Tips for New Nurses in the ICU

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).

“Have a routine for your day…and then expect it to blow up in your face and be ready to constantly modify your routine because nursing is unpredictable. PRIORITIZE!” -ES

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.

“Take physical notes, ask questions no matter how dumb you may think the question is.” ES

“Questions, questions, questions! Know who to go to.” SB

“Know when to ask for help. It’s always better to ask for help than to do something that could potentially harm someone. Or NOT do something and potentially harm someone. Everyone was new at some point, and YES it does get tiring when a new ICU nurse asks a lot of questions but I’d rather answer questions or help you out than have to pull out a crash cart and get everyone on the unit behind.” AC

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 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.

“Even though at first you will always feel behind and overwhelmed, NEVER give a med without knowing what it is and what it does. As time goes by you will realize you are having to look up less and less.” LA

“When you hear hooves, think horses, not zebras. Always rule out the obvious.” LD

“As scary as it is starting off, and that feeling of terror when you take patients by yourself for the first time, just remember that it is actually a lot harder to kill people than you think. Use your brain, think before you act and ALWAYS listen to that little voice that says “I hook that up here right?” “This can run in with this right?” and then PAUSE. Ask someone to be sure and move forward. If you think first every time, your patients will probably live.” AE

 4. Show compassion
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.

“Treat patients and families as if they are your own because they notice.” SB.

“Never stop allowing yourself to feel what is happening around you. You don’t have to break down and cry every time, but most of your patients are having their worst day in a very long time.” VP

“Always hold tight to your humanity….Step back, take a breath, try to imagine what they are feeling and help see them through this terrible time. Same goes for families. Sometimes they can feel like a burden but they are scared and the future is unsure. Compassion and patience is important.” ST

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.

“Find a topic/med/procedure every day that you’re not familiar with or want to know more about and go home and research that topic.” ES

“Go home and study. Look stuff up. Go to conferences.” LD

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.

“Get to know everyone you can and how they do things. You will develop your own way of nursing based on a mixture of all the ways you have seen something done.” VP.

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!)

“Make friends because they will help you save lives and likely save yours. Wash your clothes in something that smells good so this new buddy can bury their nose in it when you clean up a GI bleed.” SB.

“Help other people when you can. As a new ICU nurse you’re likely going to be slower than other nurses but if you do have the opportunity to help someone else out that’s really busy or having a rough day, it makes a world of difference, and people remember that” AC

“Everyone shares a special talent. We are a team! You are never alone.” KS

“Make sure your significant other understands how close you and your work family will be-no need for jealousy. You need these brothers, sisters and mama Kathy’s* to be successful.” LD
*Kathy is our charge nurse and our "work mama." We all look to her when we have questions/need something. Find your person that you can go to when you need advice.

“Blowing out someone else’s candle does not make yours shine brighter, think of the blaze we have when we ALL shine.” CM

“Lean on and love your coworkers. Forgive when they frustrate you and know that you are sometimes frustrating too. Bottom line, we need each other. You just can’t do it alone.” AE

8. Assess your patient and be aware of changes
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! 
“Assess, assess, assess. When you think you’ve turned over every rock start over and turn them all over again…we are in an ever changing environment” CM

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.)

“Go with your gut instinct if you feel something is wrong even if you can’t put your finger on it. ASK FOR HELP IF YOU NEED IT!” ES

10. Help people die with dignity
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:

I remember a specific patient who had terminal cancer and had stated that he was "ready to go." He was tired of suffering and he knew that he was in his last weeks. He and his family talked with the doctor and decided to make him a DNR. At the time he was still incredibly stable, was able to get up and move around and required minimal oxygen. So at that time they were still going to treat him as normal instead of implementing end of life "comfort measures." This is understandable. He still got his pain medication as often as he needed it and he was still being treated medically as any other patient. 

A few days later, he said that he was just tired. He was ready. Throughout the day you could see his level of consciousness change. He got very tired. We could hardly keep him awake. His blood pressure started to drop. His oxygen level started to drop. He had given up mentally and his body knew it. 

Well, the doctor decided to put him on Neo to get his BP up. I wondered, what is the point of this? His daughter was not at the hospital yet so I thought maybe he's giving her a chance to get here to say goodbye. This went on for hours. He was just about maxed out on Neo because his body was saying it was ready to go. 

[He was not my patient that day but I had taken care of him the week before and he had kind of stolen my heart so it's safe to say that my heart was broken when I saw his death being prolonged like this. I kept checking on him incessantly all day long. Multiple times I had to hide in the bathroom to cry.]

After his daughter got there she was not wanting to accept that this was the end. She was very young (younger than me actually - I can't imagine losing my daddy this young) so I can understand why she didn't want to let him go. But he still steadily declined. The doctor, instead of just letting nature take it's course, wanted to throw a face mask on him and stick him to get ABG's in the final moments of his life. I was angry. I thought why would they do that to him? There are healthcare workers all around his bed trying to stick him for ABG's when he barely has a pulse. His family should be by his side holding his hand. He should be allowed to go in peace. 

Luckily they decided to stop trying to get the blood gases, give him some Morphine to make him comfortable and to just let him go. 

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.

“Know when you’re fighting for your patient, when to let them go, and when your attention needs to be turned to their loved ones.” ST

“Be there when nobody else is.” SB

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. 

“Treat yourself. It’s a stressful job so get that massage, have that beer and sleep! Black out curtains are a must, especially if you work night shift!” JM

“Yoga. Or hunting. Or traveling. Or knitting. Or reading. Find an outlet.” LD

Remember it does get better
“It gets better, don’t give up. (My first couple of months I DREADED going to work. I wasn’t confident, I was usually scared, but eventually I figured it out and it got so much better.)”AC

Many of us have been there. We dread going in. We're afraid we will miss something and potentially harm a patient. We have a big job to do. Very sick people's lives are literally in our hands. As a new nurse, especially, you feel this weight.

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!

“You CAN do this. There’s so much to learn but be patient and humble and you’ll get 
there.” AC

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