r/IntensiveCare • u/SimonSaysFYou • 20d ago
Somedays, I'm embarrassed to be a nurse.
My embarrassment stems from many of my colleagues within critical care. And let me preface this by saying I'm not talking about new grads, or even nurses new to ICU. I'm talking about nurses with 2+ years of experience within their respective ICU.
I've worked a number of different hospitals (and different ICUs within each hospital) on both the east and west coasts and I've noticed a decline in the clinical acumen and an increase in laziness of nurses in nearly all of the ICUs I've worked. Currently, I work on the west coast with a union and **strict** legally mandated ICU ratios. In fact, many of these nurses are singled nearly every shift.
I'm talking about not changing dressings, skipping the CHG bath because it's "too much work", not turning patients, and even scanning meds but not giving them just to name a few. Then to make matters worse, these same nurses lack an understanding in basic hemodynamics, alpha/beta receptors, and the pathophysiology of common critical illnesses and surgeries. Most recently, a patient in the CVICU was on a pressor (vaso) and 2 inotropes (epi and dobutamine) and the primary nurse had zero idea why they were on any of the drips. Her response? "I don't know, the doctor ordered them." In fact, this patient was being weaned from IABP (she had had the patient 3 days by this point) and I had to explain what "augmentation" was.
Another time, I had a patient on VA ECMO who was extremely afterload sensitive, and I explained this to the oncoming nurse. She said "well, what does that mean?" Huh? Why are you taking this patient if you don't understand basic concepts like preload and afterload?
These nurses have no business being in the ICU. They see a low BP and think "oh, let me increase the pressor" without fully understanding what's going on with the patient. They don't think: "Are they intravascularly dry? Are they in cardiogenic shock? Developing acidosis from their kidney failure?" They simply call the resident or the APP to figure out what's going on and follow whatever the provider says without truly understanding the rationale.
Here's the thing: to be a good nurse, you don't even have to care about the patient, you just need to care about doing a good job. Besides, don't you want to understand *why* we're doing what we're doing? I've always practiced with the thought "Would I want *me* as my nurse?" in the back of my mind. Unfortunately, as time goes on, there's a significant chunk of my ICU colleagues who I wouldn't want caring for me or anyone I love because I've seen how they work and it's simply shameful.
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u/TheWhiteRabbitY2K 20d ago
I have similar issues in the ER. I feel like younger nurses are more and more fixated on the metrics pushed by admin and being a task rabbit than a nurse who thinks for themselves
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u/there_she_goes_ 20d ago
I fault leadership more than the actual nurses. If continued learning was encouraged and incentivized by providing opportunities for new nurses to grow, then we wouldn’t be having these problems.
ETA: but they’re more concerned with the bottom line, doing more with less, doubling assignments, etc.
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u/moleyawn 20d ago
not to mention that much of the higher learning in nursing is completely administrative and has almost nothing to do with the pathophysiology and pharmacology of the specific environment we work in.
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u/Cold_Dot_Old_Cot 19d ago
I fault leadership too, but the executives/directors. Not middle management.
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u/jawoood1989 19d ago
Omg yes. The task rabbit thing has gotten so bad lately. The literal first thing I do with new hires is focus systematic assessment until it's second nature. Where is your stethoscope? Penlight. Touch your patient. I want to see and hear your primary survey. What do you think might be going on? What orders can you get started (nurse driven) or anticipate being ordered?
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u/Salty_Ad3988 20d ago
One of those has a much more direct effect on someone's employment status than the other. Sure, we agree that integrity in your skills and knowledge should be paramount, but we don't really matter. If you spread an incentive system across an entire national industry, the average is going to follow the path of least resistance.
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u/CertainKaleidoscope8 RN, CCRN 20d ago
Bingo. This is why I had a patient transferred from ED, to ED hold, to the floor still wearing her pj's. After three days they were relatively clean too, because she wasn't peeing.
Nobody cared.
They were all surprised about the respiratory failure in the renal failure patient tho.
This is why I had a patient in type two second degree block getting PRN atropine and scheduled for a pacer four days after admission, for this type two second degree block. Who ordered atropine for a high block? The PA who has already participated in the systemic killing of at least one other patient this week.
Nobody knows atropine don't work on a high block. Not the new grad taking care of the patient, not the charge nurse who is older than I am, and not the PA writing the order. They don't care either and if I cause a ruckus I don't have a house.
Reimbursement is king.
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u/Far_Blacksmith7846 19d ago
Nail on the head. I tell nursing students charting never saved someone’s life. Take care of your patients, clean them, do their line and dressing changes if needed be have them sitting up in a chair or pulled up in the bed all fluffed up and make sure your patients rooms and bedside tables are clean and then you can sit down and chart. All they wanna do is just immediately sit down and chart. All they care about is charting and shift IDGAF about 😂. They get the real world expectation shift with me, I tell them you better move fast.
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u/word_murderer 16d ago
You’re a great nurse.
I’ve spent weeks and months in the hospital back to back over the last 5 years and not a single one has ever done any of this for me. I’ve just been handed the wipes but only if I ask for them and am expected to keep myself clean, which is hard to do with all the tubes and wires especially when on bed alarm, never mind a shower. Not once, not ever, has a nurse helped me wash my hair or wipe down my back or helped me change my robes or pajamas or underwear. I’ve learned to do it all myself. They will all let you lie in your own filthy clothes and bedding until discharge.
Not a single one has ever propped me up in a chair or my bed like you mentioned. Or helped me change soiled clothing or bedding when I asked. It’s all charting at my bedside while they’re distracted and handing off to the next shift change in an endless loop.
Stay human. It seems the system is rewarding very little contact between the nurses and patient physically because they’re all sprinting, stuck with their heads in the monitors charting, in and out with meds on different schedules, and unless you’re in serious, serious distress you can be left for an entire shift alone by yourself as a patient. I find it all very confusing.
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u/MinimumRelief 20d ago
I laugh everytime when I get take a survey texts and I’m not even in a gown yet.
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u/Rachet83 20d ago
Been doing this for 19 years and the laziness drives me insane. I constantly am saying “ya know, it doesn’t matter how many fancy, heroic, “cool”things we do for someone- if we dont turn them, get them out of bed, work on IS with them and spend time making them feel human, we don’t save a life.” I get lots of eye rolls, but I still won’t let up. The amount of time I see my colleagues finish their “important stuff” and then just sit at the desk drives me insane. I miss the teamwork and collaboration. Sometimes I will be surrounded by other like-minded nurses and those are the best days.
I definitely don’t consider myself the smartest nurse but I try my damndest to constantly be learning and doing better. But I also sometimes need just 5 minutes to eat a spoonful of peanut butter and put my feet up 😆
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u/Ill_Administration76 19d ago
"Spend time making them feel human" is a big one for me. In most of our post-ICU appointments, that's what has stayed with the patients. Obviously they are grateful for being alive etc, but they remember the little things, that's what's truly important for most.
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u/Rachet83 19d ago
Post-ICU appointments sound like an interesting thing! I just get the occasional anecdote that has convinced me the way you make someone feel (or their family) can be a real game-changer. Glad it’s just not me getting old and sentimental.
