Why do unit nurses have bad reps?

[SheriLynnRN]

I will be transferring to ICU from general surg next week. When I told one of my co-workers (whom I respect) that I was going to the unit, she said "Just promise me you won't go up there and turn into a B***H." I asked around my unit and got the same type of response. I have not had many interactions with our ICU nurses, so I don't have much to go on, but my co-workers seem to think that unit nurses are holier-than-thou and that they all look down on "floor nurses", talking down to us. I realize that these are opinions, and are in all probabilty, stemming from isolated incidents, but I just wanted to get some perspective on what you all thought of this.

[martylcg]

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[LoriAlabamaRN]

I've always held high respect for the unit nurses. I honestly don't think I could do what they do. I had an ICU preceptor during one of my clinical rotations, and her efficiency and reaction times left me dazed. I don't think unit nurses are mean, I think that they are just used to not having the luxury of being politically correct (timewise).

[geekgolightly, BSN, RN]

I've always held high respect for the unit nurses. I honestly don't think I could do what they do. I had an ICU preceptor during one of my clinical rotations, and her efficiency and reaction times left me dazed. I don't think unit nurses are mean, I think that they are just used to not having the luxury of being politically correct (timewise).

?? Floor nurses can have anywhere from 5-10 patients in various states of ill health, some circling the drain and those floor nurses manage to do all of this without using the excuse of not having time to be politically correct. That is a poor excuse for bad behavior.

[ZASHAGALKA, RN]

I was a floor nurse for 3 yrs, and now a critical care nurse for going on 10.

3 reasons why.

1. ICU/ER tend to attract more 'assertive' nurses. That's not an insult - there are lots of equipment and protocols in critical care that are daunting if you don't have experience w/ them. I tell my floor nurse friends all the time that critical care is not more difficult, but def more different. And being willing to take on that challenge of learning different things, and closer interactions w/ docs and families (because you just have more time w/ fewer pts - it's not about motivation to have closer interactions, but the time to have them), etc requires assertiveness. It's like going to nursing school again in many ways - a different kind of nursing school w/ different priorities - see #2, below)

Not only that, but it's a culture of assertiveness. If you can't stand your own w/ assertive people, you will get run over working in critical care. So even if an unassertive nurse could learn all the new things in ICU, they will still tend to be run off.

Now in lots of ways, assertive can easily be misread or border on being aggressive. There's your bad rep. Frankly, the more assertive the crowd, the more nurses that deserve bad reps will be present.

2. Critical care focuses on critical analysis of details. With 2 pts, I have the time to know every detail about both pts. And if called on it, I had better know.

That's not the same when you have 6 pts.

So what ends up happening is that a critical care nurse will ask a floor nurse a question that might be important to critical care, but not so important on the floor. Well, having to say, "I don't know" alot can put you in a defensive position.

Think about it this way: when these same nurses ask the same questions to the docs/residents/pharms/etc in critical care, they normally get the answer. The focus is different. Being used to asking those kinds of questions, they can sometime have higher expectations than they should that somebody w/ six pts knows the last bun/cr/HH/k/glucose of a pt off the top of their head.

And some of them can be snooty about it, too, I admit. There is a holier than thou attitude sometimes.

3. Critical care nurses tend to be very experienced nurses. EVEN if the critical care opens itself up to new nurses, the orientation period is 1. MUCH longer. 2. The ratio of experienced to inexperienced nurses is much more weighted to experience, 3. On the floor, a new nurse is expected to have the skills from nursing school to make it, and the orientation process is to bring them up to snuff. In critical care, the orientation period can also be a wash out period. Not all nurses out of school survive in critical care.

The result is that critical care nurses expect that the nurses working around them are highly competent based on lots of experience. And they don't understand that the floors tend to be a mix of experience. Those same nurses shouldn't have a high tolerance for mistakes/judgements based on inexperience in critical care. But they should be more understanding of the experience mix on the floors.

