New Grads in PICU

[kessadawn, BSN, RN]

How does your PICU handle new grads? Do you hire them at all? If so, do they get a different type of orientation than the new hire with experience?

Our PICU has grown in size and acuity over the last few years, and we are hiring a ton of nurses right now. 99% just became rns. (nothing personal against any of them, they are a great bunch of people.) they get the same basic orientation as the experienced hire, although we have done some adjusting to our orientation ( and still are adjusting as needed), I feel they get moved through so fast. But, I myself still feel like a new grad sometimes, we see so many really sick kids. I graduated 3 years ago, have been in PICU for 2 of those. What worries me is that,there will most certainly come a point in time when the poo is going to hit the fan, and I may be one of the most experienced nurses in the unit when it does. I don't know how prepared these new ones are for an admission that is circling the drain before it even hits the doors, like a HLHS that was undiagnosed in utero, born at a little local hospital that doesn't even stock prostin (that has happened) or when the experienced nurses are on the floor at a code when that 12hr post op trach suddenly falls out in the PICU(that's happened too). I think all of these new hires are team players, and willing to learn, but experience does count for a heck of a lot in PICU, and with so few seasoned nurses here anymore, well...

Any thoughts?

[AliRae]

As a former PICU new grad, I'll answer! =)

My orientation was 20 weeks. First 6 of those were on other floors in the children's hospital to get an idea of "normal" sick kids. The rest was in PICU, not counted in staffing numbers. I had a primary preceptor and a secondary for when she wasn't there. We also had a pICU course, 8 hours once a week for 10 or so weeks, that covered main topics/issues/disease processes we'd be seeing on the floor.

Orientation started out with easy kids and progressed to harder ones. By the end of orientation, I was working with my preceptor to take the sickest kids. Once I was on my own, they started me out with easier kids to get my confidence up and then "upgraded" me as I felt confident. I was put on the same weekend as my preceptors, and was encouraged to schedule myself for days with them initially. They were great about being mentors to me once I was on my own; I was just talking to one of them today, actually, reminiscing about my first sick kid, and how they gave him to me when both my preceptors were in the rooms to the left and right of me for backup.

I recently had a conversation with one of our attendings who told me that "new grads should never be hired to the PICU" and "I STRONGLY reccomended against them hiring you." I couldn't disagree more. I'm a year and a half on my own now, and consistently take the sickest kids on the unit. I take charge and go on transports, and my former preceptor told me today that I've "grown up really well."

I think, as long as the orientation program is strong, new grads can be a great asset in an ICU setting. They take a little longer to train, but if they're brave enough to jump in with both feet, I'm guessing that's the kind of enthusiasm you need!

[Jolie, BSN]

I think your concerns are justified.

I started in a NICU as a new grad, one of 20 oriented over the summer following graduation. However, our unit had a staff of over 100 full-time RNs, and a typical shift was staffed with 20(+) nurses, so accomodating that many newbies was not really a problem. Our manager had a rule that there had to be at least 50% EXPERIENCED RNs (more than 2 years seniority on that unit) working at any given time.

Is your unit staff large enough to accomodate these nurses' orientation and then provide coverage with at least 1/2 of the nurses working any given shift being experienced nurses? If not, then I think you have a problem that your manager, educator, and administration must address.

Good luck!

[NotReady4PrimeTime, RN]

kessadawn, I read your post aloud in our staff break room the other day and it ignited a firestorm. The nurses who had been hired into the unit as new grads were offended, until I explained what it is exactly that you were asking. The nurses who came to the unit with experience got it without the explanation. I found that to be quite interesting.

To answer your questions... obviously our unit hires new grads. And in and of itself, there's nothing wrong with that, providing they are given a solid orientation and the opportunity to develop their skills before being thrown in at the deep end. Oh, and selection plays a huge part in how successful they are. Some of our new grads have been crackerjack and are definite assets to our staff. Others "interviewed well" but come to the ob thinking they know everything there is to know, and a couple recently have gone so far as to lecture senior staff about complex pathophysiology... incorrectly. That doesn't make for good staff relations, and it tends to create a stereotype toward new grads.