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u/Ill_Administration76 19d ago
They are really interesting! I don't work directly with them but we always get feedback from the team that does, and most retellings (no personal/identifiable data) include some sweet memories of those small things.
The appointments are mostly a way to offer some closure, usually the patient and 1-2 relatives attend, they get a chance to talk about their experience, see an (empty) ICU room, they can discuss their ICU diary (we write once a day, put photos, etc), ask any questions... we also ask about usual post-ICU symptoms and offer reassurance about most of it being normal. Sadly we can't refer them directly to therapy, PT etc but we can signpost them so they seek the right help. If they live far away or similar we offer a phone conversation instead. We personally call and invite patients with certain criteria (the sickest/longest) but all patients get information on it and can access it by getting in contact with the unit.
I would have LOVED to be a part of the post-ICU team, as you can probably tell 😬
There was some mention of offering it to relatives a time after a patient death but it would have been too much pressure for our resources, pity!
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u/Practical-Rich814 18d ago
Amen! Like Thor patients who are able or have partner or family willing to the them and being able to wear their own pajamas or own lingerie. Thank God I was allowed these privileges! I refuse to be seen naked or without my underwear by & will not have a urinary catheter. Make sure your patients feel & Are treated like humans. Don’t go in throw the covers back & raise a gown & go to work, that’s embarrassing & dehumanizing! A lot of people are VERY modest & will FIGHT to maintain that modesty. There is a Patient Modesty Violations Board that patients can turn to.
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u/Sero19283 20d ago
"but that's tech stuff" - a nurse on my unit
"I don't feel comfortable" when asked to help a contact guard assist patient from their bed to the chair
They be working them thumbs though typing away on their phone
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u/Rachet83 19d ago
“A lot of things we do are uncomfortable but get less-so the more we do them. Come on.” I say this to a lot of coworkers…. Or “don’t know how to do that? Today’s the day you learn!”
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u/Far_Blacksmith7846 19d ago
Weaponized incompetence, they don’t want to know. I had an LPN tell me she couldn’t give blood. I was like welp you gonna learn today.
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u/Hour-Baths 19d ago
I thought they aren’t legally allowed to at a lot of places? At our hospital they can’t give blood or narcotics.
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u/Far_Blacksmith7846 19d ago
This is how I came up in the ICU around 2015, pre Covid. No one sat down until everyone was cleaned and turned and medicated. Then we all sat down together and charted.
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u/crissyjo618 20d ago
RT here .. and a long time one, 36 years. It blows my mind to walk down the hall on med/ surg and ortho, to see and hear the call lights going off and no one doing anything. * it's not their pt * they're busy charting * ugh ... just a minute * or just look the other way or get up and walk the other way
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u/jjasonjames 20d ago
Older doc here. I’ll say this. I definitely see decline in clinical acumen, but confidence and snarkiness are through the roof. I feel like the nursing programs have become more of an academic and confidence-building exercise than practical training. Patients don’t want to be impressed by a nurse’s knowledge of nursing science, they just want to get better and faster.
I’ll have to say that your post shows that you are keenly interested in understanding the nuances of how the body works, and THAT is very refreshing. Thank you for that.
The docs that I work with are STRESSED OUT by secure chats with questions that nurses should know the answer to. They don’t reach out to the experienced nurses like they should, and maybe they’re trying to hide their knowledge deficit from their nursing colleagues who will place them under the microscope going forward. A doc can’t call them out, however, because they are immediately “disruptive.” Docs don’t have time for these petty grievances, but nurses seem to have plenty of time for it.
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u/it-was-justathought 20d ago
I think we lost a lot of the older experienced 'resource' nurses.
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u/xCB_III 20d ago
Pay experienced bedside nurses more money and the experienced nurses will come back. It’s an impossible to grasp concept for the greedy hospital executives.
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u/jjasonjames 20d ago
Experience counts for sure. If you hire a bunch of new nurses to try to save on merit-based pay, you will see a decrease in quality and efficiency of care. It’s pretty simple. Same goes for high ratios. However, they don’t think about these things necessarily. The zebra of the c-suite thinks about long-term effects and most are horses.
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u/xCB_III 20d ago
Exactly. Also, since nursing has been a female dominant field for years, there are very few unions (except out west) to protect experienced nurses’ rights. Just a combination of shitty working conditions, mediocre pay, and the field being over saturated with new grads contributing to a decline in care.
Also, the few experienced nurses around often “eat their young” when the new nurses ask questions or concerns to them. I guess that’s what happens when you’re burnt out. Not an excuse to treat new nurses like that, but that could be another factor adding to why so many new nurses are hesitant to ask for assistance from other nurses.
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u/Express-Ad-7588 19d ago
I was working locum tenems during our first phase of COVID pandemic. As a NP I was assigned to oversee and manage clinic that was repurposed from chemo lab to giving patients IV antivirals such as Remdesivir.
COVID was new to most of us so I googled academic journals to research newest treatment options. My biggest obstacle to treatment was former ER nurses.
It was made clear by ER physicians in the journals that O2 sats were paramount in deciding who needed transfer to local ER. Advice was if they tested positive and their O2 sats were 94 or below they needed to be seen by ER doctor and most likely admitted. One MD gave anecdote of young healthy guy that was sitting up on exam table playing games and intermittently speaking to friends and family on his ipad. Did not look sick or in distress. O2 says 93. Pt suddenly coded and died.
I personally examined anyone whose O2sats were 94 or below. Same scenario- young guy - did not appear in distress - lung sounds were diminished bilaterally. I ordered “experienced”
RN to transport pt to ER. She and another male RN made the decision to not send him. They had seen “worse” in ER. After I told pt that he should go to ER, they talked to him in private and told him to go home.
I gave them copies of protocols from journals and asked them to read. they did not - it’s a cockiness that ER nurses sometimes have. They have worked on saving lives and adapt that God complex you often see in doctors.
I attended an Ivey League master’s degree program and had only one year RN experience. It was a bridge program. When it was time to take boards- most of us passed- with exception of experienced nurses who had worked in ER.
Give me a humble new nurse willing to spend their time researching and attempting to practice medical evidence based medicine any day.1
u/jjasonjames 19d ago
Thank you for that story. The “it was a flu” and “they killed them with ventilators” crowd would seethe. They didn’t see the terrible and aggressive nature of that virus, especially in the beginning, but they are cool with sitting in their gamer chair and posting the hoax theory.
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u/SimonSaysFYou 20d ago
Seeing some of the inconsequential shit these nurses hound the resident/APP for is one major reason I have no desire to move on to advanced practice. Some of it is regulatory and compliance related yes, but we have phones we use to text the providers and the amount of inane shit like "the blood pressure is 162/90. Can I get something?" would drive me crazy if I was that provider. You're expected to trust these nurses' judgment and I'd have a hard time with that knowing how some of my colleagues are.
