Is NICU much different from PICU??

brownbook · May 30, 2019

I would think NICU is more intimidating than PICU per the seriousness and fragility of the newborn and the anxiety of the parents.

I don't understand your comment, "but the orientation would be 9 months long" for the cath lab. Your "but" makes it sound like it's a bad deal?

Anyway I vote for the adult cath lab.

nurseglam · May 30, 2019

Hi. Thanks for the response. You have a few valid points. Sorry for any confusion, but to clarify, the Cath Lab residency will be 9 months. I have no problem with that. The NICU residency will be 10-20 weeks. I also understand what you mean by speciality. However, Med Surg/PCU will not give me the skills I need to possible pursue CRNA school or many other areas. Unfortunately med/surg doesn’t hold that much weight when trying to pursue more critical areas. At least this has been my experience. Once again, thanks for your feedback. I have to really think about this :))

adventure_rn, MSN, NP · May 31, 2019

I've worked in the NICU and PICU, and I have a lot of feedback on several of the points you bring up.

Yes, in my experience, NICU and PICU are quite different, especially in the way they go about treating conditions; that said, the concerns that you bring up are probably issues you'd face in the NICU.

First, tiny NICU babies are a whole new level of fragile; if you were scared of harming PICU kids, you may be even more stressed out caring for 1.5 lb NICU kiddos who have absolutely no reserve. If that's a dealbreaker for you, then NICU may be even more challenging. That said, I personally feel that NICU babies are generally easier to 'fix' in a resuscitation event than PICU kids; 90% of the time, if you can establish an airway and start to bag them, you'll resolve most of their problems (at least temporarily).

Second, families are a huge part of NICU nursing, perhaps even more-so than PICU. I did personally find some PICU families to be far more intimidating than the average NICU family. Most NICU parents are entirely out of their element, and they're terrified, so they'll go along with pretty much anything you recommend that they do. In contrast, some chronic PICU families can be a little pushier; they know their home routine, they know their preferred inpatient routine (since it isn't their first rodeo), they know their child better than you, and they may push boundaries in order to play by their own rules. I've worked with some PICU families who are phenomenal, but I've worked with others who make me want to pull my hair out. In contrast, I found that on the whole, NICU families can be easier to work with.

5 hours ago, nurseglam said:
However, Med Surg/PCU will not give me the skills I need to possible pursue CRNA school or many other areas.

Honestly, if your end goal is CRNA, I don't think that either of those areas will be particularly helpful. IMO, PICU is definitely more valuable than NICU for CRNA purposes. Yes, NICU is technically critical care, but the majority of cases in the majority of NICUs are feeder-growers. The handful of truly high-acuity patients are often reserved for the nurses who have several years of experience; you probably won't be taking those patient until you prove to your charge nurses that you're responsible enough to handle those cases (which can literally take years, depending on the unit).

Even when you do have critical care patients (i.e. PPHN kids on ECMO), the medical problems are only relevant to that precise population. Familiarity with PPHN, NEC, meconium aspiration, diphragmatic hernias, PDA ligations, or most other NICU emergencies is pretty much useless in the adult world; it's 'critical care,' but really won't have any application to CRNA. That's the primary reason why most CRNA schools won't consider NICU (or even PICU) experience as critical care.

After one year in the PICU, I'm very comfortable titrating vasoactive drips (epi, dopa, dobuta, nicard, milrinone, esmalol, lidocaine), paralytic drips (vec, roc, succs), and sedation drips (opiates, versed, precedex, ketamine, propofol). During several years in the NICU, I could count the kids I took care of who required pressors (only dopa) on one hand. If your end route is CRNA school, I honestly don't think that NICU will help further your goals. Even if you go on to get adult critical care experience, I personally don't think that the skills you learn in NICU will translate to adult ICU because they are so fundamentally different. If you have the opportunity, I'd hold out for an adult ICU position, or possibly even adult step-down. NICU is a fabulous specialty (I absolutely love it), but it doesn't seem especially relevant or useful for that career path.

If you're dead set on accepting one of these jobs, can you shadow? That may help you to get a better sense for which is the best fit. In particular, shadowing in the NICU may help address the concerns you expressed in your previous post (working with parents, fear of patient harm). In the NICU, I suggest you ask about shadowing on the sickest kid(s) in the unit (to get a sense for the potential acuity) as well as an average 3-baby 'feeder-grower' assignment.

nurseglam · May 31, 2019

THANK YOU for such a thorough response. You hit every point. Fortunately, I’ve had the opportunity to shadow in both areas. I have worked in a an adult PCU/Stepdown setting, just to give you some background info. That sense of discomfort was still there for me in NICU, but I understand that is normal when transferring from adults/PICU to NICU. The one detail I left out about the Cath Lab is that I’d have to relocate to another area (only about 3 hours away).

