So, what's it like?

[CardiacDork]

I work at a level 1 teaching hospital. This is the only place I've worked and I could not see myself working at NON teaching facilities. I'm so used to this. I love our morning rounds and learning with the residents. I have such great relations with the residents. I've even made friends with several residents and many of our own students outside the hospital. (We have parties and dinners/gatherings) and being in the ICU we work so closely! It's fun. It's open environment of learning.

For those nurses that have worked as RNs at both environments Big trauma university hospitals vs non teaching facilities.... What's it like? Physician relations? Nursing management? Nursing care? EBP (medicine and nursing)?

Im just curious and want to learn. Thanks

[VANurse2010]

I work at a level 1 teaching hospital. This is the only place I've worked and I could not see myself working at NON teaching facilities. I'm so used to this. I love our morning rounds and learning with the residents. I have such great relations with the residents. I've even made friends with several residents and many of our own students outside the hospital. (We have parties and dinners/gatherings) and being in the ICU we work so closely! It's fun. It's open environment of learning.

For those nurses that have worked as RNs at both environments Big trauma university hospitals vs non teaching facilities.... What's it like? Physician relations? Nursing management? Nursing care? EBP (medicine and nursing)?

Im just curious and want to learn. Thanks

I spent the last two and a half years at an academic medical center (level 1) and now completing a travel assignment at a level 1 trauma center that is technically a teaching hospital but is definitely not an academic medical center. I work ICU.

It's been a negative experience for the most part. I was expecting them to be fairly similar in terms of adherence to safe, evidence driven practice, and staffing safely (albeit by using travelers). That has not been the case.

I've learned that it's apparently OK to have hospitalists managing medically complex patients in an ICU without critical care consults, a corollary to that being that apparently you can call a unit an ICU without intensivists consulting or running the cases (p.s. you can't/shouldn't).

I've learned that having all nurses on the floor having 3 patients including the charge is apparently acceptable staffing.

I've learned that having a stable CRRT on no pressors should be singled while everyone else is tripled (um, no). I realize this one is more controversial, but CRRT was not automatically singled where I cam from.

I've learned that cisatracurium should be used a behavioral control agent (it isn't and I refused to use it as such).

I've learned learned that large CVAs with mid-line shift are acceptable on a MSICU with no neuro consult in a hospital with a neuro ICU.

I've learned that hanging up on nurses and saying "I'm just night cover and headed out the door - call the day team" is appropriate when a patient has a HR in the 160s and breathing 50 times a minute.

I've learned that being a condescending prick to nurses is general isn't only acceptable but a way of life.

I could go on, but suffice it to say I can't wait to get out of here. My former facility is much more akin to what the OP described.

[KatieMI, BSN, MSN, RN]

I worked in both, and encountered other nurses working in both, and can tell that environment is absolutely place-dependent.

Some of my MSN classmates told that they are prohibited from doing blood sugar check if it is not ordered. That happens in one of the leading teaching centers of the state. In my unit, Charge RN can order whole bunch of stuff including ABG, ECG, chest Xray, etc., administer emergency meds outside of code and do many other things which are unknown in "host" hospital one floor below. I recently got involved in a project of developing education/policies for nurses reg. recognition of post-interventional bleeds. In two teaching hospitals nearby, everything a nurse can do is contact physician and circle the bruise, if any appears. God forbids her to call IR, although early IR intervention is the best way to find and patch the bleeding spot without withdrawal of anticoagulation. Also God forbids her to call the other doc who forgot to stop Coumadin before procedure (so that patient is now on 4 anticoags total), leave alone request for fluid challenge. Both actions are considered "violations of Practice Act" punishable by termination and letter to the Boards. Really?? (P.S. both places go bananas about "customer service").

About the knowledge, the last time I checked The Big Harrison and every other medical book I know was free for purchase, ownership and study for everyone, whether MD or not. And, trust me, it all is far from rocket science.

