If you want to know how to be a good icu nurse, these tips for new grads in the ICU are for you!
In the beginning… Hopefully, you did your homework by learning what to expect in a critical care unit. Bonus points for you if you had the opportunity to observe nurses in a critical care setting. Extra credit + Bonus points if you were able to do an extending preceptorship/internship during nursing school. Those students who did that will have the best idea of ICU reality. If you have no idea what to expect or haven’t been able to observe nurses in critical care, we’ve got you covered.
This is a guest post.
The purpose of this episode is to offer tips and advice to new graduate RNs starting in an ICU.
All opinions in this post are that of the guest author and not those of their employer.
All is not lost if you didn’t have those opportunities. Or, even if you DID have these opportunities, reality as a student nurse is very different than reality as a credentialed nurse. Which leads to…
New Grads in the ICU Nurse Advice
This post covers a lot of information. You can use the table of contents to jump to the section you want.
- Have an Open Mind
- ICU Nurse Characteristics
- Showing Initiative
- Be Your Own Advocate
- Organized Orientation
- Organized Routine
- Learn your Alarms
- Downtime
- More Resources
Come in with an open, actively engaged mind
You will have to pull together/brush up on every skill you learned in school and then add many more. Expect to be overwhelmed for a while. Seriously. A minimum of 6 months.
Be Aware of Typical ICU Nurse Characteristics
Some of the qualities of a ICU nurse may be well understood until you’ve worked in the setting and have seen it in action. Some even say there is a distinct ICU nurse personality that is either inherent or develops after you work as an ICU nurse.
Here are are some of the most common an desirable ICU nurse qualities:
- Assertive – We have a reputation for being “bossy,” but there is more to that. We have to be advocates for our patients (or sometimes families). Sometimes we need to be more direct with doctors when the patient is showing early signs of decompensation. Maybe the doctor orders a chest x-ray for a patient who is short of breath and confused, but we think the patient may need a blood gas to check for hypoxia not detected by simple pulse oximetry. Or, a patient’s family expresses concerns regarding aggressive treatment when the patient had previously indicated they did not want “life support”, and you need to help the family communicate this to the MD.
- Detail-oriented – This is more than Type-A or control-freak personality, although there really is no denying its presence. ICU nurses need to know their patients… their lab values, their x-ray results, what medicines the patient is on, their head-to-toe assessment. We need to know it all because it helps us anticipate complications and respond quickly.
- Critical thinkers/problem solvers – Successful critical care nurses have a good grasp of pathophysiology. This helps us recognize early changes and anticipate/direct the necessary treatments.
- Intense – Here is where I’d say the term “adrenaline junky” applies. Many critical care nurses thrive in challenging situations. We want the sickest patient with the most invasive lines. A code blue? Let’s go! (As long as it’s not our patient, whose AM assessment we still haven’t documented because there was too much stuff to do!)
- Autonomous – We are self-directed, independent workers. We thrive on doing as much for our patients as we can (within our scope) BEFORE we have to call a doctor.
You will likely come across many nurses with these characteristics; some will be easier to interact with than others. Identify those with whom you feel comfortable and take the others with a grain of salt. We recognize that experienced nurses can be intimidating, but remember that it does not make them any more or less valuable to the team than you. Everyone has something to bring to the table, and that includes you!
If you don’t possess all these ICU nurse traits, don’t worry. These are nursing skills that can be honed over time.
New Grads in the ICU: Show Initiative
One of the most important qualities of a critical care nurse is the ability to show initiative.
It develops rapport. Every single interaction with every single patient, family, nurse, doctor, and other health care partner will be a learning opportunity. Seeking out learning opportunities shows your co-workers that you are engaged. There’s a patient getting a bedside trach or ICP bolt? Ask to be in the room and tell them you’ve never seen it before. Ask questions. Most doctors appreciate the new nurse who demonstrates the desire to learn.
RT can teach you about blood gases or lung sounds, or modes of the ventilator. PT can teach you the best way(s) to mobilize patients (a huge AACN initiative). OT can show you adaptive maneuvers to help the patient learn new ways for ADLs (like feeding themselves after a stroke). ST is not just about safe swallowing (though important)… they can teach you about other cognitive deficits and how to recognize them and help patients adapt. BE A SPONGE and soak up the opportunities. That being said, be careful not to over-extend yourself in any given shift.
