A Critical Role

“Sometimes we have hours of advance notice. Sometimes moments.”

That’s the way Ellen Dreibelbis, AGACNP-BC, Nu’11, GNu’20 describes how long a Penn Medicine surgical and trauma critical care team has to prepare for a patient in the intensive care unit (ICU). Someone with a traumatic brain injury from a car accident. A woman who just had a liver transplant. A man with a gunshot wound.

The critically ill patient might come from the emergency department or arrive from surgery. They may be transferred from another facility that didn’t have the resources to treat them. Dreibelbis’s team acts fast to manage airways and blood pressure. They collaborate with specialty services and arrange for surgeries, if necessary. Post-surgery, they closely monitor for signs of complications.

The team Dreibelbis works on covers three hospitals in Philadelphia: the Hospital of the University of Pennsylvania (HUP), Penn Presbyterian Medical Center, and Pennsylvania Hospital. Penn Medicine’s ICUs are organized into specialties, including medical, surgical, neuro, and heart and vascular. In these units, bedside nurses focus intently on one to two patients, while nurse practitioners like Dreibelbis work with each of them, overseeing care.

Though critical care nurses can be found working throughout the U.S. healthcare system, most are drawn to ICUs where they care for the sickest of the sick patients, who need constant monitoring, continual interventions, and the support of cutting-edge technology.

“You’re checking vital signs every 15 minutes, or every hour at a minimum, because things can change so drastically,” says James Ballinghoff, DNP, MBA, RN, NEA-BC, GRN’17, University of Pennsylvania Health System Chief Nurse Executive. “It can be a matter of life and death at any moment. [Nurses] get to work with the technological bells and whistles that give you data to analyze and intervene, but you have to be able to pivot very quickly with the information that you’re given.”

The cases are complex. Often, multiple body systems are affected. Mechanical ventilators help people breathe. Sophisticated heart-lung machines allow blood to be oxygenated outside the body, so a patient’s organs can rest. Critical care nurse practitioners use tools such as ultrasounds and echocardiograms at the bedside to assess, prescribe medications, and advance care plans day-by-day. “It’s like a puzzle, where you’re trying to put all the different data together to figure out and diagnose what’s going on with the patient,” Dreibelbis says.

With patients intubated or sedated, Dreibelbis’s team communicates with their families about their status. She believes it’s important to get a sense of the person underneath the machinery. Recently, she learned a patient, an older gentleman, loved to ride his motorcycle.

“So to have that frame of mind—this was someone that last week was riding their motorcycle and now they’re very severely sick—that gives us a goal. How can we get them back to that?” she says.

ICU patients who recover may not even remember their first hours or days in the ICU. But, she says, “it’s very rewarding to play a role in taking care of patients who are so critically ill. Especially with trauma patients. Within a matter of seconds, the trajectory of their lives has been completely altered. It’s always amazing when you see them get better,” she says.

Preparing Nurses for Critical Care

There’s no such thing as “too soon” when it comes to pursuing a critical care nursing career, says Amanda Bettencourt, PhD, APRN, CCRN-K, ACCNS-P, GRu’19. As an Assistant Professor, she dispels myths students may have about whether they can go into critical care roles right after graduating.

“I always share with them that I did that. Penn is preparing exceptional nurses, and I think each one of them is a leader in their own right,” says Bettencourt, who is currently serving as president of the American Association of Critical-Care Nurses (AACN) board of directors. “I always encourage students to let go of this idea that they have to do other things before they could do critical care. If that’s what they’re passionate about, that’s what they love, then go for it.”

There’s certainly a need.

“We have a growing number of ICU beds in the country and patients with ICU needs filling those beds,” says Jessica Strohm Farber, DNP, CRNP, CRNP-AC, PPCNPBC, CCRN, CFRN, CMTE, Nu’94, DNU’99. Strohm Farber is a nurse practitioner at Children’s Hospital of Philadelphia (CHOP) and Program Director of Penn’s Pediatric Acute Care Nurse Practitioner Program. “We need to make sure we’re continuing to prepare enough providers to take care of those patients, both as bedside nurses as well as advanced practice nurses.”

Penn Nursing’s baccalaureate programs allow students to gain experience by requesting a clinical rotation in adult or pediatric ICUs. And most hospitals have residency programs in critical care for new-to-practice nurses. For example, Penn Medicine’s Gateway to Critical Care Program offers classroom instruction, workshops, and clinical experience over 16 to 20 weeks.

