New Grad RN - ICU

Ruby Vee, BSN · Aug 9, 2012

Hi There,
I'm a recent New Grad RN hoping to get my start off in the ICU. I've read many posts both for and against this issue and I was hoping to get some advice either from New Grads who had gotten their start in the ICU or experienced ICU nurses! I have my first interview for an ICU unit this coming week and I'm both excited yet terrified. I know I am ready for the challenge and I did have my senior preceptorship as charge in a 12 bed ICU as well as many clinical experiences in the ICU.
What kind of advice do you have for me?
What should I expect? study?
Any help would be greatly appreciated!

I don't think starting off in the ICU is ideal, but in this economy you take whatever job you can get. I know many, many who have started off in the ICU and most of them are competent.

Your first year of nursing is going to be difficult no matter where you start. I think there's an advantage to starting somewhere less acute where you can learn to be a nurse before you learn all the extras that go into critical care nursing. But I know that's an unpopular opinion these days. Folks who start off in the ICU seem to burn out quicker and to last less long in nursing, but that's anecdotal. I have no studies to quote; just the observations of a few old ICU nurses.

Expect a 3 to 6 month orientation with 2 or three main preceptors. Expect to follow the schedules of your preceptors, to work weekends and nights and to skip vacations for at least the first six months. Expect that there will be days when you're abjectly miserable and absolutely convinced that you're the worst nurse in history. (If you don't have days like this, you have far too much confidence and are dangerous.) Expect a lot of feedback, much of it negative and most of it delivered in a way you find objectionable. (I mean to write an article about feedback one of these days when I'm not so freaking tired!) Preceptors, like most people, are quicker to correct mistakes than to dole out praise, and if you're someone who cannot function without praise, discuss that with your preceptor right up front and be sure to seek it out from time to time. In the ICU, mistakes can actually KILL someone, so mistakes may be jumped on quicker and more emphatically than in a less acute environment. I'm not advocating for this approach to precepting, and I try very hard to praise when it is due and deliver criticism as honestly, factually and softly as I can, but you did ask what to expect, not what to hope for.

Expect that you will be clumsy and inept with "skills" like NGs, IVs and Foleys. As you learn and gain experience, it will get better. Your preceptor will know this, but some cannot adequately express it. Expect to be quizzed about disease processes, medications, procedures and lab values. Arrive at work a half hour early to find out who your patient will be and look up the meds and lab values, etc.

Develop a thick skin. ICU nurses have strong personalities and they'll tell you when you've screwed up. It's not personal, and it might save someone's life someday. ASK for feedback. It defuses those who might be inclined to bite your head off and it impresses the rest of us.

Expect to study at home after work. What to study depends upon where you work. If there's an ECMO patient on your unit, go home and look up ECMO just in case you have the opportunity to care for that patient tomorrow. If you can, get your preceptor to give you some sort of an idea what kind of patients you'll be taking tomorrow.

Find someone safe to ventilate to -- make sure it is NOT someone you work with. You may have only been ventilating when you said Bed B's husband was probably a wife abuser or that Bed C is psychotic, but someone is bound to remember that you said that and hold it against you at some future date. And never, ever take part in a colleague-bashing session. Again, Matilda might be lazy and incompetent, and some of her alleged friends may be right in there bashing her, but they'll remember -- and may repeat -- what ever you contribute.

Expect to be challenged, overworked and worn into the ground. That happens everywhere in nursing, not just in the ICU, but we've lost some promising new grads because they thought they wouldn't have to work as hard elsewhere.

I'm sorry this has gotten so long. I've found ICU to be interesting, challenging, exciting and rewarding. If this is the path that you choose, I hope you find all of those things as well. It will not be easy, but few things that are worthwhile ever are. Good luck.

californiarnbsn · Aug 9, 2012

Thank you so much for you input! I will take that all into consideration. Don't worry about it being long it really did help me get a sense of what to expect.

THANK YOU! :]

OnlybyHisgraceRN, ASN, RN · Aug 10, 2012

Ruby answered it all! Well done, RUBY. I'm a new grad RN ( with 2.5 years of LPN exp.) and I started in ICU ! I love it! I went through and currently going through every thing ruby described. I get to work every day at least 1/2 hr early to go through my chart. I start with the H/P, LABS, and progress notes. I work in CVICU so I usually print my strips off too.

If I have time I write down my meds and get them from the pyxis, that way I can give meds and do my assessment all in one stop. Time management will probably be one of your biggest weakness, as it is for many new grads. Just prioritize and do one thing at a time. Take care of yourself first. Documenation, sometimes takes priority because it means you are not staying 1-2 hours behind charting.

Always ask for help when in doubt. No question is stupid except the one that is not asked.

Hang in there. There will be days when you'll whether do anything but go to work. I've been there and will have more days like this, but it'll get better. :hug:

RUBY and ESME are great resources! Both worked in ICU and have a wealth of advice and wisdom.

casias12 · Aug 10, 2012

Good information. I second the need for a thick skin. After almost 20 years in ICU, I can say that new nurses coming in are more prone to decry aggressive behavior as a punishment. As corporations change as a result of the fear of "bullying" lawsuits, I think new ICU nurses are going to ultimately run off the better, older nursesThat being said, those older ICU nurses are your resources.

