New Nurse In a Step Down Unit and I hate it

Been there,done that, ASN, RN · Feb 8, 2019

Please see the many threads here on this topic. I started out in the same place. Managed to make it... somehow.

You will only make it if you delegate. Delegate to the charge nurse, RT, and push the docs to order ICU transfer. Use nursing supervision in the process. You also need to get the help of more experienced nurses. Do you have nursing assistants?

Career Columnist / Author · Feb 8, 2019

Even though you're new, this sounds more like an unmanageable workload. I'm in California and by law, nurses can only be assigned 3 pts in SDU.

Some things do get easier as your first year progresses, but unfortunately, some nurses learn to take shortcuts when they are in such an environment.

I'm sorry, that's not a solution, but I just wanted you to know it may not be you, it may be the unrealistic expectations.

Horseshoe, BSN, RN · Feb 8, 2019

I worked ICU and floated among all of the units. Step-down was under the critical care umbrella and they had a strict 3:1 ratio. Those patients were often very sick, just not intubated. They were on titrated drips, often had femoral catheters still in place that eventually had to be pulled, on and on, just as you've described. I cannot imagine having more than three of those. Your patient ratio is unsafe in my opinion. So no, your anxiety is not unfounded. It's just disgusting what nurses are expected to (and apparently do) tolerate these days. Glad I'm not part of it anymore. I work OR and never have more than one patient, so I'm pretty content.

ruby_jane, BSN, RN · Feb 8, 2019

As others have mentioned, it's a lot. You're dealing with A LOT. I love the delegate what you can suggestion. In my medical ICU job if someone could ask me for a breakfast tray that meant they were being immediately discharged!

You have two choices: Stick it out for the year you need to get another job or try to find something else. Remember, it takes at least 18 months to become somewhat competent at what you're doing. The learning curve will likely be just as steep if you leave.

I left inpatient acute care six months in and have never looked back - BUT I can't get back to acute care (even in the unlikely event I'd want to) because I don't have a year's worth of experience.

At this point - you KNOW you don't know enough and believe it or not, that's a good thing. Stay focused. Be careful. And speak up if you feel something is truly unsafe because that may save your license or sanity.

Do you have an EAP at work? You may be eligible for some brief solution-focused counseling.

Swellz · Feb 8, 2019

I would encourage you to talk to your coworkers. You'd probably be surprised how many of them started out in the same place and felt how you felt. When you're out of your depth, ask for help. You have to learn how to ask for help.

pedi_nurse · Feb 8, 2019

My first job out of nursing school was pretty close to a stepdown (it wasn't called stepdown, but we were paid ICU rates). It was pediatric pulmonology with trachs and vents, and even continuous albuterol asthma kids. Very sick kids. A lot of watching resp status nervously. On top of that, CF kids with tight IV med schedules and diabetes, random oncology or neuro patients, cardiac, etc. It was ridiculously stressful and that was with a pretty strict 1:3 ratio (even 1:2, in some cases, rarely 1:4 if we had general peds overflow).

To echo ruby, what you are dealing with is most definitely A LOT. Even for an experienced nurse. I'd really encourage you to first, make sure you are prioritizing your sleep and eating habits. This is really, super important, especially working night shift. I'd also encourage you to look for ways to advocate for yourself. This was really hard for me as a new nurse and resulted in a lot of stress that I didn't need to be holding onto. I've recently been listening to a podcast called FreshRN that's focused on new nurses, especially in critical care type settings. They talk a lot about how to speak up for yourself, and that may give you some confidence to do so. Finally, I think it's important to remind you that you are new... you are still learning good time management, meds, procedures, guideline, etc. I don't know about you, but adding my imposter syndrome and self-doubt on top of my stressful unit just about did me in.

I ended up leaving my unit after 2 1/2 years. The first 1 1/2 to 2 were really rocky and a huge strain on my mental health. I loved that unit, but after 6 months of doing okay, I could feel myself starting to struggle again and I didn't want to wait around to see if it got worse. In my subsequent positions (primary care, now school nursing), I have gained so much more confidence in my skills as a nurse though and am actually considering returning to the bedside again in a few years. I'm not perfect and have things to learn in any role, but I'm no longer feeling "out of my league" among the nursing profession, and I now realize I have the capability of learning and advocating for myself to get the help I need to be successful.

Whatever you decide to do though, please hang in there. Either find a way to improve the support you get for yourself or find a job where self-advocacy is easier and grow there. Nursing is a journey with many paths and you are just getting started!

Aurora0941 · Feb 8, 2019

19 hours ago, Been there,done that said:
Please see the many threads here on this topic. I started out in the same place. Managed to make it... somehow.
You will only make it if you delegate. Delegate to the charge nurse, RT, and push the docs to order ICU transfer. Use nursing supervision in the process. You also need to get the help of more experienced nurses. Do you have nursing assistants?

Thank you for replying and for the advice. I have been searching for similar posts as mine and am finding several other people in similar situations. We do have nursing assistants, nurses get the first set of vital signs and the CNAs get the last two, we do Q4 vital signs. which is helpful. It seems like nursing assistants are also overworked, there are only 2 of them and sometimes they are busy which means I will clean up a patient or take them to the bathroom myself.