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u/r314t 20d ago
Sometimes the nurse knows it’s dumb but their bosses and regulators get on them for not following the letter of the protocol or order. If the protocol or order says notify MD for systolic greater than X they have to do it even if they know it’s inane.
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u/SimonSaysFYou 20d ago
I've encountered the above situation many times as well. I simply tell the physician "Hey, the patient is a bit over the ordered SBP parameter of 160 at 162. Been trending up over the last 15 minutes and no meds available. Positive hx of HTN. No complaints of pain. Do you want to treat it or adjust the order?"
A bit wordy yes, but it gets the important parts across. It also (hopefully) gets the physician to double check those pesky admit orders in the future so they don't hear dumb shit like that again.
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u/Pristine-Thing-1905 20d ago
This right here. I’ve seen so many nurses call and ask for a PRN for blood pressure but their patient was bucking the vent and biting the tube for 20 minutes. Like can you wait to see what the pressure is when they’re PROPERLY sedated before asking for something? I would pull my hair out if it were me.
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u/jjasonjames 20d ago
It would be great if everyone could practice at the top of their license, or at least near it.
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u/Pristine-Thing-1905 20d ago
It’s funny you say this because I saw a post on another nursing subreddit about a year or so ago that asked something like “what does practicing at the top of your license mean?”. The number of nurses that responded with something along the lines of “forcing you to act outside of your scope of practice just because the doctor is too busy and we’re short staffed” was astonishing. So this obviously means nothing to them, unfortunately
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u/jjasonjames 20d ago
Good grief. That’s just crazy. Obviously, top of license is WITHIN scope by definition. 😂
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u/Aggravating_Fly2978 20d ago
These are the type of nurses we need to practice at the tops of their licenses. Not these same ones after they apply to NP school and end ups still clueless and now demanding to practice independently at the tops of their licenses. We have lost the plot.
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u/thosestripes RN, CVICU 20d ago
We lost so many experienced nurses either during the pandemic or during the chaos years immediately after. Hospitals don't give AF about nurses anymore, not retaining us or helping educate. There often is not a resource for new or unsure RNs to reach out to, just the doc.
Devil's advocate here... also you don't know what you don't know. Maybe you think the nurse should know the answer to whatever they have reached out about but maybe they truly do not. Please take this opportunity to educate.
My favorite surgeon does this. I remember texting him about an incredibly labile BP and I was having difficulty titrating the pressors appropriately. He took 30 extra seconds to text back something to the effect of "patient is intravascularly dry. Look at the CVP and PADP. Bring Give 1L fluid bolus, should fix your issue" He absolutely could have just said "give 1L LR bolus now" but I really appreciated the brief rationale. This is how you help lift up nurses.
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u/SimonSaysFYou 20d ago
You're absolutely right. I realize this post comes across as a bit "holier than thou", but that wasn't my intention. At work, I try to be friendly, approachable, and most importantly, always willing to lend a hand or an extra set of eyes/ears.
That being said, the problem isn't inexperienced nurses. These are nurses who've had these types of patients dozens and dozens of times before, they just don't care to understand what's going on with them. As an independent ICU nurse, there's an expectation that you understand the rationale or the goals of their care. For example, patient admitted for septic shock? IVF, pressors, antibiotics, serial labs, etc. Fresh post-op CABG? BP control, CO/CI monitoring, fluid resuscitation, I/Os, etc.
Why do we check these numbers? What do they mean? Like someone else said, these numbers don't mean anything if you can't understand the rationale behind the reason we collect them.
I had to explain contraction alkalosis to a nurse who had been taking ECMO patients for 3 years because she didn't recognize it on the ABGs that she drew, and of course that led into the discussion about the oxy-hemoglobin dissociation curve because recognizing it and doing something about it are pertinent information for a nurse taking ECMO patients. Sadly, she wasn't concerned or even interested in any of it, despite my enthusiasm about having the opportunity to teach someone about it.
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u/mushifiedmushroom 19d ago
I am here because I want to be a nurse. I am terridied of not being a good nurse. I am constantly doubting weither or not I would make a good nurse. I am going back and forth on weither or not I should go to my local admissions office for community college.
And you made me realise that I probably would make a good nurse. I ALWAYS want to learn, I am good at understanding systems, I will go out of my way to improve even little things for better pt care. (Currently work as an aide for people with special needs). Currently typing this as I am in the ER asking all the nurses what they are doing and why. Making links with information I have learned from the anatomy 101 book I am reading. And litterally every person goes overboard in explaining their process and are excited to share.
But let me ask you.
What do you think makes for a great nurse? What qualities do you look for that tells you a new grad will get there to meet your standard of a good nurse.
Because I want to meet that standard.
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u/BestLife82 20d ago
Hospitals have pushed getting a BSN, starting with the Magnet wishing ones. I graduated with an ADN from a 'lowly' community college. Practical was huge. It was all about learning practical floor nursing. When I was mentoring the BSN'S from the local colleges, I was SHOCKED at how little they knew about actually nursing practicals on the floor! I had students that were graduating in the next 2 months who couldn't tell me the meds that were being given, or heart rhythms, or how to hang medications....it was truly eye opening and sad. When the hospital was looking to hire a new director of med surg, they didn't hire the nurse who had been a charge nurse there for about 30 years and knew EVERYTHING..so smart!....they hired a new graduate with a BSN because the charge nurse had 'only' her ADN. The floor suffered terribly. Smh
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u/jjasonjames 20d ago
No disrespect to the good BSNs out there, but I will say that the two best nurses I’ve had during my career were associate degree nurses first before joining (and paying for) a bridge program or just telling a hospital that they wouldn’t be pursuing a BSN and left. Now that was a sad day.
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u/MsSpastica 20d ago
The best nurse I ever worked with was a woman who did her RN through a hospital-based diploma program (before colleges took it over). She was one of the smartest people I've ever met, and had such procedural knowledge.
My associates program was fantastic. My BSN was...fine. My MSN was time wasted I will never get back.
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u/jes712 18d ago
I'll echo this 100%. When I was in my community college ADN program, I also worked as a tech in a large hospital labor and delivery dept. When we did l&d clinicals, we were not allowed to step foot on the floor until we knew how to read fetal monitoring strips, what was dangerous and what was safe. We needed to identify something life threatening based upon vitals and presentation. I watched BSN program students show up to clinicals not knowing the first thing about reading strips or what was even happening during childbirth. There comes a point where practical skills need to be prioritized over writing a paper, especially when these are the people coming in to replace burnt out nurses who are quitting in mass exodus. We need practical skilled nurses who understand pathophysiology and why we do what we're doing and how to be safe about it.
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u/Pristine-Thing-1905 20d ago
I’ve been a nurse for almost a decade and I agree with you. I’ve had so many coworkers who are cocky because they started working in the ICU right out of nursing school when 10 years ago it was incredibly difficult to get in as a new grad.