In short, nobody prohibits anybody to know as much, or as little, as one would like in this society. Individual willingness to sacrifize time and efforts is the only one barrier there. The opportunity to apply this knowledge, though, is entirely another question and more depends on local quirks and objective needs. If a NM has a "C-is-a-degree" complex because that was the highest score she ever got, or a hospital sees nurses as overqualified waitresses with additional option of distributing drugs, this maybe a teaching hospital or not, but any nurse with knowledge already and thirst for more will not be comfortable there.

[CardiacDork, MSN, RN]

I spent the last two and a half years at an academic medical center (level 1) and now completing a travel assignment at a level 1 trauma center that is technically a teaching hospital but is definitely not an academic medical center. I work ICU.

It's been a negative experience for the most part. I was expecting them to be fairly similar in terms of adherence to safe, evidence driven practice, and staffing safely (albeit by using travelers). That has not been the case.

I've learned that it's apparently OK to have hospitalists managing medically complex patients in an ICU without critical care consults, a corollary to that being that apparently you can call a unit an ICU without intensivists consulting or running the cases (p.s. you can't/shouldn't).

I've learned that having all nurses on the floor having 3 patients including the charge is apparently acceptable staffing.

I've learned that having a stable CRRT on no pressors should be singled while everyone else is tripled (um, no). I realize this one is more controversial, but CRRT was not automatically singled where I cam from.

I've learned that cisatracurium should be used a behavioral control agent (it isn't and I refused to use it as such).

I've learned learned that large CVAs with mid-line shift are acceptable on a MSICU with no neuro consult in a hospital with a neuro ICU.

I've learned that hanging up on nurses and saying "I'm just night cover and headed out the door - call the day team" is appropriate when a patient has a HR in the 160s and breathing 50 times a minute.

I've learned that being a condescending prick to nurses is general isn't only acceptable but a way of life.

I could go on, but suffice it to say I can't wait to get out of here. My former facility is much more akin to what the OP described.

We only single our CRRTs if we titrating the UF.

For those non critical care nurses.

CRRT is a type of dialysis and the UF is how much we pull off. CRRT is a very slow dialysis for unstable patients that cannot handle having 4 liters taken off in 5 hours by conventional HD.

Nornally CRRT has a fixed UF of anywhere from 50to300. Fixed means we don't mess with the UF

A titrable UF means that you as the RN are moving that number up and down hourly based on

-Your assessment (hemodynamics and patient assssment)

-Your INs and OUTs (totals, you clear your pumps sand do hourly I/Os)

-The goals the nephrologist sets. If a net loss of 150 is desired, you try your best while maintaining hemodynamical stability to achieve such goals.

Keep in mind these patients are very ill and have up to 10 drips many many time as this has been my experience. So imagine keeping all that CRRT business in consideration whilst also titrating and managing multiple drips. Whilst also managing other things that may be going on such as DKA of multiple complex dressing changes or multiple transufusions of blood products.

[VANurse2010]

We only single our CRRTs if we titrating the UF.

For those non critical care nurses.

CRRT is a type of dialysis and the UF is how much we pull off. CRRT is a very slow dialysis for unstable patients that cannot handle having 4 liters taken off in 5 hours by conventional HD.

Nornally CRRT has a fixed UF of anywhere from 50to300. Fixed means we don't mess with the UF

A titrable UF means that you as the RN are moving that number up and down hourly based on

-Your assessment (hemodynamics and patient assssment)

-Your INs and OUTs (totals, you clear your pumps sand do hourly I/Os)

-The goals the nephrologist sets. If a net loss of 150 is desired, you try your best while maintaining hemodynamical stability to achieve such goals.

Keep in mind these patients are very ill and have up to 10 drips many many time as this has been my experience. So imagine keeping all that CRRT business in consideration whilst also titrating and managing multiple drips. Whilst also managing other things that may be going on such as DKA of multiple complex dressing changes or multiple transufusions of blood products.

