ICU in community hospital VS. Stepdown in academic hospital?

  1. 1
    Hi to all ICU RN's/CRNA's,

    I'm a new grad with full-time immersion experience in the ICU and am hoping to become a CRNA one day. I know that I'll need to get experience in the ICU as a prerequisite, however I do have a dilemma that I would appreciate some advice on:

    I have a job offer in an ICU at a smaller community hospital (where I did my immersion) and a potential job offer on a stepdown unit at a large, university teaching hospital. I am stuck in between the two because I feel that the patient acuity in the smaller hospital would not give me enough learning experience to prepare me for CRNA school (~30% mechanically ventilated, but more opportunities for titratable drips/ART)---most of the very critical patients are transferred out into teaching hospitals and we also get stepdown patients since the hospital doesn't have a stepdown unit. If I take the job offer, I THINK I might have to eventually apply to a teaching hospital's ICU in order to gain adequate experience.

    On the other hand, the teaching hospital would give me a wider range of learning experiences but I might have to start on a stepdown unit and not be guaranteed an internal transfer to an ICU. So I might lose some time in the ICU. If I choose this option, I hope to transfer to an ICU in less than a year.

    So my question from your experience, is it better to start at smaller hosp ICU and apply to larger hosp later? or it is better/realistic to start at the larger hospital's stepdown and do internal transfer?

    which would be a better/quicker/more "guaranteed" option to gaining ICU experience that would ultimately benefit my goal of becoming an ICU nurse and becoming a CRNA one day? This is simply a question of which would be a better option to get to my career goal and not where I can "get my feet wet" as I am very confident I will be able to pick up skills quickly even if I am to start in an ICU immediately.

    Any insight would be helpful! Thanks!
    Joe V likes this.
  2. Poll: ICU in community hospital vs. Stepdown in academic? (goal: ICU RN in teaching hosp.)

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  5. 10 Comments so far...

  6. 4
    I'm not a CRNA yet, but will be starting school in a couple months. I started off in a small community ICU where I transferred in from the ER. After gaining some experience there, I moved on to a large teaching hospital in the surgical/trauma ICU. I would recommend taking the ICU job and moving on when you are ready. This will help build a nice foundation for and get your foot in the door so to speak. This time will also count as your critical care experience. As you mentioned, there is no guarantee about an a transfer. The facility I work at will not let you transfer unless you have been there for at least six months and have no marks against your record. I have met people who wanted to transfer to different units, but were denied due to marks on their record.

    I personally think the previous ICU experience helped me land the job at the teaching hospital because they don't have to invest as much time and money into you as a new grad or transfer from another floor.

    The only "guarantee" option to getting ICU experience is to work in an ICU. They type of ICU experience that programs want vary from program to program.
    CPhT2RNstudent, opossum, LindseyRN86, and 1 other like this.
  7. 4
    I agree with the above. You will learn a lot in a smaller hospital because you have to because you are it. No residents, no in house NPs or PAs on the unit, no hospitalist 24/7, no ancillary staff available on nights/weekends, holidays. Sometimes they are too sick to transfer too, so you do get the real sickies once in a while, and you will have them while they circle the drain for a few days before transferring, etc. It will be good experience, and it counts.

    I loved my time in the big academic med center, but it isn't always what it is cracked up to be.
    opossum, LindseyRN86, Esme12, and 1 other like this.
  8. 0
    Most of what I learned working in a small hospital, I still use it today. You have to learn good judgement because back-up is minimal or non-existent. I graduated in the 80's and don't agree with the philosophy of today - CICU experience being the "best." The patients come in all lined up, house staff is around, outcomes tend to be predictable because most people are having the same procedures. I don't get it.
  9. 1
    I am not a CRNA nor a student CRNA. I am an experienced nurse in critical care for 33 years. Like everyone has already said. The ICU nurse in a community hospital. There is not back up other than the hospitalist so you do the decision making. In an academic facility the focus is in the training of the MD's, not nurses. Get good solid ICU experience then transfer and get some cardiovascular ICU experience.

    Good Luck!
    opossum likes this.
  10. 0
    I graduated with my BSN in 2010 and started working at a small community ICU/stepdown almost a year later; I did my immersion at a big university hospital trauma stepdown unit.

    I agree with what everyone is saying here; start with the small ICU. You get a lot of experience sharpening your nursing judgment in an environment where resources are minimal (and if you really want the barebones experience, do night shift!).

    I'm so thankful I was offered this position, as it's not easy for a new grad to stumble upon - and for me, the learning curve has been huge. I plan to stay here for another year or so and maybe transfer to a larger hospital closer to where I live.

    This bit of advice may be unsolicited, but I also would take whatever job is actually offered to you and not bank on potential offers. Since 2008 or so, new grads are having a hard time getting that first job...best of luck to you!!
  11. 0
    Thanks for all the advice, everyone! I'm definitely aiming for the ICU then! I did talk to the teaching hospital again to try to get an in-person interview in the ICU (I originally applied for the ICU and the recruiter seemed to want me to interview with stepdown--hence my question to you all earlier). Will keep everyone posted!
  12. 0
    Thanks again, everyone. Still in the process for the positions. Wondering if you all think the following factors would make a difference in the decision or if you think the ICU experience in itself is valuable enough to still have that as the first option. I'm still leaning more toward the ICU but the commute and start time makes the decision-making process a bit more interesting....

    - ICU: about 1 hour commute without traffic, position doesn't start til about 3 months later
    - stepdown: about 20 min commute, orientation starts mid-june
  13. 0
    I don't know how many days you will be commuting. If it's a five day work week, think of the commute in the long-term.
    A one hour commute each way really becomes two hours on the way home by the time you stop off at the grocery, etc.
    Even without stopping, that's 10 hours a week in the car..another whole day of work. In the long run, it's very wearing. BUT, if you have extreme youth on your side and an intense desire to go to grad school, you can do it for a few years. However, step-down will still provide you experience with high-acuity patients with, what sounds like, a better quality of life. Yeah, hard stuff to decide. Enjoy..
  14. 0
    Thanks for your insight, Subee! The job would be 3 12-hr shifts per week, so it's definitely much more feasible than 5 days. But you're right, even then, it's about 10 hours a week in the car. I guess it would depend on how much I value the ICU experience.


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