Are some people just not cut out for ICU?

[TigerGalLE, BSN, RN]

I'm currently orienting a nurse to our ICU. She has 1 year med-surg experience. We are going into our 14th week of orientation. She still doesn't seem to get it. It seems as if she still doesn't see the big picture. She is very task oriented. Completing her "tasks" without knowing the reasons or importance for doing so. I have to repeat the same things over and over without her showing signs of remembering to do these things on her own. She doesn't do any "homework." Even misses educational opportunities that are provided for her. I encourage her to study drugs, shock states, and other common diagnoses at home. But when asked about these things she continuously fails to know the answers.

On week 14 she still cannot tell me how dopamine, levophed, fentanyl, vasopressin ect are routinely ordered. She was going to give IV digoxin thinking it was an antihypertensive. She doesn't recognize subtle changes in vitals. HR trending up, BP trending down, UOP non-existant.

We have met with my director on many occasions and continue to talk about goals for the upcoming week.

Her bedside mannor is wonderful, she develops great relationships with patients and families. But her knowledge of nursing and drugs is so far from where she should be at this point. I'm afraid she will not succeed. I want her to succeed.

She is late everyday. This has been addressed but the behavior continues. She is unaware of what is going on in the unit. She goes to lunch without telling me or other staff. Without handing her patients off. And then will sit and eat a 45 minute lunch while her patient is crashing. She gives almost all of her meds late. And i mean hours late. She forgets to check temps, blood sugars.

Usually our director gives 8-12 weeks of orientation to nurses with prior hospital experience. At week 14 I do not see the light at the end of the tunnel.

Other nurses tell me I'm too patient, I should fuss at her and "light a fire under her" so to speak. I've attempted that approach before and have found that she freezes when someone is harsh with her. I've taken the more patient, stand back and see, intervene when necessary, drop clues kind of approach. I try to educate her. I give her websites and books to read/study.

Are some people just not cut out for ICU?

[surferbettycrocker]

almost soundsl ike she is laisse faire about the acuity in a way? or is it she doesnt know what she doesnt know? i wonder why she chose icu... did you ever ask her opinion on how she is progressing? like how does she view her progress? does she feel she is exceeding her own expectations or is right where she should be at this point?

soundsl ike she is not 'scared' enough of icu! honestly esp. since she is still newbie nurse.

[TigerGalLE, BSN, RN]

I agree with her not being "scared" enough of ICU. I don't think she grasps how sick these patients really are. She is at the point where she is taking both patients independently. And the patients aren't declining under her care which is good. But they aren't necessarily making huge improvements either.

I had to tell her 5 times the other day to get her adolescent aspiration pneumonia patient OOB and to use his IS. And it wasn't until the respiratory therapist came in and said "if you don't help me get this kid up, I'm gonna find a nurse that will." She didn't see what the big deal was. And then let him crawl back into bed after only sitting up 25 minutes and only pulling 250 on his IS. I will ask her at the beginning of the shift. What are some things we need to get done today? We talk it out. Orders SCDs, get patient OOB, Bath, Make sure MD orders GI prophylaxis, ect..... It takes multiple reminders and me going as far as setting an IS or SCD machine on her desk before it gets done. These easy things get patients out of ICU so much quicker. But because it isn't on her MAR she doesn't think to do it. I understand if the patient is crashing and she is overwhelmed. But lately our acuity has been DOWN. Easy patients.

I know everyone is different in how they do things. But there has to be some sort of urgency in ICU.

Let me add. We talked about how she thought her orientation was going last week. And she mentioned that she didn't want to be the dummy that couldn't get off orientation. My response to her was that it is better than coming off and having to go back on orientation. We talked a lot about procrastination and the importance of doing things on time. I'm hoping to see improvement over the next few weeks.

[360jRN]

Are ya'll hiring!? LOL! Which city do you work in? I'm assumin' youre from La... Any idea where Natchitoches is?

[NurseKitten, MSN, RN]

How does she organize her work? I was originally taught to outline my patients by hour and write in the meds, and whatever else I'm going to have to do (blood sugars, temps, IS, etc) by the hour. If she's task-oriented, maybe this would help, if you haven't already done it with her? Give her checklists of "this gets done on every patient, no matter what", "these should be considered for this diagnosis", etc etc etc...

