Expected to manage ventilated patients without training

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by Nurse Beth Nurse Beth, MSN (Columnist) Educator Columnist Innovator Expert Nurse

Specializes in Med Surg, Tele, ICU, Ortho. Has 30 years experience.

Dear Nurse Beth,

I'm a nurse with 15 years of experience in a very small, rural hospital. After working med-surg, L&D, OP infusion/chemo, and a short stint as a nurse educator I wanted to finally get into critical care. I started a year ago in our 5-bed ICU where we rarely see very critical patients.

I have felt a lot of anxiety over the years as a nurse and much of it came from feeling unsupported by inadequate admin - but once I learn and feel confident in what I know I'm usually the nurse orienting new nurses in whichever department I'm in. However, my level of anxiety has grown significantly with this ICU job. Over the past year, I've become comfortable managing COVID patients on heated high flow and BiPAP, but have not had experience with any ventilator patients until recently.

I expressed concern over this from day one. Is it unreasonable of me to expect that I should have some guidance from a preceptor before being fully responsible for an intubated patient? I learn best by asking a lot of questions and have no opportunity to do so. Or if my anxiety is getting the best of me when I'm expected to care for an intubated patient, is ICU not the right choice? I'm sad and devastated because I love being able to learn, the individualized care and being able to deeper dive into labs, tests, diagnoses, etc. I'm viewed as a confident and competent nurse by peers and nursing admin and no one seems to understand my fears or concerns. I have worked so much extra during this pandemic I'm too exhausted to study on my days off. Is it possible to do enough studying on my own to feel competent at the bedside of an intubated patient?

Dear Sad and Devastated,

Should you have had guidance from a preceptor before being fully responsible for an intubated patient? Yes. Ideally, the nurse's skills and competencies should match the needs of the patient when patient assignments are made. 

Your educator or manager should absolutely have provided education and checked you off on ventilator competency before expecting you to practice independently. What is the orientation process for other ICU nurses at your facility? 

That day when you were first assigned an intubated and ventilated patient was the time to have spoken up. You can still have that conversation with your manager and say "I'm being assigned ventilated patients but I've never demonstrated competency or been trained/oriented to manage a ventilator."

Having said that, you have been in the ICU for one year, and at the one-year mark, it is probably expected that you care for ventilated patients. We're also in a pandemic and while there's no excuse for not educating you, many nurses are over ratio and caring for higher acuity patients than usual.

Then there's your part or responsibility for your own professional growth. You say you're too exhausted to study but surely you could review ABGs, watch a Youtube, print out and read your facility's weaning protocol. 

The most effective learning is on the job. Take advantage of teachable moments. Connect with one of the respiratory therapists and start asking questions. What is assist control? What are usual vent settings, and why? 

It seems that after one year in the ICU setting, your anxiety should be decreasing, not increasing. You should be fairly comfortable and therefore very teachable. See your provider about your sadness and anxiety to rule out depression/anxiety and get some help if needed.

Best wishes,

Nurse Beth

subee, MSN, CRNA

Specializes in CRNA, Finally retired. Has 50 years experience. 4,152 Posts

If it helps, you can think of ventilated patients as having a CONTROLLED airway which is easier to care for than an uncontrolled airway.  The worst that can happen is the patient extubates themselves or the trach tube comes out.  I think if you can work on being competent in these two situations, it would decrease your anxiety since you are mastering the complications (rare) and know that you can certainly handle the uncomplicated airway (usual).  Also consider if you are bringing other free-floating anxieties to work that have nothing to do with your competence.  You've made it a year so competence it not the issue.