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

[SnowSeal]

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.

Sounds like you work at my hospital!

I had the best experience when I did my preceptorship in PICU at a large teaching hospital. They had high standards, but if you were struggling with stuff, the nurses & doctors were more than happy to help you out. I got some criticism, but the whole environement was so supportive and the staff loved their job, so the criticism just motivated me to try harder.

My current hospital is the level 1 trauma center for the county and, while technically a teaching hospital, the only students they have are those doing preceptorships or are residents. Terrible environment to work in, identical to what VANurse2010 describes.

[nutella, MSN, RN]

We have had an influx of these ICU nurses from the community hospitals around the area and levels 2 centers show up to our level 1 ICU and be completely surprised and overwhelmed. They've told me the patient population they cater to, lots of patients that should really be on the medsurg floor or step down unit. I'm blessed to be at a level one. I was looking back at the patients I've taken care of. I try to keep a list of times I've taken care of patients on a device and in the last 6 months I've taken care of 7 ECMO patients, 10 balloon pumps, 10 VADs, and 27 CRRT patients. That means that out of 72 shifts, about 54 were days with device patients.

I have a vented or two vented patients everyday so I do not even count the vent really.

I totally agree that there is a huge difference between level 1 and doing "all things known to mankind" and the community hospital. Personally, I enjoyed the devices and patients who pose challenges...

I liked ICU and CCU in major teaching hospitals - was not as stressful as med/surg tele. Even though the patient could have IABP, CRRT, intubated (which is a plus unless the patient is having a wake -up trial...) PA catheter and so on and forth.

[HouTx, BSN, MSN, EdD]

Very interesting thread - my clinical practice area is Critical Care & I've worked in and around a wide range of settings from teaching hospitals to the smallest of the small critical access rural hospitals.

Felt I needed to react to this...

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.

Some of these things are outside the scope of nursing practice in my state. If you're doing them without the coverage of a standing delegated order, you can find yourself in deep caca... especially when something goes awry and left out to dry by the physicians who quickly circle the wagons.

As an educator, I am well aware of the skills gaps that usually have to be addressed when nurses work in community hospitals for the first time (after experience in a teaching facility). Depending on the unit/area they worked, this even may include things like IV starts & Foley insertions, because these were done by physicians-in-training because they needed the experience. We also had to provide training on dealing with IICP, IABP, VAD, etc. management (insertion site care, changing pressure lines,etc) because - again... baby docs had to learn. But it's all good. Skills are easy to learn ....

[CardiacDork, MSN, RN]

HouTx,

Youve said it. I am always perplexed by nurses namely (LPN vs RN or even MA) naming off skills they can perform in a who has the biggest pecker contest. AS IF skills made the nurse. Psychomotor skills can be learned with practice and the fact is a monkey can learn a skill. We need to move from a skills mindset to a mindset if which we constantly question and explore the reasons, indicadons, EBP, and so forth.

[VANurse2010]

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.

IABP doesn't need to be singled unless unstable (but usually if they're *that* unstable they are going to need something more invasive than IABP). We did our timing/waveform checks every hour along with site and pulse assessment.

I still don't think adjusting UF is difficult regardless of blood products, boluses, or multiple drips. When you're at that point, the patient needs to be singled, but not because calculating the UF is hard (it isn't).

[MDMBSNRN]

I have worked in both teaching and non-teaching facilities. In fact, I just ended my job at one of the largest, and most prestigious, teaching hospitals in the country. What I found was that I had significantly more autonomy at non-teaching facilities than I did at the teaching hospital.

In terms of physician relations, I had much better relations with my intensivists in the non-teaching hospital than I did with the two to three ACNPs, two residents, one to two fellows, and at least one attending that were constantly present in my ICU at the teaching hospital. Physicians consulted from other services darted in and out of the room without ever even acknowledging the bedside nurse, so I rarely even knew their names.

I can say that the teaching hospital had a bigger focus on evidenced based practice (to a degree) than the non-teaching hospital did. However, a lot of the nurses in my ICU leveraged this as a tool they could use to brag, and it became a competition of who could throw the most impressive academic study in someone's face. At the non-teaching hospital, I felt like EBP was truly implemented to attempt to improve patient outcomes. In my ICU at the teaching hospital, I felt like EBP was a tool used to make oneself look intelligent, and put others down.

I enjoyed the time I spent in the teaching hospital environment overall. However, I enjoyed the greater autonomy afforded to my nursing practice by working in a large non-teaching hospital. I also felt that the nurses in the non-teaching facility were friendlier, and that we worked more cohesively as a team. The poor attitudes of nursing staff most likely don't hold true of every department at the teaching hospital, but I have seen more rude, hateful, and arrogant attitudes than I have seen anything else.