Being Kicked Out of the ICU?

Ruby Vee, BSN · Mar 15, 2018

I have never done this but at this point I feel like I need feedback from other nurses. I got hired as a MedSurg Float before I even graduate school. I worked in that field for about a year and a half and then there was an opening in the ICU and I always wanted to work in the ICU, during my time I had floated there several times as helping hands. So 10 weeks ago I started orientation to ICU, I already had all the training/certificates I needed. I had my ACLS, I had CAPD before, I just had to do this online ECCO modules which was fine, I finished that with no problem. The first 6 weeks felt like a piece of cake for ICU, I didn't really have critically crashing patients. I did express this to my manager several times when we had our every 2 week meeting. She told me not worry and that I would get the experience and that I'm doing well and everyone has nothing but good things to say about me. Week 8 comes by and I have an arctic sun and a major trauma admission who I also have to set up for ICP monitoring which I've never done so that week was extremely overwhelming. So because of that they wanted to give me an extra day on the day shift, because I'm going to be working nights. Since my preceptor felt that I need more time during the day to listen to rounds with the MD's, communicate with them more, get more admissions, have more things to do during the day basically. Also at this point, I ended up having to have 3 preceptors because the "main preceptor" ended up with a back injury so part way through my orientation I had to switch so the preceptor that wanted me to have more time on days was a preceptor that I only worked with for 4 days.
I didn't think have the extra week on days was going to be a huge blow to me. But I guess that may have been what made my manager start thinking that she didn't want me to stay in the ICU. Because by the end of week 10 I felt like things were going fine, I was on top of everything, sure I forget to change my limits of the alarm but once I remembered I went and did it, It's not like I didn't realize a patient was crashing or anything. I had a patient transfer from the floor that was intubated and every hour I would have to sedate her even in wrist restraints but it would tank her pressure and the MD's didn't want to put her on pressors and just wanted to use fluids, so most of my time was in there with that patient. So 4 hours into the shift my preceptor said to me, "Why haven't you titrated the levo on your other patient? Her pressure is 130/70? Because I am kind of a wuss, I responded with, "I was going to. I'm going to do it now." I should have explained that because I was in with the other patient I didn't have a chance to go in and titrate the levo down and really be able to keep a close eye on that patient because I was occupied with the other patient. So my manager brought this up as one of the reasons why I am not a "good fit" for the ICU. Another reason was because a pt's BP was 40/30 and I didn't tell anyone. Which wasn't true. When I saw that BP, I went into the room, recycled the BP and waited to see if it was "real" or not. And then went and told the MD first but I guess I was supposed to tell the preceptor first.
Am I completely crazy? Did I do all of these things wrong? This morning felt like the worst morning of my life because I was completely blindsided when my manager said that she had to make a decision that it wasn't safe for me to keep working in the ICU. She didn't think that in 4 weeks I could handle things on my own. This has never happened to me before. I feel like crap. Does stuff like this happen? All of my coworkers are now going to know that I "couldn't make it in ICU" once they see me in another position. And that is another thing I'm not going to want to deal with.

Yes, this stuff happens. Some folks just cannot make it in the ICU for one reason or another. Is your manager going to help you find another position? Or are you able to go back to your old position?

I had a colleague whose only goal was CRNA school. That's all he talked about, and he spent most of his time at work studying, gathering his references, etc. He went to CRNA school and flunked out after the second semester. He came back to work in our ICU and deflected any criticism and gossip about the whole thing by saying that he didn't think anesthesia was a good fit for him; he enjoyed the interactions with patients and families. As far as I know, he was respected for knowing what he wanted and going back to where he wanted to be.

Now, as to the other questions about whether you did all of this stuff wrong -- I don't know for sure. I wasn't there. But if I had an orientee who was four hours into the shift and hadn't titrated drips on one patient because she was spending all of her time with the other, I'd question whether they were safe to be on their own. You were responsible for both patients. If you couldn't deliver the care that both patients needed, you should have been talking to your preceptor. Together, the two of you could have figured out a way for you to make it work, changed the assignment or had your preceptor do for the other patient. Perhaps the intubated patient needed a sitter.

And if I had an orientee who didn't tell me about a systolic blood pressure of 40 -- even if it was in error -- I'd again question whether the orientee even knew about the blood pressure.

