New Grad Stuck In Orientation In A Covid MICU. Help!

[themurse]

I just started my first nursing job as a new grad in the MICU two months ago and I want to quit so bad. I need advice. We are at max capacity Covid right now and have been since the beginning of November.

While I knew it would be challenging starting in the MICU as a new grad, I feel like I did not sign on to work on a Covid only floor. Our hospital system has a lot of MICUs throughout the general area, but we are the one that gets all the Covid. Nobody told me this before I started at all. I had done a rotation in a different  MICU in late January 2021, during the second wave and that MICU had maybe 1 or 2 Covid. So I thought it would be similar to that. Not full capacity that’s for sure.  

Long story short, I feel being on this floor is severely hindering my learning, growth and development. And it’s absolutely exhausting, not being able to walk in and out of pts rooms freely.

Not to mention, I have yet to see a Covid patient who is intubated, actually walk out of our unit alive. And 99 percentage are vented, paralyzed, RASS of -5 and proned —  waiting to get on CRT and die. 

All of these pts follow the same course of treatment, all are on the same drugs. It’s just the same thing everyday. I feel like I’m losing skills. And the death is affecting my mental health. And I know it’s only going to get worse when I’m out of orientation because then I’m going to be responsible for withdrawing care on these patients or coding them knowing there’s nothing I can do for them. 

I know working in an ICU, I would see death at some point, but when none of the care you provide has any impact on patient outcomes you feel like everything you do is hopeless. I want to feel empowered as a nurse. Like the care I’m providing is actually doing something. I want to see a patient get better. I want to see a patient actually walk out alive. I just don’t think that’s ever going to happen in this MICU. 

The nurses on my floor are super tight knit, lots of power cliques. The ones that are left from 2020 are really close. There’s a lot of new grads on the floor and they are very cold to us. Preceptors don’t want to teach. They are exhausted. I don’t feel supported at all. It’s a lot of blaming new grads for things as well. There’s been a lot of serious errors by new grads, and that makes me worried that obviously the training isn’t what it needs to be. They are just rushing us through orientation/residency because they need all the help they can get. 

When I interviewed in April, they had maybe 1 Covid patient. And when I shadowed in early May there were none. I asked how many Covid pts they had during the fall 2020 and Winter of 2021 and the manger said maybe half. Obviously that was a lie. She practically handed me the job I didn’t even have to sell myself at all either. Now I’m thinking that was a huge red flag. 

Should I leave this job? It’s at one the best hospital systems in the US. It seemed like a great opportunity with plenty of training and a two year residency. I just don’t know what to do. But I feel sick every time I go into work. I have dreams about work when I sleep.  And I’m petrified of getting Covid and giving it to a loved one who is severely immunocompromised.  

[Guest219794]

This is a terrible time to learn to be a nurse.  Many face the same challenges.  Your bosses are well aware that you are getting a bad orientation, and that you will need further training if this ever ends.

That does not mean you have no options.

1- talk to the actual decision makers.  Let them know your concerns.  Diplomatically let them know that you are considering other options.

2- Look for a better job.  You may not find one.  You also might get conned and get a worse one.

3- pick your best option, cross your fingers.

Good luck.

[Emergent, RN]

You have presented a very coherent and intelligent analysis of your situation. Honestly,  it sounds horrible. 

I'm sure you are learning lots, but is this really what you want to do? The above advice is very good. 

[JBMmom, MSN, NP]

I would encourage you to stick with it if at all possible. The waves of COVID we are currently experiencing are likely to pass more quickly than the first round, depending on where you are, and while dealing with the type of patients you are seeing seems like the same old you are definitely getting valuable skills at the same time. Focus on learning about the ventilator settings, and you're probably good at proning patients which is a really good skill to have. Many of our COVID patients are ending up on pressors, you will gain experience with those as well. I completely understand the difficulty in constantly donning and doffing PPE, my unit is almost entirely COVID. There are challenges in being stuck in a room and unable to respond if your other patient experiences an acute event. 

It is VERY unfortunate that your coworkers aren't providing a supportive environment for the new grads. As you astutely pointed out, they are exhausted as well. When the current wave passes, they are likely going to feel better and hopefully be in a better place mentally.

