« NPs and PAs: Opening Doors | Main | Visiting America »

December 12, 2006

New Grads in the ICU?

Bekaserdans72x723_3 Beka - A chest was to be opened by the bedside. We quickly converted the ICU room into an operating room. The 56-year-old CABG x 4 had been bleeding from her chest tubes profusely, almost like water running from a faucet. She had not stopped her Plavix in time, before her unexpected surgery. Our CT Fellow wrapped himself in a sterile blue gown. An Anesthesia Fellow was standing by the head of the bed administering drugs. I was scrambling, hanging blood and FFP as fast as I could while Aimee began titrating drips as the monitor showed a dropping, cascading downward spiral. Scott was managing the crash cart, staying one step ahead with calcium gluconate syringes.

The patient wasn’t mine, or Aimee’s or Scott’s. She belonged to a new grad who had just completed her orientation to the CTICU -- a young, unseasoned nurse in critical care. She had stepped out of the room overwhelmed by the adrenalin rush that we seasoned nurses felt during events like these. The surgical blade sliced through the patients’ sternal incision. Bright red blood sprayed out of the patient’s chest towards the Fellows’ face masks. Retractors were set in place. The rush was on to find the “bleeder.” 

As we worked together, I saw the new grad cringe at what she observed. To lighten the seriousness of the situation, Scott set into motion a few laughable “Greys’ Anatomy” scenarios. We all chuckled and laughed as the bleeder was finally sutured with 3-0 silk ties. The patient’s blood pressure returned to normal and we decided to pack the chest and leave it open for the night in case more bleeding began later. I hung more FFP to correct the patient’s coags. Soon we were cleaning up the room, converting it back to a typical patient room.

Later on in the shift we seasoned nurses (combined years in critical care 13+10 + 20 = 43 years), began discussing whether we thought new grads should be working in an ICU such as ours.  Our unit has a high acuity and requires constant problem solving abilities. We had noticed that many of the new grads who are orienting in our ICU have no critical care experience. They are fresh out of school and perhaps lack critical thinking skills, something that we believe comes with years of experience.

Is this the new trend in ICU nursing to resolve the nursing shortage? Hiring new grads? What is your opinion?

December 12, 2006 in Beka | Permalink


I am a new grad in the PICU and I understand the challenges from a new grad perspective. I think the quality of a new grad has a lot to do with the amount of effort the unit puts in to teaching. New grad or not- seeing your patient have emergency open heart at the bed side for the 1st time would leave anyone overwhelmed, overtime those situations become more and more comfortable. I'm sure the 1st time this seasoned nurse saw something similar chances are she probably did not know exactly what to do either. In this situation it would have been nice if the nurses who were so comfortable with the situation walked the new grad through all things they were doing, and used it as a teaching opportunity instead of what they did. Certain facilities spend a lot of time working with new grads and certain ones, unfourtunately, just don't have the patience. New grads can work in ICUs and be very sucessful, they just require the support of their "seasoned" co-workers.

Posted by: Makenna | Oct 5, 2010 3:29:01 AM

Well done on polishing up the job. It must be all those seasons lingering along with all those years. Should we really be jumping to a conclusion that fast. This short story of a nurses glory seems rather biased. You can take a person right off the street, blast blood all over his or her face and they may just as likely be still standing there. We as people all have a variable of thresholds and that itself can even vary from day to day. Everyone and every career out there has to have a starting point. The day that young lady received her Nursing Degree as an RN she should also have received access to the field of her choice so that she to may become as seasoned as who ever the nurse is who originally posted. Though lets have some popcorn with more season and less salt.

Posted by: Chris Cruz | Feb 16, 2009 6:50:51 AM

Thank you all for your candor and professional opinions regarding the "new grad." I R one. I have also just been hired to an ICU department (after 9 months of ED in trauma 2 hospitals). Not unfounded, nor unappreciated are either your concerns or condemnations of new grads or the administrations desire to have us in specialty units. I served for 18 years in mental health, with the last 3 as an MHP serving suicidal and homicidal patients in ED. I came to nursing because I could trust both nurse as mentor as well as nurse as critic, however unwelcome I may be. I will reflect on your words as fueling aspirations.

Posted by: Patrick | Feb 1, 2009 8:16:21 PM

Everyone is a new nurse at one point. And that was not a situation that a lone nurse would be left alone to deal with. It took three nurses to manage the patient plus a MD plus an anestheologist. Does answering call lights on a medical floor somehow prepare you to handle an emergency situation like that?

