An ICU nurse manager told my wife that her Med/surg experience was hurting her!?

caroladybelle, BSN, RN · Jul 19, 2005

Your ICU manager has been in the ICU too long and needs a dose of real M/S experience over about a year or so.

Admittedly, there are M/S positions that are low acuity but they are few and far between. These days M/S nurses are required to handle much higher tech duties than previously done.

It also has to do with the ICU vs M/S bias. Yes, they require different thinking but not necessarily less "critical" thinking. I know M/S nurses must keep track of 5-10 patients and keep them from crashing, give all their meds, keep them from falling, start their IVs, draw their labs (without a central line), and spot that one (or two or more) going bad without the advantage of a lower ratio and a lot of equipment/extra tests. This requires some very heavy critical thinking. Yes, there are a few nurses that may "coast" a little but they are not the good ones.

ICU also has its "coasters" also. They rely on the technology to tell them what good observation and assessment should, and use the technology to avoid some basic care (he has an ET tube so I can't turn him or do mouthcare, and I can restrain him so he doesn't fall). And it has those nurses that use the technology to reinforce what good assessment tells them and do excellent work. It is just different.

Part of "critical" thinking is assessing which of your 5-10 patients requires your greater time. and assessment.

A good M/S nurse nurse knows that her patient is going into renal failure by noting that the creatnine and BUN is worsening, K+ is increasing and the urine output is falling. S/he will not necessarily have them memorized and written exactly for the last 5 days on her "brain" sheet. S/he will have assessed the possible causes such as meds/hydration/chemo. The ICU nurse will have them on spread sheets with the precise numbers. Both nurses will see the renal failure and report it. And it is both of them using "Critical" thinking. It is merely on a different level.

It is also to the nurse to maintain her/his critical thinking. If you see a abnormal result and do not question the possible causes, you are not exercising your brain. If you do investigate the possible causes, you are thinking critically. It matters little whether you are on M/S or ICU.

DidiRN · Jul 19, 2005

I wonder if this manager has always worked in the unit and never on the floor.

In my own experience, I have found that the vast majority of RN's who are new to the ICU with experience in med-surg and/or stepdown experience do fantastic in the unit. The ones who have come from the floor have a good foundation on basic skills and for the most part seem to do terrific.

I am really perplexed that your wife has had so much trouble getting an ICU position in her area....that's really odd. Maybe you should come east a bit to Ohio...I'm sure she wouldn't have a problem over here.

We went to a job fair at a new North side hospital today only to learn that all positions (including med/surg) required two years experience. I started up a conversation with the manager of the new ICU, and related how important it was for my wife to get in the ICU. I also told her of my hypothesis that it might be more difficult for a nurse with some nursing experience, but not two years to find an ICU job than a new grad (based upon my observation that several of my wife's classmates had no trouble going straight to the ICU, but that she has had problems trying to transfer after six months).
I was surprised to find that she (the ICU manager) absolutely agreed with me. In fact she said that my wife going to Med/sugical in the first place was a mistake if she had the ambition of going to the ICU, and then becomeing a CRNA. She indicated that Med/surg was in fact making her a worse ICU prospect since it tended to degrade critical thinking skills necessary to the ICU. Personally, I don't see how caring for four to five very sick patients most with multiple IV's, and many with telemetry could degrade the skills of a new nurse! However, in the real world perception is reality and I'm left to wonder is this really what ICU managers think? IF so why would someone become acceptable after two years experience in med/surg? After all if being in med/surg degrades critical thinking skills then one would think that those skills would be significantly more degraded after two years than only after six months.

