Step-Down Travel Nurse Career Guide

Step-Down Travel Nurse Career Overview

Step-down unit travel nurses have their hands busy caring for patients who live on the brink of needing higher-leveled care in the intensive care unit. Because of this, these versatile and proficient nurses straddle the fine line between critical care nursing and floor nursing. The definition of a step-down unit has evolved since the 1980s; today, depending on the hospital, step-down may also be referred to as an intermediate care unit (IMC), a transitional care unit (TCU), or a progressive care unit (PCU).

Step-Down Travel RN Jobs With Nomad Health

At Nomad, step-down travel nurse jobs rank as the second most popular category out of over 40 different specialties. Now with Nomad’s mobile app, it’s easier than ever to filter through hundreds of step-down travel nursing jobs for pay, best location, ideal length of contract, and shift preference. Aside from plentiful job options, we offer our travelers a full package of benefits such as medical, vision, dental, and malpractice insurance. Step-down travel nurses can also enjoy travel reimbursement of up to $1,000, a stipend for housing and utilities, and state license and certification reimbursement.

Step-Down Travel Nurse Job Description

Step-down travel nurses are excellent at time management and accomplish a lot for their patients in a single shift. They document and perform comprehensive assessments frequently, manage medical devices and troubleshoot them, administer medications, perform complex wound care, and encourage patient mobility. They respond to medical emergencies and communicate with the physician team to escalate their patients to the ICU if they begin to decompensate. Step-down travel nurses also offer compassionate and culturally-sensitive support for their patients and the family's psychosocial needs.

Step-down travel nursing jobs differ from staff nursing jobs in that travel nurses are able to choose flexibly between day or night shifts, access better pay, work in different hospitals nationwide, and take breaks for longer spans of time. These differences make step-down travel nursing a very attractive and rewarding career choice for nurses.

Step-Down Travel Nurse Skills

The requirements of a step-down travel nurse job encompass managing medical devices, utilizing core nursing skills, and collaborating with a large team of clinicians. Some of the most common medical devices used by step-down travel nurses are bilevel positive airway pressure (BiPAP), hi-flow nasal cannula, ventilators, and tracheostomies. 

Bilevel Positive Airway Pressure (BiPAP)

BiPAP is a form of non-invasive ventilation that gives extra support during inspiration and exhalation to assist with the delivery of air and oxygen. Patients with medical conditions such as chronic obstructive pulmonary disease (COPD) and pulmonary edema can benefit greatly from this treatment. Step-down travel nurses may be expected to know the basic settings of this therapy, along with knowing how to fit a patient with an appropriately sized mask, and troubleshooting any mask or machine alarms. Nurses work in tandem with respiratory therapists to run this device.

Hi-Flow Nasal Cannula

Hi-flow nasal cannula (HFNC) is a form of supplemental oxygen that can deliver 100% humidified and heated oxygen at a high flow rate. This therapy can be beneficial for patients who require support but aren’t ready for a ventilator. HFNC works to decrease the pressure of the nasopharyngeal airway so that oxygen can be delivered more effectively, while also allowing greater alveolar recruitment so the exchange of oxygen and carbon dioxide can occur more efficiently. Patients with acute respiratory distress syndrome (ARDS), like COVID-19 patients, may benefit from this therapy. 

Step-down travel nurses will conduct comprehensive cardio-pulmonary assessments and evaluate the patient’s response to this treatment. They may have to set up and operate a hi-flow nasal cannula machine, and collaborate with respiratory therapists and physicians to maintain therapeutic treatment.

Ventilators and Tracheostomies

Although more commonly seen in intensive care units (ICU), step-down travel nurses may encounter an occasional ventilator depending on the facility. These ventilated patients may be considered more stable and easier to manage, but a step-down travel nurse should know how to suction the patient, perform oral care, prevent mucus plugs, identify tube occlusions, and evaluate patient responses to ventilator setting changes. In some cases, patients may be weaned off of the ventilator, so it’s important to have knowledge of weaning protocols. Nurses should be familiar with best practices for preventing complications related to ventilator use such as venous thromboembolism (VTE), pneumonia, pressure injury, and aspiration.

