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New grad in icu not ready

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I'm a new grad in the icu, my 12 week orientation is 3 weeks away from being over. I'm not ready. I haven't even taken over full care for two patients yet. I'm pretty sure I'm at fault for not pushing it. I had a meeting with my charge and preceptor for and both don't think I'm ready and strongly hinted at working at a regular floor for a year. I have a meeting with my supervisor this week. I feel like crawling into a hole and dying.

Cvepo

Specializes in CCU, SICU, CVICU. Has 3 years experience.

My honest opinion, and many may disagree, but the ICU is no place for a new graduate. There is so much to learn without focusing on critically ill patients. I started on a Vascular Surgery/Medical Telemetry unit for about 14 months before I went to MICU. You would be surprised what a year of floor nursing does for your assessment, critical thinking, time management, etc. All things you need to master to work in the ICU. By the time I started my MICU orientation, I just needed to learn the critical care aspect, because my charting was done, my prioritization was better, etc. That being said, I had a 10 week orientation AS AN EXPERIENCED TELE NURSE, so a mere 12 weeks for a new grad sounds like it is setting you up to fail.

If you have an option to transition to an Intermediate/Step Down unit instead, I would highly recommend. You will get a higher acuity than a floor and better insight to critical care!

No need to die or go into a hole. If both of these nurses think you're not ready, heed their advice. Cvepo's too. Did they have any hints for you? Specific things you should do at this point to get ready? When do they think you will be ready?

Can they get you a Med/surg position for a year? Would they then reconsider you for ICU?

calivianya, BSN, RN

Specializes in ICU.

I'm in the minority in that I don't feel like ICU is necessarily an impossible place for new grads. I started out in ICU with the same orientation as you - 12 weeks - and I've been a MICU nurse for four years now.

The good thing is you have three weeks left - to me, that's a VERY positive sign. One thing I see here over and over is people not getting told until the very end of orientation that they're not working out. They gave you *three weeks* notice. That makes me think they're giving you time to fix things, and maybe your situation is not totally hopeless.

The fastest way to learn a language is through immersion. I believe the fastest way to learn any type of nursing is the same. Starting on your next shift, insist on doing all of the assessments and medications for both patients. Take note of what meds you give most often, write them down, and study them when you get home. Know your facility's typical dose ranges for all sedatives and pressors off the top of your head - make flash cards if you need to. I find flash cards a particularly useful way to memorize information.

Print off a copy of any of your unit protocols and take those home to study, too. Especially memorize the electrolyte replacement protocols, glycemic protocols, sepsis protocols, and blood administration protocols, because you're going to use those all the time. Looking up that stuff every time you have to do it is a huge waste of time.

Know off the top of your head which sedatives and pressors are compatible, because what probably saves the most time on a day to day basis is not having to look up IV compatibility. If you know a stock set of things that can run together, you can hopefully just free up lines for your antibiotics/secondaries. If you can free up two dedicated abx/secondary lines, the odds that you're going to have to run your secondaries with your drips or with each other are low, and you'll never have to look up compatibility again.

If you're not 100% solid on your rhythms, practice with the SkillStat ECG Simulator until you are. Play the game over and over again until you are able to consistently identify at least 10 strips 100% accurately in less than a minute. This is how I learned my rhythms.

Ask your manager when the next ACLS class is and go ahead and get certified. Show that you're willing and able to put the work in... and besides, it will make you a lot more confident when you have a code of your own.

Treat all of this stuff like it's going to be on the NCLEX and you have to take the NCLEX again tomorrow - study hard like your life depends on it.

I don't think your job is completely unsalvageable - it might just require a whole lot of legwork on your part. Good luck!

Edited by calivianya

I loved being in the ICU as a new grad. I learned so much and really honed my assessment skills. But it's not for everybody. You have to have a go get it attitude every, single, day you are there. You can't be timid. You can be nervous and a little scared, but you just have to jump in and go for it.

Being nervous and scared are good things. I've been in the ICU for almost 3 years now since graduating and I'm still scared sometimes. It keeps me vigilant. But if there's too much trepidation, then ICU may not be for you.

It does get easier.

Semper_Gumby

Has 2 years experience.

I'm in the minority in that I don't feel like ICU is necessarily an impossible place for new grads. I started out in ICU with the same orientation as you - 12 weeks - and I've been a MICU nurse for four years now.

