Tips for New Critical Care NP

Ruby Vee, BSN · Sep 15, 2017

I'm sure that your post was directed at other NPs, but here's the thing. You'll be working with bedside nurses, too.

Be humble (I've had brand new NPs tell me that they're "better than" me because they have an advanced degree. So do I.) LISTEN to the experienced ICU nurse. Our experience can augment your education, but only if you're ready and willing to seek and accept input from the experienced ICU nurse who has probably seen this sort of thing before. We've also helped educate physicians . . . and some of the physicians I've helped to educate are now internationally famous. One internationally famous physician came through the ICU with a group of first year residents and introduced them. "This is Ruby. She is an experienced ICU nurse, and we go WAY back. She's saved my butt numerous times, starting with when I was an intern. Listen to her. If she questions your plan, stop what you're doing, and call your resident, chief resident or fellow. I don't want to EVER hear about any of you disrespecting an experienced critical care nurse because right now, they know a lot more than you do."

Be friendly. Good workplace relationships lead to good teamwork. And besides, you just might find your new best friend.

Know your stuff, but if someone questions your knowledge seek to verify. Don't dismiss opinions from CNAs, bedside nurses, respiratory therapists or the patient's spouse just because your education tells you something different. That CNA may well have been a physician in Monrovia have treated that particular disease in the past. (Not so far-fetched -- I've seen it happen.) Even if that isn't the case, the CNA probably knows the patient better than you do.

Expect to study after work and on your days off. Transitioning to critical care demands homework for NPs as well as new RNs.

Participate in the potlucks, bring treats now and again, order out with the staff and make a point of eating lunch with everyone in the ICU. We all have greater respect for new NPs who treat us as colleagues.

ColoradoKT · Sep 15, 2017

Ruby,

Thank you so much for the advice. I have the firm belief that nurses make the ICU go round. As an ICU nurse myself, I have the utmost respect for ALL ICU employees and hospital employees in general regardless of their title. I will make sure to maintain this stance going into my future career! Any tips on homework I can do before?

Thanks,

KT

Dodongo, APRN, NP · Sep 15, 2017

Marino's "The ICU Book" is standard for all the residents rotating through our ICU. It's fairly short (in the world of text books) and is well written. Although I own the book I've only ever used it as a reference text, however all the intensivists I work with have read it.

JellyDonut · Sep 16, 2017

I was an ICU nurse for many years but it is a different world when you step in as the provider and make decisions. In the beginning you may have some older RNs who think they know more than you and want to question every order you make..You learn how to deal with those and also with the nurse who tun to you in a panic over everything. My first year I would look up everything and ask a slew of questions of my partners, but then along the way you just sort of feel like you got this and it gets easier. The staff works better with you and the other providers look to you as a resource, You will still have bad days and days where you question yourself but you see the same stuff over and over and it just gets easier....

Advanced Practice Columnist / Guide · Sep 17, 2017

Agree with JellyDonut. There's certainly a better "political" way of dealing with the dynamics of transitioning from the RN to the NP role in the ICU. You certainly rely on nurses and RT's assessments and listen to their input. Sooner or later, you will know which nurses and RT's are solid, which ones need more hand holding, which ones are "unsafe", and which ones contradict your opinion all the time for no reason. Collaboration and collegiality is very important in this role and you have many other team members that you must reach out to frequently...the ICU Pharmacist and Dietitian for instance are quite indispensable as are Social Work.

Also remember the responsibility that comes with being a provider. Yes, you listen to input from others but at the end of the day, your name is going to be attached to that order. Use multiple resources for knowledge...ICU textbooks are good but lag behind in terms of new and emerging evidence. That said, you must stick to landmark journal articles and guidelines such as those from the surviving sepsis campaign, ARDS.net, delirium management, etc. Learn new tricks such as bedside ultrasound. Know your facility antibiogram and have a handy reference for antibiotics spectrum of activity. Up to date is a good resource. I also find that having a Hospitalist reference handy is necessary if you will be in an MICU and dealing with work-up for electrolyte imbalances, DKA, endocrine issues, etc. There are many good ones you can buy and there are some good electronic versions of these as well.

Work closely with your intensivist. Listen, watch, ask questions, and learn. You will be dealing with the sickest patients in the hospital and communicating with families many of which have challenging dynamics. You will be frustrated with goals of care discussions that go nowhere and sometimes you question your own ethics when care seem futile. Be humbled by the scope of the role and the high acuity of the patients you will be dealing with but continue to strive for excellence.