Posted by: | Jan 27, 2009 1:18:22 AM

Simply stated, how would you feel about a brand new nurse taking care of your loved one in the ICU? Do you think that they have the critical thinking skills necessary to ensure safe patient care (or the ability to prevent someone from crashing)?

Posted by: Karen | Nov 28, 2008 6:50:40 PM

My aunt has been an ICU nurse for 35 years....yes 35 years... both her and her daughter entered into ICU as new grads and have done very well. My aunt tells me (a new grad) that I would be crazy to spend a day on med/surg and that some new grads do very well in ICU(she knows, she used to hire them). I think some new grads like it because it is challenging and "cool" but only a few can critically think quickly and prioritize their time. In my final days of nursing school I was asked by an ICU nurse to apply to the unit because she was impressed.... I plan to do so and hope to.

Posted by: Chris | Oct 31, 2008 10:51:32 PM

There is a real mix of opinions regarding ICU nursing and new grads. I am a new grad with an opportunity to work at a small ICU. They offer 4-6 months of preceptorship where I am always sharing the patients. Never providing care without guidance. FOr those working in ICU, is this a good place for me to be starting? Does this length of preceptorship provide me with the right supports to be successful?

Posted by: Shaw | Oct 20, 2008 10:44:36 AM

Im a new grad in the CCU. My orientation is 6 months long and well needed. I could not imagine being in any other setting because if I were I do not think I would have the fire that burns in me. Im never alone in what I do when I care for patients. I talk to the docs consult my preceptor and make decisions based on whats going on and try to get an edge on being 2 steps ahead of someones progress. Its a team effort. Yes getting down the routine is going to take time, but no matter how many years of nursing someone has under their belt, no one can know everything thats why care of a patient is a collaboration among many people. In my unit we get an overall UNIT report and we all need to know a little bit of every pt's status prior to shift change in the event we need to cover or help out. Then we have our individual shift report. Im naturally inquisitive and a "need to know" kind of person. If I don't know, I will not risk anyone's safetly, but will use common sense to get assistance. Its all about attitude, leave the bias out of the unit and lets make things work. Its inevitable, every unit will get a new grad, its you baby to the unit. Just nurture them in becoming the best possible nurse the units combined experience can give.

Posted by: Janet | Oct 14, 2008 10:58:30 PM

I recently passed my boards after being a scrub tech for 10 years. I've always considered ICU as my top choice to work. There are some new grads who already have some kind of medical experience that would benefit their ICU setting. I think ICU is a good place for anyone who is willing to learn.

Posted by: lisa | Jul 9, 2008 5:18:09 PM

I think it is a very good idea for new grads to come into ICU with the shortage of nurses and some nurses just not wanted to go into ICU we need it. What is to happen that we have more of a shortage in ICU where it is needed most. I will be one of the graduates going into the ICU but I also have some training from the military. Maybe one way to help resolve to problem is that the training should be longer with a mentor until you are ready.

Posted by: sekeena | May 26, 2008 6:16:42 PM

Well I am new grad and an ICU intern, I half way through the 12 week program and I have been both thrilled to be given such a great opportunity and overwhelmed by information and situations. However I have also been embraced by an incredibly supportive and encouraging staff of people. I am too in a second career and graduated just after my 40th birthday. I am finding one of the most difficult balances to create that of the reality of someones life being dependant upon my care and not letting that overwhelm me to the point being inadequate. I ultimately pray daily (and as needed more often) that GOD will lead me and that I will be given what is needed to be a safe and prudent nurse. All must know that as a new grads we trust that these opportunites are designed to be as safe as possible for us as well as the patients. This will only be possible with the support of the seasoned nurses. We want to be helpful and safe for all.

Posted by: Elaine | Feb 20, 2007 11:09:07 PM

Well Beka, this is a complicated one that I think about a lot. As a new grad, I eagerly sought a position on a med-surg tele floor. This was not part of a path toward the ICU, but simply the area where I wanted to work. For many reasons, I chose to transition to the MICU after about one year. Now, over a year later I look back on my nursing career so far and I feel that my time on the floor enabled me to become a more succesful, confident, assertive and safe ICU nurse quickly. I don't necessarily think it is 100% necessary, but acute care nursing in our country today is high stress, high stakes, complex stuff and it is a lot to put together when you first start. While working in ICU is not necessary "harder" or more challenging than floor nursing, it does require a level of attention to detail and being "tuned in" to your patient that comes easier when you are not brand new.

Additionally, I worry sometimes that the new graduates who track directly into specialty units do not develop a healthy respect for general floor nurses and the unique challenges of their important work.

