New Grad Job Offers in ICU versus IMC/Tele: Need Input Please

[NurseK1986]

Hi Everyone, and thank you in advance for reading my novella below --

I am a new graduate who just completed an ABSN program. I had 5+ years of experience in healthcare as a tech and M.A. in areas including pharmacy tech, ED, trauma ED, IMC, Cardiology, urgent care ... I've been around the block, and nursing is a second career for me (I'm in my lower 30's).

I am a fast learner who excels in whatever specialty I land in, because I take interest and am very engaged (it was a hard choice between nursing school and med school, just because I love school). I decided nursing would allow me to bring more of myself to the table, so to say, and offered more flexibility in my life and career as I have other hobbies, and I enjoy the prospect of being able to work while pursuing advanced nursing education in the form of my masters, doctorate, MBA, etc. down the road. Over the past 2 years my interest shifted from emergency medicine to critical care and cardiology, because I enjoy getting to dive in to the patients and their patho/conditions/comorbidities on a deeper level. I did my senior capstone in a combined MICU/CTICU and loved it. I enjoyed the different flavor of fast-paced that the ICU has to offer, and the level of teamwork and collaboration is incredible.

Anywho, here I am all freshly graduated and lucky enough to have been on about 6 interviews thus far, all in areas I am interested in. I currently have 2 job offers in 2 different states (with a potential 3rd) to consider and would like some insight:

Job #1: Combined cardio-pulmonary IMC/Tele unit in a hospital located in a busy metropolis. The unit is still considered "critical care" based on the fact that it is IMC, but sounds like it has a med surg component as well based on the tele section of the unit. Amazing manager who mentors her nurses, and reputable new-grad program. Shares a clinical educator with the ICU. Potential to move into the ICU after 1-1.5 years on the IMC unit (the manager stressed that she primes nurses for the ICU i that is their goal). Mandatory 2-year contract with financial repercussions for leaving early. Keep in mind this hospital does not do CT surgery or transplants, but its sister hospitals in the same city include a heart hospital AND a level I trauma hospital. Other pros of this job would include a sign-on bonus, being in the same city/state as my significant other (who recently relocated there for a job), my mom, one of my sisters, my brother. I have lived in this city before and still have a couple of friends who I have remained close with as well.

Job #2: Cardiothoracic ICU at a level I trauma hospital in another busy metropolis in the city where I currently live/went to nursing school. This CT-ICU also takes MICU overflow and some IMC-status patients, as many do. Their new-grad RN program is brand new, but the hospital has a great reputation and is currently in the process of seeking Magnet status. This hospital does NOT require a 2-year contract, and openly offers inter-network transfers to their other units/hospitals in case an employee ends up needing a better fit. This network of hospitals also does transplants (kidney, liver, pancreas). Other pros of this job would include: starting in a CTICU! Being in a city/state where I enjoy the weather more, have the mountains, and more access to outdoor hobbies and other neighboring Western states. I've lived here for 1.5 years and have friends. Cons are obviously no sign on incentive, lack of family in the same city/state, having to continue to balance a long-ish distance relationship (14 hour drive/1.5 hour plane ride away from one another), and it's slightly more expensive to live here.

Job # 3 (If I get it): CT-ICU at the local university hospital, which also does heart transplants. 2-year contract required, it's a teaching hospital, yadda yadda yadda.

So, considering all of that ... what are your thoughts? Would it actually be BETTER to get the IMC/Tele/Med-surg-esque experience with a trajectory into an ICU, or go big for the CTICU at a hospital where the patient cases sound like they will be more complex given the various resources in trauma/surgical programs that the hospital has? I see many comments on other posts that bring up time management and prioritization, which is already a strength of mine. I took full patient loads in all of my clinical rotations with very little prompting from preceptors (including my ICU rotation) and have no trouble shifting gears due to having a firm background in healthcare. I simply want to set myself up for success by developing a wide range of knowledge that I admire in many seasoned nurses I have worked with. In my ICU rotation, I worked with new grads who had only been on the unit for 1-1.5 years and they were sharp as a tack! I also worked with the nurses who did anywhere from 3-6 years in Tele, oncology, med surg, started in the ED, etc. who were obviously excellent resources. I know being slightly older and having a background as a tech/MA will help me, as it already has. Personal feedback to me from preceptors and clinical scholars has been to go for critical care.

