Insight & advice on Critical care(ICU) VS. general Med-Surg floor? - page 5

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   wonderbee
    Oh how I wish I had a better general experience (one I got in med-surg) before making the leap from nursing school directly into critical care. I watched others go through much the same experience. There were lots of tears and awful days. Some make it and some don't. Getting off to a bad start can really sour one on a career choice. I think lots of nurses get into water far deeper than they can tread right off the bat and wind up becoming real estate agents before the end of their first year or two. In the grand scheme of things, what's one year out of a lifetime to devote to the basics for a good foundation.

    BTW, I have a lot of respect for med-surg nurses who stay in that genre. We need good generalists out there to keep patients out of the ICU.
  2. by   mced
    Rabid Badger,

    What you are stating as your job description is what many nurses that work in modern day Medical/Surgical, Telemetry, and ICU stepdown units deal with continuously in the United States. It is a hard job, but people with adequate orientations and preceptorships negotiate these tasks and other complications each day they come to work!
  3. by   WolfpackRed
    Quote from 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
    Thanks for finding these.
  4. by   Freedom42
    Quote from antidote
    I'm an intensive care nurse, and I have to say that its an entirely different mindset in there. The more experience you have on a med surge floor or in the ER would help greatly before advancing up to the ICU.

    My advice would be too get as much experience as possible before jumping into something such as the ICU. The ICU takes a certain personality and certain level of skills. The more experience the better you'll do when you get there!
    Interesting thread. I've had the same discussion with my adviser about whether starting out in med/surg is necessary. She's adamant that it is.

    Antidote, what personality do you think the ICU requires? And how many years of experience do you think a nurse needs to have before working at that level? This interests me because I spotted a want ad today for a "new grad" in critical care, and I wondered what nurses would think of that.
  5. by   nurse4theplanet
    Quote from 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.
    Yes. That was my point. While I could have gotten many of those experiences on a MS floor, I was not able to for many different reasons (short staffing, high pt loads, nurses who didn't have enough time to teach me, etc.). I was put into a CNA position basically, and while I loved taking care of the pts I just didn't get alot of helpful experience in my nursing skills and critical thinking. Every unit is different and there will be others that did an internship in MS that have much better experiences then I had...and of course, when you have your license and go through the nurse orientation then you will gain these experiences then. I feel like choosing an ICU internship gave me a head start.
  6. by   nurse4theplanet
    Quote from Rabid Badger
    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
    Yes, we do most of the same things you do on your unit. However, our pt load is not as high (2-3 at the most) and we don't experience that many codes a day. Sometimes we go several days without a code. That's an accomplishment, IMO. Our nurses work very hard to prevent that from happening.

    Your unit sounds very intense and I am sure you are a great nurse. I can say that without a shadow of a doubt, I would be intimidated on your unit. Ours is not quite as intense. I think the smartest thing you can do as a new grad is to admit your limitations.

    Thank you for sharing.
  7. by   Tweety
    Quote from asoldierswife05
    Yes, we do most of the same things you do on your unit. However, our pt load is not as high (2-3 at the most) and we don't experience that many codes a day. Sometimes we go several days without a code. That's an accomplishment, IMO. Our nurses work very hard to prevent that from happening.

    Your unit sounds very intense and I am sure you are a great nurse. I can say that without a shadow of a doubt, I would be intimidated on your unit. Ours is not quite as intense. I think the smartest thing you can do as a new grad is to admit your limitations.

    Thank you for sharing.

    I haven't had a patient code in years, and I mean years. Med-surg sometimes does because like a mini-icu with borderline unstable patients. It can get scarey sometimes.
  8. by   Tweety
    Quote from asoldierswife05
    Yes. That was my point. While I could have gotten many of those experiences on a MS floor, I was not able to for many different reasons (short staffing, high pt loads, nurses who didn't have enough time to teach me, etc.). I was put into a CNA position basically, and while I loved taking care of the pts I just didn't get alot of helpful experience in my nursing skills and critical thinking. Every unit is different and there will be others that did an internship in MS that have much better experiences then I had...and of course, when you have your license and go through the nurse orientation then you will gain these experiences then. I feel like choosing an ICU internship gave me a head start.
    I understand, your MS didn't pave the way for ICU experience. ICU nurses are very quick to point out that ICU is so much more complex and skilled than ICU, but yet are quick to make us work a year in med-surg to prepare ourselves. Seems a bit contradictory.
    Last edit by Tweety on Feb 18, '07
  9. by   RUcon08
    Quote from asoldierswife05
    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.
    Great post.