Our new grad orientation is a little different from the experienced nurse orientation, but not by much. Most of the didactic is identical, so if you come to the job with limited basic nursing care experience and limited assessment skills, you will have trouble. Then clinical orientation is tailored to the individual, sort of. If you're a new grad, you will have a total of 16 weeks' orientation, a week of classes and 48 x 12 hour buddied shifts. If you're experienced, you will get fewer buddied shifts, based on the evaluation of your preceptor, and if you come with PICU experience, it will be shortened even more. (I got 5 buddied shifts, and on my 5th, my preceptor and I received a cardiac surgical patient. Then I was on my own.) We have a 3 phase training plan, with critical care basics in phase 1, care of the post-op cardiac patient in phase 2 and care of the patient on ECLS and the functions of the code team in phase 3. Progress through the phases seems to be politically determined these days, though and not an indicator of the skill and efficacy of the nurse.

In an ideal world, people should be allowed to progress from novice to intermediate to expert in a natural progression based on their abilities, their readiness and their grasp of the potential, in a supportive and resourceful environment. But in our real world, our staffing has taken a real $#!+kicking and our management has turned over so that we have managers who don't know anybody, and don't know what's appropriate for them to be doing, and don't even know what's involved in the assignment being made. So we have very junior nurses being pushed to take on assignments that are far over their heads. It's (perhaps unintentionally) setting them up to fail, and that's what it sounds like is happening in your unit too. Yesterday, out of the 15 nurses on days, only four of us had more than 2 years' experience. They pulled the nurse in charge off nights to days because we were so short senior staff. Our acuity is very high all the time and yesterday was no different. We had 2 oncology patients, a burn, 2 multi-traumas, 3 cardiacs with open chests, 2 chronically critical patients, one of whom was deteriorating very rapidly and needed 2 nurses for most of the day, and a couple of simpler kids, then we got two cardiac admissions. When my kid came out at 1240, there was no one to help me admit her, and it took me the rest of the shift to get caught up.

So I hear what is concerning you and I'm letting you know that you're right and that it shouldn't be that way, but what can you do? When the fertilizer hits the ventilator, you may just be the most senior nurse on the scene. It won't be your fault.

[kessadawn, BSN, RN]

Thanks for the pep talk! Your right, the "Ideal world" would be so much simpler, wouldn't it? The orientation you described sounds very similar to what we are moving towards, and it is making differences. Baby steps, I guess, but in the right direction.

I agree with you on the unfortunate stigma the new grads are getting from the actions of just a few. They all have potential, many are really good already, and a few have really impressed the heck out of me. But, while they are talented, many have no fear, and that is what scares me the most. I don't think I should ever walk into the unit and have absolutely no fear doing anything to any type of pt, no matter how unstable. That's when it will be time to find a new job. It's just not safe, and bottom line, it affects pt safety. My nursing instructors taught me that while I need a certain level of confidence, I should never become fearless, that none of us are infalliable. Some of our junior staff have had to learn that the hard way.

I guess that when the day comes, I'll have to hope that all goes well. It's not an ideal world after all.

[NotReady4PrimeTime, RN]

I know exactly what you mean about the lack of fear. I see it too and it scares the bejeepers out of me! I can think of a couple of recent new grads who fit that profile perfectly, and I can see things getting so far out of hand that there may be no reversing them, all because they don't know what they don't know and think things are perfectly fine. But then, as I said, there are others who are just so on-the-ball from the beginning and it's so unfair to tar everyone with the same brush.

Last night our staff mix was completely different from Tuesday days... we had 10 senior PICU staff on, 1 experienced floor nurse, 1 experienced neonatal nurse and 1 experienced ER nurse on out of 15. We traded an onc patient for a burn, but the rest of the patients were the same. It's just ridiculous that we can't have a balance. I have a healthy amount of fear every time I work, so much so that it's affecting my sleep and giving me heartburn...

One of our intensivists is doing a study, in collaboration with several others, on morale in PICU. He wants to interview nurses across the spectrum of experience. A couple of years ago we were the subject of another study by a nursing PhD candidate with a similar focus, and another of our intensivists did a study of end-of-life care issues; when the results came out, our management and physician team were stunned at how poor our morale was, how divisive management and the physician group were and the level of frustration experienced. When Dr. G starts his interviews, he wants to start with the old war horses to see how we've managed to survive and then work his way through the levels of experience to see if there are common themes. He will be getting an earful and he's not going to like what he hears. But he is one person who will take the bull by the horns and try to fix it. He cares about the nursing staff and he has some influence. I hope...