And this is especially true when it comes to picking up on subtle changes. A critical care nurse might be completely valid in criticizing a fellow CCU nurses' failure to pick up on a subtle change, but be completely out of reason when they expect the same from a nurse that isn't always right in front of their pts with monitors that scream out a whole variety of subtle changes.

~

So the result is a bad rep. Sometimes earned. Sometimes based on misconceptions of the differences (not the difficulties) of each other's jobs.

~faith,

Timothy.

[RN34TX]

3. Critical care nurses tend to be very experienced nurses. EVEN if the critical care opens itself up to new nurses, the orientation period is 1. MUCH longer. 2. The ratio of experienced to inexperienced nurses is much more weighted to experience

I disagree. Critical care nurses have to start somewhere. The 3 month orientation period does not wash out the bad ones and make the good ones all instant ICU nurses able to pick up on subtle changes.

My experience has been that there is just as much of a mix of experience in ICU as in Med/Surg.

I worked Med/Surg for years before moving to ICU. I left that job because they were expecting me to charge after 8-9 months of working there.

I might have been ok with this if it wasn't for the fact that many nights would have invoved me being the most experienced nurse on the floor, with no one to turn to for help and advice when things came up.

The unit would have been run with me in charge after not even a year of ICU experience, and the rest of the staff were often new grads who weren't even LPN's or anything prior to starting in ICU.

That situation is not all that uncommon in ICU's.

They are not all chock full of seasoned nurses. And often the ones that are full of that much wisdom are also filled with so many big headed nurses that can be so difficult to work with that you don't even want to be there.

[geekgolightly, BSN, RN]

There is a H U G E difference between being snide and condescending and assertive and knowlegable. The ICU nurses in my MICU are, for the most part, very experienced. Some nurses have more than twenty years under their belt. These are the nurses who are easy to deal with; they ask pertinent questions (and yes I know my lab values and consider that pertinent), they are laid back in giving and receiving report, and they do not talk down to me. ever. Even when I don't know anything about what they are asking each of them has always been the most pleasant about it. Not pushy, not assertive, what's the POINT in being pushy and assertive when giving or taking report? You ask questions, you say Hi How are you, you try and find as much about the patients history and current condition and then you accept the patient into your care. No dramatics necessary.

I have found that the less experienced an ICU nurse, the more condescending they are. Many of the NSICU nurses in our hospital are brand spanking new, and it shows. They are defensive, haughty and almost appear to enjoy their holier-than-thou game with us lowly floor nurses. I honestly believe because they feel so overwhelmed and out of their element most of their shift day after day, that it must feel good to them to finally "know more" and they milk that for all it's worth to their egos.

If you find yourself being condescending it truly only reflects on YOUR comfort level. Nurses who are very good at what they do and knowlegable and confident do not waste anyones time by being condescending.

[geekgolightly, BSN, RN]

p.s. papawjohn here is an excellent example of having tons of knowlege and absolutely zero attitude. everyone should strive for that. i do, at least.

[Ruby Vee, BSN]

i agree with this.

floor nurses are not permitted to decline to take report, whether they are caring for a patient, in shift report or eating for the only 15 minutes in the 12 hours that she is on duty. in many places the er/icu nurse is. er/pacu/icu time is considered expensive and their nurses' time is considered "more valuable". it may not be fair or right, but it is the way that things are. just as md satisfaction is valued more than nursing satisfaction...they are customers and we are employees.

