Insight & advice on Critical care(ICU) VS. general Med-Surg floor?

RUcon08 · Feb 19, 2007

I took an intern position at two different hospitals in two different areas. One was ICU and the other Med-Surg. I gained more knowledge from my ICU internship in one day than my entire med-surg internship.
After school ended, I was certain which area I wanted to go to and I am now in the Critical Care Orientation Program. It is minimum of 24 weeks with a preceptor. All our preceptors have attended special training to prepare them for training new grads. My preceptor happens to be a former nursing instructor. She's really great. We alternate our time initially between working on the floor with our preceptor, attending classes on various topics related to care of the critically ill pt, completing an online orientation module that covers each body system, case study days, and feild trips to various other departments throughout the hospital. I have been working 40 hours a week and studying harder than in nursing school on my days off. It is very intense. As the orientation progresses, we check off on competencies and have a weekly evaluation. We then begin spending more time on the floor and taking on more responsibility until we work our way up to a full pt load. For the next six months after orientation, we still are accountable to our preceptors to complete all unit competency requirements, training/classes, and evaluations.
The new grads that finished the orientation program before me have done quite well. I feel that working as an intern for over a year has given me invaluable experience that makes the transition to nurse somewhat easier on my unit in comparison to the other new grads in my orientation group.
I have had a really positive experience. Ultimately, the choice is yours. I think it is best to choose the area where you are most interested, because you are more apt to go above and beyond to learn the things you need to know.
Things my MS internship taught me:
How to get a pt ice
How to transfer a pt from the bed to chair
How to ambulate a pt
How to change linens/give a bed bath
How to take vitals
(actually nursing school taught me these things but my MS internship turned me into a professional:rotfl: )
Things my ICU internship taught me:
How to take/give a good report
What to have ready before you call the physician
A thorough physical assessment
How to care for a central line
Interpretation of EKG waves and what to do when your pt has a rhythm change
How to do trach care, suctioning trached and vented pt's
Plenty of opportunities for IV starts/restarts
Plenty of opp. to insert catheter
Hemodynamic monitoring
What to do if your pt codes
Monitoring a pt during CRRT
Recovering a post-op CABG
What to do if your pt is declared brain dead and is an organ donor
postmortem care
comforting pt's families after death of loved one
I could go on and on but I am tired and my brain is not working well
(Whether I was performing the task, following behing the RN and comparing my findings with his/hers, or observing the RN...I learned SO much that I can apply to my current practice)
You may find you get more experience in the ICU as an extern. However, functioning as a tech is not the same as functioning as a nurse and if you do not feel comfortable in your abilities then perhaps you should start at a lower level of care once you graduate. I feel I am capable of functioning safely in the Critical Care Environment. Good Luck to you.

Great post.

What little doubts I had about choosing a unit (for the sake of my summer externship) are effectively gone and I will be calling the nursing recruiter who contacted me last week to get the ball rolling and secure this ICU position, ASAP.

Thanks. :nuke:

P.S. I just hope she doesn't offer me several critical care unit positions, then I'll be back to square one with decision making. :uhoh3:

nurse4theplanet, RN · Feb 19, 2007

I understand, your MS didn't pave the way for ICU experience. ICU nurses are very quick to point out that ICU is so much more complex and skilled than ICU, but yet are quick to make us work a year in med-surg to prepare ourselves. Seems a bit contradictory.

I agree.

nurse4theplanet, RN · Feb 19, 2007

Great post.
What little doubts I had about choosing a unit (for the sake of my summer externship) are effectively gone and I will be calling the nursing recruiter who contacted me last week to get the ball rolling and secure this ICU position, ASAP.
Thanks. :nuke:
P.S. I just hope she doesn't offer me several critical care unit positions, then I'll be back to square one with decision making.

Good Luck to you! I hope you have a positive experience as I did. Hopefully, you will gain some good working experience and be able to fine tune your assessment skills.

Some advice for your externship:

Do NOT be timid...if there is something you know how to do ask the nurse if you can do it. Hands on learning is best!

Ask lots of questions, don't be afraid. Most of the ICU nurses I have met have loved to teach...just don't ask questions to simply show off your knowledge

Stick it out. I was terrified the first few times I was on my unit because it all seemed so overwhelming...very sick pts, sedated and on a ventilator, getting hemodialysis, lines everywhere, alarms ringing, pumps beeping, doctors calling...it was very fast paced and I felt like a deer in the headlights. But I stuck it out and started asking questions, helping the nurses where ever I could...and it all began to come together.

Don't overestimate your knowledge. It's great to have confidence, but realize that being overconfident could harm your pt. Always ask for help and run things by the nurse even if you feel that it's just a routine task.

