New nurses in ICU

Nurses General Nursing


Will be graduating as an RN in May and want to know what experienced nurses think about starting right out in critical care as opposed to the traditional one year on a med-surg floor? I've worked on a med surg floor as an intern all through school and found through clinical rotations that I really like MICU a lot better. The hospital I'm at commonly hires new grads right into the unit with a 3 mo orientation. Can a new nurse be effective in intensive care (without the experience) to pick up on subtle changes and make the quick decisions? Also, if any new nurses have went right into ICU, please let me know how its going. Thanks!

Originally posted by janine3&5:

Will be graduating as an RN in May and want to know what experienced nurses think about starting right out in critical care as opposed to the traditional one year on a med-surg floor?

As an experienced ICU RN, I think the new Rn is short-changed by going directly into ICU without first gaining the knowledge, skills, critical thinking, and base foundation that a well-rounded med-surg experience affords them. I know people will disagree but I really believe you shouldnt specialize until you have some experience. That doesnt mean you cant - just that its a disservice to yourself and new RNs shouldnt be used like this. In the 80's, we had clinical educators, clinical specialists, individual preceptors, nurse managers and other RN support available on the units to train & guide these new grads, giving them individual attention and all that they need. Then came the 90's and clicla educators, clinical specialists, nurse managers were the first to be down sized out of a job. Now our nurse managers are responsible for managing more than just one unit & is not usually readily available on yours, if a clinical specialist is employed at all she is used for special projects for the whole nursing dept, there are just a few clinical educators on staff - mostly to provide mandatory JCAHO inservices for the entire hospital's nursing staff - not hands on one-to-one training. Staff Rns were next in line to be kicked out of their jobs thru "restrucutring" & so now there is a staff RN shortage and preceptors are few. They are precepting more than one new orientee at a time - new grad and otherwise -

There is not the individual support there that a new grad needs & should have. From what Ive seen, critical care internships teach technicalities like tasks, using the equipment, and recognizing an abnormal heart beat. But there is so much more to critical care than that. Get a good foundation. ICU, the ER, CCU and the PACU will still be there a year from now.

Janine, I have to disagree with jt. I started in an ICU right out of school and have never been sorry. I note that you said you would have a 3-month orientation, which is exactly what I had. You DO have to be willing to work a little harder, as you have to pick up "basic" nursing skills as well as the high-tech skills. I presume you will also have some didactic instruction (i.e., theory classes) to go with your hands-on practice. It will be important for you to have a strong, SUPPORTIVE preceptor who understands that you are a new nurse, period, and not just new to ICU.

Given that, there are some advantages to going straight into ICU. After just 2 months in med-surg, my former classmates were moaning to me that they were already! burned out and felt like "overworked, underpaid grunts" (their words, not mine), whereas I was thrilled and excited to go to work every day. I also observed that all the other (experienced) med-surg nurses in my ICU orientation group were often depressed, tearful and discouraged during orientation. They had come to think of themselves as having a certain level of competency on the floor and found that their skills and level of practice were not up to the standards they were being taught. Consequently, they had to relearn a lot. I never went through this because I was basically tabula rasa. I KNEW I didn't know anything, and just soaked it all up like a sponge.

It IS a little like "trial by fire", but then, so is being the sole RN on a large med-surg floor at night straight out of school. In the ICU, you will develop exceptional assessment skills, you will learn to anticipate and deal with worst-case scenarios regularly (which helps a lot of that new-grad fear) and there will ALWAYS be experienced RN's around for a second opinion and for help. All my charge nurses and preceptors told me that I became clinically strong much more quickly than they had expected.

Only you know if you're ready, but I highly encourage it! My love of critical care nursing has stayed with me. Good luck in whatever you decide.

I think this is the wave of the future although I agree with jt. Stargazer, you're presuming alot when you believe janine will have a strong preceptor and theory classes, along with a 3 month orientation.

janine-you have to ask yourself..

-Are you ready to refuse an assignment outside of your "orientation" role, because your hospital will most likely use you as a "regular" on a short-staffed day?

-Are you ready to insist on the availabilility of a preceptor?

-Are you ready to refuse a patient assignment outside your scope?

-Are you ready to insist on your FULL orientation?

It's hard enough to begin your first nursing job, but the "tabula rasa" theory on med-surf vs ICU doesn't hold water. ALL NEW NURSES ARE TABULA RASA.

The only difference with ICU is you're dealing with CRITICALLY ILL patients. CRITICAL being the operative word.

So if you are the type of person to be intimidated by management, if you are not able to explicitly define your NURSING STANDARDS to management, if you are not able to handle a mistake in a CRITICAL DECISION, and if you don't trust your hospital's administration, then don't do it. Most of us cannot say we had all that together in our first job, AND protect these sick, sick patients.

If, on the other hand, you know you're a quick learner and you have developed great assessment skills in school, and none of the above warnings apply, then you might succeed.

To go from nursing student to critical care nurse just doesn't make sense.

