Insight & advice on Critical care(ICU) VS. general Med-Surg floor? - page 4

New here and just seeking some advice... I'm a third-year nursing student who's in the process of getting an externship at a hospital. Currently I have a choice between either University of... Read More

  1. by   marilynmom
    Quote from Rabid Badger
    I don't think it takes a rocket scientist to figure this one out. Benner's "Novice to Expert" theory and research is widely accepted and incorporated into schools of nursing and licencing bodies. Novice nurses are not equipped for the independent and quick problem solving required for ICU work.
    • Stage 1: Novice
    Beginners have had no experience of the situations in which they are expected to perform. Novices are taught rules to help them perform. The rules are context-free and independent of specific cases; hence the rules tend to be applied universally. The rule-governed behavior typical of the novice is extremely limited and inflexible. As such, novices have no "life experience" in the application of rules. "Just tell me what I need to do and I'll do it."
    • Stage 2: Advanced Beginner
    Advanced beginners are those who can demonstrate marginally acceptable performance, those who have coped with enough real situations to note, or to have pointed out to them by a mentor, the recurring meaningful situational components. These components require prior experience in actual situations for recognition. Principles to guide actions begin to be formulated. The principles are based on experience.

    Graduate nurses are widely accepted to work on at the Novice stage of development. Reaching the competent level was found to require approximately 2 years of experience. Personally, I've finally reached the competent stage, and I know this by introspection and reflection. A grad nurse who is unable to realize their limitations is clearly at the novice stage and requires closer supervision. If you've ever worked with students or been one yourself you know full well that when you first start out you need plenty of guidance, help with prioritizing, and have greater difficulty recognizing changes that require intervention. It also doesn't take a million studies to know that overconfidence kills patients.

    Cross research in any field and the evidence solidly points to greater experience = better outcomes. If the nursing research lacks publications on such matter, let me know, and I will be more than happy to conduct the first study. I honestly have a little difficulty understanding how we are even questioning the veracity of this.

    I honestly think the US idea that grad nurses can head into ICU with 14 weeks of training is based on widespread ICU staffing shortages. If you require experience and 8 months of additional unpaid training, it is more difficult to staff such areas, understandably. Our ICUs are short staffed as well, but despite that, our health authority has sought to aggressively recruit using incentives for experienced nurses, while maintaining a standard of care and minimum expertice requirements.

    I've gone online and researched ICU positions in the US, and I've seen that I can hop right into an ICU position, without further training. That my dear, should frighten us all. I guarantee you don't want your family members cared for by a novice overconfident nurse. Don't get me wrong, I love working with students, I love teaching, I'm precepting a senior student nurse currently. So I'm more than fully aware of their capabilities.
    I'm still in nursing school and I think you make some very valid points.
  2. by   mced
    Dude, Benner's Novice to Expert Theory is exactly that, A THEORY. Below are some publications that back up actual practice. New graduates with adequate orientation programs and preceptorships function and survive in a critical care setting without increasing M&M to the patients they care for. Almost everyone I am in school with now went straight in to critical care after graduating from their nursing program. None of us had any trouble functioning at a competent level after completing an orientation and preceptorship program mentioned above. Though my statement only speaks for a small number of nurses (n=19), the articles cited below show that when applied nationally, these programs work.

    Ihlenfeld, JT. Hiring and mentoring graduate nurses in the intensive care unit. Dimens Crit Care Nurse. 2005; (24) 4 175.

    Lindsey, GL. & Kleiner B. Nurse residency program: an effective tool for recruitment and retention. Journal of Health Care Finance. 2005; (31) 3; 25.

    Nibert, AT. New graduates a precious critical care resource. Critical Care Nurse 2003; (23) 5: 47.

    Reising DL. Early socialization of new critical care nurse. Am J Crit Care. 2002;11: 19-26.