New Grads in the ICU: Be Your Own Advocate
One of the most valuable ICU nurse strengths is the ability to be your own advocate. This requires a large amount of self awareness and developing your confidence to speak up when you need to.
- Learning style vs. teaching style If I’m going to teach you how to knit me a scarf, how do you learn best? Can I just talk you through it? Do you want me to give you an article to read? Do you want to watch me do it? Or, do you need to hold the needles and do the stitches? Or… do you learn best with a combination of those things? Your learning style and my teaching style may be very different, so we should talk about that at the beginning. Or, the best way you learn knitting may not be the best way to learn figure skating. Talk to your preceptor about things that are or are not working, that’s how you’ll learn to adapt to each other.
- Know your limitations. Recognize what you don’t know. Nothing will kill your credibility quite like being the ‘know-it-all’. As a new grad, it will make you look dangerous. I would recommend you have regular conversations with your preceptor.
- Example: Your post-op patient is becoming increasingly tachycardic.
- You: “My patient is tachycardic. I’m concerned they might have internal bleeding”.
- Preceptor: “Why do you think that? The patient has a fever.”
- This would be your opportunity to show your critical thinking skills by reviewing the patient’s other vital signs (say a low BP), or your preceptor may direct you to check the patient’s lab work or the most recent dose of pain medication.
- It takes time for your preceptor to validate your knowledge and technical skills. By allowing this natural progression, you will only improve your credibility among your peers, which will help demonstrate your independence.
- Ask for help. This coincides with knowing your limitations. Asking for help is not always a weakness. Sometimes it can be a key strength in safe patient care. If you aren’t sure how to titrate your vasoactive drips on the new IV pump, or if you need a refresher on how to perform trach care, ask. Your preceptor may want you to demonstrate what you do know, but this will help identify learning opportunities.
- Find a mentor. This will likely NOT be your preceptor during orientation (but they will often become one after you are on your own). This person does not have to be the most experienced person. But, it should be someone who has experience in the unit who can offer a sounding board after a rough day, suggestions for your performance, or how to interact with your preceptor. This would be someone who is not grading your knowledge/technical skills, but someone focused more on personal and interpersonal development.
- Own your orientation. Orientation is an extension of nursing school, without formal grading. Use resources like textbooks, professional nursing organization references, or reputable internet sites to look up unfamiliar things (like disease processes) on your own time. Your preceptor and manager will appreciate your self-motivation to learn! Bonus: These notes will give you something to go back to when it comes back up again in the distant future.
Keep your Orientation Organized
There will be a lot of paperwork during orientation. You will be (or should be) exposed to many types of patients during orientation. The same goes for types of equipment (IVs, vents, monitors, pressure lines, etc.) You should keep notes on what you’ve experienced, what you’ve done well, and what you need help with. I hope you’ve got a preceptor helping with this one!
Organized Routine is Key
Whether it pertains to organizing orientation paperwork (as above) or to how you run your day, having an organized routine will help things run smoother. Below are some of my thoughts for starting out.
- Assessments: Head to toe. Getting in a routine on what/how to assess your patients will help you master the patient assessment. Furthermore, good assessments are the foundation for success in critical care. This is how you will learn to recognize changes early. Technical skills are important, but your assessment skills are more so.
- Report: Needs to be organized/streamlined whether giving or receiving. You should have a tool (whether self-developed or a borrowed) for report. It’ll help you organize your thoughts, ask questions, and plan your day. CAUTION: Do not regurgitate the report you received as the report you are giving someone else.
- Receive report. I need to know why my patient is here and the most pressing issues. (WARNING: you will likely not receive every piece of information you need during report. For this reason, do not rely on word of mouth for your orders. Review the chart for active orders and current MD notes)
- Assess the patient: Your eyes should go to the patient first, NOT the monitor. Seeing your patient is dusky and short of breath will tell you way more than an SpO2 of 94%. Same goes for an awake, chatty, pink healthy patient whose SpO2 is reading 52%.