[kessadawn, BSN, RN]

janfrn said:

One of our intensivists is doing a study, in collaboration with several others, on morale in PICU. He wants to interview nurses across the spectrum of experience. A couple of years ago we were the subject of another study by a nursing PhD candidate with a similar focus, and another of our intensivists did a study of end-of-life care issues; when the results came out, our management and physician team were stunned at how poor our morale was, how divisive management and the physician group were and the level of frustration experienced. When Dr. G starts his interviews, he wants to start with the old war horses to see how we've managed to survive and then work his way through the levels of experience to see if there are common themes. He will be getting an earful and he's not going to like what he hears. But he is one person who will take the bull by the horns and try to fix it. He cares about the nursing staff and he has some influence. I hope...

I would be very interested to hear the results of that study. I wonder what the results of a similar study would be in my unit...

I've really been thinking about this dilemma of minimal nursing experience in the PICU. I've decided that a proactive approach is the best I can do. Time to drag out the books, read up, study like I haven't done in a long time. It may not be the same as the years of experience I lack, but it certainly cannot hurt.

Off subject, I noticed your mention of burn patients in your unit. Do you take all burn patients, or is there a regional burn center that takes the more severe cases? We have a burn center in our hospital, so we only take them in PICU if there's an underlying that requires more intense vent management, and of those few they were all steven-johnson patients, not actual burns.

[NotReady4PrimeTime, RN]

I'm thinking it'll be some time before we know the results of the study, but I'll keep in mind that you're interested. Maybe your unit is participating too.

Medscape has a lot of great articles on a variety of peds-related critical care topics, as does pedsccm.org, that you might find useful. And of course AACN's Core Curriculum of Pediatric Critical Care Nursing is a goldmine.

We don't get all that many burns. It seems like they go in twos or threes. The ones that come to us are the ones with airway and/or ventilation issues and/or the need for pressors. The rest go to our burn unit, which takes all ages. When we do have a burn in the unit, they send their staff over to do the dressings, which is a godsend. Where I worked before, we got all the pediatric burns, at least initially; the burn unit would send a nurse to help with the dressing. I haven't seen a Stevens-Johnson syndrome since 1997! When I first started in PICU there was a 16 year old mammoth-sized boy with virtually 100% involvement from carbamazepine. They called it SJS, but I think it was actually toxic epidermal necrolysis. I transfered him to the ward when the time came; I ran into him in the hallway about 6 months later and he looked like he'd never been sick! I was amazed that he didn't have any visible scars.

[kessadawn, BSN, RN]

janfrn said:

Medscape has a lot of great articles on a variety of peds-related critical care topics, as does pedsccm.org, that you might find useful. And of course AACN's Core Curriculum of Pediatric Critical Care Nursing is a goldmine.

Great resource! Had to make myself close the window so I can go to bed, very interesting stuff!

Quote

We don't get all that many burns. It seems like they go in twos or threes. The ones that come to us are the ones with airway and/or ventilation issues and/or the need for pressors. The rest go to our burn unit, which takes all ages. When we do have a burn in the unit, they send their staff over to do the dressings, which is a godsend. Where I worked before, we got all the pediatric burns, at least initially; the burn unit would send a nurse to help with the dressing. I haven't seen a Stevens-Johnson syndrome since 1997! When I first started in PICU there was a 16 year old mammoth-sized boy with virtually 100% involvement from carbamazepine. They called it SJS, but I think it was actually toxic epidermal necrolysis. I transfered him to the ward when the time came; I ran into him in the hallway about 6 months later and he looked like he'd never been sick! I was amazed that he didn't have any visible scars.

Amazing! That's the best part of peds...these kids are miracles sometimes.

[NotReady4PrimeTime, RN]

kessadawn said:

Amazing! That's the best part of peds...these kids are miracles sometimes.

I agree. For years, his lesions were the most fearsome and disturbing things I'd ever seen. (And my son has had both open-heart surgery and a liver transplant, so I wasn't a babe in the woods!) Of course, in the last few years I've seen far worse, but he will stay in my memory as an amazing person.