Unit to start out in (step down or icu)?? r/o

Everyone defines their units differently. For my facility, the entire floor would be acute care, as it's cardiac, then stepdown, then there's a bunch of different types of ICU, and neuro is on there somewhere.

But as for the unit I work on, that's cardiac, not stepdown. They can get my patients for overflow, but I can't get theirs. So find out what your facility defines as a "cardiac stepdown floor." Do you have pre-bypass patients, pre- and post- cardiac cath patients? Is everyone mostly on telemetry? Who is responsible for sitting there looking at telemetry monitors? What types of equipment do they most commonly see in these patients? Chest tubes? Do the nurses or the doctors pull pacer wires? Do the nurses have to use an external pacemaker for the patients?

In the alcoholic and/or drug abuser patients, are the doctors shy about ordering detox (tranxene) protocols? What's the turnover and what's the difference in nurse to patient ratio from days to nights?

Just giving you an idea of some questions to ask. Happy job hunting!

Ghost- I would tend to agree that you may fair better in an ICU starting out. I know a lot of people on tele floors and I was on a tele floor of sorts, and it seems that patients would get transferred out of the ICU as soon as possible. One of my friends on a step-down was explaining to me that she has a lot of rather unstable patients, and the only difference between her floor and the ICU is that none of her patients are on ventilators but she has four or five of these patients while the nurses in the ICU will have no more than three (usually two). So it does depend on what kind of orientation program you and how much you trust your new employer, but I would say if you have long orientation and good training, and given the fact that your nurse-patient ratios will usually be 1:2, the ICU would be a fabulous place for a new grad.

You know,

I think it depends on the unit. I started out in ICU...it was stressful and difficult (plus the nurses didn't want new grads, so they were alright...but not overly friendly). When I had to float to the Step Down area, I went Crazy...Everyone needed something, tons of different lab draws, incontinence, recovering head injuries (who are not easily redirected from unsafe behavior). I hated Step Down because it was so crazy busy. There is however, a big difference between an ICU patient and a step down patient, and it goes beyond Ventilators. You can be entirely busy adjusting drips all day long on 2 patients, as well as doing all the regular nursing care, and trying to figure out sometimes which drip to go up or down on (which is often a nursing judgement, sure you can get some help from residents, but...sometimes you have to go with advice from others and your gut to keep a pressure at a key value...) and the stress of the ICU...

Well, the patients are sometimes really touch and go.

Really it is going to depend on your orientation offerred and the team of nurses...its a difficult thing, that first job! Also the type of hospital. For example, an ICU in a community hospital would be a super place for a new grad, a speciality ICU at an academic teaching center can also be a great place for a new grad, but the stress- is going to be ten fold because in general the patients have more unusual conditions, or are sicker (transferred in from the community hospitals...etc)

Best Wishes.

Ghost- I would tend to agree that you may fair better in an ICU starting out. I know a lot of people on tele floors and I was on a tele floor of sorts, and it seems that patients would get transferred out of the ICU as soon as possible. One of my friends on a step-down was explaining to me that she has a lot of rather unstable patients, and the only difference between her floor and the ICU is that none of her patients are on ventilators but she has four or five of these patients while the nurses in the ICU will have no more than three (usually two). So it does depend on what kind of orientation program you and how much you trust your new employer, but I would say if you have long orientation and good training, and given the fact that your nurse-patient ratios will usually be 1:2, the ICU would be a fabulous place for a new grad.

If I hear one more time that the ICU is a FABULOUS place for a new grad because your nurse:patient ratio is so wonderful, I think I will scream.

This is one thing we experienced ICU nurses hear over and over again as the reason for a new grad choosing ICU as their first employment choice.

Two patients in ICU can totally overwhelm you. ONE patient in ICU can have you going twelve hours without a break.

Only those who have never worked in a busy ICU will happily quote the "ratio" rationale. Those of us who have know better.

Thank you Windward, that was what I was trying to point out.

However, I am not against New Grads in the units. I'm against lots of new grads, and I'm against poor precepting of new grads. And I'm against new grads who think because it is just 2 pt's that it will somehow be less stressful. Those two pts can be just minutes from a bad outcome and the outcome often depends on the nurse, not the physician.

:chair: Oh I'm sorry Katiebell and Windward, I didn't meant to imply that it was easier JUST because you have two patients. I know you have some really complicated patients. I have to admit I just somewhat regret not going after an ICU job a while ago on a unit where one of my friends is very happy. I'm just coming from the perspective of a nurse who would often have two patients very recently transferred from the ICU (and still not really stable) in addition to two other patients, and I felt most days like I was going crazy. I guess the grass isn't always greener on the other side, but I think there are a lot of aspects of working in an ICU that I would like, and I think it's worth looking into working in an ICU as a new grad if there is a good orientation program in place. I guess that's what I really meant. Anyways, I of course would say you two certainly know what you're talking about more than me in this area, so I stand corrected.

Thank you Windward, that was what I was trying to point out.

However, I am not against New Grads in the units. I'm against lots of new grads, and I'm against poor precepting of new grads. And I'm against new grads who think because it is just 2 pt's that it will somehow be less stressful. Those two pts can be just minutes from a bad outcome and the outcome often depends on the nurse, not the physician.

I'm not against new grads in the unit either. But we are getting too many, too fast, and it seems that, on my particular unit, they are "pushed through" whether they are ready or not and others are expected to pick up the slack.

Some (not all) of our new grads are operating under the belief that they were chosen for the program because they were special but, in truth, I don't know of a new grad who has been turned away from the program. Applying seems to guarantee admission. Our NM believes that if we get them at the beginning of their careers, we can train them "our way" and they will stay. In truth, many leave for exciting travel assignments after they get the requisite one year of ICU experience.

Soooo........new grads in the ICU are commonplace now, and this is the way it is going to be. As with any other group of human beings, some are great, some mediocre, and some downright awful. Attitude plays an enormous part. They are our future, and we do owe them good training. It's not their fault that we are often too busy to give them what they deserve.

Like you said, I think a huge part of the problem lies in the sheer number of new grads many places are hiring. I am thinking that they should hire more ICU nurses who will be assigned just one patient and whose job it is to precept the new grad, one on one, with that one patient. When you get two or three unstable critical patients, you very often have more than your hands full without having to precept.

If I could have gotten the hours I wanted in ICU, I would have taken it. I did my leadership there, and the pace was MUCH slower than my current step-down assignment. The ICU nurses ALWAYS get their lunches. We quite often don't. It seems like a silly thing to base a decision on--but it IS an indicator of the overall pace of the floor. (I know it may be different at different hospitals.) Plus, with ICU experience, you have more choices for that second job.