Melissa1522 · Sep 19, 2017

Ruby says ask a seasoned ICU nurse? I think it more appropriate to ask a seasoned ICU physician -- an intensivist.

eCCU · Sep 20, 2017

I will not lie it's a steep learning curve and it doesn't matter how long a critical care nurse you were. That being said every decision must have an evidenced based rationale remember every action must be defensible in a court of law. No longer documenting you told so and so.

Dealing with staff nurses is easy, appreciate their input by doing clinical rounds instead of intervening when something comes up. It also gives you an opportunity to meet the family and talk to them. You will have some nurses that will try to bully you, I see it happening mostly to NPs who haven't had a lot of experience previously as ICU nurses or work in the same ICU from staff RN to NP. Handle it gracefully and professionally, most workplaces now have bullying statements on their policies. Recognize your staff, be a role model, don't get into workplace gossip and politics.

Know your go to people example...I love my ICU PCA! I rarely place a Central line without them. They literally know where my ultrasound sits, what size sterile gloves I wear, they drop all my required sterile stuff in my field before I even ask for anything. They are truly a blessing!

Develop a relationship with the clinical pharmacist they are walking pharmacology books with current research.

Several specialties to develop strong relationship and have their numbers... nephrologist I have been known to call them in the middle of the night to get the okay to start CRRT or emergency dialysis.

Cardiologist...cause they do crazy stuff that works that's not in any textbook í ½í¸¹and I have yet to meet one that freaks out.

Pulmonologist or intensivist when you have tried all the vent settings on your vent on that ARDS patient and you and the experienced RT are out of ideas in the middle of the night!

Infectious disease if your facility doesn't have a sepsis team. Find out their pet peeves..Sanford guide is awesome

Chaplain...if you are spiritual there are those cases that will have you wanting some spiritual guidance or continue to believe in humanity.

Earn your FCCS by SCCM they have several classes around the country. Attend CE offered by the local medical school if your place of work is affiliated with one.

Familiarize yourself with vent settings off the top of your head...I have heard the RTs complain there is nothing more annoying than intubating a patient emergently and the provider has no clue on basic settings.

Imaging position of ETTubes, Central lines, chest tube can be the determinants of life or death. Ask to rotate with radiologist and anesthesia. I learned how bag appropriately with the anesthesiologist years later! And intubate gracefully with anesthesia, intubate with head of bed up with ED doc.

Keep learning ask your intensivist for feedback consistently and ask for areas of improvement.

The rest enjoy it it's actually funí ½í±Œ

Hope that helps

allnurses Guide · Sep 27, 2017

Agree with most of the above.

- Read, read, read.

- Listen to everyone (nurses, RT, specialists, ccm), but don't act on every suggestion, or that's all you will do all day. You have to sort and filter the input you get, and with time you get better at triaging whose advice to listen to and act on immediately. It takes a long time to develop your own instincts.

- Err on the side of caution, always, particularly with invasive procedures. If you can check something twice, ensure that they are acting safely, do it. If you ever get a bad, sinking, gut feeling - ask your CCM for help. There's often a valid reason you are worried.

- The seasoned ICU nurses need you stat? Go. They have probably already tried several interventions, before they ever even thought of calling you. This is good and bad. But be warned that if they need you, they generally REALLY need you.

- There is a high turnover of ICU RNs because it is very demanding and not for everyone. Be supportive of the RNs, teach where you can, but don't get sucked into a beginner RN's paranoia. Listen to their concerns, explain what they should be watching for, and leave it.

- Treat the patient, not the numbers or data. It's easy in ICU to collect infinite labs and numbers and values- these are irrelevant if the patient looks perfect with a paO2 of 54, or crap with a paO2 of 100.

- Don't forget to ASK THE PATIENT or their family stuff you don't know. ie. what year they had such-and-such done, why they are on this med, how long this has been happening. So often people now rely on the EMR, which is only as good as whatever the past people entered.

- Use the available resources. SCCM membership is a must, use their website and get involved where you can.

- All your collaborating intensivists may tell you a different way of doing something. Don't get too attached to a particular way, or say "but so and so said xxx". Just listen, ask why they do it that way, try it their way - and when you are more experienced, you can take pieces of each advice and come up with how you prefer doing things. Just collect information and skills as a newbie.

- Don't try to be an ICU nurse. The transition at times can be tough, and sometimes to engender collegiality, you have to jump in and reposition a patient, or help with some "nurse duties" - continue to do so, but don't forget to delegate non-APP tasks too.

There's not much you can totally learn before starting - its a constant learning process to work in critical care!