Step down vs. ICU

[ixchel]

I've been doing some soul searching.

Right now I'm on a step down unit. It's a small hospital, so we get all specialties on our unit, which I love. I'm a person who wants to learn everything.

I'm still in that new grad first year, and in the last few months, I've really been feeling things come together. I've started jumping at every chance to float because I want to be an asset to the facility and I want to learn absolutely everything I can. At this point in my career, I feel like the time to be a sponge is now. So I seize the moment.

Lately the staffing shortage at my hospital is wearing me down. I started a thread asking how other facilities staff their step downs. It seems "normal" is 3:1, with the occasional 4:1. My unit is the first to get pulled, and we are normally at 5:1 lately. Everyone rallied for 4:1 awhile back and they got it. It was a really big deal. But because that was a big deal, they have no problem pulling us because we should be used to 5:1. So we staff 4:1, but work 5:1. Frankly, I'm tired of it. We're having higher patient falls than usual and we're being held responsible for it. Our satisfaction scores suck, and we're being told that's not acceptable. But management won't acknowledge the big elephant in the room - staffing.

I was floated to ICU recently and I loved it. ICU is never short staffed. They are always 2:1. They must always be 2:1. With good reason, obviously. There is more to do, more to know, more uncertainty, more dying. It's harder. But you have the staffing to help when things are overwhelming. I've been overwhelmed where I am, which turns to fear when I realize that because of staffing, I'm all alone.

Don't get me wrong - the "all alone" thing has developed me, made me think things through more and made me capable of handling more, but my god. No, it's not safe. It's not okay.

So ICU. I don't think it's appropriate to transfer simply for staffing. It makes more sense to transfer because I'm ready, because it's where I want to be. Both of those qualifiers are definitely in my future. I'm not sure if they are yet, but they could be, will be.

For those of you who have done step down and ICU, do you have advice? Thoughts? Comparisons you could share? I'm feeling lost. ICU definitely needs staff right now, and this would be the time to make the move, if I were to get approved for transfer. I just need BTDT perspectives.

[canigraduate]

I think it is perfectly OK to transfer because of staffing. I also think that your willingness to be a sponge and learn is probably the best thing going for you.

I think the 5:1 ratio for step down is ridiculous. I have that many patients currently on a Med-Surg floor and some days I find myself still drowning. It sounds like your management doesn't care about safety, but they will care about liability once someone sues.

I think that for your own safety, and as a wake up call to the powers that be, you should definitely leave that unit, and encourage the other nurses to do the same. Especially since they are reneging on the 4:1 deal. It just shows that your administration is dishonest and untrustworthy. If it was safe, they wouldn't have had to make concessions in the first place.

If it were me, I would threaten to go to the legal department every time someone was pulled and your ratio went to 5:1. That kind of liability will get heads rolling quickly. If you or someone else on your unit is motivated enough, I would suggest doing the numbers as far as falls, near-misses, and med errors go with the ratio being 4:1 versus 5:1 on your way out.

As far as the ICU goes, I wouldn't necessarily go only because of staffing, but I think it is definitely a large part of the equation. If I were you, I would make sure that you really want ICU for the acuity, the more intense environment, and the opportunity to expand your knowledge. Just because the ratio is better doesn't necessarily mean that you will feel any less stressed or have any less to do, especially the first year. You need to have more reasons other than staffing to hang on to so you will keep going through the transition.

When I went to ICU, it was partly because I felt that I wanted to learn more in depth when it came to patho, and partly because I was tired of the hectic pace of Med-Surg. I loved having time at night to learn more about each patient and the processes underlying their current medical situation. Days were not as conducive to in depth learning, but I was able to learn a lot from the providers' explanations and rationales for care. I liked having more autonomy, as well. This is shallow, but the best part for me was not having to answer call lights constantly while I was trying to pass meds or call docs. It was also great having the intensivists right there when you needed them, rather than having to page and hope for a timely call back.

I hope your situation gets better soon. Best of luck to you!

[ThatBigGuy]

It's absolutely ok for you to transfer because of staffing. Every time you clock in, you put your license at risk. You have to take care of yourself, because your administration obviously isn't.

[ixchel]

Thank you so much for your feedback! It is very well received.

ICU is a fantastic next step for me, I think, so even though I hesitate on readiness, the desire to be there exists.

A couple of things hold me back. First - my unit invested in me as a new grad. In spite of my personal feelings toward my preceptors (which aren't very warm and fuzzy), they invested themselves in me. Is it terrible to walk away roughly 5 months off orientation? I feel an obligation there.

Crashing patients. We whisk them away all messed up and crashing to the ICU where the ICU makes them all better (usually). I'm afraid of being on the receiving end of that. Well, intimidated. With more exposure, that'll be less intimidating, hopefully, but this part makes me hesitate as well.

On one hand, I feel like I should sit down and talk to management, find out the plan for the future and advocate for better ratios. But on the other hand, I doubt very much I'll be the first to have that conversation and if I do decide to stick it out on my unit, I don't want to jeopardize what I believe is my good standing.

[icuRNmaggie, BSN, RN]

It is bad form, and somewhat disrespectful to your manager, to jump ship six months after completing a new grad preceptorship. Yes the ratios are unsafe, they know it and if you complain too loudly, this manager is going to take that very personally which isn't going to help your cause.

Remember that he or she can block your transfer by saying we need her here more, and he or she might do just that if your leaving will have a negative effect on the budget.

Realistically, the understaffing in your unit is there to stay (at least until the cardiologists threaten to take their patients elsewhere) and probably the reason they are hiring new grads whom they wamboozle into accepting these ratios. You are correct, it is unsafe and you need to plan to transfer to the ICU. In the meantime never be afraid to ask the ICU to come look at this patient, we will respect you more because that's what we do, we bounce things off each other when we need help to put it all together.

At the end of your eighteen months of employment in stepdown, go to your manager, and never, never behind her back, and ask if you could do a couple of shadow days in the ICU with whomever is the strongest nurse in there. This is your real interview. If I see your potential, you will be hired. I don't have to teach you the computer, the processes or how to be a nurse. I only have to teach you the technical skills and how to think like an ICU nurse.

If people invest their time, energy, patience, effort and budget into helping you succeed, please stay for at least two years.

Please be honest and upfront with your nursing management and transfer out on a good note. Your professional reputation as a mature and responsible employee is everything. Take that Balloon pump class and anything and everything they offer so that you have the theory to back up the skills that you will be acquiring over the next few years. Best wishes.

[icuRNmaggie, BSN, RN]

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