Float nursing and PICU

Pediatric Critical Care Columnist · Feb 16, 2008

Here in Edmonton, Alberta, Canada, our hospital does NOT float anyone to our unit. Under any circumstances. We have two mini-float pools of nurses who have been specifically hired for NICU-PICU (right now there are only three nurses in this group for 2 full time equivalents) and for cardiology intermediate care-PICU (a group of about eight full time equivalents). Their orientation is similar to a new staff member for the unit, individualized for their previous experience and can run anywhere from a month to four months. Of course, the need always seems to be much greater in the other units and PICU is left to flounder along as best we can. In recent months the only time I've seen the pool members is when they're in on OT specifically booked for us. Big sore spot. Especially when they tried to float us out to the floors. Ummm, no.

kessadawn, BSN, RN · Feb 16, 2008

thanks, jan. that's interesting. i never thought of a separate float pool for icu floors. my hospital is a pediatric hospital, and we also will get pulled to cover the floors. i really feel bad when the floor nurses get pulled to picu. the may have been oriented for a few days 6 or 12 months ago, and are expected to remember everything. not fair to them, i say. we have hired a great number of staff this year, and the eventual goal is to make us a closed unit, we don't float out and the floors don't float in. however, they still will use the float pool. i really think we need to expand the education we provide our floats if we are going to expect them to function well in the picu. they are encouraged to take the critical care and cardiac classes our staff takes, but it's not required like it is for picu staff. the other night i was one of the most experienced nurses on the 24 bed unit, tons of new grads just off orientation and floats, many of whom also just graduated in the past year. i have only been a licensed nurse for 3 1/2 years. i went to suction an intubated baby with a float nurse, the bag wasn't even hooked to oxygen. the baby didn't even need suctioned, really, but the float saw on the vent that the peak pressures were increased. it was just a large amount of condensation built up in the tubing. the poor float told me she'd only ever had one day of orientation with a ventilated pt, and she really didn't understand the basics of the vent itself. a train wreck in the making. one good thing, the nurse acting as our interim nurse manager at this time is also in charge of the float pool, and he agrees there is a need for more education. maybe he'll make something happen, i hope!

Pediatric Critical Care Columnist · Feb 16, 2008

Boy do I know what you mean about the lack of experience and the lack of adequate education and time to consolidate theory and skills. I usually arrive at work early, often the first one to arrive. I always take a recce through the unit to see what's different from my last shift and to stop by and see the patients I've become close to. I make note of the beds with the triple pump trees, Prisma or PD, ECMO and so on. THEN I look at the assignment sheet. There have been times when I've been on my recce that there are 15 people around a bed, and oh BTW that's MY patient. I stomp off muttering under my breath about why is always me... then I go back to the staff room and look around. Oh, that's why... there are three people on that shift that I've never even seen before, another couple who have been off orientation a matter of days, three or four that are still in their first year in nursing (never mind PICU), a couple who have been around but came after I did, the charge nurse and ME!

Over the last year, I'd say we've replaced about 40% of our staff. Perhaps a quarter of those new staff have any prior nursing experience, the rest being new grads. Our management thinks we have a great orientation program but the choice of preceptors is always rather questionable; the assignments aren't really geared for foundation-building and are more for the preceptor... don't want them to be bored! So we might have a preceptor with 18 months of time in the unit since graduation buddied with a new grad, caring for a post-op Norwood with an open sternum on PD. What is that new nurse going to learn? Last Saturday I was buddied with an orientee whose primary preceptors were not working. This nurse was within a couple of shifts of being finished her orientation but hadn't even been given basic education in intracranial pressure monitoring. (Not her fault.) Our patient was a Tylenol OD with fulminant liver failure post op Tx whose ICP was quite high from cerebral edema. I talked my vocal cords raw. (Yeah, imagine that!) At the end of the shift she asked me if I'd been a teacher before I went into nursing (I'm a second-career nurse, previous pharm tech) and when I asked her why she thought that she said it was because I was a really good teacher and that she'd learned more from me in 12 hours than she had in 16 weeks with her two primary preceptors. How does one react to that?

We too have a new nurse educator and also a new clinical nurse specialist. I'm really hoping that the orientation is overhauled and made more appropriate. I've had lots of discussion with the CNS, who used to be our educator, and now a couple of chats with the new one, and feel at least a little hopeful. We've also had a change in our patient care management and that looks like it might turn out well. One can only hope.

ECMOismygame · Feb 17, 2008

Last Saturday I was buddied with an orientee whose primary preceptors were not working. This nurse was within a couple of shifts of being finished her orientation but hadn't even been given basic education in intracranial pressure monitoring. (Not her fault.) Our patient was a Tylenol OD with fulminant liver failure post op Tx whose ICP was quite high from cerebral edema. I talked my vocal cords raw. (Yeah, imagine that!) At the end of the shift she asked me if I'd been a teacher before I went into nursing (I'm a second-career nurse, previous pharm tech) and when I asked her why she thought that she said it was because I was a really good teacher and that she'd learned more from me in 12 hours than she had in 16 weeks with her two primary preceptors. How does one react to that?

I guess good and bad.

Bad = the other preceptors suck and the new grad is poorly prepared.

Good = you are making a difference.

And I don't think the new grad was exaggerating. Just from reading your posts I have learned a lot and gained more insight into the PICU world. :bowingpur

Again thanks for all the free "lessons".... at least on the forum only your fingers get tired, instead of your vocal cords.

Ventjock, CRT :smokin:

Pediatric Critical Care Columnist · Feb 17, 2008

:imbar

AlabamaBelle · Feb 18, 2008

We have a Peds Float Pool at our facility. Several of those RNs were PICU RNs previous to their float positions. Some of the other RNs in the float pool were floor RNs - we generally have assignments that are appropriate to their skill level.

Qwiigley, BSN, MSN, DNP, RN, CRNA · Feb 18, 2008

When I did work PICU, our managers all 4, could also take a case or do charge. We only floated other critical care nurses to our unit. Never should a floor-trained nurse be expected to take care of a PICU pt. It is a disservice to the pt, the unit and the nurse. (We had 4 different pediatric critical care units that floated within each other). Even with that said, I didn't feel comfortable going to the NICU, but I was ok in the ER, and Cardio-thoracic unit)

nursprl · Feb 23, 2008

My old hospital had a Critical Care Float pool and an Acute Float pool. So whenever a pool nurse is needed, its from the CC Float and they get about a 6 week orientation and they rotate to each ICU and get about a week on each unit. I worked in the PICU and we get NICU and floor nurses if CC float isnt available and they get the less serious patients.

stefaniePICURN · Mar 1, 2008

here in CT, we float our nurses between NICU, PICU, and MS units.. and the orientation is ONE 12 hour shift!! the floats that come to the PICU, depending on if they are trained on vents, get the least sick patients, who can 'crap out' (for lack of a better term) just as easily as anyone else.. i cant help but wonder how we can make it better!

Qwiigley, BSN, MSN, DNP, RN, CRNA · Mar 1, 2008

Our critical care RNs at Childrens hospital Los Angeles get a 2 month course before they are part of the critical care team. In it, they have specific classes for their unit as well as classes that apply to all of the critical care units, so they can float as well as take care of most kids. There are yet other required classes on 12 lead ekg, etc. Everyone must be BLS, ACLS, PALS and NRP trained/certified just to keep their job. Therefore the classes are paid for and provided by the hospital. Expensive but excellence usually is.