“All critical care nurses receive extensive training in their specialty area to ensure they have the knowledge, skills, and attitude to effectively care for this very complex and challenging patient population,” Ballinghoff says of Penn Medicine’s approach.

For nurses who want to pursue a higher degree and advance their practice, Penn Nursing has three paths: the Adult Gerontology Acute Care Nurse Practitioner program (AGACNP), the Streamlined Adult Gerontology Acute Care NP Post-Graduate program, and the Pediatric Acute Care Nurse Practitioner program.

“I always encourage students to let go of this idea that they have to do other things before they could do critical care. If that’s what they’re passionate about, that’s what they love, then go for it.”

AGACNP and the pediatric program take a little over one year to complete at a full-time pace, but both also offer part-time flexibility. There’s didactic and clinical curriculum, with in-person classes taught by accomplished faculty and lecturers who are leading practitioners, educators, and researchers in their field, skills labs with expert specialists, and high-fidelity simulations that are held at the Helene Fuld Pavilion for Innovative Learning and Simulation.

Pediatric students can choose from one of three concentrations: oncology, critical care, and acute chronic.

“A lot of times our students come to school looking to specialize. There’s no ‘introduction to critical care.’ They are high-achieving nurses at the bedside who want to take this next step,” explains Kerry Shields, MSN, CRNP, GNu’03. Shields is the Associate Program Director of the critical care concentration, and a nurse practitioner at CHOP. “They’re sitting in the classroom after practicing, and light bulbs go off because they think ‘I’ve seen that. Now I know why that happens.”

Students can also shape their own education. When Janakiram “Jani” Rameswaran, MSN, MPH, CPNP-AC, CCRN, CPEN, PHRN, MPH’21, GNu’22 wanted to combine his passions, he spoke with Strohm and Shields and ended up combining a master’s in nursing and master’s of public health.

“I really wanted to bring together pediatric critical care and community health,” Rameswaran says. “The combination hadn’t been done before. But they were very enthusiastic about helping me make this a dual degree program of my own. I was able to bring my clinical experiences into the public health classroom and my MPH program really helped me approach the NP coursework with a public health lens.”

To prepare nurses for adult patients, the School once had separate programs for acute care and critical care, but they blended those in 2000. In today’s health care environment, says Practice Assistant Professor Patricia Pawlow, PhD, ACNP, BC, GNu’94, GRN’20, “it’s hard to separate out acutely ill and critically ill. Even though some of our graduates may work in an ICU, some may work on floors, or even with outpatients. But they’re taking care of patients who could decompensate, who could get critically ill, quickly. And so they have to be prepared to take care of all of those patients,” explains Pawlow, who will become the program director in July.

The school works closely with students in the AGACNP and pediatric programs, to arrange clinical placements with preceptors around the country.

“We don’t have a prescribed way of moving through clinical, so no two students have the same clinical sequence of rotations,” says Patricia Griffith, MSN, CRNP, ACNP-BC, GNu’94, who manages placements for the adult program. (Griffith will become associate director for the AGACNP program in July.) “There’s so much to experience out there, and we let students give us some direction about how they want to progress, and we guide them. It’s personalized. We also find preceptors for students, which is helpful to them to know that we’re going to take care of that.”

Students in both programs also sharpen their research skills through projects that prompt them to examine clinical questions and consider how research is translated into practice. “We give our students the advantage of seeing the power of nurse-led research on patient outcomes,” says Professor Martha A. Q. Curley, PhD, RN, FAAN, who engages with students at all levels on pediatric critical care research.

Jarae Payne, MSN, CRNP, GNu’20 was at the bedside in CHOP’s cardiac intensive care unit for five years before she was drawn to enroll in the pediatric program part-time. She says she never thought she’d pursue publishing, but that quickly changed. In 2022, her examination of at-home administration of milrinone for cardiac support was published in Pediatric Nursing. Today, she’s a nurse practitioner in the same unit, and she’s working with a physician-mentor to look at rates of necrotizing enterocolitis in single ventricle neonates.

“The program made sure research was an integral part, and developing that skill for us was very helpful and very empowering. It made me realize I can do it. I have the tools,” Payne says. Exploring nurses’ clinical questions, she adds, “can help make patients safer.”

One course is particularly popular with both the AGACNP and the pediatric nurse practitioner students— and it happens to be one they take together. Advanced Technologies & Clinical Decisions in Acute Care covers all the technologies that patients may require while they’re in an ICU, and their risks and benefits.

“They’re taking care of patients who could decompensate, who could get critically ill, quickly. And so they have to be prepared to take care of all of those patients.”

