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.  

[themurse]

@londonflo 

The original post you are referring to was the first two months (first semester) of a 15 month ABSN program. I ended finishing that program with 3.6 GPA with no issues. And that professor actually got fired the following semester for dating students. But you are correct, being that COVID hit the second semester we lost out on a lot of hands on clinical experience. And I’m definitely looking at lower acuity jobs to reflect that lack of hands on experience. 

I went up by 15 on prop for a pt that was desatting into the 70s. The preceptor I was with that was my second and last night with her when it happened. She was standing right next to me while it was happening. She watched me do it, and even said she would of done the exact same thing. But she told me, next time go up by 5 only. Hell she’s the one who charted we went up by 5 at a time.

She never made it out to be a big deal at the time. Which is why I was so surprised she went to the NM about it. Not only that, but I was only doing what I had seen done in the past. Before her, I was with a preceptor for 8 weeks, who would go up by 15 of prop all the time. Who would bolus prop. Who would take a 10cc syringe and bolus it into someone who was ordered to be off it.

 So I was only doing what I had learned up until that point in time. And in actuality, I had absolutely no idea we were only aloud to go up by 5 at a time cause I’d never seen it done like that before. I was only aware after it happened. So it’s not like I broke protocol on purpose. I was only doing what I had been trained to do in that situation. I had also had that pt before, my preceptor didn’t, and that pt was very very difficult to sedate properly.

Also, the night before, that same preceptor who reported me, told me I needed to take more initiative because I wasn’t titrating down on my Levo, for a pt who’s MAP was 85, BP 100/60. The order said titrate to a MAP >65. So I never touched the Levo because it was already above the parameters of the order. So in my eyes, I’m wrong if I follow an order and wrong if I do. I get the whole “just because I’ve seen others do it doesn’t make it right.” But they can’t expect something different, if I’m only doing what I was taught during my first 8 weeks. Monkey see monkey do. 

Hell, I saw the preceptor who reported me miss a straight cath on a pt, pull it out of her lady parts and try again with the same cath, before grabbing a new kit. So it just baffles me how I’m getting reported for something, when all I’m seeing is unsafe care and broken protocols happening anyway. 

In my option that floor was just a  *** show. Everyday I would come in and in huddle it would be another med error by a new grad. Fet running greater than 250mcg. Heparin running as insulin and insulin running as heparin. Or heparin running dangerously high. So this situation just woke me up to the fact that the training isn’t adequate on this floor at all. There are more new grads on that floor than experienced nurses. They hired so many new grads they can’t keep up. People were writing SERS reports on each other for everything. So I’m glad I got out. 

[londonflo]

12 hours ago, themurse said:

 So I’m glad I got out. 

I am glad you got out too.

I cited your comments on your education to highlight when you are approached with a new situation you do not question yourself, rather you are more critical of those who were instructing you in unfamiliar situations to you. 

You do reply with anger or disillusionment for the following examples  cited. (not all inclusive)

12 hours ago, themurse said:

So I was only doing what I had learned up until that point in time. And in actuality, I had absolutely no idea we were only aloud to go up by 5 at a time cause I’d never seen it done like that before.

12 hours ago, themurse said:

. Not only that, but I was only doing what I had seen done in the past.

12 hours ago, themurse said:

Hell, I saw the preceptor who reported me miss a straight cath on a pt, pull it out of her lady parts and try again with the same cath, before grabbing a new kit. 

12 hours ago, themurse said:

In my option that floor was just a  *** show. Everyday I would come in and in huddle it would be another med error by a new grad.

It sounds like it was a *** show but it was a *** show you wanted to join. Think very hard for your next job  with what you aspire to before you agree to the position. What is allowed in your RN position and what is not allowed.

12 hours ago, themurse said:

And that professor actually got fired the following semester for dating students.

Please stop blaming others... I haven't read where you questioned/discussed with  your preceptor or a fellow MICU nurse on what your were going to do with regards to the propofal. Continue your job search with being totally honest with yourself on what you are already capable of and what you will strive for in the future. 

I respect your decision entirely to approach another job that will help you with your critical clinical knowledge application.

Best wishes for the future...

