New icu nurse and feeling discouraged

ClauICURN · Jun 12, 2017

Hi there,

Sorry to hear that you are going through a difficult time. I've been in the ICU less than two years, so kinda new myself. I can share what helped me when I was starting out, and maybe some of it can make this transition easier for you.

What helped me the most as a new RN in the ICU was to get organized into a sort of tentative routine for the work day. Right after getting report I'd go assess my patients and see if there was anything urgent that needed to be done like drips running out or whatnot. If not I moved on to looking at their labs, X-rays, pending procedures, am meds, reading last progress notes from physicians, and just getting an overall idea of why the patients were in the ICU and their clinical situation. After that I'd get all the charting and assessment documentation done. By this time it'd be around 8-8:30am. If my patients had a diet I'd help them with am care and getting OOB to chair (unless I needed help from PT for that) and pass their their breakfast tray. For vented patients, do oral care and tidy up patient and room. Once this was done I'd pull up all the routine meds and by 9:30am I'd usually be done with that. The rest of the day would follow kind of the same structure, trying to stay flexible and adjust during the day. The most important thing I feel is to form a plan of care for the day that works for you, always doing everything ahead of time and taking at least thirty minutes early during your shift to look at the labs and read notes to see what's going on with your patient and what you can do during your shift to move the plan of care ahead.

The second piece of advice I can give you is to read and study on your own when you get home, even if it's just an hour every night. You can get better at nursing skills just by observing your fellow experienced nurses and having the opportunity to practice them yourself with patients as time goes on. However, it takes a little more extra effort to learn about pathophysiology and disease process and that is something that you will mostly need to do independently. Make note of the most common conditions you see in your ICU (I know, mine also feels like a step down or LTAC most of the time) and research them. Little by little you will start feeling more confident as your knowledge base grows, and this should translate into ease of communication with colleagues and physicians.

So, sorry about the long post but don't feel discouraged! It is a rite of passage of sorts, but the ICU is a very stimulating environment that will open many doors for you in the future.

Audi3181 · Jun 13, 2017

Hi thank you so much for your response I very much appreciate you taking the time to read my post and comment. It means a lot to me. I will take your advice and put it into my practice.

**NICU Guy, BSN, RN** · Jun 13, 2017

The problem with working at a small ICU as a new nurse is that you are not exposed to very sick patients on a routine basis. When one of your patients crashes, you are not as prepared as a seasoned nurse would be. If you had started out in a Large ICU with a long preceptorship which involved care of very sick patients, you would be better prepared when your patient crashes. It is not a factor of you not being smart, just don't have the exposure to the very sick patients. Your coworkers realize this and do not think you are not smart. It took me 2 yrs in a large ICU (neonatal) to get comfortable in my judgement and confidence that I can handle a patient when they crash until help arrives. That is something that you need to burn into your brain. ICU nursing is a team sport. That is why there is a "code TEAM" and not a "code NURSE". Needing help is necessary when a patient is crashing. Give yourself some time to get comfortable in the job and don't be so hard on yourself. No one is expecting you to be at the level of a nurse with 10 yrs experience.

Cowboyardee · Jun 13, 2017

Id bet those knowledgeable icu coworkers with 10 years of experience didnt get all of their experience in a 4 bed icu.

Here's the bad news (it is unfortunately also the truth): learning to be a competent icu nurse is extraordinarily difficult in a low acuity 4 bed icu. You just dont get exposed to the kinds of situations you need often enough to build your skills rapidly. Lack of access to physicians may be an additional barrier.

The good news: you probably are about where you should be in terms of skills and understanding given your experience and the environment youre in. Catching up on 10 years of experience doesnt happen fast or easily in the first place, and that's all the more the case in your environment.

So, on the upside, you have knowledgeable coworkers whose minds you can pick; you eventually may have extra time to study and develop your understanding of medicine given the relatively low acuity environment; and you have 'icu experience' which should make it easier to get hired elsewhere if you decide to look into other units or hospitals to build your skillset. Not a terrible position to be in.

