Overwhelmed New Grad

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Hey, ya'll. Just need to vent a little, maybe get some advice!

So, I graduated this May and started working in August. This is my 11th week working on the unit (It is a CTICU- surgical...we get post op heart transplants/CABGs/AVRs/LVADs/Pneumonectomies etc). I know it is a super super acute unit that even experienced nurses find challenging but I thought since I was in a 24 week orientation/"residency program" I would be set up for success and be able to really learn and hone my skills. WELL...I was wrong! This is so hard. The shift I just came off of I cried 4 different times. And I feel like since next week is my halfway point I should NOT feel like this. I do not see myself being ready to take my own patient assignment in January...if at all, ever.

My first (and biggest?) struggle is the IV pumps at this hospital. In school/clinical/as a nurses aid...every hospital used Alaris...the one I work at uses hospira plum pumps (but they are changing to alaris . s december thank you jesus). BUT I NEVER GOT A MODULE OR ANYTHING TO WATCH OR AN INSERVICE ON THESE HOSPIRA PUMPS....so as a new grad in a high acuity icu with patients on multiple vasoactive drips...I'm supposed to just figure these pumps out? Because of this pumps, I accidentally changed my patient's heparin drip dose. My preceptor told me to add 6 hours of time to the pump but I didn't know if you didn't clear the VTBI, it would mess up the dosing...obviously I should have double checked the dose was still correct but I didn't and the nurse that followed us had to correct it (I could have gotten written up for this!!)

BUT ALSO- the "residency" program I am has a guideline for the acuity of patient assignments I should be getting with my preceptor and I have been getting WAY more unstable/more complex patients than I should at this point in my opinion and also according to the guidelines. But bc of the high acuity of my unit, there is not always a stable/non complex assignment for me. So after 6 weeks on days with one preceptor, I switched to nights with Preceptor number 2. Also at the 6 week mark, I was supposed to transition to two patients. TWO STABLE NON COMPLEX PATIENTS. aka learn how to get report/assess/chart on/give meds to TWO patients. The FIRST night im on nights, the FIRST night I'm with preceptor #2 (who does things SOOOO differently than preceptor #1 so I was a little out of practice), I get two patients who are both intubated, both on vasoactive drips and both on ENDOTOOL (if youve never had endotool, lucky you! its a system that titrates your insulin drip...aka you are taking BGs every hour) and my unit does midnight labs which I had never done...let alone on two patients.

Now I'm almost done with the 6 weeks on nights, but I feel like I never got a chance to have one complex patient and really focus on them. My assignment last night was two patients. 1. POD 17 LVAD implant and POD 9 bowel resection, intubated, on nitric, on epi drip, on ENDOTOOL,ostomy bag, NG tube to suction, foley that needed to be changed and urine cultures taken, had to do the LVAD dressing change which is sterile, on a heparin drip so needs q6 PTT levels and titrate that per protocol, and antibiotics q4. oh and his K was 3.4 needed to be replaced and his Mag 1.9 needed to be replaced. Probably more that I am forgetting. He also had a pleural effusion that they would not tap d/t INR levels

Then pt #2 was POD 1 CABGx3, AVR (mosiac), and OM endardectomy.Intubated. He had to bounce back to the OR bc of bleeding in L chest tube. They threw in another stitch in the OM. His pressure was extremely labile and sensitive to the vasoactive/inotropes. He had an echo and was hyperdynamic so I weaned off epi and started neo. Titrated the neo all night from 10-80 mcg/min. His pressures would drop when turned/bathed. Chest tube output was ok. Gave 500 albumin, gave methlyne blue, he was on precedex. CI was good but dropped at one pointto 1.8 and the NP saw and was like why is his CI 1.8 we need to pace him at 90 but he came back up on his own to like 3.2 without pacing him.

I just don't think I was ready for that assignment and preceptor #2 took PTO this week so I was with another nurse who has a lot of experience and shes actually usually charge but she was sitting at the nurses station eating oatmeal with whole night talking to other nurses. She kept telling me I was doing so good and working so hard but I felt like I was DROWNING the whole time. I cried 4 times!!!! At one point I couldnt even get my pump to go on standby mode bc I didnt know you had to have some VTBI for it to be on standby. Ugh!!!

Am I in over my head? Should I have taken a position on a med surg unit??

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Believe me when I tell you I completely understand your situation.

Last year, as a new graduate, I was employed in the same type of program as you: 24-week residency program in CVICU.

Unlike you, it took me FOUR shifts to learn I was in over my head. My hospital did use Alaris pumps, which I struggled to operate on a daily basis. We did have an online tutorial on their use. I now work for hospital that uses the pumps you are now using, and find them so much easier to navigate. I could never figure out the Alaris pump with various channels, etc. But that was the least of my problems!