The good thing is you have three weeks left - to me, that's a VERY positive sign. One thing I see here over and over is people not getting told until the very end of orientation that they're not working out. They gave you *three weeks* notice. That makes me think they're giving you time to fix things, and maybe your situation is not totally hopeless.

The fastest way to learn a language is through immersion. I believe the fastest way to learn any type of nursing is the same. Starting on your next shift, insist on doing all of the assessments and medications for both patients. Take note of what meds you give most often, write them down, and study them when you get home. Know your facility's typical dose ranges for all sedatives and pressors off the top of your head - make flash cards if you need to. I find flash cards a particularly useful way to memorize information.

Print off a copy of any of your unit protocols and take those home to study, too. Especially memorize the electrolyte replacement protocols, glycemic protocols, sepsis protocols, and blood administration protocols, because you're going to use those all the time. Looking up that stuff every time you have to do it is a huge waste of time.

Know off the top of your head which sedatives and pressors are compatible, because what probably saves the most time on a day to day basis is not having to look up IV compatibility. If you know a stock set of things that can run together, you can hopefully just free up lines for your antibiotics/secondaries. If you can free up two dedicated abx/secondary lines, the odds that you're going to have to run your secondaries with your drips or with each other are low, and you'll never have to look up compatibility again.

If you're not 100% solid on your rhythms, practice with the SkillStat ECG Simulator until you are. Play the game over and over again until you are able to consistently identify at least 10 strips 100% accurately in less than a minute. This is how I learned my rhythms.

Ask your manager when the next ACLS class is and go ahead and get certified. Show that you're willing and able to put the work in... and besides, it will make you a lot more confident when you have a code of your own.

Treat all of this stuff like it's going to be on the NCLEX and you have to take the NCLEX again tomorrow - study hard like your life depends on it.

I don't think your job is completely unsalvageable - it might just require a whole lot of legwork on your part. Good luck!

What an awesome summary! I am saving this as I am one of those who (on my second nursing job) was told throughout orientation that I was doing well and at what should have been the end of it, I was told I had not been doing well and ended up with a total of two half-shifts to fix it before being fired in the middle of the afternoon and sent home. The disconnect between what I had been told previously and what I was told at the end was mind-boggling.

Follow these suggestions and you may be able to save your job; if not, see if they will let you transfer to a regular floor. It's true that time on the regular floor will give you the chance to really hone your assessment skills and see the pieces you've learned in school and then at work come together--but this will also happen if you're able to make the ICU work. Regardless of where you are, it takes some time for it to all come together, but it does happen eventually.

I hope you're able to succeed in the ICU now, but if not, perhaps ICU is in your future. Good luck! :)

OUxPhys, BSN, RN

Specializes in Cardiology. Has 4 years experience.

Starting as a new grad in an ICU is doable but it isnt for everyone. I wanted an ICU job right out of nursing school because I saw in clinicals how stepdowns and regular floors worked and I wanted no part of it. Unfortunately we didnt have a true critical care rotation and I didnt have a practicum nor did I work in an ICU as an aide so essentially my chance was zero.

Im coming up on 2 years on my stepdown and Im glad I started here. It made me realize I dont want to do bedside nursing. At all.

If you feel you cant make it request to go to a cardiac stepdown. There is no shame in that. We have 2 RNs who worked in the CICU as aides but ended up coming to our floor. One of them realized the ICU wasnt for her and the other was essentially told she needed time on the floor first.

Do not look at it as a failure. Get some experience and confidence on a stepdown and then make the transition to the ICU.

Cvepo

Specializes in CCU, SICU, CVICU. Has 3 years experience.

Starting as a new grad in an ICU is doable but it isnt for everyone. I wanted an ICU job right out of nursing school because I saw in clinicals how stepdowns and regular floors worked and I wanted no part of it. Unfortunately we didnt have a true critical care rotation and I didnt have a practicum nor did I work in an ICU as an aide so essentially my chance was zero.

Im coming up on 2 years on my stepdown and Im glad I started here. It made me realize I dont want to do bedside nursing. At all.

If you feel you cant make it request to go to a cardiac stepdown. There is no shame in that. We have 2 RNs who worked in the CICU as aides but ended up coming to our floor. One of them realized the ICU wasnt for her and the other was essentially told she needed time on the floor first.

Do not look at it as a failure. Get some experience and confidence on a stepdown and then make the transition to the ICU.

