Need advice about new job... please help!

[bluesky, BSN, RN]

I just started working on a new MICU/SICU a couple of weeks ago. I am very concerned about a number of issues inclusing;

1) No mandatory 30 deg HOB orders or nurses who do it.

2) Routine use of trendelenburg for hypotension (not just elevation of extremeties.

3) No tight blood sugar control in SICU patients

4) No mandatory resusciation bag on transports.

5) Massive diuresis of a patient who was never given a CVP, didn't have clinical signs of overload, based on history of diagnosis only, with very poor pt response (ie massive hypotension and fluid rescusitation the day after)

I know that newbies shouldn't make any comments for a couple of years when they start at a new place, but I find it really hard not to say anything. To make matters worse, the head nurse is someone who knew me when I was a secretary at another local hospital and keeps on (apparently) viewing me with suspicion as if I wasn't really an RN or something (I could give examples of why this is but I won't get into it now).

I hate to say this but my preceptor who is the sweetest, most wonderful human being on earth (whom I would never hurt for the life of me) is more of a med surg type of nurse and even she has admitted that I have a stronger ICU skill base than she. I mean the woman has only had a patient on Nipride gtt once and doesn't know Swanns well because she hasn't been assigned thosed pts! Scary. My one real weakness is that I am not good at IV sticks because my old hospital had and IV therapy team that would do all that for me.

On the other hand, all the nurses at this new job are completely nice and supportive and basically your dream crew. So it's basically the opposite situation of my old job where the competency was very high but the culture was the pits.

So, given my bad experience of staying way too long in my first bad situation, (3 more seasoned nurses quit right after I did), I am debating whether to just cut and run now or give this place more time...

What do you think?

Thanks for any advice

[PJMommy]

Does the hospital have a CNS for critical care? How about a quality improvement team? A clinical practice committee? You could give any of these types of groups a good bit of evidence and research related to the items you mention -- or just make the suggestion that the body of research would support a change in practice. Let them run with it.

[AnnieRN]

It sounds like you have an opportunity to be a leader in your new job.

Having a great crew to work with is crucial to job satisfaction. Just because

something isn't deemed mandatory doesn't mean it can't be done,right?

Lead by example and refrain from the age old..'where I USED to work we did.."

Good Luck

[dorimar, BSN, RN]

You need to get on a unit base, self governance type committee that bases decisions on evidenced based practice. Maybe, if your facility doesn't have one ( doesn't sound like it does), this could be a QI project. Try to look at it as your chance to really make a difference. If they don't buy it, then I recommend you leave, but not before all efforts are made. Good luck!

[dfk, RN, CRNA]

i'd get the hell out of there.. sounds like poor management to me.. and unsafe as well.. it may be your license on the line for other's decisions.. those things listed in the beginning of thread are all basic icu practices.. i would do them even if it's not protocol on your unit.. can't be fired for safe work practices and patient safety, eh? who's managing the icu anyway? is this a teaching facility?

[dfk, RN, CRNA]

btw/ trendelenburg is not considered routine practice for hypotn anymore.. what u are basically doing is pooling blood in the supra-thoracic region, making the heart actually work harder.. legs elevated with flat hob is ok.. check with any critical care literature, and you should find similar info.. i believe a mild trendelenburg at best would be used..

[pricklypear]

I agree that this could be a good opportunity for leadership and innovation for you. On the other hand, being the "newbie" you could engender bad feelings from your coworkers for being an "upstart," and criticizing their current practice. Of course, that would be a very counterproductive and immature way for them to behave, but hey, we know how groups of nurses are sometimes!

Maybe start out small, pick one thing (like HOB protocol) and bring it to your manager (or CNS as someone else mentioned). Good luck, I know how frustrating it is.