Some patients may be transferred from the ICU on a ventilator attached to a tracheostomy. A tracheostomy is a surgically placed opening in the anterior trachea used to facilitate breathing. Patients in the ICU may have started with an endotracheal (ET) tube in the mouth. Some eventually require a tracheostomy in the neck if the need for invasive breathing support is prolonged. A step-down travel nurse is expected to be familiar with how to clean a tracheostomy, change the inner cannula, perform deep-suctioning, and troubleshoot any attachment issues with the ventilator. Step-down travel nurses will know how to ensure a safe environment for tracheostomy patients by placing an extra tracheostomy cannula at the head of the bed, securing an Ambu bag with a peep valve, and preparing clean and functional suction canisters with catheters at the bedside.

Core Nursing Skills

Commonly utilized nursing skills by travel step-down RNs include performing comprehensive head-to-toe assessments, interpreting ECG patterns, ensuring adequate nutrition, monitoring medication reactions and adverse effects, interpreting lab values and trends, collaborating with multiple disciplines on the care team, and providing culturally sensitive communication to patients and their families. Like ICU nurses, they may encounter central lines and arterial lines in their patients, especially after a procedure or an operation. Being comfortable with responding to emergency situations is vital as well. Patients may suddenly go into lethal heart arrhythmias and require accurate ECG interpretation and medication administration or need rapid intubation for respiratory failure.

Medication Management

A core skill of step-down travel nursing is administering oral, nasogastric tube (NGT), and intravenous medications appropriately. Many of the patients receive multiple vasoactive drips through peripheral and central line access. These drips need to be checked for adverse interactions with each other and may need to be titrated frequently to reach a therapeutic goal as directed by the provider’s order.

Multidisciplinary Teamwork

In order to care for their patients, step-down travel nurses collaborate with multiple disciplines such as physical therapists, surgeons, occupational therapists, respiratory therapists, speech-language pathologists, nurse practitioners, and physician’s assistants (PA). Step-down nurses utilize evidence-based communication tools recommended by the Agency for Healthcare Research and Quality (AHRQ), such as the CUS tool and the SBAR method, to advocate for their patients to other team members.

Types of Step-Down RN Travel Jobs

A step-down unit is a unique place where many different types of patients come from all over the hospital; some patients are directly admitted from the ER, others are upgraded from med-surg, and some are downgraded from the ICU, but still require close monitoring and nursing interventions. Because of this diversity, there are multiple specialties that step-down travel nurses can work, such as cardiac and progressive care. Take a look at some of the different kinds of step-down travel nursing specialties.

PCU Step-Down Travel RN

Progressive care unit (PCU) step-down nurses are strong, clinically adept nurses. According to the American Association of Critical Care Nursing (AACN), a progressive care unit (PCU) has patients that 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 an increased intensity of care.” 

Step-down travel nurses in these settings commonly provide care to patients with conditions such as seizures, diabetes insipidus, alcohol withdrawal, dialysis-dependent end-stage renal failure, flash pulmonary edema, sepsis, heart failure, and COPD (chronic obstructive pulmonary exacerbation). Some patients may be post-procedural from a thoracentesis or chest tube placement. Furthermore, some may require supportive medical devices such as high-flow nasal cannula (HFNC) or bilevel-positive airway pressure (BIPAP). Others may be on ventilators and have tracheostomies from failing weaning trials in the ICU; PCU step-down travel nurses are expected to know how to manage these devices.

A successful PCU step-down travel nurse will have a solid foundation in skills such as cardiac monitoring and ECG interpretation, basic and advanced cardiac life support, arterial blood gas (ABG) interpretation, titration of vasoactive medication such as nitroglycerin, management of high-risk drugs like insulin, and administration of conscious sedation. Like ICU travel nurses, PCU step-down travel nurses are vigilant and anticipate the needs of their patients, as conditions may change in the blink of an eye. Having an accurate baseline assessment, identifying emerging changes, and intervening promptly are vital nursing skills. 

