New Grads in the ICU

[Mr. Murse]

I'm just curious about the general thoughts on new grads in the ICU.

The units I work in have been seeing a huge influx over the last 2-3 years, mostly out of necessity. For the most part, they have been doing well, and we all know there are nurses of 30 years out there who can be more scary than a new grad. We are a medium acuity ICU and it's probably a good place for new grads interested in critical care to get into.

On the downside, there has definitely seemed to be an increase in rookie mistakes, some of which have been potentially deadly to patients (pneumos from badly dropped dobhoffs, extubation without turning off sedation, missing critical changes in condition, etc).

Part of me feels like we've dumbed down the nursing process to the point that even in critical care any average nurse can do it. ICU used to be a respected nursing position and they were considered the "best of the best" (I've even heard patients say that a time or two). We were called on to start IVs and answer tough questions and handle difficult situations, but now we have a bunch of one year old nurses who have barely put in a foley running around the units.

Again, most are doing well, and I don't intend this to be a condescending post, but I find myself skeptical of the decision I've seen in at least 2 or 3 hospitals to allow a lot of new grads into staffing.

We need the staffing, yes, but when a rookie mistake is putting patient's lives at risk, is it worth it?

[HalfBoiled, BSN, RN]

Be the role model for those new grads.

[37changes, ASN, RN]

OP, like you said, it's a necessity. There are reasons for this. Unless you can fix the root causes of this necessity, then really ~ the focus needs to be on supporting those new grads in every way you can think of.

I spoke with a 10-year ICU nurse about this at length during clinicals. She said, for a time, they decided not to hire new grads. Hired seasoned nurses only. She said ended up being a disaster, and they lost almost all of them ... whereas they tend to keep new grads pretty well. New grads are like a clean slate, they can be shaped and molded. Sure, they have their own ideas about some things ~ we all do ~ but they are much more likely to follow all of the policies of that particular ICU, because they have no prior experience from another facility or unit. It sounded to me like that was the problem with them losing the more seasoned nurses ... clashes.

This nurse I spoke with started out in ICU as a new grad herself. Still there and perfectly happy after 10 years. I'd say she was one of the "best of the best", and most definitely respected. But she didn't start out that way. With the help and support of those surrounding her, she grew into that role.

[Cowboyardee]

This topic is something of a minefield. On the one hand, I firmly believe that nursing skill level is a major factor in patient outcomes and the effective day-to-day operations of any ICU. On the other hand, I also firmly believe that neither years of experience, education-level, nor even specialty certification are reliable predictors of a nurse's skill level - that's been my first hand observation. And it is my understanding that the few actual studies correlating nursing experience with patient outcomes have shown weak correlations or limited benefit.

So here the biggest problems with keeping ICUs staffed with skillful staff:

1) The literature doesn't strongly support hiring and paying for more experienced nurses.

2) Very much related to number 1, the nursing industry does not have any metrics that reliably and accurately test for an RNs skill level. This is a big problem and not an easy one to solve, especially since the most important skills or knowledge base in one ICU may be less important in another ICU.

3) Patient outcomes may not be the primary decider of hiring practices for hospitals anyway.

4) Smart and skillful ICU nurses are hard to retain because they typically realise they are under-valued by their employers, and also that their experience makes them fine candidates for further education or other employment opportunities.

So about number 1... The studies I'm most familiar with are a 2001 study by Aiken et al, a 2010 study by McHugh and Lake, and a number of studies by Blegen and various cohorts. I encourage others to search them out. You'll see that the link between nursing experience and patient outcomes is supported weakly in some and not at all in others. You'll also see that the experience variable is usually only a report of an RN's total years of experience, not a measure of relevant experience, responsibility level, or the acuity in said experience. Also, level of expertise is often self-reported, which is problematic for a number of reasons, not least of which that most people report their expertise level in comparison to their peers, so a nurse with 3 years of experience surrounded by extremely skillful veterans in a high-skill, high acuity environment would likely self-report a lower level of expertise than another nurse who has 3 years of experience and is among the senior staff on her lower-acuity unit, even though the former likely has far better-developed skills than the latter.

The lack of quantifiable measures of RN skill is the big problem with the studies above, and I wish I had some kind of proposed solution for it. I've seen increased reliance upon the BKAT and personality tests by employers, on top of valuing BSNs (over-valuing them, IMO), certifications (same deal, IMO), and the like. I doubt any of the above have especially strong correlations with skill level, but I'm not sure what alternatives could exist.

About problem #3... I must admit I don't have insider access to the hiring process at various ICUs - just what I've witnessed at a few of them. At these, I've often seen unit directors seeking out more experienced staff and settling for less experienced staff. Clearly, one issue here is that HR departments and hospital higher management aren't willing to pay enough of a differential for more experienced nurses to be flooded with applicants. Also though, I suspect that HR amd management may believe that more experienced staff is more expensive in ways beyond just their higher hourly rate - simply shortening the orientation period for experienced nurses saves so much money that the difference in hourly rate doesn't even come into play until many months or even years after hiring. I suspect that hospital management has figured that more experienced nurses are often more resistant or defiant of cost- cutting measures, and that these measures may be among the primary deciders of who to hire, depending on the institution.