Halp!

[CalicoKitty, BSN, MSN, RN]

I think it somewhat depends on your relationship. If you take the more appealing job (location, position), you are choosing to keep the long-distance relationship or expect your partner to join you where you are.

The other position likely is tele/med-surg with a bit of IMC put in. At my hospital IMC isn't really considered ICU (financial reimbursement from insurance).

So, the choice is romance or location/job. It is a hard choice to make, but only you can make that one.

[Guest219794]

None are bad choices.

My recommendation: Disregard the specifics of the specialty. Focus on the training program. Pick the opportunity with the best track record training new grads.

Congrats and good luck.

[EDNURSE20, BSN]

I think it's obvious. The first job.

It has a Good reputation. The manager obviously know you want to go to icu and is ok with it and will give you the training you need. And your family is there, there's only so long you can do long distance for.

If your still unsure look at all the post there are on here about new grads starting in icu and not coping. Even with healthcare experience.

[NurseK1986]

Thank you all for your insight ... I have to say, I am not one to "move for a boy," which is why I am being so level-headed about this. We have been long distance for about 5 months now, which is nothing compared to what some of our friends and others in the medical community have been through given residencies, etc. Neither of us want to end up in the state he currently lives in long-term, which is yet another reason why taking the job in my current city is appealing as we both have a network here.

The university CTICU job is backed by an excellent training program, which is why it is so competitive to get into. My only hesitancy about the current CTICU that i've been offered a position with is that their new grad program is new ... but I've always trained on the job so I wasn't really interested in doing a new grad program to begin with, and much of the feedback I've received from nurses is that they felt the new grad program was a waste of their time because they end up learning on the unit anyway. These programs weren't around until a few years ago, so my thought is ... well how did you train nurses originally? And how do you train nurses who come into an ICU who AREN'T GNs? The answer I get is: "Trust me, we still get trained." In summary, I feel as though the "new grad residency" is partially a way to scare new grads into taking low-paying jobs by making them feel as though they will be lost without this extended version of orientation ... and maybe we will! Who am I to say?

[CCU BSN RN]

Look at the sheer volume of posts here from overwhelmed new grads, no matter their background or previous training. You're not prepared for how bad your first year is probably going to suck. The transition from Tech/MA/Student to fully-fledged RN sucks in ways you won't fully appreciate until you get a few months deep into your first job. It does sound like you have a stronger background than most in your position, which is great, and will certainly only serve to help you.

That said, the importance of a strong nurse residency program and an IMC position with the option to move to ICU once you get competent...not to mention one that's close to your support system (family too, not just your significant other)...those are tough things to come by. I know that there are new grads who go right into ICU and excel. I won't doubt that they exist. But most new grads don't excel in that environment. I will also say from personal experience that understanding the way things work on tele/stepdown has given me a lot of understanding when I have to cover RRT/Code beepers and respond to emergencies on telemetry and intermediate care floors. I'm not snotty about having to be the one to push adenosine or IV metoprolol because the telemetry nurses aren't always allowed to. I get that they have 6-8 patients at times and can't spend 2h in a critical situation with one of their patients without the other 7 suffering. I understand that they probably spent 2 hours paging the covering MD without a response before they paged me. Learning a charting system, how to follow policies and protocols for an institution, and getting to know providers, shift supervisors, etc. in a less stressful environment is a huge asset. Not to mention that the manager at job #1 seems great. Your manager can make or break your experience on any unit. Find one who is kind, addresses issues, and whose staff don't talk smack about her during your entire job shadowing experience. You have probably 30+ more years of working, so making the safe choice for your first year to ensure a good experience in the long run is not that big of a deal. Just my .02

[Been there,done that, ASN, RN]

"I've been around the block, and nursing is a second career for me ". You may have been around the block, but you haven't been around the nursing block.

