New grad PACU

Editorial Team / Admin · Mar 1, 2016

Have you discussed with your manager what the expectations are? Nine weeks for a new grad is awfully short for a good orientation.

Trauma Columnist · Mar 2, 2016

Move to PACU nursing

twozer0, NP · Mar 2, 2016

No offense here but in my opinion PACU isnt a good place for a new grad. I'm surprised your facility hires new grads in the PACU. It comes down to exactly what you are experiencing in that 1. you only got 9 weeks and 2. its one of the more critical areas in the hospital. 9 weeks is hard to learn how to manage ventilated patients, use pressors, etc. Our PACU is filled with ex ER and ICU nurses and i'm the one with the least amount of experience with 9 years (4 in the ER before coming here).

I started ER, which I think is good for new grads because you arent expected to know everything, you're just expected to run your ass off. I got 6 months of orientation and even then I still didnt feel comfortable. I had enough to get by and really up to the two year mark I still felt inadequate. The two year mark I had experienced pretty much everything but extremely rare things that you're going to see in a community ER. Since you are already vested in the PACU I would stick it out here but I would also be picking up books and picking the brains of everyone you come in contact with. Get comfortable with your airways, know what all the vent settings are, learn to use a bipap, learn your drugs (how they work, why they work, where they work, halflives, reversals, etc), understand bodily systems at a minimum function related to the expectations of your surgical patient, know all of your ECG rhythms front to back blindfolded, be ACLS/PALS certified, learn proper fluid management, know chronic disease and its influence on what you'll do (aortic stenosis is a good example here), undestanding capnography and hypercapnia, arterial line useage and management, understanding lab values and what to expect if they are off, understanding ABG's, inserting foleys, inserting IV's, inserting NG/OG tubes, and suction, just to name a few things!

At your juncture the only thing to do is 1. move forward 2. move to another dept. If you like the job, do all in your power to learn the things I suggested and then some. You'll get there but you did yourself into disservice by going to PACU first. Good Luck!

troy14 · Mar 8, 2016

Not sure how much my reply will help but here goes nothing, I am a relatively new grad with 1.5 yrs of experience in a Level 2 trauma hospital.. except my floor is strictly a surgical / step down unit. That being said, I receive almost all of my patients directly from our SICU or PACU. Before my first job, I wanted to work ICU or PACU very bad, and was kind of "bummed" I got stuck on a floor. Looking back, I can't imagine being a new grad in the PACU or ICU (I know many new grads do, but.....), especially the PACU. 9 weeks is an awful short orientation, especially in a PACU. My hospital will not hire anyone in the PACU without ICU experience. We had a new grad who was an aid/extern in our PACU for ~2 years, very very bright and knows what she is doing...she still did not get hired in the PACU and is on my floor now.

Kudos to you for doing such a tough job as a new nurse, but, I also hope your patients are getting the proper safe care they deserve.

theRNJedi · Mar 27, 2016

As a Perianesthesia Professional Practice Leader, Nurse Manager, and dually board certified Perianesthesia nurse...I will suggest that you have not been properly set up for success. There's no regulation for minimum hiring criteria for the PACU, it's up to each org and unit leadership...what's regulated is that you have been deemed 'competent' through some process to work in that unit....however across the nation most PACU units require nursing experience in perienathesia, Critical Care, and many use ED as a qualifier. But this varies widely from org to org.

Traditionally, PACU does not hire new grad nurses because of the level of acumen and clinical prowess necessary to provide safe comprehensive complex care to high acuity surgical patients. In order for a new grad to be successful there should be a well developed 'internship' which would last months...not weeks. It sounds as though you have been put through a standard orientation for a new PACU nurse, and really you should have been allowed a much longer time to develop into the specialty from a novice nursing role. To put it into perspective, experienced PACU nurses that I hire at my level 1 trauma center inpatient units (adults and children)...will be oriented for at least 6-9 weeks on orientation before being 'on their own'...and that's with being an experienced nurse in the specialty. A new grad will need a different curriculum and program to onboard in PACU than a standard new orientation.