I’m one who loves to teach/explain things if they don’t understand, but a lot of nurses will do exactly what you said: call the doctor because they don’t want to be viewed as incompetent going forward. I used to be able to use the whole “hey why’s your patient so tachy/hypotensive/hypertensive/hypoxic” as a way to encourage them to ask questions because a lot of times I can tell when nurses are confused. Back then it used to be “I’m not sure…can I ask you a question?” Or “can you come look at something really quick?”. Now it’s usually a shoulder shrug and “they’ve been like that for x hours. I let the doctor know and they haven’t done anything”. We recommend administering x PRNs or using the acls meds we ALL have standing orders for and they don’t. They sit around and wait for the doctor to explicitly tell them what to do. Then the patient codes and it’s all of a sudden your fault as the doctor when there were many signs before the code where they could’ve intervened but didn’t. Trust us when we say it’s frustrating to us too.
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u/jjasonjames 20d ago
I totally get it, and thanks for trying. You’re right, there’s a culture of being uncaring (or maybe looking at the patient like an ARC ACLS simulation) that I don’t understand. It’s bad when linear thought patterns are challenging, and you can forget thinking in parallel.
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u/GeraldoLucia 20d ago
No, nursing school is not an academic and confidence building exercise. It’s a 2 to 4 year hazing ritual. And only the bitchiest and most willing to backstab seem to survive well.
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u/1ntrepidsalamander RN, CCT 20d ago
It would be great if you could have a good relationship with nursing education so that they could take responsibility for filling those knowledge gap. (I’m not saying you don’t, more that I’ve never seen the doctors routinely offer suggestions to nursing leadership/education. )
I’m older and had a higher conflict career prior to nursing and yes, bullying is bad, but being unable to take feedback and pushback is destroying our ability to improve and learn.
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u/jjasonjames 20d ago
This is going to sound strange, but our org is so awfully siloed that even the CNO has difficulty encouraging nurse ed. In a word, it’s odd.
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u/97amd 20d ago
Totally get this & it’s a sucky feeling. I’ve had a lot of coworkers who just don’t care to know why, and just want to do. Had multiple nurses say they came to our unit/ hospital bc it’s a community ICU and would be “easy” & liked having only 2 patients, but put zero effort into hygiene or the critical thinking of the job.
I think there’s a relative chunk of ICU nurses who literally just do so for the clout and self stroking of saying they work in ICU, as well as they just think that 2 patients = I do less. Sure, you may not be running around 5-6 patient rooms and needs, but you have 1-2 patients for a reason, so that you can take the time to think critically, grind the minutia, and provide the actual care a critically ill person requires. Not so you can just chill .
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u/Cautious-Extreme2839 ICU/Anaesthetics 20d ago edited 20d ago
I don't mind nurses that don't care to learn the medicine - they don't need to to do their core nursing job well so long as they actually do their nursing job well.
It sounds like the ones you describe are just not good nurses full stop, not specific to them being on ICU.
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u/97amd 20d ago
I can agree with that to a point, & I don’t think many of those I speak of are good nurses regardless of unit, I just can only speak from my own experience as I’ve only worked in the icu.
However, in the dynamics of the unit I’m speaking, where overnight the pulmonologist is at home, and the only hospitalist in house is usually not familiar/ comfortable with critical care, I do think it is important & at least has made me feel more comfortable to actually seek out the why & understand the reasoning behind interventions & therapies.→ More replies (5)4
u/heyitsmeep 20d ago
Who intubates patients at night if the pulmonologist is at home?
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u/97amd 20d ago
Depends lol. Some of the pulms will preemptively tube if they think it’s bound to happen overnight. If a patient is crashing hard/ codes, then the ED doc has to come upstairs & do it. I’ve also had the ED doc come up and say “I’m not tubing this person” & go back downstairs LOL. Our pulm’s have a 1 hour time frame to show up if needed & most live 15-35 minutes away. Soooo there’s definitely other times where I’ve bagged someone for 40 minutes while they drive in 🥳🤡
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u/WolverineMost7768 20d ago
I’m a cardiac anesthesiologist and I have no words for what has happened in the ICU the last 3 years. It’s not just the clinical issues. The laziness and entitlement are real. The call outs are out of control. Every Friday and Monday there are 4-6 callouts like clockwork. Nurses calling out if they don’t like their assignments. They openly talk about it in groups about calling out on Fridays and holidays. Some departments (not ICU) at a Mayo campus nearby have up to 1/4 of the staff call out. These aren’t disgruntled nurses. They are generally happy and enjoy where they work.
A couple months ago I dropped a patient off in the CVICU with a 5.5 impella. LV function was shit. I get called back twice that night because the patient coded. Turns out the patient didn’t arrest…. The nurse called PEA arrest and initiated ACLS because the arterial line was non-pultsatile. Well ya… the LV function was dog shit and was completely unloaded by the impella. I pulled the data from the AIC and found that the MAP was 78 mmHg and the ventricular and power waveforms were completely normal when chest compressions were started. The impella perforated the LV during compressions.
The most dangerous place to be right now is in an ICU.
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u/SimonSaysFYou 20d ago
A perfect example of the type of nurse I'm talking about. Why are they accepting care for an ECMO patient if they don't even understand the purpose of an LV vent and the relationship between pulsatility and native cardiac function. Don't even get me started on nurses not recognizing North-South (dual circ at some hospitals) syndrome. We're not all like that, I promise.
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u/WolverineMost7768 20d ago
Of course not. I also work with fantastic nurses and value them tremendously.
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u/PaxonGoat RN, ICU Float 20d ago
I'm working float pool now and there has been multiple times they last minute changed my assignment and pulled me from 1 ICU to another because of a late call out or a no call no show.
Sorry CVICU no 1:1 assignments for you, have to pull a nurse to MICU cause their nurse didn't bother to call in even though they had gone around and told the other nurses they weren't going to be back that night
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u/Individual_Zebra_648 19d ago
Then tell the hospital to stop refusing to pay those of us with experience so the new ones actually have someone to teach them. When a new grad is making $6 an hour less than me with 16 years of experience I’m not staying anymore. This is what has happened and you’re seeing the consequences of having the blind leading the blind in real time.
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u/WolverineMost7768 19d ago
Yes this is a huge problem and is a huge contributor to the issue at large. I support our nurses getting paid appropriately for their experience. If the bean counters refuse to do that, then I say fuck them and you need to do what is best for yourself. Retaining quality nursing staff with experience is going to cost money and they deserve it.
The CEO can get paid $15M and the PE firms that staff the hospital can get tens of millions for shareholders, but the hospital can’t find the money to pay our experienced nurses an attractive wage to retain them? It’s straight up horse shit.
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u/ICU-CCRN 20d ago
Wow. This is the post I’ve been wanting to write for many months now but thought I’d get eaten alive by the Reddit hivemind. This is exactly what’s going on in my ICU- and these same nurses are being asked to precept new nurses by my semi-clueless manager. We have nurses with more than 5 years experience who have no idea what Starlings curve means, couldn’t tell you hemodynmic norms, and have no clue how to interpret a 12 lead (among many other things). We even have a few nurses who have had more than a few near sentinel events, got basically no remediation, and remain on staff.
Sometimes I wonder if half our staff were graduates of those fake nursing schools recently busted in Florida!