[themurse]

@londonflo

You can say I’m being critical of others rather than taking responsibility for my actions. That’s fine. I feel horrible for what I did. Not a day goes by that I don’t think about it. The example you bring up about my first ever post and having a hard time during my first semester of nursing school, I feel is very common for a lot of new nursing students. I see their posts all the time. But I picked it up and ended up being very successful in it. So obviously, I didn’t blame everyone around me, I blamed myself and literally got my own *** together and stuck it out. 

In terms of the situation on my floor, I feel betrayed by my preceptor more than anything. I think I have a right to be angry about the situation. I believe there were people on this post who said they go up by 15 on prop all the time. So what I did is NOT unheard of. But what I did should of been made into a learning opportunity, rather than punishment. 

Did I make a mistake? Yep sure did. Should I have went up by 5 instead? Yep, I’ll own it. 

But what I can’t understand, is that if what I did was so wrong, why my preceptor said she would have done the same thing in that situation. If what I did was so wrong, why didn’t she stop the situation immediately? She was standing right next to me, she could of immediately turned it down before it even hit the patient. But nope, she stands there and lets it go. So why is it all on me? 

If she was so afraid of me practicing unsafe nursing care than why leave me alone for the last eight hours of that shift, after that  happened? In fact, I don’t believe I saw her the rest of the night. 

Why punish the orient in this situation? What’s the angle? What are they going to take away from that? That they can’t trust their preceptors in the future? That their preceptors are only their to report mistakes, not teach you how to become an effective nurse? To not report med errors and cover them up? That “just culture” is a lie? 

But it’s fine. I’ll take the blame and move on from it. And I will be a lot more careful in the future that’s for sure. 

[zoidberg, BSN, RN]

Don't dwell on it. If you have been with covid ARDS patients for a bit you know they need a crap ton of sedation. Just take note of what the orders say on paper so you can chart pretty (titrate by 5 mcg blah blah blah) but that isn't how this works in real life. I think you made the right choice with the prop honestly.

It is a known issue that drip titration parameters are a hinderance to nursing, it doesn't fit into reality. It sounds like that unit was not doing you right as a new nurse. They should be able to provide non-punitive feedback in real time. I hope you find a good place to call home. 

[Tweety, BSN, RN]

At first I was going to tell you to try to tough it out.  Here in Florida we were in the same situation with covid overwhelming us, maxing out our units, and now we just have a couple of patients.   Delta ripped through us and went away almost as fast as it came.  

Too bad about the cliques but no need to be part of that.  Every new nurse walks into an existing culture of people that have worked together, sometimes for a long time.  If we are just ourselves and do our best it works out.

But reading your next post I just am not sure about that.  Doesn't sound like a supportive environment at all.   Good luck in whatever happens.  

[JBMmom, MSN, NP]

20 hours ago, themurse said:

I wasn’t titrating down on my Levo, for a pt who’s MAP was 85, BP 100/60. The order said titrate to a MAP >65. So I never touched the Levo because it was already above the parameters of the order. So in my eyes, I’m wrong if I follow an order and wrong if I do.

This is an example of where you're in a tough spot because you're in the "know just enough to be dangerous" phase. This phase has nothing to do with you as a person, you're learning as you go and that can have negative effects- especially on patients. For levophed- the order is to titrate to MAP >65, that doesn't mean a MAP of 85 is better. The goal of pressors should ALWAYS be to use the minimal necessary dose to maintain cerebral and kidney perfusion, generally a MAP of 65. Leaving your patient with a MAP of 85 isn't helping their perfusion, and it leaves the patient at risk for potential side effects. We have had patients lose digits because of necrosis due to pressor use. Levophed can cause headache, dizziness, brady or tachycardia, generalized weakness or even allergic reaction. So, your inaction by not titrating wasn't wrong according to the order parameters, it was wrong because of the goal of medicating the patient. 

