New Grad in ICU - Having Difficulty

Specialties Critical


Hi everyone! I am hoping someone can share tips/advice on being a new grad in the ICU.. 

in just a couple of weeks I will finish my training and I will be on my own. I have noticed I lack critical thinking and have difficulty in knowing what to ask the doctors for my patient.

I am completely new to nursing! No nursing experience whatsoever. Is is normal to lack critical thinking and not know what to ask from the MD or am I behind? Should I take a step back and not continue in the ICU. 

I don’t feel nervous going into my shifts. I am able to do my tasks, assessments and have a overall good workflow but I don’t want to be a task type of person. 

I am looking for any advice on how to better my critical thinking and how to know what to ask the MD. Any advice/tips are greatly appreciated! Thank you! 

Specializes in RETIRED Cath Lab/Cardiology/Radiology.

Moved to Critical Care area, for (hopefully) increased Critical Care RN views and responses.

First , take a deep breath. You just came off orientation. You’re not going to have critical thinking skills yet. That comes with time and experience. I started as a new grad in an ICU many years ago. It’s def intimidating, but that’s why they give you simple pairs first and then advance you over time to sicker patients. If your unit is like mine was, they put you next to or near your preceptor once you’re on your own so you have them as a resource. And beyond that, look around you…you have an entire unit of nurses and doctors and likely respiratory therapists to learn from. Take advantage of that. Talk to them. In your down time look up things you are unsure about or don’t know. When talking to the doctors just tell them your concerns and ask what they think. Do NOT quit the ICU. You just started. Give yourself some grace. Everything comes with time. You’re going to be fine!

Specializes in New Critical care NP, Critical care, Med-surg, LTC.

I think that you can probably be very successful in the ICU and agree with much of what traumanightsRN already said. However, I will temper my enthusiasm just a little because it's hard to know given what you have shared, where you are at with your development. Are you happy with the orientation you have received? Do you feel like you have been well supported, and that you will have CONTINUED support as you transition off orientation? Some of these things are beyond your control and will influence your own likelihood to be successful. I know that in my unit we are hiring brand new grads and we do NOT have a robust orientation. I have precepted a few people when I've picked up shifts and they are lacking in BASICS skills and information that they need. Then they come off orientation onto nights where there are mostly travel nurses. We are NOT set up to properly support new grads and help them to be successful. It's to the detriment of these nurses and the patients. We have had four new grads all leave within a year of starting, two within a month of coming off orientation. Many of us have raised concerns to our manager and we're told we're being too negative. You need to be in a good environment to develop the right skills. Good luck to you!

It is normal to experience imposter syndrome as a new grad especially in the ICU as well as anticipatory anxiety prior to a shift.  It is stressful to communicate our needs when we are inexperienced but the critical thinking aspect will develop gradually as you care for different patients and start to notice trends.  I think that as long as you know how to do an assessment where you are able to identify abnormal findings and have the ability to notice acute abnormalities in a patient's vitals and EKG, then that will be the information you communicate to the doctor.  Ultimately, it is not only on you to find a possible solution or treatment.  Once you communicate those findings to the doctor, they should have their own recommendations.  Again, practice and experience will help develop those critical thinking skills.


Hey OP, 

Well, welcome to the ICU. The most frustrating, ever-changing, demanding, and MOST REWARDING field of nursing.... I may also be biased... So, when I came into nursing, I had all of past experience in forklift operating.... So, you can say that I had a bit of a disadvantage coming into critical care. The best advice I can give you is NEVER STOP LEARNING. I still carry a small notebook in my pocket that I write things down when I come across them that I can look up outside of work. Coming off orientation, and even a year or two in I still get slapped around some shifts. I left thinking "what the f@#k just happened"... You CANNOT give up though, while many days in your career will be rough, they do get easier. So, in order to try and facilitate my learning and also just get a solid foundation in ICU nursing, here's some of the resources I have used. 

Book Resources: Nancy H. Diepenbrock "Quick Reference to Critical Care". This is a GREAT pocket book, one you can carry with you to each shift, and it will allow you quick access to ALL THINGS ICU. I have gifted this book to COUNTLESS RN's in my short career when they are looking for an edge, and I keep multiple copies of this on hand. This will have all your pressers, your doses, your MOA, uses, etc. It will have quick references for things like IABP, Impella devices, lab interpretations, EKG interpretations, CRRT, etc. A lot of the information is even broken up by body systems for your leisure as well. I will include a link at the bottom for it. 

Online: Eddie Watson of ICU Advantage is GREAT, you can find him on YouTube and he covers a large variety of subjects from your basic assessments, to Impella devices, CRRT, and PA catheters, to differentiating your shocks, lab interpretations, etc. I HIGHLY recommend. Even watching just video or two a night and screenshotting the illustrations (highly visual). This outta get you started, as you begin specializing within the ICU (or continue to work a mixed ICU), you can add more resources.                           

Additionally, I also find myself ensuring that on my drive home (or whenever you get time) I self reflect about my day. I look at the things that went well, the things I did well, and the things I did not, and the things that did not go well. Then, I set goals for myself each day. They are usually small, like staying on time for my CRRT numbers, knowing all the medications I am giving, or getting all my turns in on time, and they are always very attainable for a shift. I use the "things that didn't go well" from previous shifts to build these goals and I believe they allow you to always continue to develop. I am 4 years in and STILL find myself doing this. Anyway, reach out if you have any questions and above all else, NEVER STOP LEARNING.                                                                                                                                           

Link for Book:

Specializes in ICU.

With experience, your recommendations will come. I would start first with lab results - being able to look at a patient's labs, related to their diagnosis and recommend medications.

It's important to give yourself grace in a time of growth, and to listen during physician rounds. Ask questions to see where the doctor's train of thoughts are and why they ordered certain things for the patient.

Use your assessment skills to your advantage and impress the physicians you are working with by noting abnormalities. That is a good start to get recognized and to show the team you are working with that you take your job seriously.

Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.

I've told this story here before.
When I had my first ICU job one year out of school, it was in a world-class hot-**** unit, about half open heart and cardiac transplant, and half everything else critical care (neuro, medical, respiratory, general surg). After a few months I found myself waiting for shift report in the break room with Sarah, an extremely experience nurse who'd been there for many years. I said, "How long does it take before you're not scared anymore?” 
And this very wise woman told me, "The day that I no longer feel that little tingle of anxiety before report is the day that I know I have to quit. I know I can do anything they throw at me but I still need to be alert.” 

Anxiety releases endogenous catecholamines from your adrenals, which dilate your pupils so you can see the tiger better, releases glucose from your liver to support your muscles in running away from the tiger or fighting it, increases your cardiac output to do the same, and temporarily diverts blood flow preferentially to your brain and CV system so you can think more clearly before you act (which might leave you a teeny bit nauseated). This is all a good thing.

At the beginning it's like drinking from a fire hose, there's so much to learn. Then one day you notice you're learning only two new things per day. Then it'll be one. Heck, I worked there for four years, eventually taking charge and orienting newbies to the most complicated pts we got, and by the end of that time I was still learning at least something new and cool every week.  

Have fun!

Specializes in ICU | Critical Care | CCRN.

It's been almost a year since original post... @RN_Lovee how's it going?

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