Some of the things that make folks a poor fit include over-confidence, failures of critical thinking and failures of prioritization. We expect time management to be an issue at first, but after 8 weeks, we'd expect an orientee to realize when her time management is leading to the neglect of one patient and be able to delegate. I'm perfectly OK with my orientee saying "I just can't get to Mrs. K's 9:00 meds. Could you check on her and give the meds?" If I think it's something the orientee should be able to manage, we'll talk about it, but I'm OK with giving the meds and checking on the patient. After all, that's what we do on the night shift when a nurse is drowning -- we help out.

KeepinitrealCCRN · Mar 16, 2018

hard to comment on things like this with only a few situations and not working with you personally but i must say getting a BP of 40/30 and then recycling it and it being "normal" is not something that is serious. this happens a lot with cuff pressures and we all recycle them. as long as the recycled one and the subsequent ones are "normal" there is nothing to say or do. also if you are dealing with a situation and you really can't leave the room you should say to your preceptor or another nurse hey can you check on my other patient but a pt on a levo drip with a systolic bp in the 130s and you aren't titrating down yet due to your other more emergent situation is really also not a big deal. i wonder if there is something else going on? also what does your original preceptor with the bad back have to say about you? maybe she can talk to your manager? I'm not sure this is reason enough to say you are not cut out for ICU. hope it works out for you!

Nurseynurse94, BSN · Mar 22, 2018

This exact thing happened to me.... brand new nurse straight to a cardiac surgery icu after graduation. I had a senior practicum there, knew it would be tough, and figured I'd work hard. Similar situations happened to me to. Them questioning me about my speed of which I did things or my confidence. Three different preceptors. 5 weeks in they told me it wasn't going to be a good fit , icu isn't for you good luck in your career. A month later I found a new job in an ICU in the same city. Smaller hospital more generalized ICU and much much more receptive to new nurses. I'm off orientation and doing just fine!

Long story short.... yeah it happens but there's much better things to come. If you want to work in an ICU, you sure can.

JKL33 · Mar 22, 2018

Because I am kind of a wuss [.....]

OP, these situations often have an overlay of "other people's perceptions" - aside from whether or not you provide care that is overall safe.

In addition to the good advice and comments above, I would also consider this experience in terms of how you carry yourself - what overall message you send to people, intended or unintended. I'm not talking about your moral/ethical character or anything like that, but assertiveness/proactiveness, communication, etc.

I don't want to add insult to the injury you've already experienced, but this whole thing could be a learning experience; a chance to grow stronger.

If you have a patient who should be having their levo gtt titrated, the question isn't whether or not it is safe for you to delay titrating it - - after a number of hours the question becomes whether you even realize it needs to be done. If you don't say anything to anyone or make a plan for taking care of that patient as well as the one who was more of a handful, people get to make their own assumptions about what you're thinking. If hours go by and you don't say or do anything about it until they bring it to your attention, it's reasonable for them to have assumed it was totally off your radar.

With critical values/vitals - - you do want to communicate very well to your preceptor what you're doing or what you've already done. No I don't think you needed to let him/her know before talking with the doctor, but s/he does need to know; sooner rather than later. ASAP. I've had orientees do the exact thing you did, and then when I go in the room, the patient is indeed starting to deteriorate - but the only people who had the opportunity to know were 1) the new person and 2) someone not there looking at the patient.

Again, I debated about using your examples in this way because what's done is done and it's not really fair to nit-pick. So these words are written in the spirit of simply giving you some food for thought as you heal from this disappointment.

You gotta get out there and be proactive, professionally assertive, and communicate very well when taking care of critically ill folks. I'm guessing this experience will become part of a stronger "you" in the future!

