Question for Experienced ICU Nurses

dcglidewell RN BSN · Aug 15, 2009

Hi Phoenixfire,

I have several thoughts about your question. I am an ICU nurse with 24+ yrs experience and have acted as preceptor for many students. Here is what I know. Many preceptors are not comfortable in their role and their ultra vigilance, while understandable, can actually make the experience of being mentored, quite uncomfortable. Many students are so eager to show what they know, especially in an area where they have some previous experience, that they can leave an impression of being unreceptive to instruction and or criticism.

If ICU is for you, do what it takes to get through this clinical course. By this I mean follow the policies and procedures of the institution to the letter. Establish a good working relationship with your preceptor and utilize clinical conferences for the bulk of your questions that do not immediately impact patient safety.

Questioning a preceptor's judgment does not equate with being 'unsafe'. I would ask for a conference with your clinical instructor about examples of that concern if she has not already provided them. Once I knew what perceptions or issues brought about the statement I would work on those. Were you perceived unsafe because of a variation in procedure for example? Learn the perceived issue and work on it. A small break or variation in technique can lead to the perception of potential harm.

Your idea about re-phrasing questions may be useful as well. I wish you the best of luck in the future. Conscientious nurses are especially needed in critical care.

greggy1 · Aug 18, 2009

Although I have been visiting this websites for many years, your question made me sign up so that I can answer your question. I am an experienced MICU RN, starting CRNA school next Monday.

There are few things I would like to tell you and while they may be wrong, one or two may help you as you face the next semester. I will tell you the way I see it, please bear with me if I sound blunt.

Congratulations for making 85 and claiming that you are an "A" student! But am sorry none of that can save a life, especially on a critically sick patient. Critical care is about paying "Critical" attention to details, staying calm and in control of any situation all the time. It is about taking "critical" attention even to the most obvious things because a simple mistake could cost a life, loss of a son/daughter, loss of a dad,mom,grandparent or a lover to someone. Swallow your pride and learn.
I understand that you are a student and your preceptor had the final say to your instructor. Theory is not always practical. Asking questions is healthy learning habbit but you need to be careful why and how you ask questions. Example: experienced critical care nurses sometimes takes critical decisions even when the doctors are not by bedside or cannot be reached on the phone. Sometimes they may make desicions before calling the MD to get an order because waiting one minute could make a difference between life and death. Your text books says "Nurses cannot make orders or do procedures without MD orders". But in practice, it may differ from theory. Learn how to ask without criticizing.
You already have an upper hand for being an ICU "TECH". "It's not like I don't know anything" if I may quote you. Again, your attitude is what your preceptor was dealing with. Best learners are humble and assumes "Idon't know role" so that they can learn. You will need to UNLEARN what you thought you knew as a TECH, re-format your learning hard-drive and learn systematically. You may have easy time bathing a critically sick patient and have an upper hand over your peers but you may miss something like "narrow Pulse Pressure" on a patient just because you knew how to take vital signs as a TECH. You may know normal blood pressure as a tech but an ischemic stroke patient may get worse or die in your hands, if you DON'T UNLEARN what you knew as a tech and LEARN critical care nursing. Your judgement is very CRITICAL.
"Trying to learn as much as you can" is a very positive thing. But like a baby learns one milestone at a time, you need to humble yourself and go systematically up the scale and master each skill as you go. There is no room mistakes, oops!, auch! sorry, etc in critical care. I have been a preceptor for 4 years now and have only failed 1 student. When I asked her what is the normal ICP when taking care of a patient with a ventric, she couldn't tell me but she knew Willis' Circle in Brain circulation like a poem. After spending 15 minutes explaining the implication of MAP & ICP and their correlation, her "after topic" questions were about "Broadman's centers of the brain". Related neural questions but irrelevant to critical care nursing. My thought here is "Be systematic & be a nurse!"
What???? What a jerk?? You might me asking! BUT no, I feel your pain, your ambitions and your goals. I like the response by the RN above. Very positive and supportive. Be humble, swallow your pride, admit that you don't know!, and always remember that you are not in school to become a supper TECH.... you are in school to become a safe critical care nurse.

Things I have learn't as a critical care nurse: -

Normal BP is not always 120/80. 160/95 could be an optimal BP for a critically sich patient.
Theory may not always = to practice. E.G. Albuterol (vasodilator) can be used to treat hyperkalemia although not documented in books
i have been in trouble/sloppy, when I had "easy patient(s). Ask yourself why?
There is nothing like easy assignment in critical care. The easiest can turn out to be the worst ina split second. Never take anything for granted!
Its fashionable to be called "anal" in critical care. It is useless to be a "Nerd"!
It doesn't matter how much you knew or how much you did to a critically sick patient. What matters is the little that you did safely and effectively.
I have learn't the difference between Effective & efficient, good and perfect.
"Nurse's eat their young"... is an old saying that am still confused about.
My unit manager is "not military", "is not mean", "is anal", "is not picking on me",... ETC. Her goal is not to have yet another FLAT LINE!
We were anatomically created with 2 ears, 2 nostrils, 2 eyes, 2 hands, 2 legs BUT 1 mouth for a reason.

Greg. BSN, CCRN, CEN, PERLS, MBA.

Lots of typos, errors & grammar mistakes. Forvive me please (E&OE)

phoenixfire · Aug 18, 2009

First, let me thank the two responders to my question. I'm not an A student, per se, I'm an A+ personality type. I often have to step back and try to bite my tongue, or sit on my hands when all I want to do is jump in and help. The hardest thing for me during clinicals is feeling so completely incompetent. The nurses that I work with in my tech job are AWESOME and are willing to teach and allow me to ask questions and help when it is feasible. They often discuss with me after an event what the play-by-play is/was, and how they know those things.

I have done some serious thinking on why I failed the clinical portion, and in doing that, I can see that I do need to repeat the course, because I wasn't able to show my instructor what she needed to see. I know that working as a tech is a great experience, and that experience is valuable. What it is not is a pass through the critical care course. On one hand, I feel like I was expected to know more than the other students because of my job, and on the other hand, I feel like my job just illuminates for me how much I DONT know. The more I see and experience, the more I realize "Holy crap, I don't know jack!".

And the more opinions I listen to, the more I can piece together the big picture, like pieces of a puzzle that show the whole scenario. While it is devastating to me personally to have failed, it also makes me want to double my efforts, because this is the first rotation during nursing school where I feel like "YES!! This is where I want to be!", and in order to be accepted in the world of critical care nursing, I have to make some changes.

Thank you again, for your insights.

dcglidewell RN BSN · Aug 18, 2009

You are most welcome. I wish you success and a rewarding professional life. Your above comment leaves little doubt.