skills while participating in the care of acutely ill patients.


New opportunities

Ten years ago, new nursing graduates rarely entered critical care units (CCUs) to begin their nursing careers. Generally, the student transitioned from a graduate nurse to a registered nurse in the medical-surgical environment. Now, most likely due to the widespread nursing shortage, hospitals and nurse recruiters are actively pursuing new graduates for these highly specialized areas, and in some instances are offering tuition forgiveness programs and/or sign-on bonuses.1-3


This new hiring trend has prompted an increase in the number of clinical learning opportunities for the nursing student in critical care settings. Generally, new nursing graduates tend to seek employment in clinical areas where they had rewarding student experiences. When nursing faculty and staff work together to promote nursing education and positive clinical experiences, nursing students may be more attracted to critical care areas for future work opportunities.


This article will highlight the vital role critical care nurses play in nursing student education, ease the apprehension nursing staff may have when educating students in the critical care setting, and offer advice and strategies to enable nursing staff and faculty to develop the partnership necessary to facilitate a successful and meaningful clinical learning experience.


The basics

The type of critical care clinical experience the nursing student is participating in will tremendously affect the role and responsibilities the nursing staff plays in the educational and evaluation process of the nursing student. Generally, there are three types of clinical experiences offered in the critical care areas: shadowing experience, nurse internship/preceptorship program and curriculum-based critical care clinical rotation.4 The following section provides an overview of each type of clinical experience.


Shadowing experience

The shadowing experience can take on many forms. Students interested in a potential career in nursing may shadow a nurse for 1 day in the CCU. This type of experience is strictly observational in nature. It allows the student to determine if she may want to pursue critical care nursing as a career option. Shadowing experiences are used to showcase the role of the professional nurse. The nursing staff's primary responsibility in this situation is to promote nursing as a rewarding career and answer any questions the student may have related to nursing in general.


Nurse internship/preceptorship program

Nursing student internship programs are typically completed by nursing students who don't have a critical care clinical opportunity in their nursing program or for students who would like additional exposure to critical care nursing. Senior-level nursing students fulfilling nursing practicum hours required by their nursing program may also take part in a nursing student internship/preceptorship program. In these instances, the nursing staff volunteers to guide and evaluate the student.


The nursing staff, unit director, and nursing faculty work closely in arranging this type of experience. In most instances, there are formal program objectives and expected student outcomes associated with the internship/preceptorship program. Some programs even offer student payment for participation.


Before the nursing student begins the clinical experience, the nursing staff should receive this information as well as a full description of their role and expectations. Most importantly, the preceptor must know how to evaluate the nursing student. The nursing faculty assigned to oversee the nursing student will communicate with the staff member via telephone and/or e-mail to track the student's progress and will intervene if a problem arises. The faculty member may also randomly visit the clinical unit to speak to both the staff and nursing student. However, there's usually no daily supervision by the faculty.


Curriculum-based critical care clinical rotation

Critical care clinical rotations may also be incorporated into the curriculum of a nursing school. Formal critical care rotations provide a structured clinical experience under the guidance and supervision of nursing faculty. This experience is generally 8 to 10 weeks long. Approximately three to five students may be assigned to a specific unit at one time. The nurse educator is present on the clinical unit at all times and acts as the students' primary resource person and evaluator. The nursing staff works with students assigned to care for patients who are included in their shift assignment. This experience differs from internship experiences because there's usually no formal staff orientation, no advance notice given to the nursing staff, and student evaluations aren't required. Critical care clinical experiences of this nature are unique because one faculty member can't independently and safely supervise three to five students caring for critically ill patients at one time. The nursing staff must closely collaborate with the available nursing faculty to ensure that safe, reliable, and accurate care is provided to all patients.


Understanding the nursing student

Generally, senior-level nursing students who've completed extensive medical-surgical clinical experiences are permitted to participate in nursing student internship programs and clinical rotations in critical care settings. Nursing staff must realize that traditional teaching strategies and teaching models previously used to educate future nurses are changing dramatically. The nursing students seen on clinical units today have likely participated in low- and/or high-fidelity patient simulation activities. Low-fidelity simulation is commonly used to develop psychomotor skills such as urinary catheter insertion on a manikin. In contrast, high-fidelity simulation uses electronically programmed manikins to create specific patient scenarios.


This cutting-edge teaching strategy allows the nursing student to participate in patient situations without the risk of catastrophic outcomes for the patient, similar to the simulations for crisis and code education often used by critical care nurses. The students assess and interpret the patient situation and make decisions based on the information provided. Simulation learning allows students to practice many skills including assessment, psychomotor skills, and clinical decision making, better preparing them to enter the high-acuity critical care environment.