.

interesting. in all of the hospitals in which i've done icu (5, so far), floor nurses are permitted to decline to take report because they're at lunch, they're due to take their lunch break soon, they just had lunch and now they need to get "caught up." they're also allowed to decline to take the transfer for all of the above reasons. nevermind that i've just gotten report from the or that my patient is coming off pump and will be out in 30 minutes and that i need to get my floor patient transferred to the floor so that we can clean the bed and turn the room around before that patient comes out of the or. nevermind that the er has a crashing patient in cardiogenic shock they want to send up to be lined. never mind that i've been here 14 hours and haven't had a break. yet i'm not allowed to decline to take report (or the patient) because "if he needs to go to the icu, it's an emergency." i've gotten patients transferred from the floor "emergently" for "low k+" (it was 3.6) "high k+" (it was 4.6), "hypotension" (103/60), "hypertension" (160/74), "chest pain" (it was from using his arms to pull himself up in bed despite being warned repeatedly about the sternotomy), "arrhythmias" (pvcs

i think we all need to use a little common sense and be courteous of and supportive to one another. if i need to turn over my bed to get someone from the or or the er, maybe your lunch break could wait 20 minutes. if you need to decline report for 20 minutes because your confused little old lady has poop from stem to stern and her roommate is hypotensive, i can hold onto my patient for those 20 minutes. i routinely bring my patients to the floor, get them settled, hook up the monitor, put their belongings away and wait for the floor nurse. maybe the floor nurse could help me get the patient into the icu bed and the monitor hooked up before she fires report at me and leave.

we all need to work together, people!

[Tweety, BSN, RN]

Interesting. In all of the hospitals in which I've done ICU (5, so far), floor nurses are permitted to decline to take report......We all need to work together, people!

We are not permitted to put off the ER when they call report.

Sometimes we try to put off ICU transfers, which ICU is all too happy to oblige, because they'd really rather not take the crashing patient in the ER and keep their stable patient. Usually we're told by the super to take a patient out of ICU ASAP, then it's four hours later when ICU calls us.

I've yet to call ICU and have them readily quickly take a patient that's crashing on the floor. "Let me settle my other patient first, the room's dirty, the nurses isn't available, we don't have a nurse you have to wait until after shift change, are you sure this patient really needs to come to ICU? We're going to come assess the patient on your unit first to see if he's really critical." (We usually don't have the bogus transfers like you have, our patients have to be practically dead or intubated before we can get a bed.)

I know this sounds like an ICU bash, and perhaps it is. I've been house supervisor and have seen both ICU and floor nurses drag their feet.

Yes, we need to work together people!

[geekgolightly, BSN, RN]

We are not permitted to put off the ER when they call report.

Sometimes we try to put off ICU transfers, which ICU is all too happy to oblige, because they'd really rather not take the crashing patient in ICU and keep their stable patient. Usually we're told by the super to take a patient out of ICU ASAP, then it's four hours later when ICU calls us.

For us, they call at shift change. I wait around all day for the phantom ICU patient whose bed has been reserved since 9:05 am, and they appear at 6:30 pm. irritating.

[geekgolightly, BSN, RN]

yet i'm not allowed to decline to take report (or the patient) because "if he needs to go to the icu, it's an emergency." i've gotten patients transferred from the floor "emergently" for "low k+" (it was 3.6) "high k+" (it was 4.6), "hypotension" (103/60), "hypertension" (160/74), "chest pain" (it was from using his arms to pull himself up in bed despite being warned repeatedly about the sternotomy), "arrhythmias" (pvcs

i don't understand what doc in their right mind would waste an icu bed on any of these patients. sounds like you have a bad system in place.

[pricklypear]

I don't understand what doc in their right mind would waste an ICU bed on any of these patients. Sounds like you have a bad system in place.

uhh, happens all the time where I work. Lord knows how they get away with it, because insurance is going to look at that and say, "You're kidding, right? We're not paying for this pt to be in ICU overnight for being slightly difficult to arouse at 0230 after 10mg of Ambien!" The docs don't care. They still get paid no matter where the pt is. It's the hospital that gets shafted. We had a pt transferred down for the sole purpose of getting Bipap (which can be done on the floor), who's gasses didn't even indicate the need for it. This was apparently precipitated by a personal vendetta between the doc and the floor over an incident earlier that day.

Every one of those pts who are improperly placed in ICU represents a percentage of a raise that I won't get this year. Not to mention less care for the true ICU patients since we are now busy with people an their call light all night wanting sandwiches and ice cream.