However, if you feel that it's just not something that you can deal with any longer, you very articulately laid out your situation and objections. Perhaps there would be an opportunity on another unit, although if you're trying to stay within the same health system they may hold you in your current position if that unit is more short staffed than others. 

Good luck! You are beginning your practice in one of the most challenging times for nurses. Take care of yourself, things will improve. 

[dianah, ASN]

You have received some very wise advice here.  May I add: please arrange for some supportive counseling.  Either private or thorough your EAP at work (which should be free).  At the very least, your workplace should recognize the particular stressors of working daily with severely ill Covid patients, and should provide some means of mitigating stress to staff.  Take care of yourself (and I mean that sincerely, not just saying it!).

[themurse]

Thank you for the replies. So I tried to give it one more shot on Sunday night and my shift went horribly. However, I was going to stick it out, but at the end of the shift management called me in and basically told me they are worried I don’t practice safe nursing care. And that if I don’t improve I would be terminated. 

I guess the preceptor I worked with on my last few shifts reported me for going from 15 to 30 on a patient’s prop who was bucking the vent, biting the ET tube and desatting in the low 80s.  I had this pt a few nights before, and she was hard to sedate properly. I decided to take initiative of the emergent situation. Because they told me I needed to take more initiative, in my last meeting with my educator. 

 My preceptor was standing in the room and let me do this. Then preceded to ask me what I should of done, and what I did wrong, and at the time I had no idea. She said I should of titrated by 5 and waited 5 minutes then went up another 5. However, she then preceded to tell me she would of done exactly the same thing I did in that situation because titrating to protocol wouldn’t have worked in time.

 If it was a serious thing I did, I had no idea. Absolutely, no clue at the time. But she could of also went over to the pump and immediately corrected my mistake and turned it down to 20 and taught me what to do in that situation.

And I feel like this is why I made this mistake because nobody is teaching me what I should be doing in these emergent situations. Like she had plenty of time to stop my actions and didn’t. And I feel like if it was that dangerous she would of stopped it. If she wanted to teach, she should of said “OK our patient is bucking the vent we need to go up on our sedation, we are going to go up by 5, wait 5mins, and go up by 5 again. Bam, instant learning opportunity for me.  

But instead, I’m getting reported for this. I’m being threatened with termination. I’m being told I may not be able to transfer to another unit because they have to tell the manager of that unit I don’t practice safe care and they wouldn’t want me. So basically I feel like I just lost my entire career in nursing in one moment. One moment that could of been prevented had I been properly trained. 

I’ve witnessed a different preceptor I’ve had  on this floor for 6 weeks, take a 10cc syringe, stick it in a prop bottle hanging on the IV pole still, and bolus it into a pts IV who was bucking the vent (we had turned the prop off early per verbal order). I knew immediately this was wrong. And I would never do that. But just to put into perspective what I am seeing here. I’ve also seen him go up and down on prop by 15 before. I’ve also seen preceptors bolus prop via the IV pump during these situations.  Which they aren’t supposed to do either. Yet, I’m getting reported for titrating up by 15 on prop during an emergency. There are new grads on this floor (out of orientation) running heparin and insulin over ordered rates. Running fet over the 250mcg limit. This is obviously a floor issue. But yet, they are still there. And those are serious med errors. 

I think this preceptor that reported me wants me out. Her and a few of her friends  on nights did this together. Like I said, they are super tight knit. They don’t like me and want me out. I don’t know what to do. Can I get another new grad job at a different hospital in med surg at this point? Do I not include this position on my resume? I can’t use my manager as a reference. I pride myself in practicing safe care. I would never hurt my patients on purpose. What do I do? I think I’m done with ICU all together. It’s too much and way to serious for me. And just gives me constant anxiety. 

[Emergent, RN]

Maybe you can transfer to a less intense unit? What you did doesn't sound particularly unsafe. I've turned up Propofol like that before. 

Some ICUs have very toxic social dynamics and intense personalities. Maybe explain to your current manager that you are reconsidering whether intensive care is the right specialty for you. 