Best wishes ~

sugarmagnolia3 · Mar 27, 2018

I have never done this but at this point I feel like I need feedback from other nurses. I got hired as a MedSurg Float before I even graduate school. I worked in that field for about a year and a half and then there was an opening in the ICU and I always wanted to work in the ICU, during my time I had floated there several times as helping hands. So 10 weeks ago I started orientation to ICU, I already had all the training/certificates I needed. I had my ACLS, I had CAPD before, I just had to do this online ECCO modules which was fine, I finished that with no problem. The first 6 weeks felt like a piece of cake for ICU, I didn't really have critically crashing patients. I did express this to my manager several times when we had our every 2 week meeting. She told me not worry and that I would get the experience and that I'm doing well and everyone has nothing but good things to say about me. Week 8 comes by and I have an arctic sun and a major trauma admission who I also have to set up for ICP monitoring which I've never done so that week was extremely overwhelming. So because of that they wanted to give me an extra day on the day shift, because I'm going to be working nights. Since my preceptor felt that I need more time during the day to listen to rounds with the MD's, communicate with them more, get more admissions, have more things to do during the day basically. Also at this point, I ended up having to have 3 preceptors because the "main preceptor" ended up with a back injury so part way through my orientation I had to switch so the preceptor that wanted me to have more time on days was a preceptor that I only worked with for 4 days.
I didn't think have the extra week on days was going to be a huge blow to me. But I guess that may have been what made my manager start thinking that she didn't want me to stay in the ICU. Because by the end of week 10 I felt like things were going fine, I was on top of everything, sure I forget to change my limits of the alarm but once I remembered I went and did it, It's not like I didn't realize a patient was crashing or anything. I had a patient transfer from the floor that was intubated and every hour I would have to sedate her even in wrist restraints but it would tank her pressure and the MD's didn't want to put her on pressors and just wanted to use fluids, so most of my time was in there with that patient. So 4 hours into the shift my preceptor said to me, "Why haven't you titrated the levo on your other patient? Her pressure is 130/70? Because I am kind of a wuss, I responded with, "I was going to. I'm going to do it now." I should have explained that because I was in with the other patient I didn't have a chance to go in and titrate the levo down and really be able to keep a close eye on that patient because I was occupied with the other patient. So my manager brought this up as one of the reasons why I am not a "good fit" for the ICU. Another reason was because a pt's BP was 40/30 and I didn't tell anyone. Which wasn't true. When I saw that BP, I went into the room, recycled the BP and waited to see if it was "real" or not. And then went and told the MD first but I guess I was supposed to tell the preceptor first.
Am I completely crazy? Did I do all of these things wrong? This morning felt like the worst morning of my life because I was completely blindsided when my manager said that she had to make a decision that it wasn't safe for me to keep working in the ICU. She didn't think that in 4 weeks I could handle things on my own. This has never happened to me before. I feel like crap. Does stuff like this happen? All of my coworkers are now going to know that I "couldn't make it in ICU" once they see me in another position. And that is another thing I'm not going to want to deal with.

The only red flags I'm seeing here is not asking for help. If you're stuck in a room with an unstable patient, ask someone to check your other patient (and their drips, you DON'T want to run out), or ask someone to watch this patient, so you can care for the other. Also, when you recycled the BP, were you looking at other indicators of instability? HR/ rhythm, RR, WOB, color, perfusion, pulses? One piece of information is not nearly as meaningful without the rest of the assessment.

Always, always, always ask for help. And if someone offers help because you're busy, don't be so proud that you turn it down. Utilize your supervisor and coworkers.

Ahua12 · Apr 26, 2018

It is very difficult to give advise only reading one perceptive on a situation. I have worked in multiple hospitals which has given me the opportunity to work with many preceptors as well as having acted as a preceptor. One question I have regarding your situation would be, where was your preceptor for the 4 hours that the levo was not titrated? Your preceptor should be keeping a close eye on you as you are still learning. Your preceptor should have asked you what your plan was regarding that patient if she had noticed you did not titrate it. I personally would have used that aa a learning opportunity to see where you where at with critical thinking skills, knowledge of medicine and rational for your actions. If as a preceptor I noticed a bp of 80/40 and did not see you take action I would question you, if the pt bp was truly 80/40 I would be in that room overseeing what your next actions where, what other vitals are you looking at, why did the bp suddenly tank or was it trending down. A good preceptor should be listening as you presented the situation to the Dr. which also gives them an opportunity to see if you understand the whole picture.

I had a new RN that was "drowning" for lack of a better term and I stopped her and asked her what was going on, where was she at with med's etc and I helped her out. I stopped her because one I was supposed to be training/teaching her and two because patient safety is first and foremost. After our shift I explained the importance of asking for help and how the other patient could have been adversely effected by her being caught in the other room. I explained and showed her examples how on a unit particularly an ICU we need to help each other.

My advise is don't give up if you love the ICU, talk to your manager for true and constructive feed back regarding your training. Get specific examples and evaluate how you could have changed the situation. Take what they say no matter how harsh it may be and learn from it. Find another ICU and ask to shadow see if the preceptors want to teach or if they are forced into training new RN's because of years of experience. Good luck in your future.

caliotter3 · Apr 27, 2018

It wasn't clear to me how long your training is supposed to last. I did a practicum in an ICU while in school. One of the younger nurses there told me when they hired her into the ICU, she was given nine months of training, X amount starting off in a formal classroom, and she felt accepted and supported by everyone involved. Apparently, not all facilities provide the same level of support. Follow some of the previous advice given and don't give up.