After great thought, CRNA isn’t the exact route, but more so traveling. For some reason I feel like traveling as a NICU Nurse May be more suitable! I have to take a risk either way!! Either area will give me a unique skill set. Once again, THANK YOU!! Will keep you posted on my decision ?

adventure_rn, MSN, NP · May 31, 2019

Awesome. NICU is a fabulous specialty for traveling (for a bunch of reasons related to supply and demand). There are usually a ton of opportunities all over the country.

I do believe that if you stick with it, especially with the tiny kids, you'll get more comfortable. I held a baby for the first time in my adult life in my OB clinical, and gave the most awkward 'first bath' you can imagine; now I literally hold the kids with one arm (leads/lines and all) while I make up the bed with the other. When parents are freaked out about doing cares, I like to remind them: "these kids are built to go through the birth canal." They're shockingly resiliant. Babies in the PICU can be nerve-wracking if you rarely have them; taking them all of the time in NICU is like exposure therapy.

A random side note about specialization, grad school, and life goals (since you've kind of alluded to this): NICU is a great specialty to stay at the bedside long-term, but it's kind of awful for graduate school prospects. Unless you want to become an NNP (which is a very specific, arguably somewhat limited role), there aren't any grad school options. With PICU, you open up the opportunity for FNP and PNP programs, which can include inpatient or outpatient care, clinic settings, and working in specialty groups; the same is true for adult ICU or even med-surg. Part of the reason I left NICU for the PICU (at least in the short-term) was to open up further graduate school options.

nurseglam · May 31, 2019

The last part makes even more sense! Idk if you have any adult care experience, but in reference to cath Lab.. would you say I’d have better grad school options from that aspect?! This is one of the issues I have with NICU is that it is sooo specialized I wonder what my options are after! Lol. PICU isn’t an option at all.. so it’s either going to be Cath Lab or NICU!! ? Looking forward to your response!!

PeakRN · Jun 1, 2019

There is a lot of variation between various NICUs and PICUs, so while there are many things that are more traditionally associated with one or another those broad strokes don't apply to everyone.

In my system we will take premies in the PICU rather than our NICU if they meet certain conditions, like if they need ECMO, CRRT, or certain other interventions. This means that we typically don't see kids under 1800 grams but will go as low as 1200.

Since we have some cross over with our level 4 NICU the way we approach care for these kids can highlight some of the biggest differences between the two.

The primary and driving force in the PICU is to keep the kids alive. We don't keep neos in incubators. We are constantly assessing. We tend to have more invasive monitoring and more interventions. Feeding is an afterthought, we tend to just place TP tubes and will work on feeding when we aren't worried about their medical problems. We are more strict with families, we are much quicker to call CPS or PD if a family is interfering with care. Developmental care is largely an afterthought, therapies can be done later.

The NICU is in many ways the opposite. If you are stable enough you will live in a box and for 30 minutes out of 3 hours you will get cares. There are those who can't tolerate this and are intervened on far more often but they are very much the minority. The NICU is more involved with families whether it is memory making or teaching about cares. Families get far more input in their kids cares. The NICU manages medical care while at the same always trying to give the best possible developmental care.

I do think it is very important to keep in mind that there is a lot of variety between various NICUs and PICUs. Some level 3 and 4 NICUs have incredibly sick neonates and essentially keep them no matter what and are equipped to do that. Many lower level and even a good number of level 3 NICUs will transfer out their sicker neonates to a referral center.

PICUs are very similar in this regard. Very few will take premature infants, and most outside of referral centers will end up transporting out their sickest kids. For many lower acuity PICUs things like asthma, diabetes, and bronchiolitis are their bread and butter; the care becomes more monotonous and the kids usually have more room before they crash.

It sounds like to me that you were far more comfortable with adults, and for many people pediatrics is something that just never works out for them. It comes with unique stressors and a different approach to care.

There is a large shortage of NNPs so there is certainly an opportunity for advanced practice, and as we see more advanced maternal age pregnancies I doubt that will change any time soon. There are also no shortage of adults with cardiac problems so there are probably plenty of NPs in that arena, but I don't know if cathlab is as good of training as working in a cardiac ICU or something similar.

nurseglam · Jun 1, 2019

Thank you!