Making it in the ICU

BeenThere2012, ASN, RN · Dec 8, 2016

Each unit/hospital can be different in how they conduct orientation and mentoring. Without knowing the details of this position, I can give you some generic advice.

1). Be clear on all the requirements and expectations of your performance. Unless, it is something minor, don't put off addressing any concerns or questions you may have. Do your absolute best to comply with whatever is expected. Be on time. Don't ask for too many special requests or accommodations, etc... In other words, be responsible and professional in your actions.

2). Keep a good relationship and communication with your preceptors. This is very important as they will be the primary people who will be teaching and reporting on your performance. Make sure you understand what they are expecting from you and be absolutely clear on whatever you need or have a problem learning. If you are having any difficulty with an individual, try to correct it first, but if necessary, make sure you communicate your concern to the appropriate person above them if you have a serious problem you cannot resolve with them. Waiting until after it is all over could result in your not having any recourse to correct the issue. Not all preceptors are good teachers, and some are burned out. It is very difficult and a lot of work to precept. Try not to be too critical of them and keep this in mind. Be as helpful as you can in the process.

3). Be open to learning all you can from other nurses on the unit as well. Try to identify any learning needs or difficulties with particular subjects or tasks. Don't panic if you struggle with a particular task or concept. A lot of students feel like they should learn everything right then and there. You will have time to learn more later...just do your best. It will be ongoing learning as is the case with any profession, but try to identify the most important skills you will need to begin working independently when your orientation period is over. Examples may be...caring for an intubated/ventilated patient, managing central lines/art lines, emergency/code meds. Be especially diligent about your assessment skills like heart tones, lung sounds, and Neuro checks. Assessments are the foundation for your ability to know how to report what you see and will help you identify problems.

4). Try to be flexible as it is sometimes difficult for ICU's to provide the best patient assignments for new grads. You don't need all the "juicy/high acuity" assignments to learn. You can learn something from any assignment. Offer to help other nurses with their patients to get exposure to new things. Plus, being willing to help and be a team player is important.

Sometimes, you will see different styles or alternative approaches to things.

Side note: Try not to get confused when you see a different way to do something from what you were taught. If it confuses you, stick to what you know. It is easier to learn alternatives when you have a broader base of knowledge later.

Well, that's about it from the top of my head. I hope it helps.

ElizabethAnsley · Dec 20, 2016

Hi hi! I am a new grad in a medical/surgical ICU who recently got off of orientation.

My advice:

1) TEAMWORK! Attitude and motivation are KEY. Always be willing to help with anything and do so pleasantly. Even grabbing an extra washcloth for another nurse while they're bathing a patient can go a long way with building rapport. I always try to ask everyone if they need any extra help when I get a second... it may be easy to sit or go drink a cup of coffee, but teamwork makes the ICU dream work. Establishing good rapport with your intensivists and co-workers makes work more enjoyable, AND you know that you have a great team of people who'll help you when things decide to hit the fan.

2) Get a critical care book and bring it to work. You'll never know when you'll get a patient going to a procedure you've never heard of!! Taking a few minutes during rounds to brush up on how something works or what exact complications you should be looking for really helps. Even if it means remembering certain ventilator settings to read about once you get home that night, my boss told me that her best new grads were the ones that studied when they got home. School can't teach you everything, but it is much easier to assess interventions when you understand how they work!

3) Get yourself a hemostat, some bandage scissors, and a sharpie. I have these on me at all times and you'd be shocked that when you need one of them, YOU NEED THEM! IV tubing snags and breaks while you're en route to a procedure? Hemostat that IV tubing and you'll have a smaller mess to deal with :) Also, carry a few IV flushes in your pocket.

4) Review a thorough head-to-toe assessment before going to work that first day. Not all under-grad clinical sites require a true head-to-toe assessment. But by brushing up, it'll help you not have to re-enter a room to check capillary refill because you forgot. And speaking of charting... check your orders at least once an hour. Worst case is when you're busy charting and a physician comes and asks how your patient responded to the Lasix he ordered an hour ago... when you haven't even given it! Try not to forget to glance for new orders.