Listen, listen, listen! There is sooooo much knowledge that can be gained from the experienced nurses on your unit.

Keep a diary of the things you experience and your pt's conditions and outcomes. Go home and look things up. Ask about why certain things were done, and why others were not. Treat this as the most important learning experience of your life. It's only as good as you make it. Take full advantage of this learning opportunity. Before you know it you will be out on your own.

pcicurn7 · Feb 19, 2007

I'm having a problem believing this one. No hospital in its right mind would allow a non-ICU-trained RN to take a true ICU-type pt load without training. ICUs are willing to take grads straight out of school and train them without prior acute care experience, but ICU training is required before being turned loose on the unsuspecting public. Not to mention all the certs that critical care nurses must acquire and keep current. New grads are never without a preceptor and new critical care nurses are rarely left alone without backup.
We may not have the stringent system that Canada has, Badger, but it doesn't mean our system is wrong or unsafe. I think Jamonit's response may have been defensive but you weren't exactly kind either.

I agree. I am a new grad who has applied for a PICU internship. I am not stupid, i did plenty of research until i found the program that was right for me. Not every hospital in the US has the same orientation guidelines, and many programs offer excellent orientation/preceptorships for new grads. This is actually a pretty good strategy for the hospitals...the get a brand new nurse, who is probably very excited to be there, and the hospital gets to mold that nurse to be the type of nurse that is needed in their unit.

The PCICU program that i have applied to has a ONE year orientation, with a one-to-one preceptor, and no direct patient assignments. Its 3 months in the ER, 3 months on the regular peds floor, and 6 months in the PCICU or PICU. I am not willing to risk my license or my sanity, and i think that the program i have applied to demonstrates that.

For the OP, my suggestion is to make sure you do your research. Talk to other nurses who work on the floor. Ask them if they were made to complete their orientation prior to being left caring for a patient. Write down all your questions. AND, as an RN (new or not), you have to make sure that you know when to say "i dont feel comfortable doing ___, but i would like to learn". Other nurses don't expect you to know everything, but they will expect that you speak up before you put yourself OR the patient, at risk.

And, for Jamonit: CONGRATULATIONS!!!!!!!!!!!!!! You are a beautiful girl! (i know graduation gives the best of glows!) And i would have died if they made us wear hats for the ceremony...lol! Now, go rock the NCLEX! (i just took mine a few weeks ago!)

Here's mine (from Dec):

pepsihla · Feb 19, 2007

I would go straight to the level of nursing you want. If you want to go straight into ICU, then do it.

I went straight into ICU after I graduated, I would not have done it any other way. Most new grad ICU training is excellent and prepares the new graduate to be a valuable member to the ICU team.

jamonit · Feb 19, 2007

And, for Jamonit: CONGRATULATIONS!!!!!!!!!!!!!! You are a beautiful girl! (i know graduation gives the best of glows!) And i would have died if they made us wear hats for the ceremony...lol! Now, go rock the NCLEX! (i just took mine a few weeks ago!)[/img]

you are too sweet! you look so cute in your white nursing dress! you are so lucky that you didn't have to wear the darn hat. totally a style cramper, hahaha. i take the nclex march 6th, i can't wait to just get it over with. i

i think people took what i was saying the wrong way. i may have come off cocky, but i'm truly just thrilled and grateful to be in the PICU straight out of school. i got all a's, i worked hard, i interviewed well and they have faith in me. they aren't going to just set me loose, there are a lot of resources at my finger tips, and specified resource nurse as well. i will graduate as a level 2 (i'll be able to work with pts on vents at that time), after more training (usually 6 mos to a year, i will be a level 3, at which point i will be able to take part in the housewide codes, if they deem my skill level appropriate. level 3 and level 4 require that i complete all that is necessary to be a CCRN, including more didactic classes and skill advancement. level 4 and 5 are a few years down the road, this is when i will get to specialize in pediatric neuromedsurg icu or pediatric cardiovascular icu. my orientation (the 1st 14 weeks are not the only training i will have). so, as you can tell, my hospital takes the time to train, is big on education and has set up a specific ladder for advancement, requiring much more than i explained previously. i work at one of the largest PICUs in the country in an all pediatric specialty hospital. the picu is 40 beds and we were chosen from hundreds of new grads. the new grad program has been in place for 7 years, and it has served the hospital well thus far, as they have top notch and awarded intensivist, hemeonc specialists, and other peds specific departments. their nurses love what they do, and are proud to be a part of this hospital.

thanks for finding those links, mced. and most of all, OP, i think by going into the ICU, you are making a wise decision. thanks everyone for your support.

JourneyCC · Feb 25, 2007

New grad opinion here.