DCaillouet · Jul 23, 2005

your icu manager has been in the icu too long and needs a dose of real m/s experience over about a year or so.
admittedly, there are m/s positions that are low acuity but they are few and far between. these days m/s nurses are required to handle much higher tech duties than previously done.
it also has to do with the icu vs m/s bias. yes, they require different thinking but not necessarily less "critical" thinking. i know m/s nurses must keep track of 5-10 patients and keep them from crashing, give all their meds, keep them from falling, start their ivs, draw their labs (without a central line), and spot that one (or two or more) going bad without the advantage of a lower ratio and a lot of equipment/extra tests. this requires some very heavy critical thinking. yes, there are a few nurses that may "coast" a little but they are not the good ones.
icu also has its "coasters" also. they rely on the technology to tell them what good observation and assessment should, and use the technology to avoid some basic care (he has an et tube so i can't turn him or do mouthcare, and i can restrain him so he doesn't fall). and it has those nurses that use the technology to reinforce what good assessment tells them and do excellent work. it is just different.
part of "critical" thinking is assessing which of your 5-10 patients requires your greater time. and assessment.
a good m/s nurse nurse knows that her patient is going into renal failure by noting that the creatnine and bun is worsening, k+ is increasing and the urine output is falling. s/he will not necessarily have them memorized and written exactly for the last 5 days on her "brain" sheet. s/he will have assessed the possible causes such as meds/hydration/chemo. the icu nurse will have them on spread sheets with the precise numbers. both nurses will see the renal failure and report it. and it is both of them using "critical" thinking. it is merely on a different level.
it is also to the nurse to maintain her/his critical thinking. if you see a abnormal result and do not question the possible causes, you are not exercising your brain. if you do investigate the possible causes, you are thinking critically. it matters little whether you are on m/s or icu.

speaking as a manager of a combined critical care unit i would have to respectfully disagree. i started out as an lpn on a med/surg unit and know exactly how valuable the time management, assessment skills and experience of med/surg can be.

i do hire new grads into our "fast track" program, which requires 6 months of intense orientation and includes at least 6 weeks on a med/surg unit, but i am extremely particular who i chose. i would give an experienced med/surg nurse preference over a new grad the majority of the time.

pricklypear · Jul 23, 2005

All I have to say is....what the????? I simply cannot see how experience in any acute setting can possible DEGRADE critical thinking skills. Critical thinking skills are critical thinking skills. There aren't ICU critical thinking skills.

The only difference I see between new grads and floor nurses in regard to transition to ICU is mindset. The floor nurses in my hospital have been led to believe that they are incapable of thinking for themselves. Nobody gives them any credit, or listens to them. They won't even start oxygen on a pt with sats in the 70s without first calling the doctor. Their skills tell them they should, but it's frowned upon. When they come to us, it takes them a while to feel comfortable using their knowledge and intervening appropriately before making that call. New grads start out with that extra rope given to them. But, believe me, those med-surg nurses prove to know their stuff once given the opportunity. They see the big picture more quickly than new grads because of the scope of their experience.

Just my 2. Hope your wife finds a great job.

mattsmom81 · Jul 23, 2005

New grads have the most problems in any critical/ICU setting I have ever worked in...based on the fact that they do NOT have their basics down. I'm not sure from where this person was coming from, but don't take it as law.

This is from my years as an ICU nurse and preceptor. I would much rather have an experienced med surg nurse as my new preceptee, believe me.

Roland · Jul 23, 2005

In all fairness to this person she didn't say that she would prefer to hire a new grad (in fact just the opposite was implied given that all of this new hospital's nursing positions required two years experience to even be considered).

Rather, she stated that my wife was doing herself a diservice given her stated goal of working in the ICU and then applying to CRNA school. She also seemed to imply that most ICU's have two modes when hiring applicants. The first is to hire nurses with at least two years experience and the other is the "fast track" alluded to above right out of nursing school. In essence I think she was saying that my wife lost the "fast track" option by taking the floor position and working there for six months. However, she did also say that in her experience critical thinking skills learned in nursing school tend to diminish on Med/surg. floors .

New grads have the most problems in any critical/ICU setting I have ever worked in...based on the fact that they do NOT have their basics down. I'm not sure from where this person was coming from, but don't take it as law.
This is from my years as an ICU nurse and preceptor. I would much rather have an experienced med surg nurse as my new preceptee, believe me.

pricklypear · Jul 23, 2005

However, she did also say that in her experience critical thinking skills learned in nursing school tend to diminish on Med/surg. floors .

I learned a framework for critical thinking skills in school. I learned how to think critically in the REAL world of nursing. I started out in tele, and the things I learned there have helped me immensely, I think. I repeat, I don't know how it's possible for critical thinking skills to do anything but grow with experience in any kind of acute care setting. Statements like the one this manager made devalue all the amazing nurses out there who don't work in ICU, but who take care of lots of patients who, 10 years ago, probably would have been in ICU.