Nursing faculty and staff would agree that it's imperative for nursing students to be oriented to the critical care environment and basic nursing routines prior to the clinical experience. It's of equal importance for the nursing staff to be oriented to the role and expectations of nursing students practicing in the CCUs. Educators need to work with staff to determine how and when to orient staff to the student role and to identify appropriate teaching and evaluation strategies.


Knowledge is everything

Before nursing staff can effectively educate nursing students in the critical care setting, it's essential that they possess basic knowledge related to the nursing student clinical learning process, course content, clinical objectives, and the skills and behaviors used for student evaluation. See Sample course content for a critical care course and Sample student clinical objectives for ideas.


Additionally, it's recommended that before students begin any critical care experience, nursing faculty share with staff the following:


* course syllabus


* course calendar specifically indicating when specific content topics will be covered


* evaluation tools used to evaluate students


* detailed list of the clinical activities and procedures that nursing students are permitted to complete and/or participate in while functioning in the nursing student role in the critical care setting.



Discussing these topics with staff during meetings can be helpful. Providing a folder of these written materials can allow them to be used for staff reference. See What nursing students can- and can't-do in most CCUs for examples of the duties students may take on. These duties may differ from facility to facility. Nursing staff and nursing faculty must check with the employing agency and school of nursing for specific guidelines.


Preparation is key

As nursing staff prepare to begin the mentoring process, it's necessary that they understand the "why" and "how" of nursing student mentoring. The following information and recommendations are also helpful for staff supervising nursing students in critical care settings. Partnerships developed between staff and the nursing student can have a meaningful and lasting impact on the student. These relationships not only impact the development of clinical skills, but the nursing student's future career, if the experience is viewed to be successful and rewarding.


Why should nursing staff educate nursing students?

Clinical teaching by staff nurses enhances role modeling, strengthens the nursing profession, and helps nursing students develop professional nurse characteristics. The goals of the staff nurse and student relationship are developed to enhance the student's nursing knowledge and aid development of a clinician. A direct benefit that may be achieved with a positive educational experience between nursing staff and nursing students is that the student will, in turn, mentor nursing students during her own nursing career.


Becoming a nursing student mentor/preceptor

Staff nurses considering participating in nursing student mentorship programs can express their interest to their unit director or administration. It's recommended that staff nurses considering the option of student mentoring are experienced staff members and have successfully completed a preceptor workshop. Preceptor workshops are commonly offered at healthcare facilities. They're designed to teach staff nurses strategies and skills to help develop a solid foundation to act as a preceptor. Topics in preceptor workshops typically include:


* critical thinking skills


* communication skills


* leadership skills


* theories of adult learning styles


* orientation to the role and responsibilities of a preceptor.



Strategies for success

Becoming a nursing student preceptor can create additional stress for the nurse. The fear and uncertainty of the planned relationship can be eased when the preceptor possesses strategies to facilitate the clinical experience. The staff nurse must also ensure that appropriate clinical decisions and safe, patient care is provided.


The mentor must not only supervise the student but encourage and nurture the student through challenging patient situations; stimulate logical, independent, and critical thinking skills; encourage self-awareness and self-evaluation; offer advice and guidance to promote safe and competent patient-centered care; and collaboratively formulate objectives with the mentee and evaluate her attainment. See Strategies for success for more information. Questions to stimulate student interaction suggests questioning approaches that can be used to help develop critical thinking skills and ensure student understanding of a clinical situation.


Creating staff nurse and nursing faculty partnerships

The goal of clinical education is to foster a dynamic learning environment for the nursing student while maintaining the patient's rights. This is accomplished when professional partnerships are developed between students, nursing faculty, and staff nurses. Educational partnerships require clear communication and delineation of roles. It's important to clarify the roles of the student, the staff nurse, and the nursing faculty to avoid staff nurse role ambiguity and role overload.


Role ambiguity occurs when clarity regarding duties, responsibilities, and/or authority is absent. Role overload may occur due to the complexity of educating nursing students and/or the interrole conflicts staff nurses may experience. Interrole conflict may occur when nurses are assigned simultaneous roles with conflicting expectations, such as student education and providing patient care. In these instances, the nurse educator must actively assist staff nurses in developing strategies to reduce tension and anxiety, which could ultimately lead to a negative clinical teaching experience.


