Becoming a PICU nurse is both an exciting and challenging journey. The Pediatric Intensive Care Unit (PICU) requires a unique blend of advanced clinical skills, emotional resilience, and adaptability. Whether you’re fresh out of nursing school or transitioning from another specialty, excelling as a PICU nurse requires dedication and strategic preparation. Here’s a detailed guide to help you not just survive, but truly thrive as a PICU nurse.
Table of Contents
What is a PICU Nurse?
A Pediatric Intensive Care Unit (PICU) nurse is a highly specialized nurse who provides critical care to children, from infants to adolescents, who are experiencing severe, life-threatening conditions. These patients often require constant monitoring, advanced life support, and complex medical interventions due to acute illnesses, injuries, or congenital conditions. PICU nurses are skilled in managing ventilators, administering potent medications, and performing critical procedures, all while providing emotional support to both the patient and their family.
Differentiating a PICU Nurse from Other Pediatric Nursing Roles
Progressive Care Nurse: While a progressive care nurse (sometimes referred to as a step-down or intermediate care nurse) also cares for patients who require close monitoring, these patients are typically more stable and do not require the intensive, life-saving interventions needed in the PICU. Progressive care patients are often transitioning out of the ICU but still need more attention than those on a general medical floor.
NICU Nurse: A Neonatal Intensive Care Unit (NICU) nurse cares for newborns, particularly premature babies or those born with critical health issues. The NICU focuses exclusively on neonatal patients (infants up to 28 days old), whereas the PICU nurse cares for a broader age range, from infants to adolescents, dealing with a wider variety of critical health conditions.
Pediatric Floor Nurse: A pediatric floor nurse works on a general pediatric unit where children are treated for various medical conditions that require hospitalization but not intensive care. These patients are typically more stable and require less complex care than those in the PICU. The focus is more on routine monitoring, medication administration, and basic nursing care.
Pediatric Emergency Room Nurse: A pediatric emergency room (ER) nurse provides care for children who need urgent treatment due to injuries, sudden illnesses, or other emergencies. While pediatric ER nurses handle acute cases and may stabilize patients before they are transferred to the PICU, their role differs in that it focuses on rapid assessment and treatment in an emergency setting rather than ongoing critical care.
How to Excel as a PICU Nurse
You may think that being a high performer as a PICU nurse means knowing all of the medications, disease processes, and diagnostics off of the top of your head. Oh, how wrong you are. Starting any high-acuity nursing specialty requires significantly more than just knowledge. (You can teach new hires information.)
What sets people apart and sets them up for success are the less tangible qualities and behaviors. Much of what we will discuss centers around appropriate expectations for yourself, a healthy growth mindset, and high levels of self-awareness. Let’s dig in.
#1 – Accept That Being a PICU Nurse Will Be Hard
The role of a PICU nurse is incredibly demanding and will test you in ways that are both mentally and emotionally challenging. Even if you have years of experience in pediatrics, the PICU is a different environment that introduces a higher level of complexity.
The ICU level of care is more complex than the regular nursing floor. Patients are sicker, situations are more urgent, and patients can decompensate in a matter of moments. In addition to recalling complex information during intense situations, you will have to be competent at a wide range of tasks (IV insertion, complex medication administration, dressing changes, assessments, telemetry, equipment management, urgent and emergent situation management).
If learning how to be a hospital nurse straight out of nursing school was like learning how to drive a car, the emergency department would be like learning to ride a motorcycle, med-surg would be like learning to drive a Toyota Corolla, and the ICU would be like learning to drive a semi-truck.
Just because you got amazing grades in school or have years of working with kids under your belt, this is a totally new beast. Don’t get me wrong, good grades and prior experience are helpful, but it’s not going to take this semi-truck and turn it into a Prius.
#2 – Give Yourself Permission to Be a Beginner
One of the most important steps in becoming a successful PICU nurse is allowing yourself the space to learn. You won’t know everything right away, and that’s okay. A lot of people who were high-performers in their previous roles assume that they’ll hit the ground running and automatically transfer their skills to this new highly specialized role.