Finally there's problem number 4. Seems like this one might be the easiest to fix: raise pay, stop capping pay after a number of years, and offer actual pensions rather than more watered-down retirement programs. But first hospitals and possibly the public at large would have to decide that the skill level of the people keeping critical patients alive is important enough to pay a premium for. For the reasons listed above, I don't see that happening.

Cheers, to anyone who has read this far.

[KeepinitrealCCRN]

I will also add these days a lot of nurses are using bedside/ICU nursing as a stepping stone to get to NP or CRNA etc. so they don't really care that much. They just want to get the experience and move on. We also live in different times and I find a lot (not all) of younger (in age) nurses tend to have a different attitude and work ethic which I think also contributes to all of this.

[Pheebz777, BSN, RN]

Most new grads are quick to pick up and have the energy to learn many new skills and concepts. In my experience, the new grads that did fairly OK or

not that great, became NPs. While the new grads that excelled are still working. One guy was even asked by our ICU director not to be assigned any complex ICU patient or be transferred to the stepdown unit. Now he's an NP

[KarenMS]

I'm a new grad in ICU (completed 12 weeks of orientation in May). I wonder about this myself. When I started, I was just one new grad. Then a lot of experienced nurses left for various reasons (CRNA school, moving, promotions) and suddenly, there are a TON of new grads on my unit. I'm nervous sometimes and I feel badly for the experienced nurses who are left who have the burden of guiding us constantly.

[Mr. Murse]

I'm a new grad in ICU (completed 12 weeks of orientation in May). I wonder about this myself. When I started, I was just one new grad. Then a lot of experienced nurses left for various reasons (CRNA school, moving, promotions) and suddenly, there are a TON of new grads on my unit. I'm nervous sometimes and I feel badly for the experienced nurses who are left who have the burden of guiding us constantly.

yes, I didn't even mention this part. The experienced nurses on the units are constantly training and having to pick up the slack. Our night shift is made up of probably at least 80% of nurses with a year or two experience, so the minority with substantial experience is carrying a lot on their shoulders, especially during codes and truly critical situations where textbook knowledge alone just isn't enough.

As Pheebz777 said though, new grads do have an eagerness to learn that gives them an advantage.

I still can't ignore the fact that there has been a noticeable increase in errors and dangerous situations since we've been hiring primarily new grads.

[guest769224]

Finally there's problem number 4. Seems like this one might be the easiest to fix: raise pay, stop capping pay after a number of years, and offer actual pensions rather than more watered-down retirement programs..

Definitely true. I work now in an ICU that has very good pay with guaranteed annual raises, a pension (even for per diem), union protection, ratio adherence, and a supportive manager that will work the floor day or night if staffing is short. Those combination of factors results in extremely low turnover on my unit. I was the first nurse they had hired in THREE years.

I compare that to where I was a new grad, in an ICU in a different state. Pay was laughable, and management wouldn't be caught dead working the floor. The turnover there was very high, I mean, literally a new nurse and new face on a bi-weekly basis. It's been interesting to observe the differences.

[jennylee321]

I feel like orientation plays a big factor in whether new grads are successful in critical care areas. Level 4 NICUs have been hiring new grads for years through children's hospital residencies. Because I had such a extensive orientation my transition was a smooth one.

[emmjayy, BSN, RN]

I'm a new grad in the ICU - just came off my 20 weeks of orientation and have been on my own for a month on the floor.

I'm painfully aware of how inexperienced I am... ALL THE TIME! I am very fortunate to be in a unit where all the nurses/respiratory therapists are willing to let me bounce thoughts and ideas off them about my patients when I feel stuck. I'm also happy that the clinical affiliates are generally very responsive and willing to come lay eyes on my patients when something is off and I need help figuring out what to ask for. I'm slowly gaining a little bit of confidence but feel dumb a lot of the time. I'm trying to expand my "ICU brain" - e.g., looking at trends in labs, vitals, etc. rather than going off of a single lab or blood pressure, correlating all the pieces of the clinical picture when I approach affiliates rather than just going over and saying "OMG THE POTASSIUM IS 3.0," thoroughly investigating even small changes, etc. It's tough but I do feel very supported by the experienced staff and I'm grateful for their willingness to teach since my unit has had a pretty big influx of new grads this year.

It's honestly been extremely overwhelming and very humbling. I am in awe of the sheer breadth of knowledge the experienced ICU nurses have and I'd like to get there someday, myself. I know a lot of people use the ICU as a stepping stone to NP school/CRNA school/whatever, but I'd like to stick around and learn a lot of things and become a proficient ICU nurse.

[AceOfHearts<3]

My ICU does not hire new grads straight out. A new grad might be hired for the hospital with the intention of moving them into the ICU, but they have to prove they can be successful on a tele or progressive care unit first.