“It’s a really nice opportunity for the adult and the pediatric students to learn from one another, and really learn about differences in practices even within critical care. We use many of the same technologies, but differently with different ages,” Shields explains.

That experience is particularly relevant in today’s critical care environment.

“In the beginning of the pandemic there were adults being taken care of in pediatric ICUs, and a lot of pediatric critical care nurses were moved to adult units, or their units became adult units,” Shields notes. “Then with the respiratory viral surge we’ve seen this past fall, a lot of children were being cared for in adult emergency departments and adult units because there weren’t available beds in some areas of the country in children’s hospitals.”

“I look at things a lot differently than how I would have before. If you want to be a better clinician, then your knowledge base must be on point. It just helps your overall clinical judgment and expertise.”

Graduates who go on to work in the Penn Medicine system have plenty of chances to continue their learning with post-graduate fellowships. There’s the year-long Penn Medicine Advanced Practice Provider Critical Care Fellowship that sees NPs and PAs rotate through every specialty ICU. CHOP offers a 16-week fellowship program for new graduate NPs and PAs, a mix of didactic classes and clinical experiences for the transition into the new provider role.

The Streamlined AGACNP Post-Graduate program is the newest of the offerings and was developed in response to the National Council of State Boards of Nursing sponsored 2008 Consensus Model for APRN Regulation, which called for nurse practitioners to align their scope of practice with the types of patients they are managing.

That meant many nurse practitioners with primary care training, even those with ICU experience, found themselves in need of further formal education and certification. While not every state mandates the Consensus Model guidelines, many hospital systems have embraced them.

“Penn Medicine hospitals jumped on it right away,” says Professor Deborah Becker, PhD, ACNP, BC, FAAN, GNu’91, AGACNP Program Director. “We worked together, with our UPHS partners, to come up with our Streamlined program.”

The Streamlined program consists of asynchronous online courses and requires 250-500 clinical experience hours, depending on previous primary care training. Pawlow recalls when they launched, some students “weren’t happy they were being required to go back to school.” But she noted that as they worked through the content, there was a change. “They could see the benefit.”

That resonates with Janelle Gibson, DNP, APN-C, GNu’22. She applied for the Streamlined program to pursue a goal of working in the medical ICU at Newark Beth Israel Medical Center, which requires acute care certification. But she admits she was hesitant at first.

“I got my DNP in 2019, and in 2014, I graduated with my NP. So I felt like, oh my God, I have to go back to school again,” Gibson says. However, it was soon clear that she was gaining important knowledge—from looking at a CT scan to manage a patient with a subdural hematoma, to deciding care for a decompensated liver cirrhosis patient.

“Even the stuff that I thought I knew. For example, I learned a different way to look at a blood gas. I never used a Winter’s Formula to calculate anything,” Gibson says. “Now I look at ABGs, I look at chemistries, I look at things a lot differently than how I would have before. If you want to be a better clinician, then your knowledge base must be on point. It just helps your overall clinical judgment and expertise.”

Influencing a Field, Yesterday and Today

Penn Nursing has a long history of influencing the field of critical care. This legacy continues to the present day, with faculty and alumni leading cutting-edge research.

The AGACNP and pediatric acute care programs were among the first to develop critical and acute care nurse practitioners, in the 1990s. Rosalyn Watts, EDD, FAAN, RN, Associate Professor Emerita of Nursing, led the shaping of the first iteration for adult gerontology, and Jane Barnsteiner, PhD, RN, FAAN, Nu’70, GNu’73 created the pediatric program. Barnsteiner, a former Director of Nursing Practice and Research at CHOP and Director of Nursing for Translational Research for the University of Pennsylvania Health System, was recently named a Living Legend by the American Academy of Nursing.

“Roz Watts, Anne Keene, and Jane Barnsteiner were thought leaders in saying we need to do this,” says Therese Richmond, PhD, RN, FAAN, GRN’95, Associate Dean for Research & Innovation. “I had colleagues out in California calling me up saying, ‘What are you doing? How?’ It’s a tribute to Penn Nursing.”

Ultimately, the graduates of the programs needed to be board certified. And once again Penn Nursing, collaborating with a few other universities, Richmond says, “was right in the mix.”

She represented the AACN Certification Corporation in helping to create the American Nurses Credentialing Center’s first certification program.

The school’s positive impact on the field of critical care is not lost on the students.

