Adjusting to Smaller Hospitals

[MIZtigerRN]

Hi everybody--

I'm an ICU nurse who has always worked at really large (900+ bed) level 1 hospitals. I've been a SICU nurse for 3 years and am on my second travel assignment. I decided to expand my horizons a bit and took an assignment at a 230 bed hospital (no trauma designation) to work in their MSICU. I'm REALLY struggling with adjusting to the way they do things. I should've known better but took a night shift position and am totally overwhelmed with not having the ability to discuss patients with residents/attendings at any time. I feel so helpless and frustrated when I have patients who I see getting sicker and the intensivists on call don't seem to care. I don't even know when it's appropriate for me to call the intensivist on call. Obviously, if there is an emergency. But I see so many patients I feel like I am watching getting sicker and nothing is done--even when I do call! Or having patients that could really benefit from certain interventions and delaying these interventions (sometimes just odds and ends type things that are often missed during the day) could prolong their recovery time. Some nurses feel fine putting in orders under doctor's names but as a traveler I don't feel comfortable doing this. I guess I'm just used to being a lot more proactive with patient care and feel almost disabled working at this facility.

I'm feeling so depressed about the situation and am wondering if any others have struggled with adjusting to facilities like these and how they ended up adapting. Please help!!

Thanks!

[NedRN]

No real help here but I feel compelled to comment. I had thought with the rise of hospitalists that the bad old days were gone forever. The point of intensivists is to be on site 24 as well. Sorry to hear different.

[pinktermite]

Placing orders under a verbal is legal in every state I have worked in, which I'm sure you already know. My advice is to do what's right for the patient at the time. As long as your position is defensible and you have the charge or house mom at your back you can't really go wrong. In fact it can go wrong for you if you knew something was awry and you did nothing. It's a crappy position to be in but the patient is most important, obviously. We have all been there, and being a traveler makes it a wee bit more challenging. Find a staff nurse or two to lean on. Hopefully you can try that as well. It's a war out there sometimes.

[Argo]

Putting in a verbal order when no order was given is not legal. *** kind of advice is that?

The only thing they can do is follow the chain of command up if its critical. The hospitalist/intensivist has a time frame per policy that they have to respond in if they are on duty. Follow hospital policy and if they dont respond follow the policy to get what you need done.

[DIV-99]

I am truly sorry for your experience. I have been a nurse for 2.5 years with a little over a year at an ICU at that same "no trauma designation" hospital you are describing...However, we have online support with the ability to run a code, video assess and write all our orders as well as one-point contact (not wondering which specialty to wake up in the middle of the night) intensivists, NP and PA at night. I have been dreaming of travelling but until I read your post I was convinced I need to have at least 1 year at a level 1, so that I would be prepared for "anything". Once thing I do know, though, is I would probably not accept an assignment where I do not have either residents or online/e-ICU support overnight as the torment you are going through during these 13 weeks, I face every night I work (the day shift bedside "team" most of the times does not agree or follow the orders, recommendations of the night e-ICU team). Wish you wisdom and patience, it will come to an end soon.