Given our current shortage, I believe we cannot completely exclude new graduates from specialty units, and I'm not sure we should do so across the board anyway. However, the MIX on each unit is key, and sometimes HR and managers don't pay nearly enough attention to that. Or, maybe they do pay attention but feel they have no choice. In the interest of safety and the future of our collective nursing culture, I think they must stop surrendering their power on this issue. It is too important.

Posted by: MICU RN | Jan 17, 2007 11:23:35 AM

I work in an ICU. I've been here for 20 years. The recent influx and herding to get new grads into the ICU's have become exhausting to say the least. 80% of the staff I work with has less than 2 years experience because everyone with seniority has left. We accept class sizes of 100-200 GN's 2x/year. Granted, I love to teach and I love what I do. However, I have precepted 8 GN's this year alone. Maybe I'm tired. I realize I can't change the trend so this is my last gasp at being heard. It becomes disheartening when you are asked which way a bedpan goes under a patient.Critical care courses are fast-tracking people into a specialty. Once on the unit, the clinical experience is limited to only that area. This may be specific to only my institution. Now those with only a few years experience are precepting those with none. The quality of patient care I teach beyond all the high-tech gadgets is going to be lost on the next generation who may or may not be going into nursing for altruistic reasons. I must say I do run into a few that have such potential. I will still nurture and give them the best I have to offer.

Posted by: Michelle | Jan 16, 2007 6:26:18 PM

I believe that any specialty unit should have an internship, and expectations that an CCU/ICU nurse be experienced in ER/Med surg is not unrealistic.
However I have to say there is something to be said about what new grads do bring to the mix, there is different education proccess now, more theory more wholism, which can not be taken for granted, and like it or not something a lot of seasoned health care workers are not open to "hearing"
I work in a very specific field of nursing (though not critical care) I have relied on previous experience to be meaningful, but the philosophy that everyone needs med/surg experience is not neccessarily a reality.
Nearly every field of nursing begs for experienced nurses, this is not the reality of the job force, and three years ago entering the nursing field for the first time, I found the "nurses eat their young" to be more true than I realized.
We were all new grads once....we need to remember that, nurses are not all at the same level when they graduate, and neither are they when they practice for years.
I have run into nurses who have been for 30 years that I would not want taking care of me....So as many others have said....It should be determined on an indivudal basis, but requiring some level of experience is responsible.

It may be considered that not only is one's nursing experience relative to their comeptency, but life experince and age, some things make other indivudals more competetent....There is a lot to be said for that....I was almost 30 years old as a new grad, and felt more comforatable with the errogant physician sydrome, and seasoned nurse sydrome....which I try to avoid developing.

I appreciate my colleagues, but be it known that as a nurse with 3 years experince, I am still a "new nurse" to my peers with 20 years experience....I fortuntaly now work in a field where they ask me about more recent info, and I rely on their experience....so the mix can be good!

The short and sweet....New grads do have their place and should be accepted with open arms....but maybe not to a field where moment to moment actions determine someones life. The critical thinking skills are there, but not at the speed an experienced nurse has developed.

Posted by: Jan | Jan 12, 2007 11:46:25 AM

I am in tandem with Bob's comments.
I teach within a university program.

No post grad, nor one that has not gained experience in a Med Surg unit for at least 3 full time years under any circumstances should "cut their teeth" working in a specialty unit.

Listen up all hospital corporations concerned of your liability cost/risks.

Medical Student/intern Staff are trained more carefully.

Posted by: DGF | Jan 9, 2007 10:36:30 PM

I hope that if and when the day comes, and I am at the mercy of nurses in the ICU, that I have a both an RN who knows what the hell she is doing and what might be around the cornor; a "seasoned" nurse who can deal with the interns egos and get me the care I need,as well as a fresh and new RN who remembers to talk sweetly and stroke my forehead, who turns me every 2 hours and washes her hands. No insults intended to either group.

Posted by: LLJ | Jan 9, 2007 8:45:11 PM

Although I am a firm believer that all new grads should spend 6 months to a year on a Med-Surg Floor as there are certain nursing skills to be developed that one will not receive in a specialty setting. It also gives insight and respect for a floor nurse when you are trying to move out your patient to let the next critical one in. However, I also believe every nurse should be evaluated on an individual basis.

Those of us seasoned nurses should impart, nurture and mentor those coming into the field new grads or not. We all know each unit has their share of the good, the bad and the ugly. Just because you have your years of experience does not necessarily make you knowledgable, clinically skilled and a "go the extra mile" nurse.

