Hey New Grads, Welcome to the ICU

I recently did a live video on tips to get into the ICU right after graduation and was surprised by the number of nurses who are strongly against this. The doctoral student in me decided I should check the research before jumping to any conclusions. It turns out that new grad nurses can be successful working in the ICU, but if the environment is healthy, the new grad will be even more successful. Therefore, it is necessary for experienced nurses to be supportive and open to the idea of new grads starting on their turf. Insinuating that new grads should not be able to start in an ICU and repetitively telling them they would be better suited on another unit, should be considered bullying and/or lateral violence in my opinion.

There is no doubt, an ICU is a very challenging place to start a nursing career, but it is right for some people. If you have a high attention to detail, thrive in high-stress, constantly changing environments, want to manage your patients with more autonomy, and learn the in-depth physiology of what is happening to your patients, then the ICU might be for you. If you are not certain yet, then getting your feet wet on another unit first is probably a better move. Either way, below are some myths and arguments to debunk the myths. Welcome to the ICU new grads.

MYTH: Bad institutions hire new grads to their ICUs

This was a new one to me since I have only worked in university hospitals, but the myth is out there. Last time I checked, if something was really wrong with a patient, they headed to a university hospital for help. In fact, of the top 10 hospitals in the country, the majority hires new grads in to their CVICUs, arguably the toughest area in the hospital to work. These hospitals include Johns Hopkins, Mayo, and Penn – I’m sure you’ve heard of at least one. Therefore, if the best hospitals in the country are doing it and this is your argument, you might reconsider.

MYTH: Nurses need to develop their skills before starting in an ICU

I started working in an ICU right after graduation and felt more than ready after working as a tech in a high acuity SICU for the previous year. While I would encourage nurses to get tech jobs prior to entering the ICU, it is not a necessity. In fact, I have known far more ICU nurses to start without any experience, than to start with experience. Some nurses will say ICU nurses need to “experience” what floor nurses go through. Arguably, ICU nursing and med-surg nursing are different skill sets. For the sake of this post, I called three ICU nurse managers and posed the question to them. All three agreed, sometimes it’s better to focus on the craft you are most interested in learning and master it. They all also agreed that they have had more issues hiring “experienced” nurses recently versus hiring student nurses who have been techs on their units.

To play the devils advocate just a bit, some nurses do better working in a step down or med-surg unit first. It is all dependent on the nurse’s personality and drive. However, these days, so many nurses are going back to nursing as a second career. They have more life experience than ever and this increased maturity level will likely help new nurses be successful in the ICU.

MYTH: Nurses just work in the ICU for the money

Once again, this was another new one to me. First of all, I do not know many nurses who go into nursing for the money. Also, ICU nurses start one to two dollars per hour more than a med-surg nurse. Likewise, the job is so difficult, one to two dollars seems like nothing. We do it because we love it, not for the money.

MYTH: New grad nurses make more mistakes in the ICU

Once again, errors have more to do with the environment than anything else. In a supportive environment, new grads can be successful. When all nurses are fatigued, distracted, burned out, and understaffed, errors are more prominent. Additionally, working multiple 12-hour shifts in a row has shown to increase errors. There is even a suggestion that more experienced workers are more prone to making mistakes. New grad nurses have to think carefully about what they are doing, whereas experienced nurses have more “automatic” way of thinking. Therefore, experienced nurses are more likely to slip and also forget what they are doing midway through a task, whereas a new grad nurse is more likely to remember.

What makes a new grad successful in the ICU?

Whether you agree to having new grads in the ICU or not, they will be in the ICU. The times have changed from 30 years ago and the demand is greater than the supply. So, how can we all help new grads be successful despite our individual beliefs?

• Supportive preceptors and peers: Much of the research focuses on the learning environment for the new graduate. New graduates can be successful with preceptors who encourage and help them achieve a higher level of thinking. Additionally, preceptors should be fully focused on their orientees. Meaning, preceptors should not be assigned patients while mentoring. Also, new grads are more successful when they have other new grads with which to identify.

• Student nurse positions: Other research focuses on the importance of a student nurse position. A student nurse position can help newly graduated nurses enculturate into the unit. They will be able to learn basic skills prior to starting and build a reputation with other unit staff.

• Residency programs: Many institutions provide new graduate nurses with an opportunity to complete a critical care residency. Residencies include specific critical care classes like advanced arrhythmia identification and information on common comorbidities of ICU patients. These programs also help new grads develop critical thinking skills and peer camaraderie.

Personal Experience

I have been working in the ICU for my entire nursing career. I was a second-degree nursing student and the ICU quickly became my passion through nursing school. In fact, I could not imagine myself doing anything else. Additionally, I have worked with more ICU nurses with five years or less experience than experienced ones. While I have a great appreciation for experienced ICU nurses and believe they are invaluable, I believe it is ill-informed to suggest certain new graduates cannot succeed in the ICU, ED, NICU, or any other high acuity unit. I also believe that insecurities should be set aside and the breath that is wasted on this argument should be used to encourage and support new nursing graduates. If a high-acuity unit is your passion and you believe you can handle the high-stress, fast-paced, environment, then I encourage any new grad to go for it.

Adams, J. M., Alexander, G. A., Chisari, R. G., Banister, G., McAuley, M. E., Whitney, K. B., & Erickson, J. I. (2015). Strengthening New Graduate Nurse Residency Programs in Critical Care: Recommendations From Nurse Residents and organizational Stakeholders. Journal Of Continuing Education In Nursing, 46(1), 41-48. doi:10.3928/00220124-20151217-01

O’Kane, C. E. (2012). Newly qualified nurses experiences in the intensive care unit. Nursing In Critical Care, 17(1), 44-51. doi:10.1111/j.1478-5153.2011.00473.x

Proulx, D., & Bourcier, B. (2008). Graduate nurses in the intensive care unit: an orientation model. Critical Care Nurse, 28(4), 44-53.

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