A PCU step-down nurse may have a nurse-to-patient ratio of 1:3, or even 1:4 depending on the facility policy and the needs of the floor that day. To qualify for a travel PCU step-down job with Nomad, you must have a minimum of 12 months of recent PCU experience in the last two years, plus BLS and ACLS certifications. Some hospitals may require you to be able to float to other units.

Cardiac Step-Down Travel RN

Cardiac step-down travel nurses have the same capabilities as PCU step-down travel nurses, but their strengths lie in caring for patients with a myriad of cardiac-related conditions; for example, many patients may come to the cardiac step-down with symptomatic arrhythmias or immediately after planned cardioversion, transesophageal echocardiograms (TEE), cardiac catheterization with percutaneous coronary intervention (PCI), and pacemaker or automatic implantable cardioverter defibrillator (AICD) placement. 

Beyond cardiac procedures, some patients may come to the step-down after major pulmonary procedures such as lung transplants, lobectomies, and pneumonectomies. The cardiac step-down travel nurse will perform comprehensive assessments and monitor vital signs at a minimum of every two hours, or more frequently based on nursing judgment. In some cases, the patient may have an arterial line and central line present, which the cardiac step-down nurse will troubleshoot and manage.

Cardiac step-down patients often have antiarrhythmic and/or vasoactive medications running to help keep them stable. Cardiac step-down travel nurses are familiar with the pharmacology and protocols related to drip medications like diltiazem, labetalol, amiodarone, heparin, furosemide, nitroglycerin, milrinone, dobutamine, and intravenous antibiotics. 

Another part of working in a cardiac step-down unit is managing frequent admissions and discharges. Cardiac stepdown travel nurses understand the fast-paced nature of how quickly a patient’s condition can change. Patients may need to upgrade to a higher level of care like CVICU or downgrade to a lower level of care like med-surg within a single shift. 

Cardiac stepdown travel nurses are usually on a 1:3 or 1:4 nurse-to-patient ratio. With Nomad, travel nurses are expected to have BLS, ACLS, and 12-24 recent months of cardiac step-down nursing experience. For some facilities, travel nurses with previous ICU experience are preferred.

Neuro Step-Down Travel RN

Similar to cardiac step-down travel nurses, neuro step-down travel nurses are specialists in managing a wide range of neurological and neurosurgical conditions. Some of the most commonly seen medical conditions are stroke, cerebral hemorrhage, transient ischemic attack (TIA), spinal fusion, laminectomy, myasthenia gravis, and multiple sclerosis. 

Neuro step-down travel nurses are familiar with post-op brain surgery procedures, post-cerebral angiography procedures, spinal precautions, seizure and aspiration precautions, and knowing about situations that can increase intracranial pressure (ICP).

Some core nursing assessment skills for neuro step-down travel nurses are assessing cranial nerves and reflexes, utilizing the Glasgow Coma Scale (GCS),  performing fall risk and aspiration risk assessments, evaluating patients with the National Institute of Health Stroke Scale (NIHSS), and doing bedside swallow studies. They must also be familiar with evidence-based guidelines regarding ischemic and hemorrhagic strokes.

Neuro step-down patients may have antiarrhythmic, anticoagulant, and vasoactive medication drips that need constant titration. Neuro step-down travel nurses are familiar with the pharmacology and protocols related to drip medications like heparin, nitroglycerin, mannitol, amiodarone, nicardipine, labetalol, and intravenous antibiotics. They will administer medications and monitor blood pressure closely to promote cerebral perfusion according to evidence-based practice guidelines.

When traveling with Nomad, neuro step-down nurses usually have a 1:3 or 1:4 nurse-to-patient ratio; travel nurses are expected to have BLS, ACLS, and a minimum of 12-24 recent months of neuro step-down travel nursing experience.