I too couldn't decide, but went straight to the ICU in a HUGE wellknown Hospital. I love it! I worked in the ER my last year of school and loved that, but felt like I was missing out (like a pp's reasons stated0. Now that I work in ICU, I see the disadvantage I was at in the ER. However, I still think I would have made an excellent RN in the ER despite my short coming in experience. I too am headed towards CRNA, and knew ICU was my pathway. Now that I am here, I just might stay LOL I love it. I occasionally float down to the ER and love that ability. But I think I love it so much b/c of the hospital I chose. It's a huge metropolitan, level 1 trauma hospital (by the way I work neuro/trauma ICU).....and I love the rush of the helicopters coming and landing on our helipad (ER has one too but more critical patients, not breathing on their own, usually come here ).....even though it's ICU, I feel more like a ER person that has the ability to see the outcome and manage that patients care. Just a thought. The downside is, ICU is not for everyone, or every personality.....it's tough and if you don't cut it, they let you know loud/clear. Our hospital has 5 adult and 5 PEDs icu's, like I said it's huge. If I were at a "normal" hospital, I would feel way less stressed. I learn sooooo much and I thrive on it.

In a nutshell, I think the hospital you choose is more of a decision maker/breaker than what area you choose. Choose a hospital that has a great RN retention ratio and that has a great "teaching" reputation too. It opens doors and I think you'll ultimately love any decision/specialty you decide on if you love going to work everyday.

Good luck!

JourneyCC · Feb 25, 2007

Oh and yes.........DEFINITELY choose a new grad program that is well known for it's reputation as being a great residency! It makes all the difference in the world! Truly, my residency is fantastic. My friends that graduated with me, many were "turned loose" on their own after 2 wks of "orientation". They come home in tears or pissed. They didn't choose hospitals/residency carefully, and they kick themselves daily over it. Just another thought LOL

sprout · Feb 25, 2007

If you can get an internship in an ICU you'll be able to see what it's really like. I work in ICU and love it. But, it's not for everyone. I worked at my hospital while going to nursing school and did my internship in ICU. I was fascinated by the pathophysiology of critical care patients and the specialized care. I knew I wanted to be in ICU but I really had to prove myself as a new grad, I also had to hit the floor running and think on my toes. I have been there for 2 years and it can be a very high stress environment.

Sometimes I think doing some med/surg time would have helped my organizational skills and adjustment to nursing. I think working at the hospital while in nursing school helped a lot because that was one less hurdle to jump - I knew the staff, the doctors, the computer system etc. So transitioning to nursing wasn't hard. However, I see that new grads on on Med/Surg units have a great preceptorship and do very well. Med/Surg nursing has it's own sub specialities and acuity levels as well. Nursing isn't only ICU, OR and ER - there are so many areas. Research, ask questions, determine why the Med/surg nurse is not an ICU nurse and vice versa. The answers you get may surprise you.

DNurse08 · Feb 28, 2007

Excuse me RUcon08, for spinning off of your original question, but it seems as though you made your decision.

First post here: I have been recently thinking about applying for an ICU externship as well. I'm in my first year of nursing school, and the MS setting wasn't very appealing to me. BUT I feel that I lack confidence in my skills (anything from organization to IV pumps). Therefore, I am willing to experience one year with MS before going into the ICU if that is where I decide to go.

So, my question is: Would it be smart to do an ICU externship, and then work on MS for a year before going into the ICU?

There is also a geriatric externship I'm applying for where I'd be witnessing different aspects of gerontology (witnessing, not practicing). I've been told that there are many elderly persons in the ICU, and that the externship will help me somewhat understand geriatric care. I love the elderly, but am not sure if I would like to specialize in it. Still, the geriatric center would love for me to come and extern with them.

I'm feeling like I need to have opportunities to practice skills, and am not sure about what path I should take. Personally, I'm a kinetic learner and need practice to make perfect. I think if i went straight to ICU, i'd fall to pieces since clinicals do not give me much room for experience. Also, I feel that if I have an ICU externship under my belt, than I'd have a better chance of getting hired.

I love nursing, but my clinicals in the MS setting weren't as thrilling as I thought it would be. I've been on different floors and haven't found a setting that I have really liked. I have just recently been thinking about the ICU for several reasons: As much as I love patients, I don't enjoy conversing with them...I just love do skills, and see results from my interventions! My favorite time with pt's on MS was when they were asleep, because it allowed me to really concentrate on what I was doing. I also work best under stress and when I'm confident. As a CNA I always loved to be on the go and hated to sit down for breaks.

I have yet to do actual research and still feel pretty ignorant about what ICU is really like, but that is just some of why I've been considering it. I just would like some input about what I should do as a nursing student. Should I go for the ICU, MS, or geriatric externship? Thanks!!

