advice requested= track to PICU

Pediatric Critical Care Columnist · Jul 23, 2006

Peds med-surg would be an excellent place to start. That would give you some good basic education on peds norms, practice for interactions with both kids and parents, organizational and assessment skills, critical thinking and a good grounding in med administration. You'll find all of that very handy when you make the jump to PICU.

As for the emotional attachment, I wouldn't ever want to lose that part of me. The secret is in keeping a professional distance. I can be attached to a child or a family, but not take their burdens onto my own shoulders. It's better to help them find ways for them to carry them and still function. Whatever we can do to make things easier for them qualifies as compassionate care, but we need to remember that we are not family members, we are not friends, we are health care professionals there to help the child and family cope with illness. When we get in the way of the people who should be providing the familial support and the friendship, the ones who will be there when the crisis is over, however it ends, and on into the future, we do everyone a disservice. I grieve when a child I've cared for dies, but it's a different kind of grief than I would feel if it were my own child or a friend's. I see too much inappropriate attachment in our unit, and it makes me very upset at times. Coworkers usurp the roles that rightfully belong to family members or friends, cause the parents to come to depend on them for the support they should be finding elsewhere and then when the child dies, the family has lost their anchor. No one knows what their needs are or how to fill them because they've been pushed aside. To me that is a crime. So please, if you find yourself heading down that path, stop and think about what will happen when you're no longer there to prop these people up, and back off...

Jennifer, RN · Sep 27, 2006

Peds med-surg would be an excellent place to start. That would give you some good basic education on peds norms, practice for interactions with both kids and parents, organizational and assessment skills, critical thinking and a good grounding in med administration. You'll find all of that very handy when you make the jump to PICU.
As for the emotional attachment, I wouldn't ever want to lose that part of me. The secret is in keeping a professional distance. I can be attached to a child or a family, but not take their burdens onto my own shoulders. It's better to help them find ways for them to carry them and still function. Whatever we can do to make things easier for them qualifies as compassionate care, but we need to remember that we are not family members, we are not friends, we are health care professionals there to help the child and family cope with illness. When we get in the way of the people who should be providing the familial support and the friendship, the ones who will be there when the crisis is over, however it ends, and on into the future, we do everyone a disservice. I grieve when a child I've cared for dies, but it's a different kind of grief than I would feel if it were my own child or a friend's. I see too much inappropriate attachment in our unit, and it makes me very upset at times. Coworkers usurp the roles that rightfully belong to family members or friends, cause the parents to come to depend on them for the support they should be finding elsewhere and then when the child dies, the family has lost their anchor. No one knows what their needs are or how to fill them because they've been pushed aside. To me that is a crime. So please, if you find yourself heading down that path, stop and think about what will happen when you're no longer there to prop these people up, and back off...

Excellent, excellent advice. Thank you!!!

bwpcicuube · Oct 12, 2006

I think that the best advice I can give you is to start where you feel the most comfortable. I began my career in a PICU as a GN. Unfortunately they did not offer any type of orientation and after 5 weeks of orientation they set me free. Well I fell flat on my face as you can well imagine. But I stuck with it and eventually it "clicked" for me and everything came together. I honestly believe that it was the right decision for me. Had I started anywhere else I would not have had to meet that challenge head on. 16 years later I am an educator for a peds cardiac ICU. The minimum orientation for an experienced nurse is 12 weeks.(Unless the experience is PCICU) and for GN's I leave them on for 6 months.

As for the emotional attachment I feel this way. The day I walk on to that unit and feel nothing or the day I don't cry when we lose someone is the day I get out of nursing.

meesa214 · Dec 1, 2006

I'm a new nurse (graduated last Dec) and I started out in the PICU right off the bat. My unit has a very good orientation. 16 weeks for new grad, includes didactic and bedside time with a preceptor. It's also a large teaching hospital with lots of resources, which makes me more comfortable.

I don't know that starting out on a different unit would have prepared me for this. Being on this unit, I KNOW that these kids are really sick and we always have a bunch of docs that I can bring to the bedside at any hour if I even have a feeling that something might be going on. And I have a lot of support from coworkers.

