Better ICU nurse with med/surg experience?

oMerMero · Feb 15, 2007

It seems like everyone has their own opinion on this issue, and I will share mine. I did a few years of med-surg before moving to the ICU, and I would definately recommend doing it that way. Working med-surg, I learned wonderful time management and organizational skills. It was hard enough learning iv pumps, looking up meds and worrying about basic nursing skills. Having stable patients allowed me to focus on other more basic things. If I went straight to the ICU, I wouldn't have been as confident with the equipment and basic nursing skills, and then throw an unstable patient on top of that, I think I would have been very overwhelmed. But, I know new grads are going straight into the ICU. They tend to be very overwhelmed at first, but eventually catch on, so it can be done.

VivaRN · Feb 15, 2007

I'm a new grad who started in the ICU. During nursing school clinicals I realized I wanted to spend more time with 2 patients vs. less time with 7 patients. The ICU was a good fit for me. There is such a nursing shortage if we didn't hire new grads we'd be hard pressed to staff the unit. I had an excellent preceptor who explained his thought processes and gradually let me take more and more responsibility. I studied up at home, bought a few books, and educated myself. It was challenging, for sure, but even the med-surg nurses on orientation have many of the same struggles. The ICU requires a different organization than the floor (our unit also has a floor and I work both). Some of the students I see coming in now have had critical care preceptorships while in school. They are very competent and knowledgeable. IMHO, it depends more on the person than the nursing experience: desire to learn, critical thinking, know your limitations and organization. With the right support we can hit the ground running! Though it is very clear in my unit that trust must be earned: if I was in any way unsafe, I would not be NEAR those patients. Of course in the beginning I took more stable patients. Part of our "safety" as new nurses lies in having an appropriate assignment. It's a growing process, but I think that's true for everyone.

Ruby Vee, BSN · Feb 16, 2007

i know this isn't a popular opinion these days, but i don't think the trend of new grads going straight into the icu is an improvement. for the reasons the first two posters have already suggested, a year or two in med surg to learn the basics makes a better icu nurse. i know we see lots of posts from nurses who've started in the icu as new grads saying that they're doing great and med-surg would have been a waste of time for them; but i'm not totally convinced. i'm wondering what their preceptors and co-workers would say.

the new grads i've worked with recently who started in the icu are very weak on the basics. just today, a nurse who has been here for a year told me she'd never checked an ng residual and didn't know how. turning every two hours seems to be a thing of the past. no one knows how to start an iv anymore because our patients come from surgery with lines in. drawing an abg without an arterial line? no way! applying an incontinece bag? nt suctioning? where's rt? check with the ostomy nurse. the basics seem to be glossed over or missed completely. worse, making assessments without the technology seems to be a lost art. so a patient who goes bad after being de-lined and assigned a room for transfer seems to get missed. "i didn't know her blood pressure was low because i'd already taken out her art line." or "i didn't know i had to check a blood pressure if his art line was out."

not every new grad who starts in the icu is this bad, but enough of them are that i'm thinking more new grads ought to start in med-surg!

meandragonbrett · Feb 16, 2007

I think it's greatly dependent on the new grad themselves. Some new grads have the basic skills down when they come out of school and just need to learn how to manage a patient load. On the other hand, some new grads don't have a clue how to insert an NGT, IV, Foley, or even what an art line or swan is. So, I think it's all based on the individual and their drive to learn.

Dinith88 · Feb 17, 2007

In my opinion, it depends on the person.... HOWEVER, i beleive that those w/experience on med-surg/tele/imcu/step-down have a much better transition and in general are superior to new-grads going straight into it. The reason for this is that nurses with prior experience have learned 90% of what nursing is...and only have to concentrate on the 10% ICU-type stuff. The new-grad on the other hand has ALOT of catching up compared to the experienced nurse.

So...2 or 3 or 4 years down the road the grad who went right into ICU may be as 'good' as the other nurse...but not always...

Also, nurses who work in a facility that floats-out icu nurses to other units (Step-down, imcu, er, etc) will be much better at it if they've had the chance to 'juggle' 4-5 patients. The nurse who has only taken care of 1-2 patients is in for a culture-shock and can find herself bewildered/melt-down...this is much less a problem for someone who's had experience at it beforehand.

The best new-grad hires are the ones who've spent time as a tech/nurse-fellow/cna in an icu...they're usually much better than the new-grads who've not worked in one because they're familiar with the environment...

In an ideal world, all icu nurses should have prior experience (esp. in tele/step-down)...the reason i say this is because if a person is critically sick (say your relative) it would make you nervous if her nurse were still 'learning the ropes'...

BUT...it's not a perfect world and we have a 'shortage' and all of that...and new-grads can (and do) fill the gaps and can survive...some better than others...