UF has never been fixed on any CRRT patient I've ever had. Just goes to show you the differences between facilities and units. Acuity with CRRT can vary greatly - they are not all on 10 drips and you wouldn't pair a patient who is on a bunch of drips with someone on CRRT. I maintain, however, that not all CRRT needs to be singled even if you're adjusting the UF which isn't complicated.

[quazar]

Teaching hospital pros: cutting edge practice, equipment, procedures, and lots of hands around. Stat means STAT. Critical means CRITICAL. It doesn't matter if it's 3am, people move at the same speed and you have the same amount of staff on hand and stuff gets done. Every resource and specialty right there at the tips of your fingers. You get to help shape new doctors, and that is a great thing, because some of those doctors turn out to be truly fantastic physicians years down the road because of the nurses that helped shape them. Very rewarding to see.

Teaching hospital cons: residents and med students constantly all up in your grill, waking up your patients, doing multiple invasive exams that are uncomfortable and that they don't always do correctly, having to deal with resident anesthesiologists who don't always get it right on the first try (this matters when you're dealing with labor epidurals....), having the "sickest of the sick" patients all. the. time. and never just having a freaking "normal" patient with low acuity and a fairly uninteresting/steady course of treatment. Drama all the time. Unnecessary consults called/treatments given in the name of learning and teaching, and it gets ridiculous. Because residents and med students need to learn, nurses don't get to do a lot of procedures.

Community hospital pros: lots of independence, docs rely heavily on nurses to be eyes/ears/brain, patients aren't "the sickest of the sick" all the time and the slower pace allows nurses to give actual patient care instead of just monitoring the machines and charting while running from room to room. Attendings who are smooth and practiced at a lot of skills and can pull them off flawlessly, especially anesthesiologists who can put an epidural in a screaming, squirming, laboring woman in 5 minutes flat without flinching and it works beautifully. Priceless. Nurses do a lot of procedures themselves, so you get a lot of experience.

Cons: Docs don't want to come in, have to sometimes be dragged in by the hair/kicking and screaming. Going up the chain of command is difficult, because the chain of command isn't resident/fellow/attending, it's attending/unit chair/medical director, and that is a really hard pill to swallow and a scary thing to do if you're a nurse. Stat doesn't always mean stat, in fact, stat at some community hospitals can mean "within an hour." WHAT?!!?? If a truly critical patient comes in, sometimes you're up a creek because the right specialties aren't always in house at your beck and call (read: OR staff, neonatology, etc.), and you have to wait and it's terrifying and frustrating. You do a lot of praying at the bedside. Skeleton staff and resources at night and on weekends, lots of Macguyvering going on. Some staff have only worked at that hospital their entire careers and know no other way of doing things and refuse to learn anything else. Frustrating.

That's my take.

[CardiacDork, MSN, RN]

UF has never been fixed on any CRRT patient I've ever had. Just goes to show you the differences between facilities and units. Acuity with CRRT can vary greatly - they are not all on 10 drips and you wouldn't pair a patient who is on a bunch of drips with someone on CRRT. I maintain, however, that not all CRRT needs to be singled even if you're adjusting the UF which isn't complicated.

I said many times, not every time. Many times has numerous drips. Almost CRRT I've ever had that we were titrating the UF on has numerous drips. Which is perhaps a good thing they were singled. Adjusting the UF starts to get tricky with these patients especially when they're being slammed with blood products.

Essentially everything boils down to the facility and the providers.

A lot of facilties single IABP based off a quick search I did.

We do not single IABP at my facility and frankly there's no need to unless they are unstable. Unless they are unstable it's pretty easy. Every hour Assess your sites and pulses. Assess your machine. Every four hours assess a waveform for adequate function.

[NurseCard, ADN]

Without wading through all of the posts... sorry... just have to say it...