Great post. Many newcomers see the floors from a clinical-rotation-only perspective and honestly, I feel like a few hours once or twice a week is a terrible indicator of what the job actually entails. There is no shame in working floor or stepdown rather than ICU! Nice to hear that stepdown worked (in some regards) to your career!

Ruby Vee, BSN

Specializes in CCU, SICU, CVSICU, Precepting & Teaching. Has 40 years experience.

My honest opinion, and many may disagree, but the ICU is no place for a new graduate. There is so much to learn without focusing on critically ill patients. I started on a Vascular Surgery/Medical Telemetry unit for about 14 months before I went to MICU. You would be surprised what a year of floor nursing does for your assessment, critical thinking, time management, etc. All things you need to master to work in the ICU. By the time I started my MICU orientation, I just needed to learn the critical care aspect, because my charting was done, my prioritization was better, etc. That being said, I had a 10 week orientation AS AN EXPERIENCED TELE NURSE, so a mere 12 weeks for a new grad sounds like it is setting you up to fail.

If you have an option to transition to an Intermediate/Step Down unit instead, I would highly recommend. You will get a higher acuity than a floor and better insight to critical care!

I've always advocated a year on Med/Surg, or Medical or Surgical or Tele -- before critical care. A 4 - 5 month orientation is standard in my unit, but it's a pretty specialized ICU in an enormous, name brand hospital. 12 weeks in the ICU of a small community hospital may not be so out of line. Some of these are ICUs in name only . . . I remember being a traveler at a community hospital ICU where the standard patient was no more sick than someone I would have gotten in a telemetry or step-down unit in the big name hospital. No invasive monitoring, no vasoactive drips, only chronic ventilators and a lot of folks who were in ICU simply because they didn't know what else to do with them or for physician convenience. In that type of environment, 12 weeks might be just fine.

Some new grads, however, don't adapt to their first jobs as quickly or as easily as other new grads -- the specialized ICU may be OK for some of those quick adapters. (I was one of those who needed a full year to "get it," even starting on the tele floor.) I still think that even those who CAN start in ICU benefit from not starting in ICU -- they seem to have greater career satisfaction and longevity. As a seasoned preceptor, it has been my experience that the majority of new grads who start in the ICU don't choose the job because they want to take care of ICU patients; they choose the job because they're on the fast track to the big bucks and CRNA school or NP school.

amzyRN

Specializes in ED, Cardiac-step down, tele, med surg.

It's good you are trying to tackle this problem ASAP prior to starting and possibly failing. I'm wondering why they allowed you to go further, knowing you weren't able to handle a full assignment. A good rule of thumb is to have at least 6 to 8 weeks with a full assignment under supervision and light help only until a new nurse is "by themselves". Nothing wrong with starting out on the floor for a year or 2. Another possibility is extending your orientation. I think it is in part their fault for not spotting this sooner. I wouldn't internalize this as a failure, but a learning opportunity.

CCU BSN RN

Specializes in CICU, Telemetry. Has 7 years experience.

Some new grads can handle the ICU. That's why hiring into the ICU for new grads should be done occasionally, on a case by case basis.

Most of the time, new grads do not belong in the ICU. Or anywhere where a few seemingly minor oversights can kill a patient in minutes. It's too much to ask of them, and it's not fair to expect them to thrive with 12 weeks of orientation with days off to complete ECCO modules. I'm incredibly bright, and I would've sank like lead under those expectations.

Anyway, you had no way of knowing if you were going to sink or swim here, it's your first nursing job. You still may not know, and that's okay. You have people looking out for you, and that's awesome. Your preceptor and supervisor WANT you to stay in ICU if you can be safe there. They've spent a lot of time and money training you, and financially, they had a vested interest in making it work to keep you in ICU. They've decided, though, that they think you should move to a less acute floor for awhile, at least until you get your sea legs. That's great! You're not fired, you don't have to come off orientation unsafe and wait for a sentinel event to get fired, you get to leave on good terms! and not have to find and apply for another job! Take this gift and run with it. Nobody is saying you can never work in ICU. They're pointing you in the direction of an opportunity to sharpen your skills and get up to speed at your own pace. They're pointing you away from burnout and frustration and anxiety.

I would STRONGLY encourage you to take their generous offer, go to med/surg or wherever, and learn everything you possibly can from the nurses there. It may take a good 3 years or so, don't rush it. Believe me, you're being given a huge gift. TAKE IT.