CT-ICU is a very narrow specialty. Learn and apply all of your nursing skills, before you specialize.

[NurseK1986]

Thank for for the feedback, perhaps that needed some context. I meant "around the block" professionally, as in I have both managed and followed teams, I respect my coworkers, I respect authority, I work to mitigate conflict instead of being the cause of conflict, I seek feedback and don't get upset by it, I ask questions, and I know when to apologize and when to keep my mouth shut. I know and accept that I don't know everything, and I go home and study up on things without having to be told to do so. I understand that my learning is my responsibility, and no matter how good the training is that this is where the real learning begins. That goes for every profession and student transitioning from the classroom to a job setting, not just nursing. Those who have an ego and don't ask questions sink fast and hurt people ... I don't intend to be that person.

Can anyone provide me with insight into why, then, do they hire new grads into the ICU to begin with? I'm seeing a lot of articles about how "evidence" is showing they are indeed successful, and that the old adage of starting in stepdown or on med-surg is not exactly true. Like I said, I agree CCU BSN RN that one of the strengths I admire about the nurses who have started elsewhere is that they are these incredible resources and "know how things work," not just in their unit, but in the entire hospital and other units. I also notice that when we (the nurses in the ICU and myself when I was doing my capstone) go to other units to respond to a RRT or a code, the way a former tele nurse interacts with the staff on the floor is way different. They know how to communicate with other units and don't come in with this "the ICU is here now" mentality.

Anyone out there who started in critical care and has a different perspective? And yes, I see the posts about the overwhelmed ICU new grads.

[NurseK1986]

Thank you for taking the time to share your thoughts with me.

Can you share more about your experience with tele and how it prepped you for the CICU? Do you feel as though tele allowed you to practice your assessment skills and critical thinking?

My other fear of going directly into CTICU is that I won't get to practice the art of assessing as much and learning to "catch" things ... it sounds like the exposure to the patient population in the tele/IMC setting helps you develop these skills. One of the things I admired most about my nursing school professors is that they had these amazing assessment stories! Like, "after 9/11 at the pentagon, I caught an internal bleed/peritonitis that the doctor totally missed all the signs and symptoms of and was giving me a hard time about, and I got this guy to CT and surgery before he died of internal injuries."

[NurseK1986]

Thank you for taking the time to share your thoughts with me.

Can you share more about your experience with tele and how it prepped you for the CICU? Do you feel as though tele allowed you to practice your assessment skills and critical thinking?

My other fear of going directly into CTICU is that I won't get to practice the art of assessing as much and learning to "catch" things ... it sounds like the exposure to the patient population in the tele/IMC setting helps you develop these skills. One of the things I admired most about my nursing school professors is that they had these amazing assessment stories! Like, "after 9/11 at the pentagon, I caught an internal bleed/peritonitis that the doctor totally missed all the signs and symptoms of and was giving me a hard time about, and I got this guy to CT and surgery before he died of internal injuries."

[cleback]

This was my first time hearing anyone refer to IMC as critical care. My understanding is that IMC/progressive care is poorly defined. My old hospital system defined it as med surg requiring tele. If your interest lies in actual critical care, you may be disappointed with option #1 and may not have any advantage over other medsurg nurses looking to transfer to icu.

I didn't read your whole post but that's what stuck out to me.

[cleback]

Thank you for taking the time to share your thoughts with me.

Can you share more about your experience with tele and how it prepped you for the CICU? Do you feel as though tele allowed you to practice your assessment skills and critical thinking?

My other fear of going directly into CTICU is that I won't get to practice the art of assessing as much and learning to "catch" things ... it sounds like the exposure to the patient population in the tele/IMC setting helps you develop these skills. One of the things I admired most about my nursing school professors is that they had these amazing assessment stories! Like, "after 9/11 at the pentagon, I caught an internal bleed/peritonitis that the doctor totally missed all the signs and symptoms of and was giving me a hard time about, and I got this guy to CT and surgery before he died of internal injuries."

ICU nurses definitely assess and catch complications.