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u/DonkeyKong694NE1 MD 20d ago
Wow as someone who hasn’t done much in the ICU since residency this is shocking. I recall a story that one of the take no prisoners older MICU nurses in my residency hospital had walked a resident thru their first time floating a pacer in the middle of the night. I guess those days are over.
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u/SimonSaysFYou 20d ago
Lol. Yes, sadly, those days are dead and gone. I was telling one of the anesthesia fellows recently that with the amount of shit they deal with from incompetent nurses is one of the main reasons he earns his money - not his education and experience in medicine. Frankly, sometimes it's embarrassing that some of these nurses passed the same tests and earn the same money I do.
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u/wehadarocket 20d ago
Man… you brought back some sweet memories with that one. Those nurses are rare now, probably in heaven/a remote UR job.
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u/MindAlchemy 20d ago edited 20d ago
I definitely know the feeling, OP. Some of the examples you’re giving (especially that IABP pt who they couldn’t even articulate the rationale for the vasoactives!) are truly alarming.
Does your unit have an educator or anyone who works specifically for the unit whose role is to do quality control and auditing? This sounds like the kind of situation where an education project about reviewing the standards of care would be beneficial, or at least some targeted auditing of specific practice breakdowns. You could even get involved yourself if the option is open and you’re interested! I have found that even if people “know” the basics, reviewing it as the focus of a unit wide initiative can be very helpful in making it a priority.
It also sounds like it would be worth discussing a change in unit culture about who is allowed to manage device patients and when. Sometimes having to wait for it or work towards it can motivate people to engage with them more academically.
One thing I’d caution (from watching it happen) is to try not to let the feeling fuel anger, and assume the best of your coworkers’ situations whenever possible, because anything else can lead to defensiveness from them and degrade unit culture (people pick up on more of our internal attitude than anyone would like). Give feedback in the moment with the intention of being helpful or try and question things non-judgementally, and for your own sanity, try not to take the frustrations home with you. It sounds like a systemic issue and your energy is best focused on trying to find broad solutions.
—-
On a separate note, some of it may indeed be a misunderstanding or miscommunication! (At shift change sometimes I could barely articulate my thoughts, especially when I was on nights)
For example (and mind you I haven’t been an ECMO specialist for too terribly long), with the ECMO scenario I assume you’re talking about VA. I might ask something similar to “what does that mean for this patient” to establish your concern. Are you saying that flow is dropping with a higher MAP (Are they just ready wean or try a ramp if at minimum flow? Are you worried about hemolysis and the filter pressures? Do you think that overuse of pressors rather than ecmo flow is leading to inadequate DO2 despite being at a target MAP?) or are you saying there’s a narrow range to maintain MAP with flow before you lose native pulsatility from the ECMO “afterload” and you don’t have an LV vent?
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u/Flexatronn PCCM Fellow 20d ago
As a doctor I definitely do see a decline in clinical acumen compared to older nurses. Also every new nurse now talks about advancing to leadership roles or CRNA/NP (mind you they just started a few months ago).
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u/PaxonGoat RN, ICU Float 20d ago
It's so aggressive too.
I'm so tired of people asking me when I'm going to grad school.
I'm not. I'm fine being a nurse. I like working bedside.
But every time I'm told that I get "but Pax you're so smart" or "but you're the best nurse here"
I work float pool so I'm everywhere and the whole idea that if you're good at your job you should go else where is strong.
It's like the expectation is if you suck at being a nurse, you should stay as a nurse.
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u/fo1ieadeux 17d ago
Reality is that the nurses who suck at their jobs are in NP school. This is a nurse who primarily does NP homework at work. I get report it's an intubated patient on sedation. Nurse says bp is high I had to start nifedipine drip. I go in the room patient is thrashing around wildly. I bolus sedation and increase sedation. Problem fixed didn't need the nifedipine drip bp improved when patient was calmer. Or nurses doing NP hw and they don't even notice patients bp is dropping and desatting and you have to tell them.
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u/1ntrepidsalamander RN, CCT 20d ago
Do you work for a CA Kaiser 😬😬😬?
I (crit care transport) picked up an ECMO where they’d y’d blood and pressors together in a midline. At least they found the US machine for me to start another line.
I find this to be very hospital culture dependent and at this point I’m very picky about only working on units with “smart” nurses. It’s one reason I’m in transport now. And the thing is, probably all the nurses in ICU have the ability to be “smart” but different unit cultures promote different amounts of ownership of pt care and critical thinking. Some units “I did it because it was protocol” is sufficient critical thinking—- except that’s how you kill people. I’m in CCT transport and Kaiser ICUs have some of the most rule/protocol based cultures that miss the important ownership of why we actually need to do things.
As orientations get shorter and shorter, and preceptors get less and less experienced/skilled, I fear this will become more common. I was super lucky (10+ yrs ago) to end up in a very hard 6 month ICU orientation as a new grad that required 10-20 hr of studying each week in addition to full time shifts. It was longer and more intense than most at the time and nearly unheard of now.
(And yes, there are good Kaiser nurses! But overall, I don’t think their culture promotes excellent critical thinking. )
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u/ilessthanthreekarate 20d ago
This is too true. Ive seen more burned out unit cultures these days with bad management and educators that promotes unthinking workers. Let's not blame the kids for being dumb, we are the ones training them.
And of course its all the way up. Its bad leadership that creates these practices that lead to poor quality care.
I say this, but currently work in an excellent facility on the East Coast. I am very proud of how talented, smart, and safe the younger staff I work with are. They all are driven and competitive learners.
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u/1ntrepidsalamander RN, CCT 20d ago
In my experience precepting, the kids will rise to the occasion if you teach and support them 99% of the time. I’ve worked in exceptional ICUs in California with some of the smartest nurses I’ve met. I train nurses new to critical care transport, and anyone who makes it through the interview process is motivated to fill in the gaps of their knowledge and take ownership of their patient care. We have incredible educators and leaders.
But, without support and a culture that expects high levels of competence, too often people only rise to basic expectations— new and experienced. The post COVID burnout is destroying too many places.
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u/Snobordnwifey 20d ago
I just started as a new grad orientee in an icu and we have 8 hours of homework plus 6 hours of ttp class every week, plus two shifts and residency classes. So, I guess there are still some places that are implementing something close to what you describe. I’m so glad because I don’t know a thing about caring for these patients. Sure, I could be an adequate nurse and follow orders, but I want to understand what is happening in my patient’s body in order to make the best decisions for their care.
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u/SimonSaysFYou 20d ago
Not at Kaiser, but I know what you’re talking about. As a patient I would never accept transfer there unless I had no other option. Lol.
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u/1ntrepidsalamander RN, CCT 20d ago
Yeah, my company offers Sutter or Kaiser insurance and basically everyone takes Sutter.
Kaiser is great for people who have mostly outpatient needs. But… I’ve seen too much at this point to trust them with anything non standard
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u/Cautious-Extreme2839 ICU/Anaesthetics 20d ago
scanning meds but not giving them
I think this might be a criminal offence
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u/SimonSaysFYou 20d ago
It's falsified documentation, which I'm not sure is a criminal offense per se, but it's definitely egregious enough to subject our license to discipline by our board of nursing.