They have paid their dues, and many don't have the personality to let a patient receive inferior treatment without speaking up.

Some survival skills that are good to develop.

1) Get to know everyone in the ICU. Especially their background. The most comfortable ICU's that I have worked in have strong teamwork attitude. It makes everyone's job easier. In most ICU's, their is an experienced resource for every body system. Some corporations have tried to develop "resource nurses", but knowing your co-workers is better.

2) Trade skills and know your weaknesses. I happen to be really good at pulling sheaths after 10 years in a cath lab. I am not as good at finding IV's in picked-over patients. I am not afraid to admit it. Very few nurses are good at everything.

3) Get to know your respiratory therapist. They are a huge resource.

4) Think outside the box. We had a very large patient who came in intubated and waited over 24 hours for an NG tube. We (another nurse and myself), borrowed the glidescope from respiratory (above), and used it to "intubate" his esophagus. Experienced nurses also have tricks for difficult foley insertions, sheath pulls, and even how to approach a practitioner to get an order (I will stop short of saying that experienced ICU nurses might do a few things and write orders later......know your doc's).

5) Work hard to develop a reputation as a "doer". If your are on days, listen to the night shift and try to take care of orders early. It is very difficult on the night shift to call physicians late, and it isn't fair to the physician.

Hope this helps.

Good Luck.

Scott

Ruby Vee, BSN · Aug 10, 2012

Good information. I second the need for a thick skin. After almost 20 years in ICU, I can say that new nurses coming in are more prone to decry aggressive behavior as a punishment. As corporations change as a result of the fear of "bullying" lawsuits, I think new ICU nurses are going to ultimately run off the better, older nursesThat being said, those older ICU nurses are your resources.
They have paid their dues, and many don't have the personality to let a patient receive inferior treatment without speaking up.
Some survival skills that are good to develop.
1) Get to know everyone in the ICU. Especially their background. The most comfortable ICU's that I have worked in have strong teamwork attitude. It makes everyone's job easier. In most ICU's, their is an experienced resource for every body system. Some corporations have tried to develop "resource nurses", but knowing your co-workers is better.
2) Trade skills and know your weaknesses. I happen to be really good at pulling sheaths after 10 years in a cath lab. I am not as good at finding IV's in picked-over patients. I am not afraid to admit it. Very few nurses are good at everything.
3) Get to know your respiratory therapist. They are a huge resource.
4) Think outside the box. We had a very large patient who came in intubated and waited over 24 hours for an NG tube. We (another nurse and myself), borrowed the glidescope from respiratory (above), and used it to "intubate" his esophagus. Experienced nurses also have tricks for difficult foley insertions, sheath pulls, and even how to approach a practitioner to get an order (I will stop short of saying that experienced ICU nurses might do a few things and write orders later......know your doc's).
5) Work hard to develop a reputation as a "doer". If your are on days, listen to the night shift and try to take care of orders early. It is very difficult on the night shift to call physicians late, and it isn't fair to the physician.
Hope this helps.
Good Luck.
Scott

Yes! I wish I'd been able to say it this clearly. Trade skills! Know your weaknesses and admit to having your strengths when someone else is looking for help!

californiarnbsn · Aug 11, 2012

Thank You for all the additional information. I definatly understand the importance of it all. I've had some expereinces in which nurses have yelled or pushed me aside but I don't mind I realize they are thinking of the patient and don't mean to put me down. I try to make sure that I ask lots of questions from everyone knowing that I have much to learn from every member of the team. As far as time management I have learned a lot during preceptorship, even though as charge, my preceptor made sure that I had came in early and had a plan of care step by step for at least two of the patients on the floor. He would occasionally test me during my shift by asking me questions in order to help me develop my critical thinking. I honestly feel that experience alone has made me feel more confident in starting off in the ICU even though I do realize the challenge I will be faced.

Annaiya, NP · Aug 12, 2012

I started in the ICU with several new grads and I felt like they had a lot easier time learning what to do than I did with 1 year of floor experience. They only had to learn what to do. I had to unlearn everything I had learned over the last year and relearn how it was done in the ICU. I felt like I "picked up" a lot of bad habits from the floor and it's much harder to change something you're used to doing than to learn something from scratch. I think after we all got off orientation, I did better figuring things out on my own, because of my prior experience, but the transition was a lot harder. So don't feel like you're at a disadvantage for being a new grad.

Talk to your educators and find out about what resources are good to have at home and refer to them when you need to look something up. Join AACN. They have a lot of resources. You will generally be too busy at work to look things up the way you should, so looking them up on your days off is just part of it. This includes everything, not just patho, but labs, procedures, medications. I don't mean looking all up every time, but just when you feel you need more information on something. The AACN Procedure Manual is excellent since there are so many procedures you either do or assist with in the ICU. The arterial line section was really helpful to me when I was new, since it's so important to understand how to troubleshoot all of the equipment.

