In Defense of On-the-Job Learning in the ICU

Image via Wikimedia Commons

By Marcy Phipps, RN, who is a regular contributor to this blog. She emphasizes that the identity of the impatient practitioner described in this post has been altered in significant ways to prevent any chance of recognition.

This is why new nurses have no place in critical care!” said the trauma physician. “I’m sure she’s a fine nurse, but she should be getting experience with these situations on the floor!”

The issue of whether new nurses should work in critical care comes up from time to time. It seems to polarize people, and it always touches a nerve with me. I was hired directly into the ICU upon passing the boards, as were many of the nurses I work with. My hospital offers a program to new graduates that includes training and education specific to critical care and an extended clinical experience with a preceptor. Admittedly, there is a steep learning curve, but I wouldn’t consider it unsafe—and comments that suggest the contrary irritate me, because they undermine new nurses and foster negativity.

This patient probably would have pulled his PEG tube out no matter how experienced his nurse was, and I’m not sure the step-down floor would have been a “better” place for a new nurse to manage that situation. The patient acuity is lower on the floor, but there are also fewer nurses around to help out, and a patient would probably have more opportunities to pull a PEG tube out, assuming that was his intention, given the more private nature of the rooms. These things do happen occasionally, regardless of the precautions taken, and I don’t know any nurse who wouldn’t have been at least a little flustered, no matter where they were. I certainly would have been.

The new nurse came back the next night and had the same patient assignment. She was composed and professional, and it occurs to me that the trauma physician was right about one thing—she is a fine nurse. And she’ll get better all the time, here in the critical care unit, where she’s losing her “fluster” and thickening her skin, despite the glare of a doctor who doesn’t think she should be here in the first place.

*PEG = percutaneous endoscopic gastrostomy

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2016-11-21T13:11:33+00:00 November 2nd, 2011|career, Nursing|6 Comments
Chief flight nurse at Global Jetcare.


  1. Melissa Correa November 21, 2011 at 10:07 pm

    As my graduation to nursing school approaches, I have considered a career in ICU nursing. The question has presented it self if new nurses are capable of being as efficient and safe as experienced nurses . My answer to them is yes. I have known of plenty of newly graduated nurses that have recieved the appropriate training from hospitals and have proven themselves as profesionals in the ICU setting. Accidents can occur at any time to anyone one including experienced nurses, but many are quick to point figures at the “new guy.” I do not disregard many nurses oppinions of gaining experience on med-surg floor prior to entering a more demanding and more stressful unit, but I do believe that many new nurses are driven enough to care for all types of patients even the most critical.

  2. Jawad November 20, 2011 at 3:57 pm

    As a current nursing student soon to graduate, I have frequently researched on this topic. Now-a-days, most hospitals require at least a year of floor experience before they hire a nurse in a critical care setting. There are some new graduate nurses who get hired and after hospital training can work in an ICU and are up for the challenge, because although critical care is a complicated setting to work at, nothing is impossible if you have proper training and background nursing knowledge. There are some experienced nurses I know who recommend new nurses to work on the med-surge or step down floor first to improve the new graduates’ confidence and skills as a nurse, which is very important. But, I know new nurse graduates who have started working in the ER and ICU after graduating and are proficient nurses because of their willingness to learn and practice critical care nursing. At the end, it is all about what setting you enjoy working in because that is where you will try your hardest to be the best.

  3. Rachel November 2, 2011 at 3:22 pm

    I would agree with the first post – physicians and other nurses (possibly just human beings generally) tend to distrust people they don’t know. If critical care nursing is the passion of a graduate nurse, she should pursue this placement, and our profession should be supportive. Floor nursing is a specialty itself- 4-6 or even 7 patients with wildly different diagnoses – that doesn’t sound any “easier” to me.

  4. Samuel Logan November 2, 2011 at 1:25 pm

    This is encouraging to me. I am nursing student soon to graduate and considering ccn. I think if we told people “you can do this” more often, we would have more success stories and stronger bonds. Thank you for your time.

  5. Robert November 2, 2011 at 10:58 am

    “That which you resist, persists.”

    Many times a person’s outlook on a situation could actually create exactly what they are trying to avoid. When working around people who are highly critical, I know my level of anxiety increases sharply and it seems the created environment contributes to mistakes. How would this person have responded if the PEG was pulled out on their watch? They probably would have given themselves a pass, chalking it up to the fact that these things just happen some times.

  6. Katheren Koehn November 2, 2011 at 10:36 am

    It has been my experience that it is much easier for a physician to “blame the nurse” when he/she doesn’t know the nurse, no matter what unit the nurse is on. Blaming the new or inexperienced nurse in the manner that this trauma MD did seems more like bullying than constructive feedback or concern for the appropriate unit for “training.”

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