I hate my job in PICU

Double-Helix, BSN, RN · Apr 24, 2017

6 weeks of orientation is not nearly enough for a new graduate in the PICU. If your lack of orientation is any indication of the support you get from the nursing department, I'm not surprised that you're struggling. It takes, in my experience, at least a year to become competent caring for critically ill children and years to become comfortable. If this were just a matter of learning the ropes, gaining the experience and taking some didactic classes, I'd encourage you to stick with it for another 6 months and see how you feel. My concern is that your facility does not seem interested in giving you the necessary training and education to safely care for these patients. For that reason, you may benefit from gaining confidence in a less intensive environment- or another facility that will dedicate the necessary time and resources to properly training you.

I'm also concerned that, while you clearly express lack of confidence and comfort caring for children who are intubated and hemodynamically unstable, you state that the only other place you'd considerâ€ is NICU, where the patients are after more fragile, more labile, and less sedated. IF you found a NICU that would offer you a decent length orientation, you may be successful. But I'm afraid that your unwillingness to consider other areas of nursing shows either a lack of understanding of NICU nursing or a lack of maturity- i.e. being more focused on having your dream jobâ€ than taking the steps necessary to become a competent nurse. What's more important to you: working in a place that allows you to learn and gain the necessary skills to safely and confidently care for patients, or being able to say you're a NICU nurse? Think about this before you decide to make a job change.

hm93 · Apr 26, 2017

Hi, thanks for your response and advice. I agree that 6 weeks was not long enough - there were 6 girls from my course who have all spread out to different PICU's around england who have all received the same orientation time so I presumed this was normal!

By saying I would only consider NICU as an alternative this isn't due to 'being able to say I'm a NICU nurse' - this is simply because I would not want to work somewhere that I am not as interested. Maybe that sounds wrong, but I had a range of placements as a student - hospices, health visiting, special care, NICU and general children's wards. My 3rd year placements (6 months in total) were spent entirely on a general children's ward and I worked independently the whole time, doing everything except administering IV's. Therefore I gained a wide range of skills, I was completely confident and competent in general nursing and nursing skills at the time of graduating and I also knew that I was not interested in working on a general ward. I loved my placements but nearly always knew how my day was going to go - the same several conditions, same treatments, same meds. I just wasn't challenged enough. I arranged an elective placement in critical care and PICU for 4 weeks and immediately knew that was where I wanted to be.

I believe that moving to a general ward now would not benefit me as I'm not going to learn any more about haemodynamically unstable children, intubated children etc on a ward, and will simply just be starting from the same place when I moved back. I feel completely competent caring for HDU patients and stable ventilated, it's just the thought of moving up from that that scares me. I realise that I have to do it at some point - take more unstable children, post-op cardiacs etc but at the moment that is making me feel depressed and anxious about going to work. That's where I stand currently.

ChryssyD · Apr 26, 2017

First, I sympathize. My initiation to PICU-type work was 3 days of following the day shift nurse around, then I was in charge of a sub-acute unit with 12 chronically ill but not-necessarily-stable kids, 9 of whom had tracheostomies, 7 of whom were ventilated; before then, I had cared for a grand total of one ET-intubated patient and one trached patient. Sink or swim.

When I did move to actual PICU, I had already had several years' experience. I know you didn't ask, but I never advise new graduates to go into ICU of any stripe--just my personal prejudice; get your feet wet and the area behind your ears dry first, is my take on the issue. But I digress.

I'm confused. Are you six weeks or six months in? Six weeks, you aren't ready for unstable kids with drips and such. Six months, you could be, but if you aren't comfortable with your assignment, you should be able to go to your charge/head nurse and let him/her know that. If you aren't comfortable with your patient, then he/she shouldn't be comfortable assigning you to be that patient's nurse. Do you have enough support from the experienced staff on your unit? Maybe it isn't you--maybe it's your co-workers; maybe you didn't get a good orientation; maybe you just haven't been exposed to enough yet--perhaps you just need more time. ICU is a uniquely stressful place, and it requires quick thinking, sound judgment, and--here's the kicker--confidence. Confidence doesn't just happen, it has to develop (not going to go into cockiness, here, as it isn't your problem; but, given a choice between the anxious newbie and the know-it-all newbie, I'll take the Nervous Nellie any day); and it develops over time. Give yourself a little more. Ask for help when you need it. Vent--get with your fellow neophytes and talk it out. Being the new kid on the block is rough, especially in ICU where everyone seems so much more competent than you; they weren't born that way, you know--they had to learn, too.

Hang in there! It will get better if you take the time to use your resources. And remember--leave work at work! Don't go home and chew your nails--relax and have fun! Life is good. :)

kjb_lpn · May 1, 2017

A general ward - or what I think we call medical - surgical (Med-surg) here in the US is always a good place to begin as a nurse. Even as an LPN I have been told if I can get into a med - surg unit to take it. That is the backbone of nursing and you will learn a lot and get a bunch of needed experience I imagine.

Good luck in what you do!

JennP122614 · May 1, 2017

A general ward - or what I think we call medical - surgical (Med-surg) here in the US is always a good place to begin as a nurse. Even as an LPN I have been told if I can get into a med - surg unit to take it. That is the backbone of nursing and you will learn a lot and get a bunch of needed experience I imagine.
Good luck in what you do!