Communication is also an essential component of the educational partnership. Providing multiple opportunities and channels to clarify the process of clinical education between staff and faculty is necessary for the development of a sound learning experience. When communication is ongoing and reciprocal, a trustworthy, meaningful, and mutually beneficial partnership can be developed. Additionally, identification and discussion of barriers that are unique to this partnership must be identified and addressed quickly so communication between staff and faculty isn't abruptly halted. Lastly, faculty should be competent and comfortable with their clinical and educator skills to best ensure a working knowledge of the critical care environment.5


A positive experience for all

Ensuring a positive learning experience for students in critical care areas is an important responsibility for faculty and nursing staff. To facilitate student learning in the critical care area, staff need to understand the various critical care teaching models, the characteristics and skills of students, and their prior learning. Having knowledge about the clinical course, expectations, students, and staff responsibilities will help to reduce confusion for all involved. Staff nurses also need formal mentoring and training to act as preceptors. They need to develop skills for success and establish a collaborative partnership with faculty. For an effective partnership, staff and faculty must work together to plan and implement care and evaluate students. Adherence to these partnership strategies may help ensure a positive learning experience for all.


Sample course content for a critical care course


* Introduction to the critical care environment, role of the critical care nurse, and client population


* Complex cardiovascular disorders: myocardial infarction; cardiovascular surgeries; hemodynamic monitoring systems; basic dysrhythmia and electrocardiogram interpretation; code management


* Complex respiratory disorders: mechanical ventilation; respiratory failure; acute respiratory distress syndrome; arterial blood gas interpretation


* Complex neurological disorders: detailed neurological assessment; increased intracranial pressure; head injury; brain tumors; spinal cord injury


* Complex renal disorders: acute renal failure; chronic kidney disease; peritoneal and hemodialysis; continuous renal replacement therapies


* GI disorders: acute abdomen, acute liver failure, acute pancreatitis, GI bleeding


* Multisystem organ failure: shock states; organ transplantation; traumatic injuries.


Sample student clinical objectives

The nursing student will provide patient-centered care in complex, high-acuity situations.


* Maintains a safe, effective care environment.


* Uses standard precautions at all times.


* Maintains patients' dignity, privacy, and confidentiality.


* Demonstrates caring behavior toward the patient and family.


* Implements the prescribed care plan.


* Performs nursing skills and uses technology competently.


* Demonstrates a basic understanding of hemodynamic monitoring systems.



What nursing students can-and can't-do in most CCUs5

Students can:


* update a patient's chart per hospital guidelines


* administer all routine, p.r.n., narcotic, and STAT medications, including all routes of administration. All medications must be verified by faculty or nursing staff prior to administration.


* initiate administration of vasoactive or narcotic medications with faculty or nursing staff present


* titrate I.V. medication with faculty or nursing staff present


* perform CPR


* perform leveling and zeroing of hemodynamic monitoring


* draw blood from peripheral, central, and/or arterial lines under the supervision of faculty or nursing staff


* insert a nasogastric and/or duodenum tube


* perform I.V. insertion and/or venipuncture


* provide all routine care required by a patient who's mechanically ventilated.


Students can't:


* administer blood transfusions


* verify blood, insulin, vasoactive medications, or patient-controlled analgesia pumps for accuracy


* administer fibrinolytics, experimental medication, emergency antiarrhythmic medications, chemotherapy agents, or emergency medications


* perform cardiac output or pulmonary artery wedge pressure readings.


Strategies for success


* Share stories and examples.


* Follow the rule of the seven Bs: Be approachable, be available, be credible, be focused, be reliable, be specific, and be vulnerable.


* Don't pretend to know when you don't.


* Model appropriate behaviors and demonstrate professionalism.


* Learn from the student.


* Listen closely to the student and maintain an open mind.


* Clarify when in doubt.


* Set boundaries.


* Offer constructive criticism.


* Clearly articulate expectations.


Questions to stimulate student interaction


* How are you feeling? Are you nervous or scared?


* What are your concerns?


* What are the steps for that procedure?


* Tell me about the patient, his needs, and your nursing care.


* What is your plan of care?


* What are you going to do next? Why?


* Why was that treatment and/or procedure ordered for the patient?


* Why was that medication ordered for the patient?


* Do you know where to start?




1. American Association of Critical-Care Nurses. About critical care nursing. Available at: Accessed October 2, 2007. [Context Link]


2. Kelley MA, Angus D, Chalfin DB, et al. The critical care crisis in the United States: A report from the profession. Chest. 2004;125(14):1514-1517. [Context Link]


3. Maiocco G. From classroom to CCU. Nurs Manage. 2003;34(3):54,56-57. [Context Link]


4. Gross C, Anderson C. Critical care practicum: An essential component in baccalaureate nursing programs. Nurs Educ Perspect. 2004;29(5):199-202. [Context Link]


5. Langan JC. Faculty practice and roles of staff nurses and clinical faculty in nursing student learning. J Prof Nurs. 2003;19(2):76-84. [Context Link]