    Seago, JA. & Barr, SJ. New graduates in critical care. The success of one hospital. J Nurses Staff Dev. 2003; (19) 6: 297-304

    Thomason, TR. ICU orientation and postorientation practices: a national survey (Intensive Care Unit). Critical Care Nursing Quarterly. 2006; 11: 237
  3. by   jamonit
    this is such an old school argument. i'm done contending with it. i love my job and i'm glad that new grads in america have the opportunity to begin their careers in critical care or where ever they please. one of the perks of entering nursing now, the shortage has kind of blown this argument out of the water. they need us there, otherwise we wouldn't be hired there.

    the end.
  4. by   jamonit
    and besides, what does evidence based practice state on this topic? what was posted from the person with the biggest problem with this appears to be a generality, not fact.

    okay, enough. done.




    that's my pinning ceremony! hehehe. enclosed for giggles.
  5. by   Logan
    Quote from RNsRWe
    Rabid Badger, I'm sorry you're experiencing such rudeness from some of these posters. I'm proud to be an American, but hardly proud of the attitude I'm seeing here. Really shameful.
    Frankly, "slapping someone upside the head" isn't exactly an attitude I find admirable nor appreciable coming from someone who claims to be an 'experienced nurse'.

    No matter how "insubordinate" the other person may be.

    We have a "report post" function on this forum for precisely this purpose.

    On topic:
    I actually agree with Rabid Badger in principle - I don't think new grads ought to work critical care (ER included). This doesn't mean that I think med-surg is "ok" to "let loose inexperienced nurses on".

    On the contrary, floor nurse experience is INVALUABLE in building core nursing skills. There is no better place for new grads to start out on than a good med/surg floor - the sheer variety of patients, the need to be able to balance tasks and time, delegation and responsiblility... just some of the things that a new grad is exposed to and expected to learn.

    And stuff that will stand them in great stead when they have to take care of intense care patients.

    When I was a new nurse, I was offered med/surg or the Neuro intensive care unit. The Neuro care unit was more tempting - better patient care ratio, better pay, more perks etc. But I chose med-surg on principle --- I wanted to hone and improve my nursing skills as a new grad before I attempted critical care.

    This is of course, MY opinion. People are free to take it or leave it as they choose.


    Thanks,
    Matthew
  6. by   Rabid Badger
    Quote from jamonit
    and besides, what does evidence based practice state on this topic? what was posted from the person with the biggest problem with this appears to be a generality, not fact.

    okay, enough. done.


    that's my pinning ceremony! hehehe. enclosed for giggles.
    Thanks for proving my points so eloquently throughout this thread! Simply genius!
  7. by   TazziRN
    Quote from Rabid Badger
    I've gone online and researched ICU positions in the US, and I've seen that I can hop right into an ICU position, without further training. That my dear, should frighten us all. I guarantee you don't want your family members cared for by a novice overconfident nurse. Don't get me wrong, I love working with students, I love teaching, I'm precepting a senior student nurse currently. So I'm more than fully aware of their capabilities.
    I'm having a problem believing this one. No hospital in its right mind would allow a non-ICU-trained RN to take a true ICU-type pt load without training. ICUs are willing to take grads straight out of school and train them without prior acute care experience, but ICU training is required before being turned loose on the unsuspecting public. Not to mention all the certs that critical care nurses must acquire and keep current. New grads are never without a preceptor and new critical care nurses are rarely left alone without backup.

    We may not have the stringent system that Canada has, Badger, but it doesn't mean our system is wrong or unsafe. I think Jamonit's response may have been defensive but you weren't exactly kind either.
  8. by   Tweety
    First of all, as a moderator of this forum, we need to respect each other's opinions as valid, based an individuals perceptions, experience, or etc. No needs to be slapped upside the head. Let's discuss the issues without talking back and forth.

    2nd....gorgeous pic of above of the pinning.

    My opinion is based on what I see. Our ICU hires new grads, and there are plenty of old folks there to help them out. The take classese and get many weeks of orientation, (I think 16). I think they do just fine.

    No nurse coming out of school is going to be ready for any department....period, critical care or med-surg. But with proper orientation they can gain the skills they need. Forcing a nurse with a desire to med-surg, or who even hates it, and then orienting them a year later to where they really want to be is a waste of talent, money and is demoralizing.

    Yes, those of us with experience see new grads flounder in the ER and in ICU. Guess, what, I see them struggle and drown in med-surg too. It's just the new grad experience. With support and time they somehow make it through.