Agree with this. You could benefit so much from a year or two of medsurg. This is where you learn all bases, and you will definitely learn how to spot signs of declining patients because medsurg (or general) patients don't always go the better route in their stay. I am a director in home health and believe all nurses should have 1-2 yrs medsurg experience before attempting a specialty area. My background is in urgent care, family practice, pediatrics, medsurg, icu, rehab, and home health. Everything leads back to medsurg knowledge. Everything else specific will fall into place.

GaleSRN, BSN, RN · May 1, 2017

You might want to consider taking this a little slower. PICU ( I am assuming this is Pediatric ICU) can be VERY intense, and scary. These are children. Why don't you try working on the regular pediatric floor while you build your knowledge base. You are not very effective if you come to work scared and stressed. Sometimes if you back off a step to the step down until for pediatrics, you may find a lot less stress and an opportunity to learn more about CVS. You may be expecting way too much of yourself at this stage. I had a nursing friend who graduated right behind me. She started working in the ICU. She HATED it but thought that she had to do what all of her friends were doing because it was "prestigious" to be offered a job in the ICU. I told her that we need nurses in every department. What she really wanted to do was take care of babies. She went to the intermediate nursery where she found her niche. Everyone has a place, you just need to find yours.

rcncmh · May 3, 2017

I'm really sorry that you are struggling with settling into PICU. I joined a PICU after 2 years of nursing including being in charge on a 18 bedded unit. I was petrified and had four weeks of supernumerary. I found that it wasn't till I had been on the unit for a year that I felt more confident. I felt like I was a student again in the beginning and would cry when I got home every day and dread going into work but things do get better when you give it a bit more time! I think maybe you should have done some general paediatrics before jumping into PICU after finishing your training. You need time to build your confidence as a registered nurse. Hope that's helps, but honestly it sounds crazy but it took me a year and everyone on my unit was the same.

Pediatric Critical Care Columnist · May 3, 2017

Several things jump to mind here. First, 6 weeks of supernumerary orientation might be enough for a nurse with experience in peds or ICU, but NOT for a newly graduated nurse.

Second, the way assignments are being made is completely backwards. The charge nurse should be assigning patients to nurses, not nurses choosing patients. The skill set of the nurse MUST match the acuity of the patient. Your patients should be those kiddos with single-system diagnoses who are relatively stable. Many post-operative cardiac surgical patients will fit that definition: the ASD or VSD closures, the PDA ligations, coarctation repairs, valve repairs... lots of those kids are on the unit more for observation post-operatively than for critical care. They may need some ventilatory support for a short time, or some milrinone to help the heart adjust to its new pressure gradients, but not large volumes of fluid or an open sternum to get them there. So you could be assigned to care for them and be quite appropriately assigned that patient. On those days when there are no appropriate patients for your skill set, then you should be assigned to the one closest to that, and have someone near at hand as a resource. As your skills and confidence grow, then you'd be assigned more complex patients. This is how good units develop their staff. But don't forget that you have a responsibility to continue learning as you go along. If your patient has an illness or condition you're unfamiliar with, you should be looking the information up so your assessments can be improved. The internet is a great resource!

Third, unplanned extubations aren't as common as people think they are. They happen, but not nearly as often as some people would have you believe. In my career of nearly 20 PICU years, I've had 3 kids do it. The key to maintaining an ETT is a good tape job. It's really that simple. If the tube is well-taped and the tape is well-secured to their face, they can turn their heads, they can even sit up and the tube won't fall out. Of course, they can pull their tube out, but appropriate restraints will help with that. Vigilance is required, but it doesn't have to be obsessive. If the kid is nearing readiness for extubation and sedation is being weaned, a discussion with the physician might help alleviate some of your anxiety. On the other hand if they're NOT ready to extubate, more sedation is a good place to start. Remember too that the smaller the child, the smaller the safety net between intubated and not. When the distance between a child's glottis and their carina is only 2 cm, they're at much higher risk of accidental extubation... and the risk is highest during turns, not so much when the kid's just awake and wiggling.

Asking for help is not a sign of weakness in any sense. If you aren't comfortable with some process or procedure, then having another pair of hands and eyes is essential. I believe your concerns here are primarily for the kids and their safety and only secondarily about your fears. Consider using the call bell when you need urgent help. It gets a lot of attention, and someone will come running. If you plan your care around those times when the patient is most settled, and wait for the right time, you can get a lot done without needing someone to hold the kid down. If you know you're giving sedation at noon, plan to do your diaper change, mouth care, turn and whatever else so you can then have them settled and asleep afterward while you chart. Another thing you can do at the very beginning of your shift is to approach one of the nurses who has a patient nearest to yours and arrange a mutual help pact. When you start off that way, saying "I'll help you with your changes, turns and whatever today if you'll help me with mine" you'll feel a lot less stressed.

You haven't exactly gotten off to the most auspicious start, but that doesn't mean it can't get better. I sincerely hope it does.

PedsMurse916 · May 4, 2017

I understand your struggle!

I just celebrated my first year in the PICU straight out of Nursing School, and every morning there is a grumble in my belly as to what I am walking into, however, I would say the unit culture makes it a different experience for me. Our orientation was 48 shifts along with supplemental classes to learn more about vasoactives, vent settings, etc. Being a level 1 Trauma Center might be why they want us to be trained so thoroughly, but it has helped so much to ease the transition.

Don't give up on PICU, maybe look for another unit where the culture is team oriented and facilitates learning, once you do, you will blossom!