FurBabyMom, MSN, RN

Has 8 years experience.

I don't know what to say. I'm torn. I want to say you can do anything because it is possible. However, I know, from my own experience, that there is utility to working on a med/surg/tele or stepdown unit. My first two jobs in nursing were combos of med/surg/tele and stepdown. I spent about a year in those environments before transferring to the OR. I'd worked as an assistant in the float pool of a large university hospital for about a year as well. My experience as an assistant helped me learn time management and I had seen some cool and scary things before being the patient's nurse. The nurses I worked with always took time, when possible, to show me assessment findings that were different than normal, or let me listen to murmurs, stuff like that. I'd been in codes before I was a new grad nurse coding my patient's visitor we knew NOTHING about.

I personally feel that my assessment skills, and awareness of the situations around me are higher because I came from an area that MY personal assessment skills determined whether I succeeded or failed, and what happened to my patients. My ratios were anywhere from 1:3 to 1:7 depending on acuity. It was nothing to have 4-6 patients on tele, we could monitor 28 of 31 beds, and we were remote/central monitoring for two other tele units (we had to have someone who had completed tele competency assessment within eyesight of our tele monitor and the other two screens at ALL times). We ran "critical meds" too, including some vasoactive meds up to a specific dosage before transferring to ICU. We were the only unit in the hospital that wasn't ICU that took trachs. We were allowed to take vents, specifically those where patients were ventilator dependent, stable patients whose settings didn't really change. We also used vents if too many patients within the hospital needed BiPAP or CPAP, we'd just put the settings in on a vent (we had specific machines for BiPAP and CPAP).

I'm in the OR now. I know what the assessments of these patients pre and post op look like. I know many of the special needs of many medications, because I've personally given them. I can put all kinds of monitors on my patients, and was responsible for putting them on when I worked the floor. I've been in enough emergency situations to know that certain drugs will be needed. I know when to run for (or delegate) running for the crash cart. I know when anesthesia residents might be in over their heads and page for anesthesia help. I didn't learn this stuff by accident... My boss has commented more than once about how strong my assessment skills are because I worked the floor. Others have talked about how calm I stay when things aren't going well, but even when we're running a code in the OR it's easy compared to the floor and waiting on the code team for help.

We have new grads in the OR. I'm okay with that, especially if they're passionate. But there are things they don't notice because they've either always been a student or they're in the OR and whatever monitor or medication is "anesthesia's thing". They eventually get it, but they don't always get it quickly. It takes them seeing things a few times to get it. I get it, I didn't always know what ABC or XYZ was, but I learned it when we weren't operating on someone's brain or heart.

I don't think that the floor or stepdown is "easy". None of it's easy. Plenty of floor and ICU nurses tell me I don't do anything all day anyways in the OR. Some of my stepdown patients were one heck of a challenge. On more than one occasion, I spent a great deal of time with just one of my 5 patients and my coworkers had to help with the others. When I rapid reponsed, transported for stat CT and transferred to the OR for re-evacuation, my patient who had been in ICU following a decompressive hemicrani, transferred to us 4 hours after extubation and lasted not even 8 hours on our unit before requiring more surgery? Yeah. I spent probably two hours on that before anesthesia took over care in PACU. Sometimes you have 5 sick patients to juggle and put out fires the entire shift. I had some patients sometimes (usually post op surgical infections) who I felt like I never saw except to pass pain meds, assess them once and hang antibiotics. Sure, I rounded on them, and they were sleeping, breathing regularly, so I left them alone.

Perhaps those nurses see something in you and don't want you to become too overwhelmed or burnt out before you could be successful at the level you want to be. Not everyone is ready for the same thing at the same time. Maybe ask for suggestions what you could improve on? Maybe it's your time management, maybe it's assertiveness, maybe it's any number of things... The feedback won't hurt. It's great that they are giving you feedback instead of letting it fester. That has to count for something. For what it's worth, my first two jobs were never part of my plan, not by any means what I wanted. But because I was looking I found my current job, which was not even close to part of the plan. But it is amazing, and I've learned so much. Never know, don't write off an experience outside what you expect or think you want.

The med/surg thing is fine for time management development as many new grads are scared of more critical patients. I use to think all are grads should start in med/surg or tele, but have seen many do well in an ICU setting. This new grads who make the smoothest transitions are the ones who worked as techs in the unit while in school.