Stargazer, for the record I pretty much concur with your thoughts related to new grad areas. A strong preceptor coupled with an adequate preceptorship would seem the best formula for success by the new grad, regardless of the area. Natalie, interesting input on your opinions about new nurses going into critical care. Does this same philosophy also apply to other specialty areas or just to the ICU? As a soon to be new grad, I am just curious as to what others think about this kind of thing. I look forward to hearing more from others on the subject as well.



"The highest reward for man's toil is not what he gets for it, but what he becomes by it."-Johan Ruskin

I have never really bought into the old adage that every new grad must work on a med-surg unit for at least a year after graduation. I believe that the place that is most meaningful and interesting to the new grad is the place they will work hardest and be most successful. Of course as many have pointed out, that is assuming support and mentoring that is often not there.

It will be important for you to have a strong, SUPPORTIVE preceptor who understands that you are a new nurse, period, and not just new to ICU.

In the ICU, you will develop exceptional assessment skills, you will learn to anticipate and deal with worst-case scenarios regularly (which helps a lot of that new-grad fear) and there will ALWAYS be experienced RN's around for a second opinion and for help.

My point is that there is not ALWAYS that preceptor or any other support for the new grad in ICU anymore....especially at night. Critical care has been hit hardest by the shortage already..... One hospital here had an ICU that was staffed solely by new grads with no support, direction, preceptor on the shift, etc. & it took our state association (read "union") fighting to get the hospital to hire at least a night shift nurse educator to be available to them**. Where the support is there to guide, teach and train the new grad over time, it may be different. Where it isnt, it is unfair to the new grad & dangerous to all. And because of cost-cutting, down-sizing, restructuring, and the shortage, that is more the norm these days than not. Anyway, its a good question for a new grad to ask at an interview: "what kind of support will I have during & AFTER my initial orientation"

** Central Suffolk Hospital hired a nurse educator, who will be on duty from 7 p.m. to 7 a.m., to provide support for the RNs in the ICU, which is staffed entirely by new graduates. Many of these new nurses didnt stay, because they were overwhelmed by their responsibilities.**

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Thanks to everyone for responding-- all the info I'm getting is what they DON'T tell us in school, and certainly not what a potential employer will tell you!

I went from Med-Surg adults+Peds, to Telemetry and ICU and now ER. I found my niche! I love ER! But I can not imagine doing my job without at least medsurg and cardiac background. These experiences help you learn to make good judgement calls. Books can't teach you that. Not entirely. So if you start out in ICU or ER you must have a good precepter program and I would reccommend 12 weeks orientation. I had a 12 week orientation in the ER and I had 3 years experience. I'm learning something new every day.

I cannot begin to imagine going to a specialty unit right out of school. If you really knew the legalities attached to being a hospital nurse, you would have to reconsider. A preceptor probably won't be the same as having a lawyer in your pocket, and, in many cases, that's about what you need. The patients on the med/surg floors now have the acuity level of patients in ICU several years ago. You can ask for help from other nurses, but you have to protect your license.


Just filed a grievance yesterday... a new grad on orientation on pediatrics night shift came into work, was told they were short-staffed & therefore she would have to count as a staff RN & take a full assignment on her own. Orientation was suspended for that night. She refused because that is not what she agreed to when she took the job - she expected a full orientation & was not yet prepared to work on her own being responsible for 7 sick kids. She was promptly suspended for the shift & sent home without pay.

reality shock.

I think there has been a lot of good responses. I am a new grad too. I am going straight to CCU, but I have also worked as an ER tech for a few years. I really enjoyed my time there. I am also at a LEVEL I trauma center that has one of the largest med schools around. It was a great learning oppurtunity for me and everyone acted like a precepter to me once they found out I was in nursing school. I actually was in nursing school before I started work there. I did an internship at another hospital in CCU and loved that area. I found my nich and am happy. I had clinical experiences in many areas throughout school. There were the places I would prefer not to ever nurse and there were places I thought, "I can do this when I graduate." But when I did that internship at the other hospital I fully and completely loved CCU. I loved the patient population. The families. The staff and the physicians. I went back to my regular job part-time when my last semester started and told people where I was interested in, so anytime a chest pain or SOB person came in, they would send me in the room and include me and teach me in the ER. I applied for CCU at this hospital and am starting there soon. I am excited. I did however ask the important questions, such as: "As a new graduate, what will your expectations be of me, before and after my CCU training. How long before I will be expected to run a code situation and what kind of orientation will I have. They told me my enthusiasm for this area is why I received the job and that their normal orientation for someone that has already been ACLS certified is 10-12 weeks. My manager said that they are making an extended orientation and that they were going to send me to several classes. He asked me if I was ready to put that much learning and work into it I feel that I can believe what I was told because as someone looking for a new job, I researched the managers reputation and the units reputation as well as if their were any staffing problems and their system of doing things before I even applied for the position. Their are so many things to consider when looking for a job, but I agree with the nurse that said if you find the place you belong and your interest is there you are going to be a little more tuned into things than if in a place you feel your skills are wasted and your just flat at bored with your job. Good luck on the job search, remember the not so obvious things about a unit before deicded to even apply.

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