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(and as an aside, ICU nurses are stereotypically known to be bold, pushy, and a little cocky ...and it seems to me that the icu new-grads REALLY exhibit these traits (and this isnt necessarily a bad thing)...but i suppose these traits would be helpful for someone jumping straight into the deep end)

cardiacRN2006, ADN, RN · Feb 19, 2007

the new grads i've worked with recently who started in the icu are very weak on the basics. just today, a nurse who has been here for a year told me she'd never checked an ng residual and didn't know how. turning every two hours seems to be a thing of the past. no one knows how to start an iv anymore because our patients come from surgery with lines in. drawing an abg without an arterial line? no way! applying an incontinece bag? nt suctioning? where's rt? check with the ostomy nurse. the basics seem to be glossed over or missed completely. worse, making assessments without the technology seems to be a lost art. so a patient who goes bad after being de-lined and assigned a room for transfer seems to get missed. "i didn't know her blood pressure was low because i'd already taken out her art line." or "i didn't know i had to check a blood pressure if his art line was out."
not every new grad who starts in the icu is this bad, but enough of them are that i'm thinking more new grads ought to start in med-surg!

ugh. i used to really argue that new grads are perfectly fine starting out in the icu as i am one myself.

but, as the last semester nursing students keep rolling through our unit, it makes me sometimes scared when i hear that they want to work in icu.

when i hand you an ivpb, and you don't know how to mix the powder with the liquid, and you don't know how to hang the miv lower, i'm thinking that icu may be out of your reach. or when i ask you about propofol, and you say it's a beta blocker-well, it's not a good sign. not to mention it tells me you didn't do your care plan properly...

i was fortunate that i got to do a lot as a tech. i was a phlebotomist as part of my tech training, and so i got a lot of iv starts thanks to some icu nurses. i also did perform some nt suctioning, was instructed on vents and swans and alines. lots of foley placements, lots of flexi-seal placements (our rectal bags). i was taught abgs, and i had to do the q2 rolls on all the icu pts (with each pts nurse). plus, working in a cvicu, i had a lot of experience with pacers, cts, chest/leg incisions, ekgs, chf'rs, and other cool stuff! in addition, i was an emt prior, which helped with my confidence.

i was lucky. and yet, it still was and is very difficult to be a new grad in the icu.

some people won't like you there. you will have to do outside studying. i have spent many a day at the barnes n noble with my critical care books and my laura gasparios vonfrolio tapes-just to be at the level of beginning to nurse at the critical care level.

MommyJoy · Feb 28, 2007

What tapes are you referring too? Laura.... something. I am externing in the SICU this summer. I am currently a tech on a step down unit. Anyway, I am very interested in ICU, and just wondering what the information is that you are referring too.

cardiacRN2006, ADN, RN · Feb 28, 2007

What tapes are you referring too? Laura.... something. I am externing in the SICU this summer. I am currently a tech on a step down unit. Anyway, I am very interested in ICU, and just wondering what the information is that you are referring too.

https://www.greatnurses.com/exp/index.php/products/item/ccrn_review/

She's the best...

GregRN · Mar 1, 2007

i know this isn't a popular opinion these days, but i don't think the trend of new grads going straight into the icu is an improvement. for the reasons the first two posters have already suggested, a year or two in med surg to learn the basics makes a better icu nurse. i know we see lots of posts from nurses who've started in the icu as new grads saying that they're doing great and med-surg would have been a waste of time for them; but i'm not totally convinced. i'm wondering what their preceptors and co-workers would say.
the new grads i've worked with recently who started in the icu are very weak on the basics. just today, a nurse who has been here for a year told me she'd never checked an ng residual and didn't know how. turning every two hours seems to be a thing of the past. no one knows how to start an iv anymore because our patients come from surgery with lines in. drawing an abg without an arterial line? no way! applying an incontinece bag? nt suctioning? where's rt? check with the ostomy nurse. the basics seem to be glossed over or missed completely. worse, making assessments without the technology seems to be a lost art. so a patient who goes bad after being de-lined and assigned a room for transfer seems to get missed. "i didn't know her blood pressure was low because i'd already taken out her art line." or "i didn't know i had to check a blood pressure if his art line was out."
not every new grad who starts in the icu is this bad, but enough of them are that i'm thinking more new grads ought to start in med-surg!

this sounds more a result of the hosptial, not the nurse. be careful about inferring to the population as a whole based your experience at one institution.

there are many variables that need to come together in order to go straight into the icu out of school and be successful. some of them have to do with the person, some have to do with the hospital. first, is the icu where you really want to be? are you aggressive/assertive enough to move at that pace and not get pushed aside when things turn south? do you work better getting to know 1-2 patients very well and at a deep level, vs. 5-8 patients on the surface? do you like the detail involved in putting together the puzzle of an icu patient? when the fit hits the shan and your patient crashes, do you want to be at the forefront in getting them stable again or would you rather let someone take care of the crisis and then you take the patient from there? can you navigate the delicate waters of family members' anger and anxiety when their loved one becomes acutely ill and they have nowhere else to place that energy except on the nurse? are you prepared to handle/learn end of life issues, both from the patient's perspective and their family's? those are just a few things to think about. if you answered "yes" to those, then the second part becomes the most important.

secondly, does the hospital where you are considering going into the icu have a track record for successfully placing new grads in the icu? what is their training program like? how long? are you 1:1 with a preceptor? does that person have a successful track record as well? what resources are available to you as a new grad icu nurse, i.e., education and training departments in the hospital, cns's, access to doc's, resource books and material, computer applications and training, hand's on education, etc? how acute is the facility in which you will be working? how long is training before you will be expected to work independently? what is the culture like on the unit in which you will be working? are they receptive to new grads or would they rather beat them up for a bit to see if they can "make it"? when working independently, is the unit very helpful to new grads just off orientation or do they give the attitude of "sorry, you're on your own now"?

i've seen very smart, driven and capable people fail miserably going straight to the icu because the facility in which they were working was not adequately set up to take on new grads. the system failed them and no matter who was placed there, it's likely they would have failed as well. likewise, i've seen people who were not quite ready for the icu get through a very good training program, only to decide later that the icu wasn't quite right for them. where you fall in the middle of all this, and the facility in which you work, will likely predict your success in going directly to the icu from school.