It's impressive that you have self-reflected enough to discern where you are. It's unfortunate if your PACU team or leadership does not or has not identified the disparity of learning curves for you as a new grad versus an experienced nurse in a 9 week orientation. You have obviously identified you need more time to develop. I would encourage you to speak up and convey this to your manager. There's nothing wrong, nor does it imply you're incompetent or incapable, with requesting to have more orientation and/or time with an educator/preceptor. Continue using your team support and never hesitate to ask for help. This is being a self-directed Leader for your nursing practice.

For this unit to hire you as a new grad and not have a new grad internship is unique, and does have some risk for you. (i.e., setting you up for failing, having unrealistic pressures of performance, ect...)...but if you have the motivation and determination then you can navigate through it and before you know it you will find a stride in the specialty. You just have a unique opportunity to be more self-directed with your development than being in an internship where it's spoon-fed to you. A typical new nurse in any specialty or unit already experiences a 'disenchantment' phase when they start, and for you it's a bit of a double whammy...because you're a new nurse and in a nursing specialty...and without a formal internship...so the feelings of disenchantment and inadequacy, or feeling a lack of being able to perform independently when you feel pressure to do so, all contribute to self-doubt and endless analysis. You will be successful, you will just need to pace yourself; every nurse has a different time and means for attaining a 'proficient' or 'expert' level of skill. As long as you feel you have the support and resources around you, then it will happen. If there's one great thing about PACU, is that it's usually really good with being a team.

On the other hand, if you find that the acuity and complexities of the unit are too much or that it's not a good fit...then I would convey that to your manager as well and discuss a plan; and maybe that plan includes a different phase of care, a transfer to another unit, a different shift, or maybe more preceptor time. You are the professional RN now, and you 'own' your practice. So I suggest taking what you have identified as your needs and engage with your resources.

-theRNjedi

dddr60120 · Mar 27, 2016

Ex-PACU RN here (3 years). Great job. I was similar in that I was a relatively new Grad in PACU. But I switched to PACU after working 10 months as an ICU nurse (4 of those months doing intensive orientation). Since I switched hospitals, my new unit literally bent some rules hiring me

azhiker96, BSN, RN · Mar 30, 2016

There has already been a lot of good advice given. I can only add one additional resource you might want to explore.

Consider joining ASPAN. That is the professional organization for this area of nursing. They host seminars which contain a wealth of information related to perianesthesia nursing.

I tell people that PACU nursing is lots of boring repetition occasionally broken up by moments of sheer terror. I've found that as I learn more the frightening times get fewer and farther between. A laryngospasm is much less unnerving once you've bagged a few dozen patients through them. Apnea is not as daunting after you've treated it a few times with chin lift, jaw thrust, OPA, nasal trumpet, narcan, or flumazenil as required by the particular incident. Good luck and welcome to my favorite area of nursing.

djmatte, ADN, MSN, RN, NP · Mar 30, 2016

Only you know or understand what you are capable of and how quickly/willing you learn what's needed. I started my career in PACU in Detroit. I have a firm belief that different positions are better for different people and no level of experience in any one part of a hospital prepares anyone for another. Anyone who enters PACU has a learning curve and where some may have more knowledge in critical disease states, they may struggle with PACU specific issues. As a new RN, you are at an uphill climb because you need to get your bearings as an RN while also working in a critical area. New RNs are put in ICU all the time, yet somehow people feel PACU is a sacred cow of which this should never happen. But the reality is it does all the time at lots of hospitals. A standard PACU orientation is not enough and you will need more thorough critical care learning on top. One thing my hospital did was place all new RNs who entered ICU or PACU into a program called ECCO (Essentials of Critical Care Online). Mostly an intensive CBT/lab program that lasted a month to get into that mindset. I also suggest you treat your job like you did school...finding as much downtime as you can to really learn and understand your trade. As someone else, ASPAN is a phenomenal organization to get involved in to stay up to date on current trends in practice. Take your time and be vocal about what you need and any manager worth their salt will recognize it and give you time.