I am currently working in a small, non teaching, community hospital with patients of, dare I say, VERY low acuity... and I absolutely LOVE it. Would not go work at a big university center if my life depended on it.

Having said all of that... my little hospital is actually looking at shutting down if a bigger one is not built in the next year or so. Company does not want to keep pouring money into this old place. So, very much hoping that the new hospital happens, but that the workload continues to be, at least relatively easy.

[AliNajaCat]

A previous employer of mine was reluctant to hire nurses who had only worked at teaching hospitals. They were perceived as less independent and used to having a doctor available on premises at all times.

I found exactly the opposite when I left big-time academic medicine to move to a small town (for love). I was astonished at the lack of independence I had there. I had been used to getting blood gases when a patient needed it, to weaning people off vents as needed, to repositioning ET tubes and SwanGanz catheters prn, to asking somebody to put a stitch in a loose central line, to get a 12-lead when new AF happened, to put dressing change instructions in the chart for a patient, to call a consult for a new problem-- all completely verboten in my new job. These nurses wouldn't do squat without asking for permission, even in an emergency. Scary.

[SmilingBluEyes]

Oh I dunno, I kinda liked the autonomy of working in a non-teaching facility. In such facilities, residents were all over and often got in the way of nurses just doing their job. Worked rural nursing for while. Talk about having to think on your feet. But I enjoyed the challenges. And just because a facility is non-teaching does not equate with "non-learning". I learned TONS in that couple years of rural hospital nursing. Wouldn't take anything for that experience. The nurses were very close-knit and we depended on being a real team to get the job done.

The doctors in such facilities used to love to teach us what they could. We knew each other so well, and ran like a well-oiled machine when the poop hit the fan.

Learning occurs anyplace your mind is open to new and different experiences, not just big teaching hospitals.

[BSN16]

I work in a level 2 trauma ICU and we have about 20 beds. We have 3 intensivists that switch every week. They are all fantastic and know us by name and will ask about our kids, lives, etc. One doc buys us pizza when we're having a rough day. they are all great

Only negative they are on call that entire night, so sometimes i feel bad calling them 10+ times a night. when do they sleep???

[Lev, MSN, RN, NP]

I have worked at two non teaching facilities (one of whom is associated with a large university teaching hospital and one of the best hospitals in the state) and I currently work for a teaching facility. Where I work now is the best place I've worked and it is a magnet facility as well and I think it does make a difference. The first place I worked was so customer service oriented that it stressed out the staff and drove the staff out. The patient population was very "city" and one that was not easily appeased. The second place I worked catered to a more "upper class" crowd and while focused on customer service the clientele is generally more reasonable. There is a great working relationship between the nurses and PAs which was lacking in the first facility. When I first started working at the second (non teaching) and before they were "Taken over" by the larger university teaching medical center I felt it was very old school and had too many rules restricting a nurse's scope of practice. They also had a very outdated charting system (meditech). Now the charting system is epic and there are more opportunities for nurses and they are encouraging specialty certification etc. Where I work currently (which is a teaching facility but also a community hospital) while we are far from a trauma center we are a very busy ED (busiest in the state and busier than the trauma centers) and have large numbers of high acuity patients. I think every facility is different and quality of care is not necessarily dependent on teaching status or trauma level designation.

[JadedCPN, BSN, RN]

While there can be some nuisances associated with teaching hospitals and academic medical centers, I think for myself personally the pros outweigh the cons. I would not only never work again in a non-teaching hospital, but from a pediatric perspective I would never work in a hospital that wasn't one of the top 5 in the country. That is simply because in my decade of experience, those teaching academic pediatric medical centers that rank high on the best hospitals list truly do have and expect and adhere to a higher standard of care and professionalism. They are always using the best and most recent evidence-based practices to continuously improve care and there is a general culture that cultivates inquiry and allows for changes. I worked at another pediatric facility which was a large teaching facility but it was not one of the top ranked ones and that level of standards and professionalism just wasn't there.