You pointed out a few times that other nurses had fentanyl above 250mcg/hr. We have patients with orders for fentanyl as high as 400, are you sure that those patients didn't have an order for a high dose fentanyl infusion? You referred to heparin running "dangerously high", what do you mean by that? The PTT may be elevated early in the titration but it should be checked every six hours and adjusted as necessary. Unfortunately, people make mistakes. We had someone hang insulin on the fluids channel and the fluids on the insulin channel. Fortunately the patient survived a bolus of 100 units of insulin over less than an hour. People make mistakes, that's not ALWAYS incompetence, but it does bear looking at the overall unit practices. 

You have taken responsibility for your actions with the propofol, when I read your initial post referring to that action, I wasn't as much concerned about your action as the fact that you didn't know it was supposed to be titrated by 5. That's in the MAR. Yes, a preceptor should point those things out, but you are also responsible for reading all of your MAR instructions on any medication that you hang. It's just not possible for a preceptor to tell you all aspects of the job- you are responsible for some of that learning as well.

As I said earlier, this is an exceedingly difficult time to join nursing, especially in COVID ICUs. I'm sorry that things didn't work out better and I wish you all the best with finding something that's a better fit for you. Best of luck!

 

[Cmbnurse, BSN, RN]

Fellow new grad who also spent most of my orientation in a Covid ICU. I had a similar experience. The deaths really got to me, we had few make it out with trach and peg but they ended up right back on the unit due to complications weeks later. You have been given good advice on this thread. Try to make the best of it and stick it out. Hopefully the wave passes soon. Ours did, took about a month and a half.

As for the propofol comment from your preceptor, that's ridiculous. You do what you have to do to save a patient. If they are desating cause they are fighting the vent your gonna go up as needed. I have done that many times, never had a preceptor tell me anything negative. Just the other day my patients BP dropped in to the 60's I titrated as needed to keep them from crashing. When the situation is not emergent then you follow titration protocol. Sounds to me like your doing just fine.

[Critcare333]

I was in a similar situation. Paired with a preceptor in the ICU, who was actually an NP for 25 years but still practicing as an RN, who never precepted before (red flag). After 3 shifts of hell, clearly she did not want to precept in the first place, I hesitantly but bravely asked the nurse manager for another preceptor. Turns out she too had asked the manager to reassign me too. This was a mixed ICU often maxed out with COVID patients, proned, sedated, paralyzed, you name it, sometimes with a 1:3 or 4 ratio. The only reason I survived that experience is because I was an experienced trauma ER RN that transferred  ? I stuck it out and even got my CCRN after only 3 months in the ICU! 

Yet, I have left a toxic nursing environment before. Luckily it was during flu season so I gave flu vaccines while searching for another job. COVID vaccine clinics are everywhere with decent pay, consider it if benefits are not pressing for you.

[kdkout, BSN, RN]

I’m sorry OP. Taking an ICU job in the midst of a pandemic experiencing a surge, surrounded by exhausted coworkers who have nothing left to give? It’s worst case scenario

The thing is, the cliques are common in ICUs especially now- right or wrong, because the nurses are trauma bonding. It’s like they are all soldiers in a war and only the other soldiers “get it. “
I think after Sunday, you should admit to your supervisor that you are in over your head, because you are. I am an excellent nurse and was an adult ICU nurse decades ago, and I know there is NO WAY I could’ve done a good job on a covid unit as a new grad, with the current expectations. They are right to be concerned. Hiring new grads into units like this is a terrible idea, imo, but they are desperate.  

Im so sorry about this.  I do think you should leave. I hope you can find another job, and soon. I’d do ICU nursing later. If you try ICU now, you will be stuck doing mostly/all covid, whether you like it or not, because those are the times we are in. 

[londonflo]

On 12/15/2021 at 9:02 AM, kdkout said:

I think after Sunday, you should admit to your supervisor that you are in over your head, because you are.

 

[themurse]

@londonflo

I don’t know why you continue to quote smart remarks? And take bits and pieces of past conversations and repost them, without any context. Better yet, quote someone’s first post from two years ago from their first two months into an accelerated nursing program, and then try to use it against them. Glady chime in with any critical care experience you have on a COVID unit, working with COVID patients who are intubated and trying to keep them sedated. But let’s continue to ridicule the new grads trying to learn during a global pandemic. I already said I left that floor, so why do you continue? I bet you’re super supportive to all the new grads on your floor, a real peach.