Go over case studies. Ask your coworkers for stories or about their thought processes. When you get a better feel for critical care, try reading something like "The ICU Book" by Paul Marino. Its not a terrible position to be in. Just dont expect to become am expert in critical care too quickly.

marlena.erika · Jun 13, 2017

Hi everyone I am a new icu nurse. I graduated in May 2016, and passed my nclex that year in October. I worked on a medical surgical floor from that time until October, where I was offered a full-time job to work in the icu. It's always been a dream/goal of mine to be in that area. Our icu is very small it's only got 4 beds. We do get some critical pts, but I find they often come in spurts. For example, if we get one vented pt. it's likely we will see a few more in the coming weeks then there will be none for up to months at a time. We just got internal medicine the program is very new and we are begging to keep sicker pts. Than we did in the past (they would often be shipped to larger facility). Our unit is staffed with two RNs one who is the icu doing pt. care and a second who is called the "float" who's helps with orders and pt. care. If the icu is not busy they often go to the med/surg floor to help. When I did my 6 week mentorship I literally saw nothing critical. With all that being said, I had a code yesterday and I totally froze up. I felt like such a scatter brain the unit was full. My float was an experienced icu nurse who has been working for 10 years. I feel that maybe this is not where I am supposed to be. As sad as it makes me, I feel I am just not pulling the concepts together and seeing the big picture. Sometimes I feel I am so focused on trying to get meds and charting done that I don't find time to put the pieces together. It's really discouraging me. We don't always have a doctor on site either. Most of the other nurses are well experienced and I feel like they probably think I am not very smart. I know I am still learning but it's hard when the other nurses I work with communicate so well with the doctor and know what's going on. I try to prioritize my work as best I can and ask for guidance but it doesn't seem to be all that helpful. The other nurses are so good at predicting outcomes and know what to expect if a pt. is going sour. I just want to make be able to make the connections they are able to. Had anyone else ever felt this way. I am honeslty considering talking to my manager and saying maybe I'd be better on the med surg floor; however, a part of me knows I can do it and keeps pushing me to keep trying. Some tips, word of advice, constructive criticism would be much appreciated.

It could be that

you have chosen the wrong field

you are lacking in confidence

or its the wrong hospital for you.

Clearly you are not being supported in any way. Don't they have a nurse educator there?

I would try to stick to it for a year and then get the hell out!

TicTok411 · Jun 15, 2017

Experience comes with time and yes it is a disadvantage being in a small ICU, but you are not going to see the highly intense patients that would turn up at a trauma center. You may get an intubated patient but I am sure if it is an involved case it would be turfed out to a facility with a higher level of care. Your ICU patients are probably more like low level ICU/PCU patients which is not a bad way to get your feet wet. You will see respiratory failure, maybe an OD or even some sepsis (maybe) which can allow you to become proficient on certain types of patients with particular orders.

What I was curious about was freezing during a code. Had a med/surg patient ever coded or needed rapid response? Knowing your role in a code is a good idea. If you are primary nurse you give report to the team and explain what has taken place. then the team leader should step in a run the thing and in a small hospital I am guessing it is ED or hospitalist running the show. If you are the ice nurse (only one) pushing meds would seem reasonable as you should be more familiar with them than the non-icu nurses. Don't worry too much you are new. You should learn from mistakes and perform better the next time. We all started out green and scared, but is you stick with it you will get better and most likely glad that you stuck with it.

Good Luck!!!

Neubers1 · Jun 18, 2017

Thank you so much for your post. I'm an ICU nurse in a busy Surgical/Neuro ICU and in 2 hours I am starting my first day precepting a brand new RN. In the past I have always precepted nurses who have several years of experience, so it is important to me to hear your concerns.

I agree with others who posted that it is difficult to become comfortable with acute patients if you don't consistently have acute patients in your unit.

However, your med-surg experience is to your advantage.

