This week I polled my fellow ICU nurse friends to get their thoughts on what advice they would give new nurses in the ICU. I got so many great responses that I had to rethink how I was going to write this!
Whether you are a new grad, or a seasoned nurse who is new to critical care, the ICU can be a very intimidating place. Your pace of work and your thought process is completely different from any other area of nursing. You have to always be on your toes and aware of your surroundings. I was told when I started in CVICU that it takes 18 months to 2 years to really feel comfortable. Well, I’ve been there for over 3 years and I still get nervous when I come in every morning! I pray each morning on my drive in that I will be a good, attentive nurse and take good care of my patients because ICU patients can go bad in the blink of an eye.
Here are a few tips on how to make it in the ICU
1. Time management and prioritization
Prioritization is drilled into our minds during nursing school. It is all over all of our tests and there is a reason for that. When you have multiple things on your to-do list you have to think about what is most important/most urgent. What’s more important? Treating a critically low potassium level or placing an NG tube? Hanging a newly ordered antibiotic on a septic patient or giving pain medication? Know your situation and prioritize.
I think time management is a “make it or break it” thing in the ICU. It does take time to learn but if you can’t manage your time and prioritize then you probably won’t last long. Make a list of things that need to be done so you don’t forget. Know when it’s appropriate to group activities when you go into a patient’s room. Gather everything you need before you go in so that you can use your time most efficiently.
If something gets thrown off schedule (i.e. you have to go to CT with your intubated patient), don’t get flustered. Know how to adjust and catch up later. Always be sure your patient is taken care of before computer charting. Even if you feel overwhelmed and that things will not get done, they always do. And don’t be afraid to ask for help (see next point).
2. Ask for help
When you’re new to any unit you will have tons of questions. If you are unsure of something, ASK. There are no stupid questions when it comes to saving a life. Even if it’s something you know someone has told you before, or something you think you should know, but you just don’t remember – ASK! You’re learning so much new information it’s hard to retain everything you’re told at first, and seasoned nurses understand this. Know who to go to when you do have questions.
Also along these lines, if you are finding yourself falling behind or if you just need help turning a patient, find another nurse/tech/charge nurse to help you. In turn, be willing to help others when they need it.
3. Think before you act
There have been so many times that I have been about to do something and something in the back of my mind told me “wait a minute…is this appropriate?” Sometimes I could stop and think it over and make a clinical decision on my own. Sometimes I would need to consult someone else to get their input. Sometimes I would just need to look something up, whether it be a medication or IV drug compatibility, to get the answer I needed.
When I first started in CV one of my biggest anxieties was whether or not I was going to give the morning beta blocker. I know it sounds silly. But there are actually times that you give a BB while the patient is on epi. And there are times that you give it when their BP is 100/53. I know the nurse practitioners would get tired of me asking whether or not it was appropriate to give, but I wanted to be sure I was doing the right thing before I bottomed out someone’s blood pressure. Eventually I became more comfortable with the various situations and was able to make more judgments on my own. Even now, there are still situations that arise that I need to ask, and that’s ok. Just think about what you are giving before you give it, and if need be, ask someone.
Compassion typically comes pretty naturally to nurses. It’s the reason that many people become nurses – because we care about people and want to help them.
But it’s easy to lose this characteristic over time. The more you see and the more difficult patients you work with, the easier it is to lump people into categories and judge them before you get to know them.
Try to have an open mind with every single person you come in contact with. Treat them like they are your own family member, even if they are giving you a hard time. Remember that they are sick and they need you. Even if they do not voice their gratitude, many times your kindness does not go unnoticed and is, in fact, appreciated. Same goes for families. Support them. Let them know what is going on. Don’t judge them by what they’re wearing or the way they smell. Just be kind and compassionate.
In another sense, the more death you see, the easier it is to shut off your emotions and to just see them as a patient, instead of a person who has lost their life. A person who is someone’s mother/father/wife/husband/son/daughter. A person who left a greiving family behind. It is 100% ok to feel pain and empathy when you lose a patient. The best advice I can give here is to pray for the family.
5. Study outside of work
There is SO much to learn in the medical field. Depending on where you work, find procedures/diseases/medications that you see frequently and become an expert on them. In CV, many of our patients are post-CABG or valve replacement patients. But our doctors also do a variety of different thoracic procedures, aortic aneurysm/dissection repairs, and esophageal surgeries, just to name a few.
It’s important that you know how a procedure is done, what your post op protocol is, and if there is anything specific you should watch for/monitor post op.
Look up IV drips that you use frequently. Know what they do. Know how to titrate. Know your max dosage. Know how to look up to see if it’s compatible with your other drips.
The more you know about a topic, the more comfortable you will be when taking care of your patient. In turn, you will also be able to spot when something is “not right” more quickly.
6. Learn from your seasoned coworkers
Listen to your preceptor. Watch how he/she does things. Watch how others do things. Take note of people’s routines and come up with something that works for you. Nurses who have been around for a while learn over time little tricks that make things easier. Observe how they do things and ask them to explain to you what they are doing. Also, ask them to explain why they made a particular clinical decision. They probably have a reason based on a particular situation they’ve come across in the past. It’s ok to learn from others’ mistakes.
7. Make friends and work as a team
Teamwork is SO important in the ICU. You can’t pull up and turn people every two hours by yourself. Your back will not appreciate it. And you definitely can’t clean up poop by yourself.
As I said earlier, it’s ok to ask for help. But you also need to be willing to give help. If you’re caught up and your friend is drowning beside you, step in and ask what you can do to help. No one can make it on their own. We lean on each other to make it through the day. (I think I got the most response about this topic, so you know it’s an important one!)
ICU patients can change in a heartbeat. They can be having a conversation with you one minute and unresponsive the next. Watch your vitals signs trends. Check your pulses. Watch your ETT placement. Monitor their level of consciousness. If anything seems off, say something!
9. Listen to your “nurses’ gut”
As a nurse you will develop a “gut instinct.” A little voice that tells you something is just not right. Maybe their BP has trended down over the last few hours. Maybe their urine output has decreased. Maybe all of their vital signs are perfect but they’re just not acting quite right.
Grab a charge nurse/nurse practitioner/doctor and just tell them “I can’t put my finger on it but something doesn’t feel right. I need another set of eyes.” It’s better to annoy someone and have them assess the patient with you than for something to really be wrong, and harm come to the patient.
(Maybe they’re not acting right because they CO2 is 70. Bipap may fix the problem. You may have just kept them from being emergently intubated.)
Something that bothers me more than anything is when a patient is ready to go and either the family members or the doctors won’t let them. A little story:
When I say “help a patient die with dignity”, I mean “do what you can to let them go the way they want to.” When death is imminent, treat their pain, make them comfortable, allow family to be with them if there is any. If there is no family, then you be there for them. I have sat with people, held their hands and cried over them as they took their last breath because there wasn’t anyone else. If at all possible, don’t let someone die in pain and don’t let someone die alone. And be there for the family.
11. Find a way to unwind when you’re not at work
This job is stressful. It’s hard not to still have your work on your mind when you come home. Try to find something that helps you unwind when you’re off.
Remember it does get better
Take all of these things into consideration, study, and think before you act, and you will get there, I promise. If you have any questions, please feel free to ask!