“I was fortunate enough to have Dr. Maureen Madden as my clinical preceptor at Robert Wood Johnson University Hospital. She is a pioneer in the pediatric nurse practitioner world. Her name is on our textbooks, so it was intimidating walking in on that first day,” Rameswaran says. Madden, DNP, RN, CPNP-AC, CCRN, FCCM, GNu’94 co-authored Pediatric Acute Care: A Guide for Interprofessional Practice. “She took me under her wing, and she still continues to give me advice.”

L—R:Deborah Becker GNu’91 GNC’98; Patricia Pawlow GNu’94 GNu’15 GR’20; David (Hyunmin) Yu GNu’18; Jani Rameswaran GR’21 GNu’22; Patricia Griffith GNu’94 GNu’18; Leonard Mancini Nu’10 GNu’17

Also in pediatrics, Strohm Farber says, Sharon Irving, PhD, CRNP, FCCM, FAAN, FASPEN, GNu’93, GRN’11 has been “instrumental in writing some of the guidelines for nutrition in pediatric ICUs and moving that practice forward not only nationally, but internationally. One of the unique things about kids who are ill and healing—they’re growing too.”

Guidelines and systems are key. “Unless we have valid and reliable tools to better describe critically ill patients’ phenomena or risk, nurses can’t lead in intervening to decrease patients’ risks or better describe patients’ status,” says Curley, who received the 2022 Asmund S. Laerdal Memorial Lecture Award from the Society of Critical Care Medicine.

Before Curley collaborated on the development of the State Behavioral Scale (SBS), there wasn’t an instrument for nurses and others to use to describe a critically ill child’s level of sedation. Similarly, she designed the Braden QD Scale so that nurses could identify a pediatric patient’s risk for pressure injuries related to immobility or the use of medical devices—and then implement interventions to prevent such injuries.

Curley’s longtime interest in how nurses use sedation to manage critically ill children was behind her leading of the RESTORE trial. When she first started practicing, Curley says, heavily instrumented patients in the ICU were “essentially rendered unconscious through sedation to keep them immobile. We learned that if you lighten all that sedation up and you help parents interact with the kids while they were critically ill, that you could get by with less sedation.” Curley also evaluated how nurses can control the environment in a way that embeds a child’s normal rhythms into the pediatric ICU. “We are getting ready to publish what worked and what didn’t,” she says. “And then we will be able to implement strategies to help make the ICU a little bit more tolerable to critically ill infants and children.”

“There has to be a recognition that we need more acute care nurses and acute care advanced practice providers.”

According to Becker, the AGACNP program regularly incorporates the work of faculty into lectures and coursework— including health policy research by Matthew D. McHugh, PhD, JD, MPH, RN, CRNP, FAAN, GNu’98, GRN’04, and Mary D. Naylor’s, PhD, RN, FAAN, GNu’73, GRN’82 transitional care model. She also cites the work of Amy M. Sawyer, PhD, RN, GRN’07 on patient sleep in the ICU, and Professor Emerita Lois Evans’s, PhD, FAAN, RN influence on moving away from physically restraining critically ill patients. And, “hot off the presses,” is how Becker characterizes the recent introduction of Patricia Griffith’s de-biasing strategies for diagnosing patients.

Becker herself has played a role in helping to define critical care nursing on an international scale. She and Pawlow were part of a team that helped Linkoping University in Sweden develop an acute care program for nurse practitioners.

In the ICU

ICUs have been challenging places to work since the first units were established in the 1950s, and they have made headlines more recently for overflowing capacity during the pandemic and the fall RSV surge.

Further, nurses who’ve been in the field for decades say those “sickest of the sick” are sicker today than they were decades ago. Part of the reason is advancements in medicine and technology.

“Many of those patients in the past probably would’ve died. And now we’re able to keep them alive,” Ballinghoff says. Becker hopes that the U.S. emphasis on primary care will make the patient population healthier, but she guesses that will take a few decades. Meanwhile, she says, “there has to be a recognition that we need more acute care nurses and acute care advanced practice providers.”

Though the pandemic raised public awareness somewhat, Becker still worries that when people hear nursing shortage, they don’t realize that “we’re talking about acute and critical care prepared nurses. We’re talking about the patients who actually need the most nurses.”

She points out there are no scholarships for students preparing to be acute care nurse practitioners. “We need to find ways to provide more financial support for individuals who are interested in non-primary care education,” she says. Meanwhile, she has the perfect recruiting pitch. “When I started nursing there were diseases and specialties and subspecialties. Now there are sub-sub-specialties. Not only cardiac care, but a particular arrhythmia. The specialties are getting more and more refined, and you can really find your niche. There are hundreds of opportunities.”