The root of the problem stems from the type of education they are receiving. No one knows what team nursing, primary nursing or modified primary nursing is.
Delegate, get your hours in critical care, continue your degree and go into administration or become a CRNA.
The clinical aspect, nursing skills, heaven forbid a bed bath, pouring meds and understanding why an intervention should or should be done is not taught. There is little advocacy or critical thinking of any sort.

It is up to us, those with years of knowledge and experience, to impart a positive atmosphere to the new nurses entering the unit (new grad or not)and educate/guide them.
Remember this will be the same nurse taking care of you or your loved one in the near future.

Posted by: | Jan 4, 2007 10:20:35 PM

I am not keen on new grads starting in specialty units. I agree with the above comment of "not knowing there is a question to ask". I have worked in Med/Surg for 6 years and know that critical care is not for me along with NICU. You have to know your limitations and gain some time management experience before specializing. I am working on my FNP and have never been interested in vents and such. Kudos to those of you who can do it!

Posted by: NPs Save Lives | Dec 31, 2006 10:40:16 PM

I think that it depends on the nurse. A blanket "ban" would not be a good thing.
I was a new grad ICU nurse 15 years ago and did well; became a charge nurse after 6 months. However, nursing was my second health related field -I had been a registered dietitian for 7 years and had worked in several hospitals including large teaching facilities and had a breadth of knowledge way beyond the typical new grad.
One facility refused to consider me for the ICU when I applied as a new grad. Their loss as I worked for nearly 10 years as an ICU nurse at the facility that did hire me.
My bias would be to evaluate each applicant on an individual basis.

Posted by: CardioNP | Dec 30, 2006 9:22:43 PM

i worked in icu's and er's for many years and strongly believe that a nurse needs at least 6 mo of working as a nurse on a general care unit, learning time management and assessment skills and hands on patient care prior to going to the icu/er enviroment. it is safer for everyone involved.

Posted by: VICKIE | Dec 28, 2006 11:29:49 AM

I was a new grad in a very high acuity ICU in Washington DC. I applaud the manager for giving me that opportunity and the "experienced" nurses who took me under their wings. It was hard work, very overwhelming at times but worth every minute and every tear I shed. My experience from that time in my life showed me that if I really wanted to be a valuable nurse I needed to be able to learn fast, not be afrain to ask questions, not be ashamed to seek help, always help others, think fast and act fast, be humble and most especially, have compassion for other new grads. We "seasoned nurses" have to pass the torch along. We cannot afford to eat our young.
That was 20 years ago. Over the past few years, I have moved on from ICU nursing after many years of nurturing many new grads. However, to this day, I still approach every thing I learn with the same passion.

Posted by: Emma | Dec 20, 2006 5:25:51 PM


Posted by: Bob Kocembo | Dec 15, 2006 11:54:06 AM

Any ICU in any hospital should not be staffing with new grads. It is not fair to the patients, the new grad, nor the rest of the staff that now have 3 - 4 patients as they watch over the new grad. Yes indeed they lack experience, you can't have 20 years of knowledge/experience without putting in the time. Worse, new grads do not always know what they don't know. They don't know to ask the question because they are not aware there is a question to be asked. If your hospital can't staff the ICU or any other unit safely, they need to close beds. You want administration to recognize your value, you have to shake their pocketbook.

Posted by: toinette | Dec 15, 2006 10:33:09 AM

i was one, almost 20 years ago, and i had recently had so-called director and manager who stated frequently that they did not care if the entire icu and the er were staffed with new grads! i couldn't believe this at first, but they said it many times. i protested, saying this was dangerous to patients, and also unfair to the new nurses, and the seasoned ones. an nurse is not just a nurse, we all come with different levels of expertise and experiences which contribute to care levels. new nurses have a lot to offer, but experience is really the best teacher. those of us who still practice bedside nursing should be valued beyond this, we are the mentors of the new,and a good mentor is a golden asset in a critical care unit, or in the er. new grads need to acitively seek and bond with a mentor figure, to gain knowledge from experiences like those you describe, and from the everyday events that occur, which should be triggering a lot of thoughts and questions. acively seeking opportunities for learning is the new grads opportunity for adding skill and judgement to her repertoire of tools. this is a proactive state for the new grad. another point is that the new grad has a responsibilty to the mentor as well, the relationship is paramount, and both parties contribute to it's success.

Posted by: | Dec 14, 2006 8:24:47 AM

The comments to this entry are closed.