/username, BSN, RN · May 10, 2018

The first 6 weeks felt like a piece of cake for ICU, I didn't really have critically crashing patients. I did express this to my manager several times when we had our every 2 week meeting. She told me not worry and that I would get the experience and that I'm doing well and everyone has nothing but good things to say about me. Week 8 comes by and I have an arctic sun and a major trauma admission who I also have to set up for ICP monitoring which I've never done so that week was extremely overwhelming.

That alone is very concerning. Going from a new grad to ICU being a piece of cake with no experience is a little strange and smells of overconfidence.

I don't really know what the arctic sun has to do with anything, as once it's set up, it just does it's thing... What does concern me is that if your hospital is a trauma center, and it sounds like it is, your "major trauma admission ..... [with] ICP monitoring" Is your bread and butter patient in SICU.

It seems that with your hourly sedation patient, you didn't call the doc to get a more effective sedation plan, or talk to your preceptor about this?

It sounds like you didn't talk to your preceptor about much, and in the ICU, that's a bad thing. All of the people we've cut loose have had the same thing in common in that they will almost over communicate what is going on with their patients and what they are thinking to their preceptor until said preceptor gets to know them and how they think... A new staff member, especially a new grad who doesn't talk is a whole cargo ship full of red flags. It sounds like you weren't talking with your preceptor and not reaching out for help BEFORE you got in over your head.

The rare, and 99% impossible scenario is if said nurse makes no mistakes and has impeccable clinical judgement, which as a new grad, you have neither going for you.

I absolutely believe it was a combination of the lack of communication, seemingly not being able to handle caring for their patient population, not reaching out for help, and potentially making mistakes in judgement or skills.

gromit1084 · May 12, 2018

I can see both sides of what is being said here but the truth is that 10 weeks is not a whole lot of time in the ICU. It really really isn't and I think everyone here could agree with that. You advocated for yourself by telling them you have not taken care of very ill patients and they reassured you it would be fine. At the same time, I also think its true that both patients are your responsibility, as frustrating as that is.

The same thing happened to me and the management at that hospital just had it out for me. I ended up leaving and picking up travel nursing to other ICU's with a year's worth of ICU experience. People said it would be impossible but it isnt. I do really well in the ICU and that first job I had was a toxic environment. If they are not willing to work with you as a baby ICU nurse, thats a major red flag. There is no way they can expect you to function as an experienced ICU nurse, especially when they aren't giving you the assignments and the support to get there. 10 weeks is almost NO time to get proficient. So if they just don't want to give you the proper orientation, I would go to another hopsital/ ICU.

I agree though with sugarmagnolia3: you need to be communicating and reaching out. This is not a job that one can do isolated. I used to feel like "oh my gosh, I need to show them I can do this!" and I mistook that for needing to be stoic, but this was a fatal mistake. You need to communicate, even when you feel like you don't need to. Tell your preceptors, the nurse's around you, the doctors, anyone involved. Don't be stoic!

you can do this!! above all, they can not define what kind of nurse you are or whether or not you can be an ICU nurse!!

BurnedoutICURN · Jun 27, 2018

"Why haven't you titrated the levo on your other patient? Her pressure is 130/70?"

The largest issue I see here is not telling your preceptor you needed help. The BP of 40/30 and rechecking it? I don't have a problem with that, and you did tell the physician, which is who you'd be calling with this problem. I can understand the preceptor needing to know when there's a problem with the patient's condition. But I also know what it's like to work with pretentious individuals who think their way is the only way to work in an ICU. I've worked ICU for the better part of my time as a nurse. When I started my current job, my lovely preceptors told the unit manager I was awful and needed to go. 18 months later, I'm still there. Don't get me wrong. They still think the world would fall apart without them to "save the day."

I'm sorry this happened to you. But use this as a learning experience. Try getting into another ICU at another facility. Don't give up just yet.

RNNai · Nov 20, 2018

OMG this is exactly my situation. I signed up for all nurses to post a question about this very same subject. Just when you think you're the only one struggling. Anyways, everyones advice here is so helpful and I believe them to be true. However, I think that as long as you are willing and you have the drive to succeed then eventually you can be the resource that you are desiring to be in the ICU. IMO it just may not happen in the context of ~6 to however many weeks long your training was, (sounded short). That being said, it may be disrespectful to piggy-back my experience on your question so I think I may have to post my own.