RN34TX · Jul 23, 2005

I think too much weight is being given for this manager's statements.

Let's not assume that she knows what she's talking about just because she's a nurse manager. She may have never worked Med/Surg in her life and that would say plenty. There are plenty of NM's are out there who did not get their jobs because they were great nurses, many were in the right place at the right time or no one else wanted to do it.

It's like listening to RN's go on and on about their theories about LPN education and practice. You come to find out that many of them never worked as LPN's, never taught in an LPN program, or had very little work experience with them. Yet they seem to know so much about them.

I started in a new grad ICU internship as brand new RN. I had almost 7 years of Med/Surg LPN experience prior to that. None of the others in my group even had CNA experience.

I was the only one to get out of orientation early, I did 8 weeks while they did 16.

Why? Because basic nursing skills like starting IV's, inserting NG tubes and drawing blood were things that they were still trying to master as any new grad would, things that Med/Surg nurses do every day and do not need coaching or practice in.

On top of that, in ICU, you're trying to throw A-lines and swans at them and they still need help with the basics.

A couple of the new grads told me that older nurses discouraged them from getting an ICU position right out of school because they theorized that you need Med/Surg experience first, which although it was helpful for me as I oriented faster than the others, I'd hardly call it necessary.

Don't take the advice of a well-meaning manager just because she runs one ICU. She may not have the best background or experience to be offering the kind of advice she's been giving you.

austin heart, BSN, RN · Jul 23, 2005

I think that a strong med/surg background is an asset, especially with todays med/surg patients getting sicker and sicker.

kat911 · Jul 23, 2005

In all fairness to this person she didn't say that she would prefer to hire a new grad (in fact just the opposite was implied given that all of this new hospital's nursing positions required two years experience to even be considered).
Rather, she stated that my wife was doing herself a diservice given her stated goal of working in the ICU and then applying to CRNA school. She also seemed to imply that most ICU's have two modes when hiring applicants. The first is to hire nurses with at least two years experience and the other is the "fast track" alluded to above right out of nursing school. In essence I think she was saying that my wife lost the "fast track" option by taking the floor position and working there for six months. However, she did also say that in her experience critical thinking skills learned in nursing school tend to diminish on Med/surg. floors .

You are probably right about the two modes for hiring at that hospital. I would be more concerned that your wife was looking to move on after only 6 months. New grads, at 6 months, are just beginning to assimilate a lot of the information they have been learning since starting thier jobs. A good employee, IMHO, stays long enough to give back to the unit that has taken the time to train them. Unless of course there are extenuating circumstances. I left one unit after 3 months because of burnout, hospital felt I was worth keeping and allowed me to transfer to different area.

Some hospitals will take med/surg nurses and have a fellowship program just for them. Her med/surg experience, of at least one year, should only be a positive because of the reasons caroladybelle described so well.

bluesky, BSN, RN · Jul 24, 2005

The new grad vs. experienced medsurg experienced candidate: who makes a better ICU trainee? is an age old debate. Personally, I think the calibur of the ICU nurse you get is more a function of that individual's personal attributes than their nursing background, but that's just me.

What does your wife, herself, believe? If she does some soul searching and finds that she believes that a year or two of med-surg will make her a better CRNA in the long run then go for it! If, on the other hand, she feels that she can handle direct entry into an ICU well then go for that!

The key, ultimately, is to find a hospital that embodies her belief system.

More than the new grad vs. m/s nurse issue, I have found one factor that contributed to poorer one year evals... night shift. The fellows that went directly to night shift after their training did disproportionately more poorly on their one year evals than those that stuck to days. On days you get to go on more roadtrips, attend rounds, assist with more procedures, be around for more consults, etc. This phenomenon was so pronounced on my unit that the new batch of fellows this summer are actually not allowed to transfer to nights for a year. I have first hand experience with this because I was one of the top fellows out of the fellowship but fell behind after I transferred to nights way too soon. Since I've gone back to days, I am getting all kinds of kudos from my managers, peers and attendings at how much I am growing and excelling (read they felt I had a lot of growing to do...)