Lisap91010 · Aug 13, 2012

As someone who went into a busy surgical ICU as a new graduate it is possible for you to thrive. I for one don't feel burned out and am going strong in the ICU 7 years later. But it wasn't easy.

Don't expect you'll know "everything". This seems like common sense but you will be amazed how much you may beat yourself up over not knowing every minute thing. I carried around a scrap of paper for months with a quote from my awesome educator "You don't know everything, & we don't expect you too. When you don't know something ask" That helped me a lot.

I heard from multiple people that I wouldn't feel comfortable until 2 years had passed. For me it was more like a year, but be prepared that you will have a lot of uncomfortable moments at work for a long time.

Identify your resources! Find those other nurses that have been the ICU gods since before you were a twinkle in your parents eye that love to teach and make them your mentors. Ask them questions, rationals, why, why, why, always ask why..... Always know why your don't something, and if not find out. And when your finally off orientation don't get into the habit of working next to other less experienced ICU RN's, seek out work buddies with the most experience and get help when you need it. Don't be a martyr. It may be more fun to hang out with the other RN's, but don't isolate yourself (I've seen this a lot with our new residents once off orientation, they are more comfortable working next to the other people they went through orientation with creating a void of experience when its needed).

Be ready to study like your still in school. I'd recommend a small pocket sized notebook to jot down questions as the happen. You won't have the time to research all the answers while your at work and if your anything like me after 13 hours of mind overload if I didn't write it down I didn't remember it. Then later you can ask your preceptor, ask your educator, pick a physicians brain, and do your reasearch at home. My first 6-8 months I'd say I was studying outside of work at least 20+ hours a week. Get some ICU books for yourself I like Pass CCRN, pocket ICU guide, and ICU made incredibly easy to start. The AACN procedure manual is also helpful but I've always just used the ones at my workplaces. Also if you become a member of AACN you get their journal, and another publication with a lot of research articles to keep up your practice and opportunities for free CEU's.

Oh and get as much extra education and certifications as they come, TNCC, ACLS, CVVHD, IABP, grand rounds, any opportunity to pound more info in your head. And as soon as you can take the CCRN, most places give you a nominal bump in pay, but more importantly it will give you an outline of everything you should know.

Good luck, its a fun ride. I love my job and look forward to working, and I'm learning something new every week.

casias12 · Aug 15, 2012

Teaching hospitals are great. There are so many opportunities, and so many levels of practitioners. It also seems that you have a little more autonomy as you develop within a teaching facility.

But study is the key. I use emedicine (medscape), epocrates, and.....yes....wikipedia almost daily. The key to wikipedia is to scroll to the bottom of an article on..say hyperinsulinemia, and search the references at the bottom for the actual research articles. I also use globalRPH for things I haven't seen in a while, like Nimbex, isoproteronol, etc. It usually gives a very concise mixture, calculations, iv compatibility, and drug monograph.

I personally burnt out at 18 years. At 7-10 years life was good, but ICU's are changing rapidly. This new quality initiative requires way too much time documenting nonsense, and places too much emphasis on the wrong things. At the last ICU I worked, we had an "open" ICU with essentially no rules. We would have the entire family (sig other, two toddlers, and grandma), living in the patients room next to their bed. Pull-out beds were provided, and families never had to leave. It made care of the patient very, very difficult. I was never against family involvement, but not having the ability to have a family "step out" for an hour or so at a time was very tiring.

So I am now in my last few months of NP school, and can honestly say that I am really loving the office.

Take care,

Scott

Bluebolt · Aug 15, 2012

I haven't read what others may have commented, but I'll weigh in on your post. I am also a new grad (last May) from a BSN program and I also did my preceptorship in the ICU. Because of my comfort in the ICU the nurse manager interviewed me for a position while I was still a student and then hired me a week after graduation. I chose to pursue ICU because I enjoy a difficult challenge and to fulfill the 1 year requirement for CRNA programs. Also it doesn't hurt that you get paid more money per hour as an ICU nurse. I'll admit that when orientation was over and I was "let go" out on my own it was very frightening. Suddenly that ease and comfort I felt with a precepting nurse beside me was gone. The safety net is no longer there and it's your licence, your nursing judgement, that keeps the patients alive.

If you can get over this terrifying hump and get through this initial shock phase, you will make it. I'm about 4 months in now and feel much more comfortable than even 1 month ago. You'll be surprised how fast your clinical judgement develops (because it must) and because you will be using it almost always. I view the ICU like the phrase "Sink or Swim" you will thrive or you will transfer depts.

As far as resources, use all those offered. I mostly use the online medical reference that the unit has. Anytime I have a specific question I ask a fellow nurse. Hope this helps!

californiarnbsn · Aug 16, 2012

Thank you everyone for all your advice!! I received my offer today for nights. Any suggestions to help me get through a night shift in the ICU?