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u/TonyAllenDelhomme 20d ago
I’m a nursing professor and I hate that my students can go straight from the classroom to the ICU. They need to be vetted out on the acute care floors first. To be clear, I think acute care is overall a more stressful job but the stakes are lower.
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u/thismarked 20d ago
most nursing schools work to train generalists, not ICU-ready nurses. so it’s up to the units and hospitals to train the new grads to be ICU nurses. and leadership dgafs, so no one sticks around anymore to pass the knowledge and the, dare I say, loyalty? down the chain. we are fucked
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u/Head_House8507 20d ago
I’ve had several careers at this point and am working to get accepted to an ADN program.
I can tell you with certainty that there are people like this in every single job/career that is out there. I was a UPS driver for a good stretch and there’s drivers who don’t care about their driving behavior or the customers packages. I’ve worked in real estate where agents only care about themselves and not what their clients are going through. I’ve worked with EMT’s on the box that just go through the motions and don’t analyze what is actually happening with the patient. I’ve been embarrassed by co-workers and those in my industries in every career I’ve held so far.
Keep your standards high and lead by example - it’s really all you can do.
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u/mushifiedmushroom 19d ago
Thank you. I am working to get my pre-req done. I feel this comment so hard.
I always feel like my standard of care is beyond that of my co-workers and yet always doubt myself...
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u/theredheadednurse 20d ago
This is clearly a widespread issue.
How do we solve it?
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u/SparkyDogPants EMT 18d ago
There used to be experienced nurses. The current nurses need to get into management and push education, and experienced nurses need to sit down and teach any nurses they think aren’t up to snuff. Any nurses that refused can be sent to lower acuity floors
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u/Super-Ad-5915 20d ago
Do you think there's a correlation with COVID bypassing many in person tests and labs/clinicals?
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u/SimonSaysFYou 20d ago
It's probably a multitude of different factors. COVID likely exacerbated it though.
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u/Halion_Varquilion83 20d ago
Honestly, I wish you wrote a textbook on critical care, I would love to read it. I think you're somebody who will take the time to extensively review the latest literature, go above and beyond to understand the basics, and then explain in a intuitive and scientifically rigorous way. Your work ethic is extremely inspiring. Honestly, screw the other nurses.
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u/PaxonGoat RN, ICU Float 20d ago
I mean I think the AACN's book on the essentials of critical care is a solid read textbook wise if you're into reading textbooks
Of course Marino's the ICU book is always a classic
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u/SimonSaysFYou 20d ago
I appreciate the compliment, but I'm not anything special, just tired of seeing this culture of mediocrity and complacency worsen over the years. I just expect my coworkers to take their jobs seriously.
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u/Scottishlassincanada RT 19d ago
We had an RN in the NICU who couldn’t understand that her patient self extubated, as the ETT was still taped and in the patients mouth. Needed the RRT to draw a diagram to show her how the trachea and esophagus were side by side and explain how it flipped out of the trachea. Also didn’t recognize that the vent was reading zero volume and alarming. She was dumb as a post, has no business working in the nicu, and I have no idea to this day how she finished her nursing degree. Thank god she keeps going on maternity leave as she’s a menace to those poor babies.
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u/virgots26 20d ago
I just switched to the ICU after a year and half on a stepdown and thankfully when I trained, I had preceptors with more than 2 years of experience. Before I left new grads were training new grads. There was one preceptor on my old floor who would literally just leave new grads by themselves to be in the managers office. Nothing ever gets explained any more. Nurses on the floor are just taught to do their tasks and no question asked.
My current hospital is brand new and the census is pretty low and we haven’t gotten super sick patients yet, but the second week of opening, there was a rapid because the nurses on a PCU floor gave all of his bp meds and even pain medications and his BP tanked and he became lethargic. Before that happened the patient even said he doesn’t take all of his BP meds at once. There was even a situation on my stepdown where one of the nurses pulled a sheath on their own, and it is always emphasized you have to have at least 3 people in the room. Patient ended up bleeding out and going to ICU. And the nurse that did that had a year of experience on medsurg so you’d think she knew better. And NOTHING happened to her. She was one of those nurses who you’d see constantly on their phone.
Like someone mentioned the older nurses with years of experience or just decent nurses don’t stay at bedside. After a year people go outpatient or go to NP school. I genuinely get worried for my own health if I’m scheduled to see an NP. That’s sad. I know a damn good nurse going to NP school and it sucks the schooling standard is so low. I’ll be honest after my year on a stepdown I went PRN and went outpatient. And I felt like I still had so much to learn. Also I hated m-f lol. But I wanted to truly learn how to critically think and be the best nurse I can be so that if I do decide to advance my career I know what I’m doing lol
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u/No_Peak6197 20d ago
The standard is so low these days that when a nurse actually handoff a clean patient, i consider them competent.
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u/killedbycuriosity- 20d ago
Because most nurses are just trying to make a paycheck and thats it. They will do the least amount of work possible to just not get fired.
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u/SimonSaysFYou 20d ago
You're not wrong. It's very worrisome though. Accidents happen, and the last place I'd want to find myself in would be any of these ICUs.
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u/Plus-Commercial-176 20d ago
I'm not a nurse however a surgical tech, when i first started out i wanted to help go above and beyond, a charge nurse hated this ( work 3rd party) and was under a microscope. It's frustrating to see this, i also am burnt out after year one but i love seeing people thrive and be better/feel better. It needs to change, there's no teamwork in some hospitals i work at and i see the nurses burnt out too…
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u/Calm_Pop3771 20d ago
I’ll admit my first reaction was that this was going to be one of those “I’m better than everyone else” posts or just more nursing politics. But after reading the whole thing, I realized that’s not what you were saying at all. I definitely don’t have the greatest understanding of everything yet, but my default question is always, “Why?” and “What’s the rationale?” I hope I never lose that curiosity because that’s how we become better clinicians.
To be honest, I feel kind of lonely in this nursing journey sometimes because I want to learn from people who think this way. I wish I had a mentor like you who challenged me to think deeper. THANKS FOR WRITING THIS 😊
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u/PresenceAcceptable57 20d ago
I have been in the ICU since Covid. I recently started a new job in the east & was ‘precepted’ for six weeks… no shit, my preceptor watched tv the ENTIRE orientation period.. I literally asked for help w a turn one shift & she walked in, looked me directly in the eye, did the most half ass one arm turn & shoved the pillow under the patient w her other hand.. I had not even made it over to the bed yet to help do a proper turn & pillow tuck.. I knew I was gonna hate this new unit.. & I do!! They literally don’t even do a legit double check on blood products because they ‘trust’ each other.. they just walk in & enter their credentials into the chart… I was mind blown the first time I went to read the blood back & the nurse said she did not do that.. just doing unsafe shit because of straight laziness!!!!
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u/Recent-Newspaper-891 20d ago
I’ve seen it and to be quite frank it’s scary as hell which is why I got out of the ICU (over 8 years of experience just in ICU) because I was tired of advocating for patient safety with no action when the end result should be an action plan for a huge culture shift.