    What little doubts I had about choosing a unit (for the sake of my summer externship) are effectively gone and I will be calling the nursing recruiter who contacted me last week to get the ball rolling and secure this ICU position, ASAP.

    Thanks.

    P.S. I just hope she doesn't offer me several critical care unit positions, then I'll be back to square one with decision making.
  10. by   nurse4theplanet
    Quote from Tweety
    I understand, your MS didn't pave the way for ICU experience. ICU nurses are very quick to point out that ICU is so much more complex and skilled than ICU, but yet are quick to make us work a year in med-surg to prepare ourselves. Seems a bit contradictory.
    I agree.
  11. by   nurse4theplanet
    Quote from RUcon08
    Great post.

    What little doubts I had about choosing a unit (for the sake of my summer externship) are effectively gone and I will be calling the nursing recruiter who contacted me last week to get the ball rolling and secure this ICU position, ASAP.

    Thanks.

    P.S. I just hope she doesn't offer me several critical care unit positions, then I'll be back to square one with decision making.
    Good Luck to you! I hope you have a positive experience as I did. Hopefully, you will gain some good working experience and be able to fine tune your assessment skills.

    Some advice for your externship:

    Do NOT be timid...if there is something you know how to do ask the nurse if you can do it. Hands on learning is best!

    Ask lots of questions, don't be afraid. Most of the ICU nurses I have met have loved to teach...just don't ask questions to simply show off your knowledge

    Stick it out. I was terrified the first few times I was on my unit because it all seemed so overwhelming...very sick pts, sedated and on a ventilator, getting hemodialysis, lines everywhere, alarms ringing, pumps beeping, doctors calling...it was very fast paced and I felt like a deer in the headlights. But I stuck it out and started asking questions, helping the nurses where ever I could...and it all began to come together.

    Don't overestimate your knowledge. It's great to have confidence, but realize that being overconfident could harm your pt. Always ask for help and run things by the nurse even if you feel that it's just a routine task.

    Listen, listen, listen! There is sooooo much knowledge that can be gained from the experienced nurses on your unit.

    Keep a diary of the things you experience and your pt's conditions and outcomes. Go home and look things up. Ask about why certain things were done, and why others were not. Treat this as the most important learning experience of your life. It's only as good as you make it. Take full advantage of this learning opportunity. Before you know it you will be out on your own.
  12. by   pcicurn7
    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.
    I agree. I am a new grad who has applied for a PICU internship. I am not stupid, i did plenty of research until i found the program that was right for me. Not every hospital in the US has the same orientation guidelines, and many programs offer excellent orientation/preceptorships for new grads. This is actually a pretty good strategy for the hospitals...the get a brand new nurse, who is probably very excited to be there, and the hospital gets to mold that nurse to be the type of nurse that is needed in their unit.

    The PCICU program that i have applied to has a ONE year orientation, with a one-to-one preceptor, and no direct patient assignments. Its 3 months in the ER, 3 months on the regular peds floor, and 6 months in the PCICU or PICU. I am not willing to risk my license or my sanity, and i think that the program i have applied to demonstrates that.

    For the OP, my suggestion is to make sure you do your research. Talk to other nurses who work on the floor. Ask them if they were made to complete their orientation prior to being left caring for a patient. Write down all your questions. AND, as an RN (new or not), you have to make sure that you know when to say "i dont feel comfortable doing ___, but i would like to learn". Other nurses don't expect you to know everything, but they will expect that you speak up before you put yourself OR the patient, at risk.

    And, for Jamonit: CONGRATULATIONS!!!!!!!!!!!!!! You are a beautiful girl! (i know graduation gives the best of glows!) And i would have died if they made us wear hats for the ceremony...lol! Now, go rock the NCLEX! (i just took mine a few weeks ago!)

    Here's mine (from Dec):

    Last edit by pcicurn7 on Feb 18, '07
  13. by   pepsihla
    I would go straight to the level of nursing you want. If you want to go straight into ICU, then do it.

    I went straight into ICU after I graduated, I would not have done it any other way. Most new grad ICU training is excellent and prepares the new graduate to be a valuable member to the ICU team.
    Last edit by pepsihla on Feb 18, '07

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