My personal opinion is that ER is not the place to start out in. In the PICU you sort of know what you're getting into when you get report. There are certain things that you may be able to anticipate happening based on the previous shifts. You don't have that luxury in the ER. Generally you don't know the pts as they come in, you don't know what's wrong with them, and you really need to know your stuff which I think comes from experience not from books.

A peds floor will definitely give you experience in (sometimes) a more slower paced environment than a PICU. But I take comfort in the fact that I have all my resources right here. There's nothing we can't handle b/c we're at the top of the chain. We HAVE to handle it. Other PICUs in the area send their pts to us when things go bad!

And I feel like it's safer here than on the floor. I'm always watching my pts. If I have to leave, my roomie is watching. I'd be afraid that if I was on the floor, something would happen to the pt when I wasn't there. Or that I would get lax thinking "Oh the kid is fine, he's going home tomorrow" and miss something.

I love the 'taskyness' of the PICU. I like art lines and titrating drips and ICP monitors. But if you're into teaching, our unit's not the place. I feel parents get very little teaching b/c we're so focused on keeping the kid stable. The floors do the teaching...diabetes, trach suctioning, etc.

CarpeDiemRN · Dec 8, 2006

I went directly into PICU upon graduation- in my last semester of nursing school I did my practicum in the ER, thinking that it would be a good transition to PICU. I changed my mind. Let me say up front, that I LOVED the ER, but in the end I didn't feel that I would be challenged to develop my clinical skills to the degree that I wanted. In the ER you do a little bit for alot of patients, and you do it quickly - in the PICU you provide very detailed, in depth care for only 1-2 patients. In the ER you don't get to practice the very detailed psychomotor skills and analysis that are required in PICU (ie; working with art lines, ICP monitoring, titrating drips, etc.). For instance, in my hospital if there is a true "peds trauma" the PICU nurses are called down to the trauma bay and manage the medication administration- if there is a code on a peds med-surge floor, again the PICU nurses go on the code team.... not the ER nurses. The more critical the patient, the quicker it will be brought to the PICU. The trauma flight team is comprised of PICU nurses and docs- not ER. Don't get me wrong, ER nurses have special and unique skills of their own- my point is, I came to realize that ER and PICU are very different environments. I have found alot of nurses who start in PICU and go to ER... but not the other way around...for whatever reason. So, it all depends on what you are looking for and how your hospital is set up I guess. My opinion- if you find a PICU with a solid orientation for new grads (and you know you want to end up in PICU), go directly to PICU! By this I mean, 16 weeks with combined classroom and hands on teaching and working side by side with a preceptor. My PICU has very detailed policies and procedures and I think it is sometimes harder for people to come in from other units and have to "unlearn" old methods. However, some people in my PICU started on the floor and say that it gave them the opportunity to solidify their basic nursing skills and develop good time management- so depending on your personal comfort level that may be the way to go. A peds med-surg floor that has some rooms designated as "intermediate care" or "critical care step down", could be a good transition spot.

As for the attachment part- Janfrn said it well!

Good luck!

Canadian_Nurse · Jan 26, 2007

Hello all!

I've been reading this forum on and off for a long while now. I'm a L&D nurse with almost nine years experience, and for many reasons, it's time for a change. I have applied for a job in PICU, talked to some nurses that work in that area, and of course read a lot here. I've been thinking about this for a long time, and the timing and the posting timing are finally right. I can see that the nurses in PICU here in the forum love it, and that is even more encouraging!

I have a few questions...

1. What sorts of things should I read up on for an interview, should I get one? I do have a PALS course that I took in the fall, I'll read up on that even though I know the course is changing as we speak.

2. Will I really love it? I love looking after the sick L&D moms, they can be very complex!

3. Interview questions I should prepare for? I started in L&D as a new grad and haven't had many interviews since that time.

4. I have no general peds experience...should I have that first?

Any advice/feedback would be invaluable and greatly appreciated!!