[~Shrek~]

On 12/7/2021 at 12:38 AM, themurse said:

Thank you for the replies. So I tried to give it one more shot on Sunday night and my shift went horribly. However, I was going to stick it out, but at the end of the shift management called me in and basically told me they are worried I don’t practice safe nursing care. And that if I don’t improve I would be terminated. 

I guess the preceptor I worked with on my last few shifts reported me for going from 15 to 30 on a patient’s prop who was bucking the vent, biting the ET tube and desatting in the low 80s.  I had this pt a few nights before, and she was hard to sedate properly. I decided to take initiative of the emergent situation. Because they told me I needed to take more initiative, in my last meeting with my educator. 

 My preceptor was standing in the room and let me do this. Then preceded to ask me what I should of done, and what I did wrong, and at the time I had no idea. She said I should of titrated by 5 and waited 5 minutes then went up another 5. However, she then preceded to tell me she would of done exactly the same thing I did in that situation because titrating to protocol wouldn’t have worked in time.

 If it was a serious thing I did, I had no idea. Absolutely, no clue at the time. But she could of also went over to the pump and immediately corrected my mistake and turned it down to 20 and taught me what to do in that situation.

And I feel like this is why I made this mistake because nobody is teaching me what I should be doing in these emergent situations. Like she had plenty of time to stop my actions and didn’t. And I feel like if it was that dangerous she would of stopped it. If she wanted to teach, she should of said “OK our patient is bucking the vent we need to go up on our sedation, we are going to go up by 5, wait 5mins, and go up by 5 again. Bam, instant learning opportunity for me.  

But instead, I’m getting reported for this. I’m being threatened with termination. I’m being told I may not be able to transfer to another unit because they have to tell the manager of that unit I don’t practice safe care and they wouldn’t want me. So basically I feel like I just lost my entire career in nursing in one moment. One moment that could of been prevented had I been properly trained. 

I’ve witnessed a different preceptor I’ve had  on this floor for 6 weeks, take a 10cc syringe, stick it in a prop bottle hanging on the IV pole still, and bolus it into a pts IV who was bucking the vent (we had turned the prop off early per verbal order). I knew immediately this was wrong. And I would never do that. But just to put into perspective what I am seeing here. I’ve also seen him go up and down on prop by 15 before. I’ve also seen preceptors bolus prop via the IV pump during these situations.  Which they aren’t supposed to do either. Yet, I’m getting reported for titrating up by 15 on prop during an emergency. There are new grads on this floor (out of orientation) running heparin and insulin over ordered rates. Running fet over the 250mcg limit. This is obviously a floor issue. But yet, they are still there. And those are serious med errors. 

I think this preceptor that reported me wants me out. Her and a few of her friends  on nights did this together. Like I said, they are super tight knit. They don’t like me and want me out. I don’t know what to do. Can I get another new grad job at a different hospital in med surg at this point? Do I not include this position on my resume? I can’t use my manager as a reference. I pride myself in practicing safe care. I would never hurt my patients on purpose. What do I do? I think I’m done with ICU all together. It’s too much and way to serious for me. And just gives me constant anxiety. 

Friend, I went through something similar. It was a traumatic experience and I almost quit nursing. In fact, if I didn’t get the job that I have now, I would quit nursing all together. And I have decided that if I can’t find a job within the specialties that I am now comfortable with, I will go to beauty school or something and quit nursing all together. I worked 5 years in a nice clinic where I was very happy and treated well. I got a job in an ICU without any acute care experience. They knew about my lack of experience and promised me extensive training, but I went through something kind of like what you are going through that and I quit the moment I had another job offer. 

This is what I did...

1. Start applying to other jobs ASAP. It doesn’t matter if you don’t have much experience. There are jobs that don’t require much acute care experience. Apply to anything that seems like it won’t be a disaster to do. 
2. If you can afford to, look into backup careers. Can you get a coding certificate? A degree in business? A job outside nursing somewhere you are better treated, even if it’s less prestigious or lower pay? I almost signed up for an MBA program LOL. 
3. Prepare to be fired or quit. Have an emergency fund ready. Consider things like moving back in with your parents, taking on a low paying job, etc. 
4. Prepare some good answers as to why you left or are leaving your current job for interviews 

Your career is NOT over. I think this happens a lot in nursing. But you will have to kind of hustle a little bit to find your next job end to make sure the new job isn’t terrible.   

