"Non Moms" good NICU nurses

[sdg]

I apologize if this question has been asked before. Do you think that generally nurses with children of their own transition better as new grads in the NICU? Do they normally have a higher comfort level that a new grad with no children?

[KRVRN, BSN, RN]

Well, I wouldn't go so far as to say you'd be an idiot! But I can tell you that if you went to work at a NICU you would likely be put through the same preceptor program complete with all the classes and 1 to 1 training as the new grads. You would be assumed to know nothing about working in a NICU just like the new grads because everything is different than in an adult ICU. Whether or not you would do well depends on your ability to think different from what you've learned before.

Of course you'll have advanced time management skills and abilities to interact with families and doctors and such but we all know that's not everything, especially in an ICU environment.

We have a 20+ year experienced nurse that's done adult ICU, oncology and med-surg her entire career and has had a hard time changing her thinking. I'm sure her knowledge base is extensive regarding everything adult. But I would sooner let one of our

[llg, PhD, RN]

i'm not arguing the fact that all nic folks are superhuman and possess skills unknown to mankind (never been a nurse from day one or not...must be a super alien gene pool you get new grads from). what does concern me is that you say that no matter how many years...nor how many procedures...nor how much education....i have...i 'm an idiot if i were to walk into your nicu. sorry, but i'm pretty incredibly intelligent and i have to say so every now and then or folks forget. i suppose it's time to agree to disagree.

?

i never said that nicu nurses were superhuman ... or that you would be an idiot ... and anyone who goes back and actually reads my posts will see that.

what i said was that much or your previous experience in an adult care environment would not be relevant in a nicu situation. in many ways, you would be a "beginner" all over again. you would need to learn the different specialty of nicu nursing from the ground up, just like everybody else.

some nurses handle such a transition better than others: they are able to "set aside" the lessons and behaviors learned in the adult care units and build a knowledge base that is required of a nicu nurse. others hate that feeling of "not being an expert" and being unsure of their judgments and don't survive orientation. i don't claim to know how well you would handle it if you had to "go back and start from the beginning" again.

nicu's have been around for over a century now -- and they have a long and strong history of providing orientation and on-going education for their staffs. they have had to do this for themselves because they have always been a little "off to the side" from the rest of the health care world. unlike med/surg units who sometimes expect the new grad to come with much of the knowledge necessary to work on that unit, we don't expect nursing schools to teach nicu and are quite prepared to teach nurses (new grads or experienced) how to care for nicu patients. nicu education has always in nicu's -- not schools -- so the fact that schools don't cover it is ok with us. we are prepared to provide that piece of education ourselves -- as we always have done.

llg

[oicu8bacilli]

I'll leave the topic with the comment that I am very glad I'm done having kids, scared for the rest...but at least I'm done. Please send your mom to me and I'll ensure my newest nurses takes care of her post CABG, we'll roll the dice like you have with your new grad. Then again, folks don't care when gramma dies, but they get pizzed when their kid croaks. Funny, I never thought of nursing as a crap shoot...but recent exposure to all of the different fields makes me wonder what we really get done every day.

[KRVRN, BSN, RN]

OH MY GOD!!!! What has happened here? GEESH!

[dianacs]

This has turned into an interesting discussion. Reminds me of another poster from some time ago who held similar views of new grads. I am about to be a new grad myself so of course my opinion counts for little. I will say that like most schools, mine does emphasize med-surg. However, I don't feel that means that I am necessarily prepared for specifically working on a med-surg floor. Or any floor or unit for that matter. Rather, med-surg is used as a context for learning about adult nursing care. I hear some diploma nurses say how when they graduated they were "floor ready" immediately. It isn't that way now, at least here. Hospitals have extended orientations for new grads in all areas, even med-surg. The new grad isn't expected to be done cooking yet. So, can anyone show that outcomes differ when you compare the new grad to an experienced nurse (experienced in other areas but also new to the NICU) after orientation is complete and the nurses are on their own? To me, that would be the real test.

[fergus51]

OH MY GOD!!!! What has happened here? GEESH!

Apparently someone who has never worked or been trained in this specialty is certain we are all rolling the dice with babies lives because we don't agree with her. Right.... some people just can't handle not being acknowledged as the all knowing expert. I would much rather orient a new grad open to new ideas than an experienced nurse who gets mad if I disagree with her.

[llg, PhD, RN]

This has turned into an interesting discussion. Reminds me of another poster from some time ago who held similar views of new grads. I am about to be a new grad myself so of course my opinion counts for little. I will say that like most schools, mine does emphasize med-surg. However, I don't feel that means that I am necessarily prepared for specifically working on a med-surg floor. Or any floor or unit for that matter. Rather, med-surg is used as a context for learning about adult nursing care. I hear some diploma nurses say how when they graduated they were "floor ready" immediately. It isn't that way now, at least here. Hospitals have extended orientations for new grads in all areas, even med-surg. The new grad isn't expected to be done cooking yet. So, can anyone show that outcomes differ when you compare the new grad to an experienced nurse (experienced in other areas but also new to the NICU) after orientation is complete and the nurses are on their own? To me, that would be the real test.

Well, I keep the statistics for my hospital (and have talked with people in other hospitals who do the same) and I have found that we have the best retention rates with new grads. Many nurses who transfer from other types of units leave within a few months. Few stay long enough to become experts. However, those who do stay certainly have the potential to become experts.

The research you suggest is really not the best question to ask because it would be impossible to get adequate controls to make fair comparisons. Too many "real life" confounding variables would enter into it. Plus, there would be the extremely controversial issue of deciding how and when to measure the quality of the nursing care.