AliRae · Jan 26, 2007

I have a few questions...

I won't be too helpful on the interview part ... I got my RN job on the same unit where I was a tech. My interview consisted of my HNs and DON sitting down with me and asking "SO! How was Africa?!" (I had quit my tech job to go there for the summer before I finished nursing school.)

As to #2, I hope you'll really love it! If you're looking for complexity, PICU's the place to go. I'm not sure how it is in L&D/PP, but I find in some other areas, NICU for example, you deal with basically the same problem set over and over. With PICU, you never know what's going to roll through the door.

#4, lacking peds experience ... You'll get it pretty quickly. You've worked L&D and thus know that babies are not miniature adults and that they have their own set of vitals and mechanisms. That'll put you on the right track already. I started in PICU straight out of school with no experience of any sort.

Already having PALS is a plus, since you'd have to get that once you started anyway. Good luck ... be sure to let us know how the search goes! I, for one, would love to welcome another PICU nurse to our ranks.

Pediatric Critical Care Columnist · Jan 26, 2007

Welcome to PICU! AliRae's already covered some things, here're some more.

1. Things to look into for your interview: The big one is respiratory. The largest percentage of patients in PICU will have respiratory issues. Review pediatric airway anatomy, a little about RSV and asthma, and normal blood gases. Know the ranges of normal vital signs by age group. Another major issue in PICU is shock... the different types, how they present and how they're treated. Don't worry about knowing everything, just an overview. The interviewer isn't going to expect you to know a lot of PICU-specific stuff, because s/he'll know you're coming from L&D.

2. As AliRae said, PICU is all about complexity. There really isn't a "typical" day in PICU, even when you have the same patient for several shifts in a row. That's one of the big attractions for some people... the variety. Today you might have a baby with pertussis and tomorrow a teenager with a spinal cord injury, then the next day a toddler with DKA. I like having to think at work, and I love helping families deal with sudden serious illness.

3. In your interview they will ask you a few scenario-based questions. One of the questions I got in my interview for the job I'm in now was about an 8 year old who had been in a bike-vs-car MVC who was coming in with a suspected closed head injury. What would I do to get ready for the patient's arrival? What would my nursing care priorities be in the first hour after admission? What are some signs of increasing intracranial pressure? What are the safety issues around use of mannitol? Things like that. Another sure thing is that they'll be assessing your ability to prioritize. So they'll give you another scenario: you're temporarily in charge of the unit; the patient in Bed 3 has just been admitted following cardiac surgery and his blood pressure is falling. The patient is Bed 5 is having a seizure, has an airway and sats in the 90's. The infant in Bed 9 has just extubated herself with her toes and is blue and bradycardic. And the nurse caring for the patient in Bed 14 is looking for someone to check her choral hydrate dose. What do you do first?

4. Many, many, many nurses come to PICU with no peds experience and no critical care experience. Learning about kids and families is ongoing and I doubt that lack of peds knowledge would be considered grounds for turning you away. Depending on where you are, the need is so desperate that they're hiring new grads, even when the posting says "minimum 2 years acute pediatric experience required" and throwing them to the lions after only a few weeks. The fact that you've already taken PALS is a bonus. I don't think the changing standards are that big a problem, since in the hospital setting you're not going to be single-handedly running a code; the resident or attending will be giving orders and deciding what to do next. Knowing the basic meds and doses is all good.

Please let us know how things go.

Canadian_Nurse · Jan 30, 2007

Hi everyone!

Well, I have an interview for next Friday, and I'm praying that it goes well and works out! I'll be reading up on my peds stuff and finding out what I can from one of my coworkers who worked PICU for years...it's great having connections.

Thanks for all your advice and tips, I've printed them out for myself as a reference. I will keep you posted.

Pediatric Critical Care Columnist · Jan 30, 2007

good luck!!!!!:smiley_aa

Canadian_Nurse · Jan 30, 2007

Thank you so much janfrn! Your responses are always excellent, and I'm thrilled to see a fellow Canuck here doing great things!

I'll keep everyone posted.