ICU in community hospital or Stepdown in academic hospital

  1. 2
    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 an ICU nurse, and possibly 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 (n an academic center one day) 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 and Blanca R like this.
  2. Poll: ICU in community hospital vs. Stepdown in academic? (goal: ICU RN in teaching hosp.)

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  4. 18 Comments so far...

  5. 0
    Start in the ICU.
  6. 0
    Thanks for the suggestion! Do you mind giving me more insight on why the ICU would be the better option? I'm definitely having a hard time deciding! Thanks!
  7. 0
    Because you will see both stepdown and ICU pts. If you take the stepdown, you will be sending them to the ICU if they start to deteriorate. Plus with your goals you set for yourself you need ICU experience. Even though its a small ICU just transfer after 1-2 years to a bigger ICU unit that is more specialized like CTICU or CVICU to increase your chances of CRNA school.
  8. 0
    Thanks for the insight! I really appreciate it!
  9. 0
    SEWRN -- Congrats on the job offer! In todays job market I would tell you to take any job you are offered, just to get your foot in the door! It seems, from reading your post, your torn between a community ICU and university step-down unit.

    Let me tell you a little about my experience...as a new grad I worked for ~8 months on a tele floor in a community hospital before moving into the SICU at that same hospital. While the time I spend on the tele floor was HELL (mainly because I knew I wanted to be in the ICU post graduation) I do have to say I gained the time management skills and basic assessment skills needed to flourish in the ICU. When you start out on the floor you dont have the technology and invasive hemodynamic monitoring to rely on so you need to depend more heavily on your basic physical assessment skills. I feel as though the time I spent working tele made me a better ICU nurse. I feel this way because I see so many ICU nurses looking at the numbers on the monitors and forgetting about utilizing their basic assessment skills. People tend to forget that when people go downhill the patient will display changes (in mentation, changes in physical assessment, urine output, etc.) before the monitor will display those critical changes.

    After a year in the SICU I was offered a per deim position working in the critical care float pool at a large university teaching hospital. In my opinion, working in a community ICU is more difficult than working in a univirsity ICU...mainly because the community hospitals simply dont have the "resources" -- mostly at night (I work 7pm-7am). I feel like community ICU RNs gain invaluable experience because they need to function with a higher level of autonomy, you dont have all the interns, residents, and fellows walking around to rely on. If you dont think you will get the experience you need to for CRNA school in a community ICU you are wrong. And you could use the points made above to argue that community ICU experience is just as valuable, if not more valuable than university ICU experience.

    Sure we dont have as many Swans, we dont do open heart, we dont have CVVHD, we may not prone patients, and we may not ambulate our mech. vents, etc. but there is so much that we do do that there is to learn when your a new grad.

    I hope this post gives you some insight! TAKE THE ICU JOB!
  10. 0
    I say go straight to the large hospital and get your foot in the door. Put in your time in the step down unit (which will probably have more complex patients than the small town ICU), make some connections, and move into the ICU there. The sickest patient in the small ICU (that's not comfort care), is probably just a 'typical' large hospital ICU patient that you'd see every day.
  11. 0
    I have worked at all varieties: small community, regional med center, and TX med center academic hospital.

    I encourage you to go to academic hospital. You will see FAR more complex, high acuity cases. After 6 months, tx to ICU.

    I think that is really the most direct path to get to where you want to go.

    SOME small Icus are barely ICUs. More like a stepdown! I have seen a week go by without a vented pt. BORING.

    As a potential CRNA, you NEED the hemodynamic monitoring experience. ANd the sickest pts. And the residents and fellows to learn from.

    ANd you will save yourself two orientations. ANd academic hospital on resume will ONLY help you. The longer the better.

    Good luck. I am applying at academic hospital which will require one hr commute each way, I feel so strongly about this.
  12. 0
    I know you probably have decided which to take by now but I'm going to advise that you take the ICU position. For one thing it gets your clock started and it's experience that you can use to transfer to that bigger hospital in the future. Small ICU or not, you can still technically apply for anesthesia schools in one year if you feel comfortable doing so. Even if the step down position does have higher acuity, no crna school will accept it. And say you work in the step down and then want to transfer there has to A) be an opening for you to transfer 2 and B) the unit manager must actually hire you (remember you wont be the only one to apply for the spot). Always go with the sure thing!
  13. 1
    Thanks for the advice everyone! I have decided to take the ICU position and will start soon! I really appreciate all the insight all of you offered! Made my decision much easier! =)
    smyates57 likes this.


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