Small vs. big NICU - what is best for new grad?

[GoldenGateNurse]

Hi everyone,

I did my senior preceptorship in a large Level III NICU. The unit was terrific, with everything from feeder growers to the very sick kiddos on HFOV and dopamine drips. I have been offered a new grad position on this unit, as well as a smaller Level III unit that is much, much closer to my home. The smaller unit seems really friendly and like the staff would make a big effort to teach; however, there are usually only 13 or 14 babies, and most of them are not very critical. Although they do have babies on vents and things...just not as many and not as consistently as the other place.

Do any of you experienced NICU nurses have advice on which unit would be best for a new grad? Is it best to be on a large unit with a high census of critically ill babies? Or is there something to be said for a smaller unit where you get a lot of attention and teaching from the more experienced nurses, albeit with less acutely ill kids??

Thank you so much for any help you can provide. I feel so lucky to have two job offers and want to start my career on the right path!

[Jolie, BSN]

My bias is to suggest that you start in a large unit, then go to a smaller one if a few years (or decades) when you are ready for a slower pace.

Most NICU's in large, teaching hospitals have comprehensive, well-organized orientation programs for new grads and RNs changing specialties. They typically include clinical and classroom instruction, NRP certification, and 1:1 training with a preceptor. Smaller units often do not have the staffing or resources to offer such comprehensive orientation programs.

Also, working in a large Level III unit will provide you with access to critically-ill infants with complex needs on a daily basis. Your preceptor will be able to pick and choose patient assignments that enable you to learn and practice skills and concepts necessary to succeed as a staff nurse. The patient population and census tend to be far more variable in smaller, Level II units, and may not enable you to learn the same range of skills.

As a new grad, I started in a 45-bed Level III NICU where I was first introduced to step-down care, then intermediate (Level II) infants, then intensive care, then admissions. I had new challenges on a daily basis, and had seen and done most of the necessary skills by the end of orientation. A number of years later, I moved to a new city and took a job in a Level II NICU. I never saw a ventilated infant during my 6-weeks of orientation. It wasn't a big deal to me, since I already was well versed in their care, but if I had been a new nurse starting out, it would have been a HUGE void in my training.

Good luck to you!

[GoldenGateNurse]

Thank you so much for the feedback!

I think I'm having such a hard time with the decision because the smaller Level III unit actually has a formalized orientation, including NRP, 1:1 precepting, and classroom time. The larger unit has that sort of training, but not this time of year....so I would essentially be placed on 4 weeks of 1:1 training and that would be it.

Anyway, I appreciate your help. Thank you.

[cathys01]

Only 4 weeks of training with critical kids? DEFINITELY not enough time to get everything there you'll need in that environment. (If you're only working 3x12 hrs/week then imagine yourself completely on your own with very sick babies after only 12 DAYS of orientation...)

If those are your only options at this point, then I'd probably take the smaller NICU and transfer to the larger one after your comfortable and competent with the less acute kids.

[GoldenGateNurse]

You just raised another interesting question for me.

Let's say I start on the smaller unit, go through the training, and get my feet solidly beneath me with the more stable babies. How receptive would the nurse managers at the large units (there are several in my area) be to hiring me? I know that you orient to any unit as a new hire. But would they want me to go through a full-fledged "new grad" program, or worse, not want to hire me at all because of the limited experiences I'd have in my first position?

Sorry to pepper you all with these questions. I know they probably sound mundane but I'm really struggling to make a good decision. I've worked my tail off to this point in order to even have a shot in the NICU, any NICU. I don't want to choose the wrong path now and be kicking myself down the line.

Thank you, thank you for all your support.