I will say, though...before I went to the ICU, I was a clinical preceptor for the local dialysis clinics. I had to tell more than one person that dialysis wasn't for them, and it didn't mean they were a bad person, or a bad nurse, just they weren't cut out for dialysis. They had a lot of the same issues you talk about here....

BUT...there is NO excuse, and I do mean NONE for showing up late, not reporting off when you leave for ANY reason, and not doing your homework. NONE. You are vicariously responsible for her practice, and if you let her off orientation and she screws up...guess who it could come back on?? If she's not doing what you're telling her to do, then she is not hacking it. Period. The end.

You sound like a lovely person...wish there were more preceptors like you out there...but I think your gut is right on for this one. She's not cut out for this kind of acuity.

[llg, PhD, RN]

I would think that the pattern of coming in late to work would be sufficient to fire her.

If she isn't willing to show up on time and/or participate in the educational offerings ... then really ... she needs to go. Someone need to "read here the riot act" and give her a clue -- a specific list of behaviors that need to improve immediately -- or else she will no longer have a job there.

Putting up with that sort of behavior on orientation will just encourage it to continue indefinitely. And that type of behavior is indicative of someone you don't want on your team.

[detroitdano]

I don't see any point in trying to develop her skills any further. She's a lost cause. Having no motivation to do homework and learn important material is reason enough to know she won't be a good independent ICU nurse. If you're just giving drugs based on a vague knowledge and don't care to look them up on your own, you're not cut out for an ICU.

[meandragonbrett]

14 weeks? Really? We give new grads 8 weeks and then give them the boot. It's time to transfer her to another department.

[queenjulie, RN]

And then let him crawl back into bed after only sitting up 25 minutes and only pulling 250 on his IS.

I know this is off topic, but what would you consider a good amount of time to keep a pneumonia patient up OOB? I'm a student RN, and I've had nurses tell me that my patient can't get back in bed yet even if they're complaining because it hasn't been long enough, but I have no idea what "enough" is! Any guidelines? I assume it varies depending on the patient, but say, for your adolescent, what IS level and amount of time OOB was your goal for him? And isn't the IS goal level often in the doctor's orders?

[RocktheBoat]

I think that some people are definitely not cut out for ICU. I think that ICU takes a person with a certain personality--I have also been told this by some of the nurses I know on the floor. If she is on her 14th week and still has no clue about vasopressors and thinks it's acceptable to leave her patients to take a break without telling anyone, she has no place in an ICU. I think her only hope would be to try feeding her to the wolves and give her little if any help with her patients for a while. She might just be too reliant on you--thinking she doesn't really have to do anything because you will be there to bail her out. She would have to be watched though so no harm comes to her patients. Her being chronically late is something I personally can't stand--I HATE it when people are late (if they are late getting there, I am late leaving which I find unacceptable).

[ckh23, BSN, RN]

No not everyone is cut out for the ICU. Not every nurse is cut out to be a good nurse is every field. I for one never like pysch, OB, or peds and I don't think I would do very well in those areas.

However from what you described it sounds like she is not putting forth much effort to improve herself. You can only help and teach someone so much, but if they don't want to learn than you might as well be orienting the wall. It sounds like this nurse really needs to evaluate if he/she thinks they are cut out to be an ICU nurse or if there is another specialty they would be better suited for.

Your story reminds me why it is ridiculous when people say nurses should have at least 1 year of med-surg experience before going to critical care. They are both so different from each other.

[Illyra01]

We have had several orientee nurses come through in my 10 yrs in ICU, who for whatever reason just never seemed to get it. Some were new, but sadly, most of them seem to be the "experienced" nurses. You can often tell early on, because it's the ones that don't have a million questions. It is sad and frustrating to be the preceptor and feel like you somehow failed them, but it sounds like you have done everything you possibly could. 14 weeks is a long time, and to still be weak on the basics means it's time to find a different position. Your manager should explore your options and either find a different position in the hospital for her to try, or let her go.