Step-Down Travel Nurse Salary Information

A step-down travel nurse with Nomad makes approximately an average of $2,400 a week, or $64 per hour. That means for a typical 13-week assignment, the gross pay could be $33,000 or more.* 

There are multiple ways to boost your salary as a step-down travel nurse, such as choosing between different facilities and obtaining certifications, like the PCCN and the CCRN. Select facilities prefer their step-down travel nurses to have the ability to float to other units such as med-surg and ICU. Gaining additional clinical experience in these specialties can increase your assignment options.

*Subject to change. Based on the average pay of Nomad Health step-down travel nurse job postings as of March 13, 2023.

Highest-Paying Step-Down Travel Nurse Jobs

For Nomad, the highest paying step-down travel nursing jobs average $3,848 a week, or $83 per hour. That means for a typical 13-week assignment, the gross pay could be approximately $50,000.*

The highest-paying states for step-down travel nurse jobs with Nomad right now are located in New Hampshire, Minnesota, and California. We know that having great, transparent pay is an essential part of finding the best travel assignment, so we’ve ensured that you can filter by the highest pay, amongst other factors. As a digital healthcare talent agency that doesn’t use recruiters, we’re able to shift our resources into putting more money in the clinician’s pocket.

*Subject to change. Based on the highest pay of Nomad Health step-down travel nurse job postings as of March 13, 2023.

How to Become a Step-Down Unit Travel Nurse

Step 1: Get Your Nursing Degree

Your first step to becoming a step-down travel nurse is getting your Bachelor of Science in Nursing (BSN) from an accredited four-year university. You can also get an Associate’s Degree in Nursing (ADN) from an accredited two-year university, although some hospitals prefer a BSN-trained nurse over an ADN-trained nurse.

Step 2: Pass the NCLEX

After graduating, you’ll have to pass the National Council Licensure Examination - RN (NCLEX-RN) in order to become a registered nurse in any state. Once you have your initial nursing license in hand, you can always apply for other state licenses or for a multistate license with the Nurse Licensure Compact (NLC).

Step 3: Gain Step-Down Nursing Experience

One of the most important requirements for step-down travel nursing is to acquire full-time experience in a step-down unit for at least 12 to 24 months. As a new nurse, you can join a step-down nurse residency program; these programs will provide clinical experience along with classroom and simulation lab-based learning opportunities specific to your specialty. 

For experienced nurses, joining a nursing fellowship is also an excellent option to transition into step-down nursing. Nursing fellowships offer newly hired nurses a dedicated preceptor and extra education to ensure a smooth transition. You can always start in a different inpatient setting like the emergency room, ICU, or med-surg before transferring to step-down. Before venturing into travel nursing, you want to have at least one to two years of solid step-down nursing experience in any specialty and most importantly, feel comfortable and confident in your skills.

Step 4: Earn Certifications

Obtaining the Progressive Care Certified Nurse (PCCN) credential with the American Association of Critical-Care Nurses (AACN) can demonstrate a commitment to clinical excellence in progressive care nursing to other nurses and facilities. This exam requires step-down nurses to have an unencumbered nursing license, along with either 1,750 hours of direct acutely ill adult patient care experience over two years, or 2,000 hours of direct acutely ill adult patient care experience over five years.

Step-Down Travel Nurse Healthcare Sources

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• American Association of Critical-Care Nurses. (n.d.). PCCN Certification. Retrieved from https://www.aacn.org/certification/get-certified/pccn-adult

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• Akgun, K. M., Crothers, K., Pisani, M. A., & Justice, A. C. (2017). Chronic obstructive pulmonary disease and HIV: a review of the literature and a case report. Journal of Medical Cases, 8(5), 155-160. doi: 10.14740/jmc2821w. PMID: 28892716. PMCID: PMC5572596. Available from https://pubmed.ncbi.nlm.nih.gov/28892716/

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