For example, should you measure degree of independence one month after orientation? Well, the person who asks a lot of questions and seeks help may actually be doing a better, safer job than the one who "feels" independent and goes off on her own.

Do you compare officially reported error rates? We all know that is only 1 component of quality and the overall rates are so low that would be a poor measure to use.

Do you look at who stays long enough to develop true expertise? Who is still there after 2 or 3 years to take on leadership roles? New grads might win that one. Most (but not all) of the really long-term NICU nurses I know and those who are in leadership positions started as new grads.

It's just not a simple, straightforward thing to measure. The new grads take longer to grow in some ways, but pick up quickly on others -- and they tend to stay long enough to develop the necessary skills at higher rates than do the nurses transferring from other units. Those who transfer from other units do just fine IF (and this is a big if) they can stick it out emotionally for a year or so to make that transition. Some either leave soon after transfering or stop developing because they just don't feel like NICU nurses inside. It doesn't feel right to them because it goes against what became ingrained in them in their previous units. So they return. Those that stay a long time and committ deeply to it do fine, but the numbers are smaller.

llg

[KRVRN, BSN, RN]

Well, it sounds like she (he?) would rather have nurse with adult experience but new to the NICU take care of her child rather than a new grad new to the NICU.

Like there's a huge difference.

[prmenrs, RN]

I have always maintained that the issue isn't the nurse, it's the patient. All thru school, the majority of what nurses learn is oriented to adult nursing. Norms for vital signs, dosages, assessment skills. If a new grad goes to that one year of med-surg, all that gets cemented into his/her brain. Then, when she goes to NICU, she keeps watching the baby, and comparing it to the adult "norm" in her head--total misfit. You need to develop that sixth sense that says somethings wrong, and you can't do it til the other [adult] norm is displaced w/ the baby norm.

Babies have much different, more subtle indications that something's wrong. Because of the immaturity of their organ systems, responses are much more non-specific. Things like thermoregulation problems, NEC, mec asp, RDS (not really the same as ARDS, I don't think), Hyperbilirubinemia, and the therapies for these problems, do not exist in the adult world.

Because new grads are not so acculturated (sp?) to the adult patient, it is easier for them to get into babies. They do not start out with really sick babies. At the level III NICU I retired from, they had a LOT of didactic work before they started working w/a preceptor 1:1 on an intermediate baby, advanced to independant practice in that area, then back to the classroom for more didactic, then being precepted again in the ICU area. The whole orientation is several months. And when they are on their own, they are still mentored by more experienced nurses for the first year.

We treated them carefully because we wanted them to stay, be great nurses for our babies. I don't think any of them ever felt thrown to the wolves, or gnawed on by some grumpy old nurse.

[prmenrs, RN]

Thank you, everyone, for keeping this discussion so cool!

[dawngloves, BSN, RN]

There are new grads in the ICU, in the CCU and in the ER now. Why not the NICU? Our orientation program is 12 weeks long. No one is thrown into the fire. The only thing that made me any different from a new grad when I oriented was my sense of urgency and my organiziation skills and after 12 weeks most have that down.

I've never had anyone ask me how long I'd been a nurse either, nor have I asked anyone caring for my children. I'm sure each hospital sets high standards and that the nurses meet those expectations. And I've seen those that haven't out on their a$$es.

[TiffyRN, BSN, PhD]

I'm one of those "dreaded" experienced nurses who changed to NICU. I think I was in a good place mentally to do it though. I had worked some as a traveler and for several years in a float pool (went to every med/surg/tele/oncology/neuro area in the hospital. That taught me open-mindedness about how to do things. I used my own nursing judgements certainly but found out how each units procedures varied.

I went into NICU with a very open mind and fully expecting to have little of my previous skills come to use. I was mostly right. I did find that at least compared to the other new grads that started about the same time I had superior time-management skills. I had no fear of talking/discussing things with doctors or NNP's. I also felt comfortable doing patient teaching (though it would be to the parents now instead of to the actual patient).

Now, if the previous poster concerned about new grads had quizzed me about my experience a couple of years ago I could have told her I had been an RN for 10 yrs, I could have failed to mention that I had been in NICU for just a few months or I could have been honest and added "but only been dealing with babies for 6, 7 months. I always told my parents that asked the full story, party to add something like "I really like this better, I'm really enjoying this" because I think it helps families to know the caregiver enjoy their jobs. I don't feel I'm a "dumb bunny" and always excelled in my cardiac nursing career (that was my main focus before) but I really feel I started over and very few assessment skills made the transition.

It's actually kind of funny. I've been in NICU for about 2 years. I think most of you out there would agree that it's around 2 years after graduation that you start to feel comfortable. I would say I've gotten to do that over again. I've just now started to pick up subtler signs/color changes/behaviours in infants in that last couple of months. I think that's what the support staff I have working with me is all about. I ask many questions and invite the charge nurse to assess any babies I have doubts about but the truth is up until recently I've had that "new grad" feeling like I'm almost getting some point!!

The babies are not going to be protected by keeping new grads away from them and only allowing "experienced" nurses to orient to the NICU. The babies will be protected by having a decent charge nurse who knows the individual skills and strengths of each nurse and distributes her staff wisely. He will know to give the 15 yrs NICU nurse in charge of the 24 weeker coming from from OR for a PDA ligation and give the new grad a couple of smallish kids with CPAP and a PICC line.

New grads in any critical care area are a reality and I think it can be an appropriate placement as described earlier (with internship classes, supportive leadership and co-workers)