-Dnurse08

RUcon08 · Feb 28, 2007

Hi DNurse08,

Your situation sounds pretty much EXACTLY like mine, (except for the geriatric part, of which I have no particular interest in .)

Anyhow, from the sounds of things, I think an ICU externship really would be beneficial for you. I can definitely understand the part about being most interested in hands-on actions with clear results, as opposed to a very intimate relationship with a patient. (It's funny because just the other day I was talking about how I personally don't have a ton of interest in garnering social relationships with patients-- I mean it's not to say I'm cold/careless and don't want to talk at all, it's that it just won't really be my priority.) And from what I've learned, ICU and OR are pretty conducive to this preference, especially OR.

Anyways just a minor update, I had my interview yesterday for a unit that's sort of considered critical care (it's in the slow process of becoming a TICU). The unit seemed really awesome! The patient population consists of mostly thoracic surgery post-op, congestive heart failure, and pulmonary hypertension patients. And best of all I got hired on the spot, which I was very surprised about. I think the unit will be a great experience, not to mention one of my interviewers, the nurse manager, informed me that the experience could be counted as the critical care requirement for those who need it (as a pre-req for nurse anesthetist programs).

Also think it's worth mentioning that you should DEFINITELY not be worried about your skill level, or lack thereof. They (and other hospitals) have really given me the impression that they're VERY aware that you as an extern are very new to clinicals and the hospital in general, so learning and practicing is paced accordingly. (They know most of us are only third-year students who've only had 2-4 clinical rotations!) For example, I asked the manager if there was any limit to the things we could do as an extern, and she replied by saying that it's basically up to the discretion of the preceptor you'll be working under during the 8-10 weeks. If they feel comfortable in your abilities to start an IV, or whatever other skill, then they'll let you! Of course this might vary between institutions, but I was VERY happy to hear that I wouldn't be limited in the things I could do/learn/practice since I'm used to certain limits in clinicals as a student.

So in short, if ICU/critical care seems really appealing to you and you have the opportunity to take it with an externship, go for it! Don't be worried about not knowing enough or being good enough, because the externship is about learning. It's not supposed to just be a job. Most hospitals want you as an extern so they can acclimate you to their institution, because ideally they want you to come back as a new grad nurse. (Hell, the manager there made it quite clear several times that I should definitely be sure about the unit because she's very big on retainment of externs. And she almost made it seem like if I had any doubts about not coming back to work as a new grad, then maybe it wouldn't be a good idea.) Hope this helps!

EDIT-- Also my decision to pursue critical care was because from what I know, and from what people discussed in this topic, I just felt more free to choose what I wanted for the sake of the externship. I DO plan on starting in med-surg as a new grad, but for my externship I'll at least get to do something I wouldn't normally be able to do at all without getting hired as an ICU nurse, etc.

nurse4theplanet, RN · Feb 28, 2007

So, my question is: Would it be smart to do an ICU externship, and then work on MS for a year before going into the ICU?

The best answer to this question is to pick an externship site that is the MOST conducive to learning and gives you ample opportunities to practice your skills.

For me, that meant choosing the ICU internship over the Med-Surg internship. However, all hospitals are different and all units are different...so it is possible that you find the very opposite to be true for you and your location.

Check into what's available in your area. Ask how you will function in your role, what your assigned duties will be, who will be training you, etc.

For example: in my ICU position, I was assigned to a nurse each time I worked. I assisted him/her with various patient care tasks, much like an aide on the floor, but there was ample time for teaching opportunities and supervised practice of skills learned in nursing school. I got to check my assessments against the nurse's assessments and follow every step of nursing care the patient received. It was similar to functioning in a student/orientee role.

in my MS position, I was given no training and thrown into a CNA role. Keep in mind, I had never worked as a CNA before and found it quite frustrating to be put in that role with no training. Training to be a nurse and being given a full CNA load was quite different. I was not assigned to anyone, I recieved my own 12-14pt assignment. I took vitals, gave bed baths, and assisted with turning, feeding, ambulation, and fetching supplies/getting ice, collecting I&O's...sounds easy right? Might be if I had recieved any training about where to chart, where supplies were, a tour of the hospital (for transporting/discharging), etc. I was 'baptized by fire' and the nurses were unsympathetic...afterall...I was in nursing school right. I catch on quick so I was rolling with the best of them by the third day, but it was hell. I was soooooooo tired and worn thin when I got off, I felt like I learned nothing, I was never able to practice any skills, and I never got to witness any nursing care besides passing the nurse in the hallway as she went from room to room or saying, "pt in room number such and such has an elevated temp/bp/whatever..."

It was not hard to make my decision. But I did give each area a fair chance. I suggest you find out what you are getting into BEFOREHAND, unlike me...and ask other students about their experiences if they are working on different units. Best of Luck whichever you choose.