Please give yourself realistic expectations and know that you will fumble, say the wrong thing, prioritize incorrectly, pull the wrong med, ask the wrong question (or forget the question entirely), miss something on an assessment, document incorrectly, and do about 900 other things wrong the first time – and heck, maybe the first five times!
You will have a PICU nurse preceptor who will create a zone of safety for you. They’re going to teach you and give you autonomy while ensuring that harm does not reach the patient. They do not expect to just tell you to assess a patient and pass meds the first week, and assume that because you have RN behind your name, you know how to do that autonomously.
#3 – Find a Mentor
Mentorship is a crucial aspect of excelling as a PICU nurse. Seek out an experienced nurse who can provide guidance and support as you navigate the complexities of the PICU.
This mentor should not be your preceptor, who is ultimately responsible for your orientation process and will give input on your formal performance review. Also, having someone outside your immediate training circle can offer unbiased advice and a different perspective and help you process situations that occurred with your preceptor.
A mentor can help you grow professionally and personally, giving you the tools to succeed in this challenging environment. This mentor can be another nurse on your unit or one you know from another unit (like the adult ICU, emergency room, or other high-acuity areas). If you are brand new at this hospital and don’t know anyone, email your unit nurse educator and ask them.
Sample Email Script
“Hi, Sarah. I’ve started working as a PICU nurse and am really enjoying it so far. It’s important to me to excel in this role and I believe that having a mentor will be critical in my development. However, I am completely new to this hospital system. My preceptor is the only nurse I personally know, and would love to have an additional support person. Is there anyone you could connect me with that would be a good fit? I am open to nurses on my unit, or even similar ones in our service line, as I know availability might be a challenge. Thank you so much!”
#4 – Lean Into the Tasks You Avoid
As a PICU nurse, it’s natural to have areas that make you uncomfortable or anxious. Whether it’s a particular procedure or a type of patient, leaning into these challenges will help you grow.
Things that often make new nurses nervous:
- Starting IVs
- Updating patients and families
- Asking physicians questions
- Managing more complex ICU equipment (ventilators, art lines, EVDs, and more)
- Running protocols
- Entering orders
Please do not underestimate the benefit of leaning into this discomfort early. Here’s why.
Think of all of the tasks you must complete during a normal shift. I’m guessing there’s a certain percentage you feel very comfortable with. That might be documenting certain tasks, getting supplies, giving a bed bath, walking someone to the bathroom, ordering a meal tray, giving oral meds, or whatever it might be. I call these green-light tasks. These are tasks that once you realize you need to do them, you just go knock them out. There isn’t self-doubt or hesitation.
Then, there are some you are mildly uncomfortable with. We will call these yellow-light tasks. These are ones that give you pause but are still doable. This might be an IV med, changing an IV bag, taking report, changing telemetry pads, etc.
And finally, there are red light tasks. These are tasks you actively avoid, ones that you might know are a higher priority, but look for excuses not to do or unconsciously see if someone else will do it for you. This could be starting an IV, updating a physician, inserting a feeding tube, answering questions from an upset family member, giving report to the super rude day shift nurse, ventilator management, troubleshooting the arterial line, and more.
My challenge to you:
- Write down your RED-LIGHT tasks
- Write down 1-3 painfully practical ways you can start to turn them into yellow-light tasks
For example, a few of them might be:
- Delegating anything to Martha
- Starting an IV
(Note: If you’re truly a new PICU nurse, your list of red-light tasks is probably 20+ tasks, not two – and that’s 100% normal.)