    That's my two cents.
  9. by   jamonit
    thanks tweety, tazzy and logan! i don't think i need a good slap, i just need some great preceptors, didactic training, and lots of critical thinking. i am an orientee with strong passion to be an amazing novice and eventual expert in pediatric critical care. i want to continue to learn, know that i have a long way to go, and for all those that believe and help us newbies, i commend you and have nothing but respect and gratitude.
    as to those with contrary opinions, to each his/her own. this is what nursing is today, they need smart, quick, passionate, gracious and eager new grads like me to fill our nursing deficit. there's a place for all of us in this profession, i just so happen to be proud that i've found mine in critical care and that someone believed i had what it takes to get there--right off the bat.

    xo

    one more pic of my pinning for posterity!
  10. by   RNsRWe
    Quote from Logan
    Frankly, "slapping someone upside the head" isn't exactly an attitude I find admirable nor appreciable coming from someone who claims to be an 'experienced nurse'.

    No matter how "insubordinate" the other person may be.

    We have a "report post" function on this forum for precisely this purpose.
    Since you quoted my post when posting this of your own, I guess I should respond. I made no comment about the "slapping someone upside the head" remark, or whether I found it appropriate. I DID comment about the rude posts made prior to that one. The posts that I found juvenile and unprofessional ("whatevs." is a comeback?).

    I wanted Rabid Badger to know, publicly (rather than a "report post" button) that I found the rude posts to be out of line. The attacks on Canadian citizenship in comparison to American citizenship was completely uncalled for. I didn't see the need to hit "report bad post" for either those remarks OR Rabid Badger's.

    I also chose not to comment on whether or not I agreed with RB. Actually, I think at this time I will: I don't agree. I do believe that recent grads can be very effective in ICU, if given an appropriate orientation. I don't believe 14 weeks is sufficient, but I have seen some really good nurses come out of 6 month orientations for ICU and do admirably. However, the quality of the orientee chosen for the unit has everything to do with their success. Pick the wrong grad nurse and yes, you're going to have the wrong future ICU nurse. Pick an appropriate choice, and there should be no problem.

    To the Original Poster, I'm sorry you've had such a string of nonsense on your thread. Now that you've gotten some GOOD information related to YOU, maybe you can now make the choices you need. And now I can leave this thread as well, since its purpose is apparently done.
  11. by   nurse4theplanet
    I took an intern position at two different hospitals in two different areas. One was ICU and the other Med-Surg. I gained more knowledge from my ICU internship in one day than my entire med-surg internship.

    After school ended, I was certain which area I wanted to go to and I am now in the Critical Care Orientation Program. It is minimum of 24 weeks with a preceptor. All our preceptors have attended special training to prepare them for training new grads. My preceptor happens to be a former nursing instructor. She's really great. We alternate our time initially between working on the floor with our preceptor, attending classes on various topics related to care of the critically ill pt, completing an online orientation module that covers each body system, case study days, and feild trips to various other departments throughout the hospital. I have been working 40 hours a week and studying harder than in nursing school on my days off. It is very intense. As the orientation progresses, we check off on competencies and have a weekly evaluation. We then begin spending more time on the floor and taking on more responsibility until we work our way up to a full pt load. For the next six months after orientation, we still are accountable to our preceptors to complete all unit competency requirements, training/classes, and evaluations.

    The new grads that finished the orientation program before me have done quite well. I feel that working as an intern for over a year has given me invaluable experience that makes the transition to nurse somewhat easier on my unit in comparison to the other new grads in my orientation group.

    I have had a really positive experience. Ultimately, the choice is yours. I think it is best to choose the area where you are most interested, because you are more apt to go above and beyond to learn the things you need to know.