Time management is essential on a med-surg unit, given that you are responsible for the care of several patients. I suspect that you may start with a plan of care in your head, but have to change that quickly if one of your many patients has greater needs than you anticipated.

It is likely that your "floor" patients exhibited the "norms" that you learned in school with some individual variations based on their illnesses.

These skills that you already have translate well to the ICU. You may not know exactly what is wrong, but because you recognize "normal", you will recognize what is wrong fairly readily. When your ICU patient crashes, you may not know exactly what to do, but you are already skilled and changing plans mid-stride. That ability is the basis for what you see experienced nurses doing when they seem to be able to predict outcomes. Give yourself credit for what you know.

That said, you will need to be self-directed to learn what you don't know. Use your coworkers as resources. Because you may not see very sick patients routinely, you'll need to learn on your own. "THE ICU BOOK" mentioned above is a good resource. I recently learned of another book from a coworker called "CONCISE REVIEW of CRITICAL CARE, TRAUMA and EMERGENCY MEDICINE" by Asif Anwar, MD. It is easily readable and covers many ICU-related illnesses. It may give you an idea of what treatments will be ordered for particular diagnoses. Also, subscribe to a journal. Critical Care Nurse '17 (or whatever the current year is) is a good one...not too "cerebral" and it does a good job of breaking down pathophysiologies and medications.

I realize that was a long response. The ICU may very well be the right place for you. Ask questions; get in there if a patient is coding; read everything you can. When you have a new, sick patient, chances are it will trigger the memory of something you read or saw before; those connections of words to real-life will make you more comfortable and will make the concepts of ICU care more concrete.

Most of all, thank you for voicing your concerns. I stand by my belief that we all become better nurses because of each other. Reading what you wrote will help me today with my new guy. Best wishes.

jojo yanson · Jun 18, 2017

Hello there, I was moved by your story and I felt the same when I started in the critical care. I tried my best to focus on the patient and not on anyone else. I read charts and doctors order and physical findings and most especially the history of the patient. It is where I can connect the dots and get findings of my own. When I became a Charge Nurse and eventually thank GOD and for the people who helped me reached where I am today. As a head nurse of the unit I not ashamed to ask the doctors to explain things which I barely understand. During my rounds on patients everyday I collect data from the Nurses and read and being curious is not a crime so it helped me a lot. Yes, feeling a bit discouraged because of what the others might think and seeing them communicating well with other practitioners. well, it's a sign that you have to believe in yourself that you can do better. Hope this words will help you and I KNOW THAT YOU CAN DO THIS.

dianearc, BSN, RN · Dec 13, 2017

It could be that
you have chosen the wrong field
you are lacking in confidence
or its the wrong hospital for you.
Clearly you are not being supported in any way. Don't they have a nurse educator there?
I would try to stick to it for a year and then get the hell out!

Wow! This is a pro telling you to quit?! If this is how life worked, or just even nursing school, would anyone ever accomplish anything? My advice to you is that a sense of discomfort is a good thing. It keeps you alert. No great things were ever achieved at comfort zones. Get an experienced ICU nurse there who can mentor you, study their strategies or work plan and then emulate, tweak or device what works for you (while still maintaining protocol and providing quality patient care, of course). Arrive early and study your assignments' diagnoses, labs, recent vitals, meds, physician notes, etc, so you're a head of the game before you even get report. Within that time (before your shift even begins), also brush your knowlegde about key aspects of their conditions and meds, so you will know what to expect and what may be off once you receive report or conduct your own assessments. At home, during your free time, work on developing your theoretical knowledge...read on ICU nursing and utilize case studies and pathopharm of the frequent medicines you see so far at the ICU...ask your mentors about these meds if need be. I'm positive that with time, you will overcome this fear and lack of confidence. Your diligence and hardwork will be vital & have a little thick skin, don't compare yourself with the 10yr experience nurses, you will get there one day. Don't let quitting be an option if you have a strong passion for ICU nursing. All the best!