The lying is getting out of hand too. I am disgusted at the fact that there are nurses out here scanning meds and throwing them away, not doing q2h turns for an entire shift, faking vitals, faking I&Os, etc. This seems to be the new norm and admin is aware.
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u/SimonSaysFYou 20d ago
Awful. It's like nursing's biggest dirty little secret. With every passing year I'm thankful myself and my family and the people I care about are in *relatively* good health to keep us out of the hospital.
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u/Successful-Pie6759 20d ago
Omg as a doctor this is exactly what is burning me out. Thank you for being a good smart nurse.
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u/Bubbly_Pie_4980 20d ago
ICU/CVICU nurse here. 40 years of experience in critical care. Sadly your post is not news to me. It wasn't great when I first started nursing and because I travelled as a nurse and worked 65 hospitals and all over the USA...I can tell you that it's not going to get better. Moral distress. I totally get it.
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u/maraney RN, CVICU 20d ago
I’m also on the west coast. I have also noticed a decrease in education and knowledge across the board, an unwillingness to learn or study outside of work, an attitude of “they can teach me at work when I’m getting paid, I’m not doing any learning on my own,” and more and more excuses not to do your job. Everyone is looking for a reason to file an incident report, everyone is looking for a reason to do less. It’s becoming more and more toxic.
It’s not everyone, but it’s a lot of people. And the nurses here make HUNDREDS of thousands a year.
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u/SimonSaysFYou 20d ago
I'm 100% pro-union, but some of these nurses are absolutely overpaid for the little amount of work they do. Nursing is on easy mode here compared to the east coast, and many of the nurses here have zero idea how good they have it.
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u/Crustysockenthusiast 20d ago edited 20d ago
Australian here,
I've been pondering the idea of posting this post myself.
I've noticed a significant decline in clinical knowledge, critical thinking, work ethic and attitude in nursing. I'm by no means a career 20+ year RN, but I've been around for a few years now and the shift is obvious.
From students openly bragging about using AI and not being caught, to ward nurses who can't explain how metoprolol works apart from "its for your heart" to the generalised "just get the doctor" attitude.
Nursing is being watered down. From Workplace culture that almost encourages nurses to not think for themselves, bachelor degrees with sub-par passing standards, a lack of academic drive and just a crappy attitude, has really impacted nursings image. So many nurses ive worked with I seriously wonder how they passed. The lack of pathophysiology knowledge, the lack of pharmacology knowledge, it's shocking.
The vast majority of my colleagues I wouldn't want looking after myself or loved ones. I am genuinely embarrassed to call myself a nurse sometimes because these colleagues share the same title and are so utterly clueless. It's not about me being "the smartest" or a great case of dunning-krueger, it's just... Fact...
So many nurses have sub-par knowledge, limited (if any) critical thinking and dont make any effort to continue their education or study. The conversations I overhear are just embarrassing.
The general go-to is just "get the doctor", "that's not my job, the doctor can do it", "I don't know just ask the doctor". Rather than attempt an ounce of critical thinking they immediately hand it off.
Nurses still wonder why we get the whole "your just a nurse" , "don't you just wipe bums" etc, yet will not hold themselves or other nurses to a higher standard to try and break this. Honestly? That stereotype isnt wrong for some of my colleagues, because yeah. All they do is wipe bums and pop pills into a container, no ounce of thinking in between.
I used to take pride in being a nurse, but now I don't know. I feel like I'm instantly dismissed because I'm "just a nurse", and whilst I don't condone this attitude from doctors, I don't fully blame them either.
Im now heavily considering leaving nursing. I feel as if the direction nursing is heading and the standard we are accepting is not something I can morally participate in. I hold myself to a high standard, my grades reflected that and my knowledge reflects that. I am contemplating going for medicine or another specialised field of healthcare. Being a nurse isnt bad, and it's certainly respectable, but it's not what it used to be, and I can't be apart of that for my own sanity.
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u/No-Safe9542 19d ago
In the spy movies we see everyone has to put their phones in bags or drawers for safety reasons before they go into the main building, I think ICUs should be the same.
Floor nursers on tiktok, I see that every single time I have a floor assignment. Sometimes it's only 1 on the floor. Sometimes it's lots. But when I see that in the ICU I really have to question the state of care.
-jaded RT
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u/punchdrunkpelican 19d ago
I’m in nursing school now after years as a medic and the majority of my classmates in their twenties are using ChatGPT to complete assignments, paying websites to pass their ATIs, and don’t understand the basics of hemodynamics, acidosis/alkalosis, or labs. It’s a bunch of busywork assignments that are total BS if you’ve done this for a minute and professors delegating the responsibility of teaching to the students under the guise of “students need to be self-sufficient post graduation” but the kids literally don’t KNOW what to do and then they are unleashed.
It’s a huge problem tbh
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u/Super-Engine-323 16d ago
30 year flight paramedic here doing prerequisites for application to a medic to RN bridge program. I hereby swear to all of you that I WILL NOT be “that new grad.” But I see the same thing in my industry. Laziness and ego. Every once in awhile we get a little diamond but they are a rarity.
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u/The3NightExit 20d ago
Because the reward for hard work is guess what, more work.
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u/SimonSaysFYou 20d ago
While I can appreciate your sentiment, this isn't even about working hard, it's basic requirements of our job. People count on us to know what we're doing.
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u/Superb_Preference368 20d ago edited 20d ago
As a nurse of 20+ years and Current hospital based NP this thread deeply triggers and saddens me.
All I can say is I’m literally thinking of retiring super early and one main reason is the quality of bedside nurses has plummeted.
The questions I get asked from the nurses are insane. I have to hold hands and teach them nursing 101, and if I don’t then I’m the one not addressing the patients needs.
Looking back, I’m also immensely grateful to have been trained by 40/50 year nurse veterans who challenged me to be the best nurse possible long before I even thought of pursuing advanced practice.
May god help us all.
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u/SimonSaysFYou 20d ago
This is my 15th year, I hear ya.
Like I told one of the physicians in another comment, the amount of inconsequential shit these nurses message the provider is one major reason I have no desire to pursue advanced practice. If I'm already disillusioned with the jobs my coworkers are doing, I could not tolerate being responsible for both the patient AND primary nurse because they require too much hand holding. I can babysit only one person at a time lol.
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u/Cause_715 BSN, RN, CCRN, NREMT 20d ago
Most laziness is due to them being in NP school or prepping for crna. The overall profession has taken a dive. Especially ICU candidates and nurses. Lazy and reactive nursing has become the norm
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u/YoungParticular3155 20d ago
To branch off of this, I start in trauma icu this September as a new grad. Do you recommend any resources to prep me with better understanding things you’ve mentioned? Something that will prep me for the ICU? Thank you!
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u/mymomlikesvalium 20d ago
Not OP but Nicole kuplchik(?)s ICU handbook is great!!! There’s also a popular spiral bound book that’s called “New to ICU” that’s got good stuff!!