And here are some painfully practical ways I can make them turn into yellow-light tasks:
- Martha delegation
- Observe how other nurses word things to her when they delegate and jot down good talking points
- Make an effort to have small talk with her to build rapport
- Listen to the FreshRN Podcast episode on delegation
- Keep a running list of things that are reasonable to delegate to a CNA on your unit
- This can vary widely depending on the unit, so pay attention to your unit’s unique norms
- Starting an IV
- Ask my preceptor to observe me each time I attempt to start one to get real-time feedback
- Take notes of feedback and questions on my phone
- Tell other nurses to let me know if their patient needs an IV so I can practice
- Ask to shadow in one-day surgery for a few hours to get more reps in
- Take the Pediatric IV insertion course from the IV Guy to get very practical tips at home
Even by making this list, you’re making it less scary. Now, imagine if you could reflect back on that full list of nursing responsibilities… what would it feel like if they were all green-light tasks? That’s what it feels like to be a competent nurse on your unit. You will get there faster with very specific intentions! Therefore, I cannot stress enough how critical it is for you to identify things that you avoid and lean into them – STAT!
#5 – Use Your Resources Effectively
Being a successful PICU nurse doesn’t mean knowing everything off the top of your head; it means knowing how to find the answers when you need them. Whether it’s consulting a colleague, utilizing online databases, or digging through the patient’s chart, mastering the use of available resources is crucial. Being resourceful will empower you to provide the best care possible.
Notice the behaviors of highly competent nurses each shift. While they are a wealth of knowledge, they don’t know everything. They know who to call when they don’t know the answer. They don’t know every drug interaction off the top of their heads, but they know how to check an IV compatibility database faster than you can sneeze.
- Which unit can take patients on a heparin drip? Check the patient placement policy.
- Different route options for the med your patient refuses to take? Call your PICU pharmacist.
- Respiratory concerns? Let’s ask RT to come by to assess and discuss.
- Can’t find the bladder scanner? Someone stole it. Start searching clean utility rooms, starting with those sneaky med-surg nurses.
- Not sure of the restraint documentation? Let’s look at the restraint policy.
- Out of ABD pads? Let’s call central supply.
For an athletic analogy, each team has to learn their team’s playbook. These are established plays to run to score a point/goal. However, whenever you run plays, there is always an unknown variable – the defense. You have to be able to adjust and adapt based on what the defense is doing.
While you may know the procedure for changing a chest tube dressing, if you don’t have 3 of the 6 required supplies, we have to adapt and know our resources. We will learn who to call and how to respond so that we can execute the play. Therefore, I argue that learning how to utilize your resources is just as important as learning the textbook way to do things.
#6 – Master Time Management
Ok, mastering time management is a bit of a tall order for a newbie. Heck, even us old experienced nurses have problems with it.
Time management is a critical skill for a PICU nurse. The PICU environment is fast-paced, and the ability to prioritize tasks and manage your time effectively is essential. Develop a system that works for you, whether it’s creating a checklist or setting time blocks for specific tasks. Efficient time management will not only reduce stress but also ensure that you provide timely and effective care to your patients.
You’ll notice that many of your colleagues will manage their time differently. I thoroughly explain my time management techniques in my ICU course, as well as this podcast episode. There will always be a bit of trial and error because a lot depends on the level of support you get from nursing assistants and other personnel, your unit norms/schedule, shift, and more.
Anticipate a learning curve. Some approaches that sound great in theory are terrible in practice. For example, assessing everyone and then going back and doing meds on everyone, then doing dressing changes, etc., is not great and will take substantially longer than knocking out as much as possible in one trip into a room. However, you can’t spend too much time in there, especially on the front end of your shift.
Juggling that many responsibilities within a 12-hour time frame absolutely requires strategic planning. Therefore, as you work through tasks during your shifts, be cognizant of ways you can safely work through them more efficiently as the days progress.
#7 – Develop a Reliable Note-Taking System
A PICU nurse is constantly bombarded with information, from patient updates to new procedures. Having a reliable note-taking system is essential to stay organized and ensure that nothing is overlooked.