AceOfHearts<3 · Feb 9, 2019

4 hours ago, Aurora0941 said:
Thank you for replying and for the advice. I have been searching for similar posts as mine and am finding several other people in similar situations. We do have nursing assistants, nurses get the first set of vital signs and the CNAs get the last two, we do Q4 vital signs. which is helpful. It seems like nursing assistants are also overworked, there are only 2 of them and sometimes they are busy which means I will clean up a patient or take them to the bathroom myself.

It sounds like the tele unit I started on. We weren’t even labeled as stepdown and had 5 patients. The insane workload and acuity of the patients is what caused me to seek an ICU position after 1.5 years. It wasn’t uncommon for many of the nurses to leave between 30-60 minutes late (there were some really really bad days where we’d leave even later).

Good luck!

Aurora0941 · Feb 9, 2019

8 hours ago, pedi_nurse said:
My first job out of nursing school was pretty close to a stepdown (it wasn't called stepdown, but we were paid ICU rates). It was pediatric pulmonology with trachs and vents, and even continuous albuterol asthma kids. Very sick kids. A lot of watching resp status nervously. On top of that, CF kids with tight IV med schedules and diabetes, random oncology or neuro patients, cardiac, etc. It was ridiculously stressful and that was with a pretty strict 1:3 ratio (even 1:2, in some cases, rarely 1:4 if we had general peds overflow).
To echo ruby, what you are dealing with is most definitely A LOT. Even for an experienced nurse. I'd really encourage you to first, make sure you are prioritizing your sleep and eating habits. This is really, super important, especially working night shift. I'd also encourage you to look for ways to advocate for yourself. This was really hard for me as a new nurse and resulted in a lot of stress that I didn't need to be holding onto. I've recently been listening to a podcast called FreshRN that's focused on new nurses, especially in critical care type settings. They talk a lot about how to speak up for yourself, and that may give you some confidence to do so. Finally, I think it's important to remind you that you are new... you are still learning good time management, meds, procedures, guideline, etc. I don't know about you, but adding my imposter syndrome and self-doubt on top of my stressful unit just about did me in.
I ended up leaving my unit after 2 1/2 years. The first 1 1/2 to 2 were really rocky and a huge strain on my mental health. I loved that unit, but after 6 months of doing okay, I could feel myself starting to struggle again and I didn't want to wait around to see if it got worse. In my subsequent positions (primary care, now school nursing), I have gained so much more confidence in my skills as a nurse though and am actually considering returning to the bedside again in a few years. I'm not perfect and have things to learn in any role, but I'm no longer feeling "out of my league" among the nursing profession, and I now realize I have the capability of learning and advocating for myself to get the help I need to be successful.
Whatever you decide to do though, please hang in there. Either find a way to improve the support you get for yourself or find a job where self-advocacy is easier and grow there. Nursing is a journey with many paths and you are just getting started!

Thank you for responding. I am going to try and hang in there like you said, I am still learning which I know adds to my stress and anxiety. However, I feel like there is no way I will be able to work here past my one year mark. You said you stayed on your unit 2.5 years? I cannot even fathom staying on this unit this long. I am considering trying to switch to mother baby, or some type of doctors office or LTC position after I complete my year. I don't know if critical care is for me, I may just enjoy taking care of more stable patients. Not sure if that sounds bad ?

Aurora0941 · Feb 9, 2019

12 hours ago, Horseshoe said:
I worked ICU and floated among all of the units. Step-down was under the critical care umbrella and they had a strict 3:1 ratio. Those patients were often very sick, just not intubated. They were on titrated drips, often had femoral catheters still in place that eventually had to be pulled, on and on, just as you've described. I cannot imagine having more than three of those. Your patient ratio is unsafe in my opinion. So no, your anxiety is not unfounded. It's just disgusting what nurses are expected to (and apparently do) tolerate these days. Glad I'm not part of it anymore. I work OR and never have more than one patient, so I'm pretty content.

Thanks for responding. My patients do not have femoral catheters in place and the only drips we really only usually titrate are amio cardizem and heparin. I've heard on rare occasions they will prescribe different drips but typically in our hospital they would have to be in the ICU. What causes me stress is dealing with patients whos O2 sats are constantly dropping, and who have low blood pressure or out of control heart rates that I am trying to closely monitor. While dealing with this I will get an admission from the ER, or have patients demanding their narcotics within the minute. I feel like I do not enjoy critical care, it makes me too nervous dealing with the instability as well as the number of patients. Not that all 4 of my patients are unstable, but having to closely monitoring 1 or 2 of them with 2 others is too much (not forget all the stupid charting). DO you have any opinions on if nurses are happy in mother baby, LTC or maybe a docs office? Trying to seek sanity and happiness here. thanks,

Horseshoe, BSN, RN · Feb 9, 2019

11 hours ago, Aurora0941 said:
DO you have any opinions on if nurses are happy in mother baby, LTC or maybe a docs office? Trying to seek sanity and happiness here. thanks,

It just depends on the person. There is a new thread here from someone working in newborn nursery who is miserable.

Most doctors offices hire MAs, not RNs because we are too expensive. NPs will often be found there, but you'd have to go back to school.

LTC usually staff with LVNs and the RNs typically supervise.

New Nurse In a Step Down Unit and I hate it

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