ICU as a NQN

ICU was my first job as a newly qualified nurse, and will always hold an incredibly special place in my heart. But, the time came for me to move on after 1.5 incredible years and I truly miss it- I loved the patient mix, the learning opportunities and my amazing colleagues.

When applying for jobs in my final year at uni, I was really torn between ICU and a short-stay medical assessment unit. There were many pros and cons lists drawn up (I'd be lying if I said that 'stethoscope' and 'sounds impressive' weren't on the pros list for ICU...) , and lots of advice asked to help me decide where would be best to start my career. Evidently, I chose ICU. But, it wasn't without people warning me that ICU may not be the ideal place to go as a newly qualified nurse (NQN).

In this post, I want to sum up some benefits and drawbacks of working in ICU, and specifically going straight into ICU after leaving university. Hopefully, it might help you to decide if ICU is the place for you!

Benefits-

The first benefit is more of a question- why not? If you know that critical care is what interests you (hopefully you've been able to experience it through placements- I only did 2 days in ICU as a spoke placement, and that was enough to fall in love) then why would you waste time starting somewhere else? It's a similar issue to one that community nurses face constantly- the rhetoric that you should get some hospital experience first and then move into community because otherwise you lose crucial nursing skills and will 'de-skill'- it's nonsense. Wherever you work, you get a huge skillset and starting in a specific, more specialist area doesn't put that in jeopardy, it just gives you a different set of skills, knowledge and abilities.

P.S.- de-skilling is a ridiculous concept. It's a lateral move, gaining a new set of skills in a new role does not cheapen the skills you already have. If some of those skills get rusty because you don't need them in your new role, whatever. There's also ways to maintain or top up skills if you wanted to, like staying on top of latest research or picking up bank/agency shifts in different clinical areas that use those skills more.

The second benefit is the foundation programme. Most UK units use the Step One competencies, a national competency framework, which although difficult and quite tedious, gives you real focus to your first year working in ICU and ensures that you're exposed to a variety of situations and skills. Alongside, most units will offer an educational programme, with study days to teach you the basics of ICU like ventilators, inotropes, renal filtration and more. The foundation programme in my unit consisted of 8 study days in the first few months, with more later in the year, and an OSCE exam of an A-E assessment near the end of the first year. Having such a solid basis to the theory of critical care really sets you up for success when you have to do it for real on an actual patient, and really helps to boost confidence.

Third up is the fact that ICU somehow manages to be incredibly specialist, yet incredibly generalist as an area. The technical components of managing a the very sickest ICU patients are skills that can take years of ICU experience and education to develop, but those very sick patients could be a spinal trauma one day, an oncology patient the next, and someone in respiratory failure after that. The breadth of patient presentations helps to keep it interesting, and gives you a fully rounded knowledge. I specifically worked mostly with surgical oncology patients, but also saw a huge range of transplant, haematology, urology, upper and lower GI surgery which kept me interested and kept me on my toes.

The teamwork in ICU is second to none. I have always felt so supported in my practice, whether that was with a patient who was deteriorating and I wasn't sure what to do next, or really simple (but never stupid) questions about things I might've forgotten. There's always a band 6 or 7, or a doctor, or a physio, or a dietician around who can help you. I feel really lucky to have worked in such a lovely team.

Next- once you've looked after somebody who is critically ill (like, Big Sick), looking after anybody else doesn't seem so daunting, and there's a huge sense of satisfaction in looking at this picture and realising that you know how to use all this equipment. I won't say that it becomes easy to look after less complicated patients, because anything can happen (some of my most difficult shifts have been looking after level 2, self ventilating patients who suddenly collapse in a heap). There can be a strange disconnection when one day you're responsible for a patient who is intubated and ventilated, on double strength inotropes, with a VAC dressing, NG tube, wound drains, catheter, blood transfusions, IV meds due every hour, so on and so on.... It hits you how sick these patients are, usually when you're crammed into a lift, side by side with a doctor carrying a backpack of emergency drugs and equipment on your way to a CT scan. Their life is literally in your hands. And then the next day, you have a self ventilating, self mobilising patient with one cannula who you get to discharge to the ward- their life is equally in your hands, but they're not actively trying to die on you and it can really give you some perspective on nursing and provides some balance.

Which leads me onto my next point- the perspective that critical care gives you on life and death can be mind-blowing. I've seen patients who I honestly thought were millimetres from death come back from the brink and be discharged to the ward. It makes you think about and value life in a completely different way. You don't go into nursing for thanks and praise, but I'll never forget many of the conversations that I've had with patients or loved ones when they thank you and the team so graciously for what you've done. The interventions that we provide in ICU are miraculous, and patients are now surviving some awful diseases that 10, even 5 years ago would've been the end of the line- take severe Covid as a relevant example. However, there is a flip side to this awareness of life, death and disability which I'll touch on later.