In the old days, you would get a pocket-sized notebook to quickly jot things down. Today, you may want to have a note in your phone that you can quickly add information to. (Make sure to keep HIPAA in mind). I recommend taking notes about these different types of things:
- Really good talking points for tough moments that you overhear from colleagues
- How a colleague explained a procedure or situation to a patient’s mother that really made sense to you
- The name of a frequently referenced policy you always forget
- The steps required to transfer a patient to the peds floor
- Frequently used unit phone numbers
The greatest lie we tell ourselves is we won’t forget something, and then we find ourselves struggling to remember. It actually takes a bit of cognitive energy to half-remember things. Therefore, offload important information to a reliable source and trust that it’s there. This will ease your stress, and with repeated references back to it, it will begin to be internalized, but we won’t have to have the routine struggle sessions to get there.
#8 – Proactively Learn About the Most Frequently Seen Diagnoses
You will quickly learn that the same 8-10 situations keep coming up. While much more can happen, there are only so many situations that will land someone in an intensive care unit. Therefore, narrow down those TOP situations and learn what you can about them. It makes it much more manageable and will accelerate your competency, and, therefore your confidence.
Chances are you touched on it in nursing school, but probably need a brush-up on the patho. I’m not saying to learn every little thing about it. Let’s save that for a bit later in development. For now, focus on having a basic understanding of how the patho works so that you can explain it to a confused family member. Often, physicians will provide an explanation, but the parent or patient might be in too much shock to really comprehend it, and minutes or hours later, they are asking the nurse to explain it again.
The times I felt most confident as a nurse were when I was able to break a complex pathological concept down for a confused family member. I could see the lightbulb go off in their brain, and it suddenly made sense. They go from scared, lost, and confused, to knowledgeable and empowered (and honestly probably still scared).
And if there are common situations that you’re not finding yourself getting assigned in orientation, advocate for yourself and ask for them. Sometimes the charge nurse assigning patients is unaware of what experience you need, and a soft ask is all that’s needed to really solidify your understanding and education.
#9 – Maintain Boundaries and Balance
Working as a nurse and dealing with death is difficult. It’s even more difficult dealing with children in urgent and emergent situations, facing death. It’s especially difficult when their health and safety are in your hands.
We can romanticize this because while it does feel awesome to be responsible and in this admirable role, it is a heavy weight of responsibility. There’s also an exorbitant amount of information to learn to develop your competency and, therefore, your confidence.
You will be exposed to secondary trauma. You will have to proactively prevent burnout. Do not assume that only certain nurses develop it, and that it’s something you will address if you see signs of it. You work in a high-acuity environment with children.
This is like injury prevention as a professional athlete. While not every athlete gets injured, it’s reckless to act as if you’re immune from it and not take any preventative measures. If you’re a pro basketball player and have knee pain, but just ignore it, you could cause lifelong damage to your knee and cause the end of your career if you’re not exploring what’s causing the pain, resting it, and developing a care plan with a medical team.
The same is true with nursing burnout. You’re in an environment ripe for injury: Sick and vulnerable patients, fast-paced, high-risk procedures and medications, lots of autonomy, emotionally devastating situations, high expectations, and we often grant ourselves very little grace. Therefore, proactively prevent your own burnout from day one.
Final Thoughts: Thriving as a PICU Nurse
Excelling as a PICU nurse requires more than just clinical skills; it demands emotional resilience, adaptability, and a commitment to continuous learning. By embracing the challenges, seeking mentorship, and focusing on your growth, you can not only survive but truly thrive in the PICU. Your journey as a PICU nurse is just the beginning, and with the right mindset and tools, you’ll make a significant impact on the lives of your patients and their families.
Keep expectations for your professional growth realistic while also keeping yourself challenged. You’ve got this!
More Resources for The New PICU Nurse
- What Does a Pediatric ICU Nurse Do?
- New ICU Nurse Master List – Medications, Skills, Procedures, Diagnostics and Diagnoses
- Empathy’s Toll: The Reality of Nurses and Secondary Trauma
0 Comments