[JBMmom, MSN, NP]

This is NOT the end of your career. As you mentioned you did something you've seen done in many situations, unfortunately, it's never the "right" thing to do even if it's the right thing to do. All of us in ICU have titrated out of protocol for patient safety/comfort, maybe the concern was that you didn't know the protocol? All titration parameters are right on the MAR and/or in the order details, so it's important to know the legal parameters in which you are working. I think it's out of scope of practice for RNs anywhere to push propofol, at least I know it is in my state, but we can do it if a CRNA/anesthesiologist is in the room for an intubation. Once they're intubated much of the risk is mitigated, however, profound hypotension can result for some patients. Maybe your preceptor wanted you to identify other possible avenues, like a PRN medication? Any chance at verbal de-escalation with this patient?

Fortunately, orientation is not an awful time to be let go because I think every hiring manager has heard "it wasn't a good fit", and that covers most things. You would still be eligible for a new grad position with less than a year experience, and right now is a good time to try and find a job. Even if it's not a new grad specific position.

Sorry that things really didn't work out well for you in your first job. Don't take it personally and don't throw away the profession as a whole. You can still find a great position in nursing. Take care. 

[mzilos, BSN, RN]

Your experience describes mine in a nutshell. I'm sorry you're having to go through this. I started on a tele floor-turned-COVID floor during the second wave of COVID last year and I felt like while I was learning a lot about COVID, I wasn't learning much about cardiac. Stuff wasn't clicking for me as quickly as I had hoped, despite my trying efforts and all the hard work I had put in. Instead I was constantly gaslighted by my preceptor and educator, at one point, they even questioned if "I really wanted to be there". It was insulting and disrespectful and I came to realize it was not a good fit, so I left before my orientation was over. 

Don't be so hard on yourself, maybe the pace of ICU is not for your right now, but that doesn't mean you can't gain experience elsewhere and try again in the future. You'd be surprised how much you can learn in different settings. Stay positive! 

[londonflo]

OP, I read another comment you had about your nursing education lacking in all kinds of things. Perhaps your program did not prepare you for an entry level job to MICU? Or perhaps you have a hard time with beginning in new programs/roles? Your frustration rings 'loud and true' in both your criticism of your nursing education experiences and the MICU job. 

I would recommend looking for a true entry job that reflects your actual learning/practice from your nursing program that you comfortably achieved. You can't expect every co-worker, job to teach you when you do not have insight into your learning style/needs. 

I know I am sounding harsh but you may need a mentor that meets your needs. And you need to find a job that has strict borders for what is nursing and what it is that you can do

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I guess the preceptor I worked with on my last few shifts reported me for going from 15 to 30 on a patient’s prop who was bucking the vent, biting the ET tube and desatting in the low 80s.

Frankly you overstepped your knowledge and experience for these actions. Were you working alone? no one to consult? 

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 start applying to other jobs ASAP. It doesn’t matter if you don’t have much experience. There are jobs that don’t require much acute care experience. Apply to anything that seems like it won’t be a disaster to do. 

[RyanCarolinaBoy, ADN, BSN, MSN]

OP, sadly the situation you describe is all too common currently with the (never ending) Covid pandemic. 

I have been an ICU nurse many years and have seen and synthesized much knowledge over the years. This knowledge base came from a huge variety of settings and ICU teams. To be a new graduate in Covid pandemic is very narrow focused. I am seeing many new nurses who know nothing but how to run a vent and sedate/paralyze a patient, yet know very little of the fine assessment skills required for ongoing maintenance (not to mention good basic skin and oral cares). 

My advice to you would be to find another position. You have only been in this unit two months. You do not have the knowledge to define “emergency” yet under your belt to double a prop gtt rate. Saying “I’ve seen others do this” will do nothing when the facility gets petty and turns you into the BON. and yes that CAN happen. 

I am sorry this has been your experience. I have seen the mean girls club before thru the years. They leave me alone. I know my s*** and they know it, thus I have little issues. But he Covid pandemic is bringing out so much burnout in nurses. It’s a scary and sad time in ICU settings.