Risks-

Firstly- going straight into ICU means that you haven't necessarily experienced patients who are well, or only slightly unwell (at least, usually not outside if a placement setting, which is actually quite different to reality). This can give you a bit of a warped view of nursing and can mean you're always expecting the worst. There's a lot to be said about caring for people on the wards who in ICU terms would be described as level 0 or level 1 patients and then being able to compare this, with some perspective, to the Big Sick patients in ICU. It can be really nice to care for patients who aren't actively trying to die 24/7 and you csn learn a lot about nursing and normal parameters from these patients.

Starting work anywhere other than ICU, whether that be on a ward or in the community, undoubtedly has its stresses and pressures. But I would still argue that ICU is one of the most stressful, and intense (clue is in the name) places in a hospital. Which makes it a very stressful environment to learn to be a nurse in. Everybody says that you learn more in your first year newly qualified than you do in 3 years as a student, and it's absolutely true. So there are definite drawbacks to trying to figure out how to be a nurse with all the added pressure of critically unwell patients. It's little things that you maybe started to develop as a student, like communicating with the MDT or making referrals to other services that you have to learn as a qualified nurse and in ICU you really don't have time to learn it- like a baby bird, you're pushed out the nest and have to hope that you'll figure out how your wings work before you hit the ground. ICU has a tendancy to be sink of swim, but the team around you can act like a life ring, as mentioned above.

Thirdly, although you are exposed to a wide range of clinical skills and nursing knowledge, there are some areas that may be missed entirely. On a clinical skills front, I was never trained in phlebotomy and cannulation- the vast majority of patients have arterial/central venous access, and in the minority who don't, we would just ask the doctors to take bloods or cannulate. This means that, moving jobs, I was very conscious that this was a core skills that I just didn't have. On a more theoretical front, caseloading. If I was to go and work a bank shift on a general medicine ward, I could probably smash out some meds and procedures but can almost guarantee that my time management would be totally off when faced with 6-8 unwell patients- because I'm so familiar with dedicating all my time to my one, maximum two patients.

Next is probably the question I get asked most often- 'isn't it really sad in ICU?'. My answer generally is that no, it's not too bad, because the vast majority of patients will make full recoveries- ansd those recoveries can be amazing to see. But that does still mean that a minority of patients won't make a full recovery. Patients do die (I only had 2 deaths, but I will always remember them incredibly vividly), or patients leave with such incredible levels of disability that it almost doesn't seem worth it. Again with Covid as an example- someone may survive their ICU admission, but in the course of that journey they've lost all kidney function and need to be started on long term dialysis, they have permanent neurological changes from delirium and prolonged sedation and are plagued by nightmares from post-traumatic stress, and their lungs are so scarred and damaged that they can barely walk the length of the corridor, if they can walk at all due to the extent of critical care myopathy. They have survived, but at what cost? It's a bit of an existential, moral dilemma.

You do have to have a huge amount of mental resilience to get through ICU. It's part of the reason I left ICU, because my mental health generally wasn't up to it (not directly caused by ICU- I already had a wonky brain and the stresses of covid ICU nursing set a lot of things in motion). Sometimes those miraculous interventions feel like torture. Prolonging suffering with invasive monitoring and procedures. As a NQN, particularly if you are young and frankly, lacking life experience like I was, ICU can morally be a really challenging place to work. Shifts can be physically exhausting and emotionally draining (see attached photo of me crying in a stairwell on my lunchbreak...)

On balance....

There's not a right or wrong answer to starting in ICU as a NQN. Overall, I think I am glad that I went straight into it. I can't imagine working anywhere else (not sure where I would've gone instead), and I worry that starting somewhere I didn't feel as passionately about might have changed my expectations of nursing as a career and possibly led to me leaving it all together. That said, I think that more life experience and work experience prior to starting, and slightly better mental health could've helped make ICU a better experience for me. Even though I've left, ICU still holds a very fond place in my heart and I do really hope that one day, I might go back, whether that's on a permanent basis or just doing bank shifts, we'll see.

I hope this post has been helpful if you're in the exciting position of picking your first job, or looking to move from an existing role into ICU. More than happy to take any questions about life as an ICU nurse via the blog, instagram or twitter (@christienursing on both!).

Love, Christie x