Thinking of going to ICU/MICU/SICU

[JetBlitz]

Ok so I'm a nurse with 2.5 years of experience. I've worked in Cardiac Tele with 9 patients on drips (in a 36-bed floor), and currently I'm working in a Med-Surge unit with up to 6 patients (in a 28-bed floor). I work nights.

Lately, I've been getting burned out on the med-surge units because

1) We just had 2 experienced nurses on my shift move to SICU (for various reasons) in January.

2) We have 2 more nurses moving to day shift by the end of April because (one is getting sick from the stress of school and working nights, and the other is having trouble balancing school and working nights in general)

3) I am having trouble managing my time since our documenting process involves meticulous "clicking" in our new documentation system (we transferred from MediTECH to a new system that does not have the "F5" function).

4) I can't educate and teach my patients and their families as effectively as I can.

5) I can't get to my patients when they call me (my rule of thumb is to get to their room in

6) We are short-staffed, and as of 2013 our unit is no longer hiring Agency or Travel nurses since it's too expensive to pay for them. (We had a net loss last year because of hiring out-of-hospital nurses to try and meet the demands of the floor)

Here are traits on what I'm really good at from what my patients and co-workers, and even educators and Managers of other units, say about me:

1) I am very compassionate.

2) Very good at teaching about pathology and explaining why the MD chose this type of treatment.

3) I am a team-player.

4) The educators are impressed of my eagerness to learn (I am PALS, ACLS, BLS certified, and I recently got my 12-lead EKG certification --- I'm not that good yet at 12-lead since I don't get the opportunity to practice it on a med-surge floor; I also don't have anyone to critique my assessment of a 12-lead strip since no one on the med-surge floor knows it besides me)

5) My manager has given me assignments here and there to educate my co-workers on various new policies or Evidenced Based Practices.

Biggest pitfall:

1) Time management - for some reason, documentation is always my downfall. I have clocked myself that it takes at least 25 min, to do 1 patient's start-of-shift assessment; 15 minutes if the patient is a walkie-talkie, independent patient who does not call for anything (this is rare). That's because our new Electronic Health Record (EHR) documentation does not have the ability to "pull up" information that has not changed from the last assessment. At the end of shift, we "close" our Notes with the Education we gave to our patients, which takes about 2 min. to "click" and type in what we did during the shift. I usually have 6 patients: so that's 2.5 hours on documentation itself, which includes the Education part. Remember, there's NO way we can "pull up" or copy the information from that last assessment; we have to "click" our way through.

I've been thinking since January that if I just skip most of my documentation except for the start-of-shift documentation (eg: head-to-toe assessment) and just place Nurse's Notes on things that are not normal, I should be able to cut down on my documentation. I don't have to open my Notes and chart q2 hours if my patient had nothing happening. I spoke with my Manager who spoke with Administration, and they said there is no consensus that charting ONCE for the entire shift is no different that charting q2 hours with no changes to the patient's condition. In other words, if I only chart ONCE (mystart-of-shift documentation) I "should" be legally covered if I am audited in the future... right?

When I look at my co-workers' documentation, there's a handful of errors, some RN's skip all-together the Education piece and some RN's don't document that an MD was called, for example, chest pain. They clock-out on time, but it's not best practice.

So Management has already warned me twice for the Overtime I'm doing (that was within 6 months). And the third one will cause Administrative discipline (whatever that means).

I am burnt out. And since January, I've been getting sick and not sleeping well (I usually work out 4-5 days a week and play sports; now I just sit at home sleeping most of the day). I still give my patients the best care I can do while trying to keep up with what is expected of the RNs when we document interventions, or input what the MD's ordered, etc. But I am extremely unhappy since I get reprimanded for doing:

a) What my patients expect of me.

b) What the State expects of me with my documentation.

Our HCAHPS have plummeted to 79 (we average 88) this past first quarter. And the surveys have said that the RNs on my floor have not met their needs in Education nor controlled their pain nor have made their stay comfortable. I am striving to turn this around, but it's impossible to meet the demands of the new documentation system and still be expected to be a "nurse" to my patients.

My coworkers sometimes ask me, "Why in the world did you want to work as a nurse? You know too much! (They say this colloquially as friends, not as a derision) "

Some of the MD's who know how I treat my patients and are pleased with my work ask me: "So tell me again, why are you working as a nurse?"

My patients who approve of my care to them even ask me, "So are you going to be a doctor some day? Are you still in school?"

I answer all of them the same: "I love what I do, I love being at bedside, I love being a nurse."

So my dilemma: I don't want to leave our unit because I'll get reprimanded/fired for putting in too much Overtime. I also don't want to make our unit more under-staffed than it already is.

But I am increasingly unhappy because:

1) I can't take care of my patients the way I want to if I'm too worried sick of clocking-out on time.

2) I can't put to use the critical thinking I have in my brain to good use.

3) I find myself hating that the nursing profession has turned more into a money-making field (no matter how you slice the cake, nursing is different from 30 years ago).

Our ICU RN's usually have a 2:1, max 3:1, nurse to patient ratio. I like a moderate dose of adrenaline --- I want to know how to do Open Heart patients on drips. I want to get better at doing Codes. I don't care about giving blood products as long as I don't have to juggle 6 patients with it (who call for pain meds, going to the bathroom, feeding them, turning them, suctioning, cleaning, calling MD's for events, etc). I don't mind doing Total Care patients (turning, cleaning, fixing vents, etc) since I "enjoy" getting to know my patients inside and out.

I know floor nursing is different from ICU, so I'm willing to take a chance so I can be enjoy nursing and still not be bogged down by time-management constraints.