Everyone is different. I do not think that one plan fits all.

Pixie.RN, MSN, RN, EMT-P

Specializes in EMS, ED, Trauma, CNE, CEN, CPEN, TCRN. Has 13 years experience.

I would STRONGLY encourage you to take their generous offer, go to med/surg or wherever, and learn everything you possibly can from the nurses there. It may take a good 3 years or so, don't rush it. Believe me, you're being given a huge gift. TAKE IT.

I agree with this! OP, rather than letting you go, they want to retain you but grow you appropriately. Do not beat yourself up!!! Critical care is tough, and some areas are more tough than others. Please keep us posted!

Nurse SMS, MSN, RN

Specializes in Critical Care; Cardiac; Professional Development. Has 10 years experience.

I have been the preceptor who has had to recommend someone be either moved to a lower acuity unit or let go entirely. Believe me, if they feel you would benefit from the experience (and internal sense of success) by a year of lower acuity, it means they think you are TERRIFIC. Please please PLEASE don't feel like failure or like curling up and dying. There are much worse things than needing a little more time to be proficient in something as important as caring for the critically ill! They would not be looking to retain you if you were hopeless or a failure or dangerous or stupid. Work hard over the next three weeks but also admit to yourself if you aren't ready and be gentle. Imagine talking to a small child the way you are talking to yourself and adjust accordingly. You have every reason to feel good about what you are doing and every reason to have faith in yourself. This will be okay in the end.

FurBabyMom, MSN, RN

Has 8 years experience.

I have been the preceptor who has had to recommend someone be either moved to a lower acuity unit or let go entirely. Believe me, if they feel you would benefit from the experience (and internal sense of success) by a year of lower acuity, it means they think you are TERRIFIC. Please please PLEASE don't feel like failure or like curling up and dying. There are much worse things than needing a little more time to be proficient in something as important as caring for the critically ill! They would not be looking to retain you if you were hopeless or a failure or dangerous or stupid. Work hard over the next three weeks but also admit to yourself if you aren't ready and be gentle. Imagine talking to a small child the way you are talking to yourself and adjust accordingly. You have every reason to feel good about what you are doing and every reason to have faith in yourself. This will be okay in the end.

I agree, 1000%.

I have had several orientees in the OR who I have had to recommend that they go to a less intricate specialty team for a while. They've learned a lot, and are valuable, but not strong enough, yet, to be cut relatively loose in situations where delaying 30 seconds can mean a life altering injury or even death. I can't recommend, in good conscience, someone who cannot function well in the most basic of the cases on our service line (neuro) to be able to do the incredibly complex cases we do. ANY procedure can become critical very quickly, as patients can have an anaphylactic reaction, or develop MH. Not only that but anesthesia induction and emergence are the two most critical times of nearly all procedures (risk of losing the patient's airway). Sure, lots of things are scary, but losing an airway proceeds to emergent trach very quickly. Any general case can go south, there are lots of important vessels in the belly, but most laparoscopic cases (appys, choles) are more routine or predictable than cranis. The number one thing I always stress with ALL of my new grads is that they should call for help when they even kind of maybe think they might need it. On day shift, we have people available to help. If you're running for the crash cart, probably need to call you manager or the charge nurse. If there is a lot of blood in a case where minimal blood loss is expected, then you need to call for help. It may be that you just need better hemostatic agents (more drugs, different type of coagulation, etc), or that you need to have blood in the room or someone to help check blood. But it's far better to call for help early or when you don't really need it than when you're up to your eyes in problems.

JonSnowedSRNA

Has 4 years experience.

Go to emcrit.com and watch these 2 videos/ podcast. The first is called "dominating the vent" and there is a part 1 and 2. The second is called "vasopressor basics". Watch them both at least 3 times a week each. Understand basics of ABGs and Vent status to correct ABGs. Know these following things pretty well: 1. What resp distress looks like 2. Treat pt not monitor, vital signs are often a late sign of crap going bad 3. Adding on to number 2, screw the monitors how does the pt look? Are they about to take a stroll through the zoo or do they look like they ate some really bad Mexican food in Mexico and washed it down with some warm Mexican tap water 4. Know sepsis 5. Know DKA. 6. Know ARDs 7. Watch every line that you have things going through regularly. 8. Know your A&P. Best wishes