5) Ask when you can get ACLS certified. I'd try to do it as soon as possible! When things go south in critical care, they do so quickly. It's important to be knowledgeable and calm when that does happen.

6) Find a good support system. Does your hospital have chaplains? Do you like to run? The ICU is often times full-force for your entire shift. It's important to have a good way to deal with the stress that comes with it. It's not always easy to encounter the severity of illnesses, so be sure to speak up if you're struggling with it. My hospital has chaplains and they've been great people to talk to post-code or post-withdrawals. Even a 15 second conversation can help get through some tough emotions!

7) Check the alarm limits on your patient FIRST thing. Maybe the night nurse didn't care if a patient's heart rate rested in the 50's, but I sure do! Don't let something like a bed alarm being accidentally turned off create a nightmare for you. Alarm fatigue is real, but remember that the alarms are there for a very important reason.

Let me know if you have any specific questions! That's just some general stuff off the top of my head!

CCU BSN RN · Dec 20, 2016

1. Ask a lot of questions but make sure you don't seem rude or anything. Literally no question is too dumb

2. Offer to help with/do/observe anything interesting. If a patient is getting a bedside line placement or tube placement, be there. Even if you're in the corner. When the experienced RN and your preceptor go in a room to troubleshoot the CVVH machine or art line or clogged PEG. You'll learn so much from watching how they deal with things.

3. Get prepared mentally. You're going to feel very dumb for at LEAST a year, probably closer to at least 2. ICU RNs are not always super warm and fuzzy, so get prepared for some heavy sarcasm and also for someone to say kind of rude stuff to you because they didn't realize they were being mean. The other nurses aren't mean (99% of the time), they're really smart and they can already see the 10 different ways your patient could crump without intervention. Use them as a resource, don't get hung up on people hurting your feelings. People die. Lots of people die. On the regular. They go from holding your hand and talking to you one second, to a messy and long code, to dead, and you have to pull your **** together right quick for your other patient and waiting admission. Then you cry in your car and spend hours nit-picking every decision/choice you made in their care. You wonder if you missed something. I can't tell you how to deal with this when it happens to you, but it will probably happen. Possibly frequently. I wish I had given more thought to how I was planning to cope with the above (clearly).

BeenThere2012, ASN, RN · Dec 20, 2016

1. Ask a lot of questions but make sure you don't seem rude or anything. Literally no question is too dumb
2. Offer to help with/do/observe anything interesting. If a patient is getting a bedside line placement or tube placement, be there. Even if you're in the corner. When the experienced RN and your preceptor go in a room to troubleshoot the CVVH machine or art line or clogged PEG. You'll learn so much from watching how they deal with things.
3. Get prepared mentally. You're going to feel very dumb for at LEAST a year, probably closer to at least 2. ICU RNs are not always super warm and fuzzy, so get prepared for some heavy sarcasm and also for someone to say kind of rude stuff to you because they didn't realize they were being mean. The other nurses aren't mean (99% of the time), they're really smart and they can already see the 10 different ways your patient could crump without intervention. Use them as a resource, don't get hung up on people hurting your feelings. People die. Lots of people die. On the regular. They go from holding your hand and talking to you one second, to a messy and long code, to dead, and you have to pull your **** together right quick for your other patient and waiting admission. Then you cry in your car and spend hours nit-picking every decision/choice you made in their care. You wonder if you missed something. I can't tell you how to deal with this when it happens to you, but it will probably happen. Possibly frequently. I wish I had given more thought to how I was planning to cope with the above (clearly).

Re #3...Very well described. I remember the first death of a patient I experienced. Afterwards, I felt as if I should be allowed to go home...kidding, but...

it can be so emotional and draining, especially after a long or messy code. You feel as though you have just gone "through something"....and you did! However, the show must go on, as they say, and this can feel very hard to do in the beginning. This is one of the hardest things about Intensive care.