    Things my MS internship taught me:
    How to get a pt ice
    How to transfer a pt from the bed to chair
    How to ambulate a pt
    How to change linens/give a bed bath
    How to take vitals
    (actually nursing school taught me these things but my MS internship turned me into a professional )

    Things my ICU internship taught me:
    How to take/give a good report
    What to have ready before you call the physician
    A thorough physical assessment
    How to care for a central line
    Interpretation of EKG waves and what to do when your pt has a rhythm change
    How to do trach care, suctioning trached and vented pt's
    Plenty of opportunities for IV starts/restarts
    Plenty of opp. to insert catheter
    Hemodynamic monitoring
    What to do if your pt codes
    Monitoring a pt during CRRT
    Recovering a post-op CABG
    What to do if your pt is declared brain dead and is an organ donor
    postmortem care
    comforting pt's families after death of loved one
    I could go on and on but I am tired and my brain is not working well
    (Whether I was performing the task, following behing the RN and comparing my findings with his/hers, or observing the RN...I learned SO much that I can apply to my current practice)

    You may find you get more experience in the ICU as an extern. However, functioning as a tech is not the same as functioning as a nurse and if you do not feel comfortable in your abilities then perhaps you should start at a lower level of care once you graduate. I feel I am capable of functioning safely in the Critical Care Environment. Good Luck to you.
  12. by   Tweety
    asoldierswife, it sounds like you were oriented on MS to be a CNA. That's very disappointing.

    The MS unit I work on we do basically what you described in ICU, except maybe the brain dead, post-CABG (but we obviously get post-ops) and a few others. But we do assessments, hemodynamic monitoring, interpreting EKG's and trachs, central lines, and other tasks. Too bad. But nonetheless that's off topic. Obviously the two areas are not the same, but being a med surg nurse is definately more than being a CNA doing "tasks" such as fetching ice.

    Good luck to you.
    Last edit by Tweety on Feb 18, '07
  13. by   Rabid Badger
    Quote from asoldierswife05
    Things my MS internship taught me:
    How to get a pt ice
    How to transfer a pt from the bed to chair
    How to ambulate a pt
    How to change linens/give a bed bath
    How to take vitals
    (actually nursing school taught me these things but my MS internship turned me into a professional )

    Things my ICU internship taught me:
    How to take/give a good report
    What to have ready before you call the physician
    A thorough physical assessment
    How to care for a central line
    Interpretation of EKG waves and what to do when your pt has a rhythm change
    How to do trach care, suctioning trached and vented pt's
    Plenty of opportunities for IV starts/restarts
    Plenty of opp. to insert catheter
    Hemodynamic monitoring
    What to do if your pt codes
    Monitoring a pt during CRRT
    Recovering a post-op CABG
    What to do if your pt is declared brain dead and is an organ donor
    postmortem care
    comforting pt's families after death of loved one
    I could go on and on but I am tired and my brain is not working well
    (Whether I was performing the task, following behing the RN and comparing my findings with his/hers, or observing the RN...I learned SO much that I can apply to my current practice)
    Well this is unfortunate.

    Actually everything you listed for what you learned in ICU we do on my Medical ward! Except we don't do CRRT, but we recover HD.

    What else I do:
    Manage codes, on a virtually daily basis.
    Run 4+ IV continuous infusions on a single patient.
    Have a patient code, work on them for 2 hours, send them up to ICU only to discover your second (of 6) turns up a pressure of 70/30, spend the next 7 hours bolusing, giving 11ty billion cc's of albumin to, vitaling q5mins, hoping you don't lose a second in 1 shift.
    Manage central lines on all 6 of your patients.
    NGs/trachs/ostomies/chest tubes/vac drsgs/tpn/etc etc.
    Give every imaginable blood product.
    Airborne isolation.
    Assist in an on-ward endoscope
    QID drsg changes on a coccyx wound the size of a dinner plate, wherein intestine and spine are exposed.
    What to do when your patient collapses and bleeds out 3 litres in 2 minutes.
    What to do when your doc doesn't want to take the above bleed seriously.
    What to do when your patient goes into flash pulmonary edema.
    What to do when your patient starts hitting your staff and threatening your life.
    Take in 2 unstable admissions in at the same time while you are transfusing another and doing above mentioned drsg changes and trach mgmt on your others.
    Learn how to not kill yourself after the first 3 months.
    Manage non-intubated ICU patients where there is no bed for them in ICU.
    Recieve transfers from ICU, have your patient code 20 minutes later, then ship them back upstairs. Thanks for stopping by!
    This is only the tip of the iceberg.

    I'm sorry your med/surg experience was a whole lot of CNA work. But that's certainly a far cry from what I do on a daily basis. Medicine on this ward is a constant case of

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