My guess is that you are doing fine. I say that because my program, after the first 12 weeks, basically had you out on your own with your preceptor for back-up.

So, if your NM or preceptors didn't feel as though you were progressing adequately, you wouldn't still be in the program.

I know that my preceptor and I had weekly meetings with the NM to discuss progress. By shift number five, I was begging to get out.

From what you described, I think you are doing fine. But you are feeling overwhelmed, and that is NORMAL. If you have doubts about your progress, speak to your NM and preceptor.

Only you will be able to decide if this specialty is the right one for you. Best wishes and good luck!

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Anxiety is a normal part of an ICU orientation. Feeling overwhelmed is normal. Being very busy is normal.

Unfortunately, so is having some orientees (new grads especially) who just don't make it. I'm not on your unit and can't really say how you're doing. Ask your preceptors and unit educator.

What I can say is the following:

- 24 weeks is a pretty decent orientation, even considering the high acuity on your unit. The hospital must be reasonably invested in your success.

- When I oriented to intensive care, I felt awful halfway through orientation (the day shift portion) and started feeling MUCH better after a few weeks on nights. The slower pace helped me get my mind around things, and I lucked out in getting a great preceptor on nights. Give orientation more time.

- For whatever it's worth, your post sounds like you have a reasonable understanding of what's going on around you. The ICU orientees who don't make it through orientation often seem to have a hard time telling a coherent story about their patients and the interventions they performed, in my experience. They're the ones who just don't 'get it.'

- Find 20 minutes of down time and ask for an informal 'in-service' on the hospira pumps from an experienced nurse. Failing that: a simple google search ('hospira pump youtube') got me a dozen or so tutorial videos on the subject you could go look at right now. There's too many things to learn in the ICU for the hospital to in-service you on all of them. Make it a habit to actively seek education about things you don't understand rather than wringing your hands about how the hospital hasn't done it for you.

- Many hospitals have policies requiring a second RN to double checks high alert medications (like a heparin infusion). Even if your hospital does not require this, there's nothing wrong with asking a second RN to check your calculation and your programming, especially since you're still new and on shaky legs. Getting written up was not the worst thing that could happen in the scenario you described above.

Best wishes.

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I had a 6 week residency and then 12 week orientation in the icu. Here is what I can tell you:

1. You can't do it all on your shift. Nursing is a 24 hour job.

2. Prioritize and Organize. After report, I sit down at the nurses station, review my chart quickly, and organize my day. Each room gets a sheet and I write down what needs to be done and at what time. And things get added. You have to be flexible. Especially after doctors round.

3. Do you have techs? Use them if you do. At my hospital, they can turn, do oral care, take blood sugars, draw labs from a peripheral stick, and other things. We don't have many techs but if I've got a lot, I will call one and ask them to schedule some time for me and my patients. You'd be surprised how much having one do maybe 2 blood sugars, a bath, foley care, or oral care, can save you on time. Plus, it lessens the amount of anxiety that you feel as well. Delegate to your preceptor too. They expect you to delegate to them, not them ask you what kind of help you need.

You will be a better nurse in the long run by drowning a little now. Trust me. It gets a lot better. Usually around 9 months to a year in.

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Specializes in Medical-Surgical/Float Pool/Stepdown.

FWIW, don't have the mindset that Med-Surg would be an easier place to start. If you're struggling with time management (like every new grad does) how do you think you would do with way more patients to deal with that mostly can use their call light and make your shift even more of a living hell.

Other specialties are not always easier...they are just a different kind of monster.

Do you not have a unit educator or even a hospital orientation educator that you can go to for help with learning the IV pumps? Healthcare is in constant change, you will just have to learn over time how to keep up, just like we all did.

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By no means did I mean to insinuate that med surg would have been EASIER per say- it's just that I relocated from NY to NC for this CTICU job when I had another offer on a med surg unit from a hospital I was a NA at (that paid me double what I make here). And I had doubts about what was the right decision in financial terms and also being new and starting in an ICU but the residency program is what sold me but now I was feeling like it's not even helping that much because I still felt like I was drowning.

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By no means did I mean to insinuate that med surg would have been EASIER per say- it's just that I relocated from NY to NC for this CTICU job when I had another offer on a med surg unit from a hospital I was a NA at (that paid me double what I make here). And I had doubts about what was the right decision in financial terms and also being new and starting in an ICU but the residency program is what sold me but now I was feeling like it's not even helping that much because I still felt like I was drowning.

Again, what kind of feedback have you gotten from your preceptor and NM? Are there weekly meetings going over your progress?

You can feel like you are drowning, and you probably are, but those on the outside are most likely better able to judge your successes and failures.

As I stated before, I highly doubt you would be this far in the residency program if you were truly doing badly.

But none of us on this thread can answer that question for you. You must ask your NM, nurse educator and preceptor for feedback.

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