- Assess the monitor: Are the vitals normal? Anything I need to address urgently. (WARNING: check to be sure your alarms are set appropriately, both numeric values as well as sounds)
- Assess IV meds: Look at what is actually hanging vs. what is programmed into the pump. Also, you should have enough fluids to get through the first couple of hours. If not, address promptly. The last thing you want to do is run out of Levophed while in the midst of starting your day.
- Go from there. You decide when charting assessments, scheduled med administrations and the dozens of other nurse tasks will get done over the next 8-12hr shift.
- Practical application: I start my day like this:
- Receive report. I need to know why my patient is here and the most pressing issues. (WARNING: you will likely not receive every piece of information you need during the report. For this reason, do not rely on word of mouth for your orders. Review the chart for active orders and current MD notes)
- Assess the patient: Your eyes should go to the patient first, NOT the monitor. Seeing your patient is dusky and short of breath will tell you way more than an SpO2 of 94%. Same goes for an awake, chatty, pink healthy patient whose SpO2 is reading 52%.
- Assess the monitor: Are the vitals normal? Anything I need to address urgently. (WARNING: check to be sure your alarms are set appropriately, both numeric values as well as sounds)
- Assess IV meds: Look at what is actually hanging vs. what is programmed into the pump (my IV insulin story). Also, you should have enough fluids to get through the first couple of hours. If not, address promptly. The last thing you want to do is run out of Levophed while in the midst of starting your day.
- Go from there. You decide when charting assessments, scheduled med administrations and the dozens of other nurse tasks will get done over the next 8-12hr shift.
Learn your alarms and use them to your advantage
There is a reason for every alarm. All alarms have to be answered promptly. Still, in an ICU there are often many alarms occurring simultaneously. It’s important that you learn to prioritize. For example, a V-fib alarm needs to be addressed before an occluded IV. Each alarm has a different sound, and therefore it is imperative that you recognize the sounds.
Even better, use these alarms to your advantage. My favorite 2 alarms to utilize in this way are IV pump alarms and tube feeding pump alarms. On an IV pump, you can program the VTBI so that you know when one antibiotic is done and it’s time to hang another one. Or, use it to remind yourself half way through to make sure you have another bag of Levophed with plenty of time before it’s empty. Titrating your tube feeding rate to goal? Use the volume to trigger an alarm on the pump as a reminder when to turn up the rate.
You need downtime
Becoming a nurse is an exciting, but stressful time. Becoming a critical care nurse right out of school adds another layer to that stress. Learn to separate from the physical, mental, and emotional stress of work. You will have good days and bad days, both to varying extremes. Sometimes things don’t go your way and sometimes is very hard to accept that. But, you cannot (and should not) be in orientation 24/7. Identify stress relievers, whether that’s exercising, bowling, painting, hanging out with friends, or shooting targets at a range. Do something fun! Home-work balance is important to your long-term success.
Bottom line: you will likely have some (or many) days where you think, “I can’t do this.. or what have I gotten myself into?” But rest assured that you can. It takes time, trial and error, and confidence in yourself to become a safe and competent ICU nurse.
Welcome to Critical Care Nursing!
You will more than likely come across many chances to use these tips; some will be easier to master than others. The ICU can be very intimidating, but remember that you are not any less valuable to the team. Everyone has something to bring to the table, and that includes you!
More Resources for New Grads in the ICU
Become a member of the American Association of Critical-Care Nurses (AACN) here.
ICU and Critical Books
About the Author
Melissa Stafford, BSN RN CCRN SCRN graduated from nursing school in 2000, and after a short time on a medical-surgical floor transitioned to neurocritical care. During her career, she has precepted multiple nurses, taught classes ranging from neurological/neurosurgical specific subjects to general critical care medicine, been involved in shared governance and resides as chair for nursing peer review. She has received various awards, including the Great 100 Nurses of North Carolina and DAISY Award. Melissa enjoys spending time with family, painting, watching sports, visiting the beach whenever possible, and vacationing at Disney World. Melissa is also one of the co-hosts in Season 2 of the FreshRN Podcasts.
Huge “Thank You” Katie & Co. for taking the time to piece out the key points for newbies! I worked as an ER tech for 12 years before graduating nursing school and thought the transition would be easy. However, far from it! I have the skills down pat, but found interacting w/ other HCP to be the most challenging.
Some nurses don’t want to hear about experience, others appreciate it.