So should I stay on the Med-Surge unit until we get more staff to cover? Or is it ok for me to switch to ICU?

[coco317]

Sounds like you're a great fit for an icu setting!

My hospital is in the process of switching to meditech 6.0 with the point and click interface. We have a recall feature (an actual button that reads recall) to replace the f5.

[Larry3373]

Go for it of course. Staffing will always fluctuate. ICU position may not last. You can let your manager know so the can get ready to hire someone else.

[meandragonbrett]

6) We are short-staffed, and as of 2013 our unit is no longer hiring Agency or Travel nurses since it's too expensive to pay for them. (We had a net loss last year because of hiring out-of-hospital nurses to try and meet the demands of the floor)

When I look at my co-workers' documentation, there's a handful of errors, some RN's skip all-together the Education piece and some RN's don't document that an MD was called, for example, chest pain. They clock-out on time, but it's not best practice.

Just a few pieces of advice for you. Don't worry about what your other RN Colleagues are doing with their documentation. It's not your responsibility, it's not your documetnation, and it's not your tail if their documentation isn't correct. 25 minutes to chart an assessment seems absolutely too long. I am not sure why it takes so long to chart a quick head to toe assessment on a medsurg patient. Are you being more detailed in your documentation that what is necessary for the medsurg arena?

And regarding the staffing and you leaving and making it worse.....Don't be a martyr. You own your unit nothing. It's a job...not your personal business. Do not think that for one minute that they will dump you if they decided they didn't want you around. Nobody is safe in the hospital environment. Their lack of action with staffing is not your concern, crisis, or emergency as a staff nurse.

I would focus on what you can do to cluster your care and improve your time management. And by all means...definitely head for the ICU if you have a desire to work in critical care. Just remember that 1-2 ICU patients can make your day just as busy as working on the floor with 7-8 patients. Just the focus and priorities are different and the interventions more frequent. :)

[a.evans]

I agree about the charting.. I've been a nurse for a year so I obviously don't have a lot of experience. I work on a very busy ortho floor (with some med-surg overflow). But I used to think charting took so long, until I actually timed myself. When I have time to sit down and focus just on charting, it takes me about 5 minutes for a full head-to-toe assessment per pt. Your hospital's policy on charting may be a little different than mine, but I chart by exception. If everything is normal for a particular system, I chart WDL and leave it at that. Only if there is something different do I go into more detail. Don't make more work for yourself. As one of my coworker nurses once said, "work smarter, not harder". :)

[ybelkahill]

I've been on a SICU for the past two years, and I learned very quickly that just one of these patients can keep you way busier than 7-8 med-surg patients!...

Everything is about prioritizing!... And of course, remember that this is a 24 hours job, not 12!.... If you don't get something done (granted is not emergent and it can wait), tell the next shift to do it!...

ICU is great!!!! Once you make the move, you'll never go back to a med-surg unit!...

[turnforthenurse, MSN, NP]

ICU *IS* floor nursing, just a different kind of floor nursing. There ratio is smaller for ICU nurses because oftentimes those 2 patients are equivalent to having 6-7 patients on a med-surg floor. Sometimes an ICU patient is so unstable they be a 1:1 or a 2:1 (two nurses for that one patient). Other floors think ICU has it so easy because they only have 2 patients but this isn't always the case.

As for the documentation issue, unfortunately, administration seems to want us to chart a million things while still providing excellent patient care. I can't quite do that because I have so much charting I have to do, now can I? Years ago the amount of charting did not equate to what we are expected to do today. It's pretty ridiculous, actually.

I would consult your hospital or unit's policy regarding charting. I used to work on a progressive care unit where we had to do a full head-to-toe Q4H. We also have computer charting, so we would chart the entire assessment between 1900-2000. If there were no changes by the time the next assessment rolled around we could just click "no change from previous assessment." We were also required to do frequent assessments Q2H, which included patient activity, patient care & pain assessments. Vital signs on that floor were Q4H minimum but you would just click and the vitals should flow over into the computer. The only thing extra you really had to do was get a temperature. For the education part, if the patient has already been there, I usually only click "plan of care," "pain management" and "when to call the healthcare provider" UNLESS there is something new, such as a new medication or if the patient is post-op/post-procedure I will go over teaching for that stuff.

Everything seems redundant, but it's policy, and if you don't follow policy you could get yourself in trouble. I work in the ER now, where charting is different...the assessments are focused. We need to round on our patients Q1H and for each hour, I type up a little nurse's note to CMA, such as "patient resting in bed, no complaints at this time. Currently pain free. Call light in reach with use encouraged." And if the next hour rolls by and that doesn't charge, then so be it, but I still chart and make a note of it.

Consider if you were to chart once your entire shift and only chart by exception. Say you chart your shift assessment at 2000 and everything is fine and dandy...then 0100 rolls around and you end up having to call a rapid on your patient for whatever reason. If you only charted by exception, it almost looks like you never checked on your patient between 2000 and 0100. If it's policy to chart frequent assessments at minimum Q2H but this happens and you didn't, that could lead to trouble, imo.

So bottom line, follow your hospital's policy regarding charting.

Starting a new computer charting system is a huge learning curve for everyone. When I started working at this hospital, I had to work with a charting system that I have never worked with before. I was slow with charting at first (unless it was free-text). Over time I got used to it and now I can chart full assessments in roughly 5 minutes. You'll get there with time as you get used to this new system.

As for you working too much overtime, you owe the unit nothing. You need to take care of your own personal wellbeing, too. Although all of that extra overtime can be nice on your paycheck, you're already complaining of burn out and that's why.

I say if your heart and desire is in critical care, then go for it! Don't feel like you're "abandoning" your current unit.