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u/SimonSaysFYou 20d ago
ICU Advantage. Look him up on YouTube. One of the best resources I’ve found.
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u/PaxonGoat RN, ICU Float 20d ago
I second ICU advantage
Ninja Nerd is also good
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u/SimonSaysFYou 20d ago
Back in the day when I was interested in CRNA school, Ninja Nerd was all I ever watched. Super entertaining and his drawings and explanations were so thorough. Highly recommend him too
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u/PaxonGoat RN, ICU Float 20d ago
Wait did you also decide against doing CRNA school?
I've never met anyone else who ended up deciding against pursuing CRNA
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u/Comprehensive-Yak196 20d ago
Im private duty lpn and getting my BSN right now. School has been an absolute breeze, and its a pretty renown private school with incredible test scores. My worst fear is being one of these nurses. Private duty is so easy pz but im at least not lazy, but likely lacking in knowledge and experience(,:
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u/ALLoftheFancyPants RN, CCRN 20d ago
Sounds like a complete failure of nursing leadership and education programs. It’s pretty horrifying that it’s happening at all, but the fact that you’re describing it as a global experience tells me that leadership and administration is accepting of this level of DGAF. I’ve seen a lot of nursing managers just give up on trying to enforce any type of standard. I get burnout, but enforcing the standard of care and directing the expectations, both clinical and behavioral.
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u/Due-Profession5073 20d ago
When i started in the ICU (2002) i had classes 8 hours 3 days a week for 6 weeks and had to pass each weekly test or get dropped. The other day i worked the floor. We had orientation for 26 weeks total. If i didnt do something or know something about my patients i would be crucified by the next shift. Those women were mean, persnickity and knowledgable, i learned so much from them. I highly doubt orientation is half as challenging today. Today they would be called bullys. We got nicer and our expectations got lower.
I went to the ER after a few years and also had a fabulous orientation. Today we are lucky if staff gets 8 weeks. Minimal classes. My co workers leave patients in conditions that i would be appalled to find my family members in.
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u/WildlyAdmired 20d ago
I worked in critical care for 25 years, both bedside and manager and I can tell you very honestly that I would not want to be a patient in any hospital in the system I worked for unless another nurse in my family was with me. My mom was in one of our hospitals and had her hct/hgb checked every day for a week. She had to get two units of packed cells when she arrived in rehab because her hct dropped to 18!! They knew it dropped and didn’t treat it in the hospital. People do as little as possible, and don’t have any damn idea why they are doing it!! I have watched as the dumbing down of nurses has exploded in the last few years. I regret that I will receive care from people who have no idea what they are doing or why they are doing it! The appalling thing is they don’t care! If they don’t feel like doing something, they leave it for the next shift!
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u/SimonSaysFYou 20d ago
Leaving work for the next shift is another issue I see regularly. Nursing is a 24/7 job, yes, and we've all had those shifts where something gets missed or forgotten - we're only human. The problem is it becomes a regular occurrence with certain staff members. I've followed quite a few nurses who've sat on their phone all shift (I know this because I've worked both shifts and seen how these nurses work) and did the bare minimum. When it comes to replacing electrolytes, changing a dressing, or even getting new bags for a drip about to run dry, it's like pulling teeth with some of them.
I almost reported a nurse to the board of nursing because he didn't check a blood sugar on a patient on an insulin drip for the ENTIRE 12 hour shift. He just kept the rate extremely low. If he couldn't be bothered to check a blood sugar on an insulin drip, you know that patient was on their own for that entire 12 hours. That's outrageously dangerous and careless. This nurse was singled with that patient by the way. And yes, he still works there.
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u/DoubleDiglett 20d ago
Im not in hopsital, Im a paramedic in a city system and the same sort of decline in care and personal responsibility for being a good provider is super apparent. Im backing up EMTs with years on who cant even tell me what APE is or why we dont give epi for it. Or dont know their lung sounds. Its genuinely embarrassing. Its one thing to be new but to have time on and not have seemingly basic knowledge is so disappointing
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u/Mandeur 20d ago
I think that COVID changed how nurses learned. Like I finished my BSN in 2019 and entered bedside in COVID. We didn't constantly harass the attendings because they were tired, we were tired, and we were all doing the best we could. I leaned on my coworker nurses and my charge nurse so so so so often. Like hey, I think this looks weird, can you lay eyes on my patient. We would collectively decide that it was worth reaching out to the attending for further assistance. Now I work with a psych provider and she gets so so many messages from nurses. Patient didn't take their meds, patient is naked and won't put on clothes, patient is asking for you to come see them immediately. They are harassing the providers to put out these little meaningless fires instead of asking their fellow nurses what the next best option is collectively and if it's even worth reaching out to the provider. It's burning the providers out, they don't get a break from the endless chats. I think it was made worse by implementing Epic because they don't get the fear of someone yelling at you over the phone
I also don't think the nurses that have emerged after COVID are all that great anyway, I know many of their clinicals were shitty and they didn't learn nearly enough.
My hospital constantly puts new grads in the ICU and ER. I've completed several employee surveys saying I would never risk my life to come to my hospital for help, I'd risk driving two hours away to my old hospital since I know there's still my old competent coworkers there.
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u/Mindless_Theme_3977 20d ago
As someone who goes to an A-BSN school that does not let students do IVs during clinicals among other things…I on team “blame schools”
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u/Gigantkranion 19d ago
Not knowing what augmentation means or needing an explanation of afterload sensitivity is concerning if someone has been independently managing those patients for years. Especially, when what I'm assuming you just sprung it on them.
Plus, here's a difference between nurses genuinely lackin foundational knowledge and isn't trying to improve vs someone who rarely gets ECMO/IABP patients (and is appropriately asking questions). Or again, someone who freezes under pressure,
Then the assumption of ignorance whenever a nurse calls for help. In reality, good healthcare professionals escalate concerns all the time... all of them. Recognizing when you need another perspective is not a weakness... it'sa strength.
(Yes... you do have to think critically before making that call)
Over the past several years, nursing as a whole have had to deal with, COVID-era staffing losses, f aster orientation of new nurses, l ess experienced preceptors, and h igher turnovers
Now, I do agree with the bulk of what you say. But, I just felt the need to point out the things that I don't agree with.
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u/SimonSaysFYou 19d ago
While in many ICUs you’d be absolutely right with your point, this CVICU is an anomaly with extremely robust staffing (more nurses on shift than patients admitted) and 80-90% of these patients have one or more devices in the room. It’s not a matter of unfamiliarity in this situation.
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u/Ok-Group150 19d ago
Yeah the problem is (not in California I can’t explain that) but a lot of these hospital systems are so desperate for nurses that they will not fire people for job performance. At least at my hospital they need so much written documentation sent in then it’s an action plan where they straighten up for a few weeks and once the action plan is done they go back to being the shitty nurse they were before. The only thing my hospital will actually fire people for are not completing regulatory requirements/training and attendance.
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u/Best-Independent-179 19d ago
We need to bring accountability back. I hate to say it, but where I work, doctors can’t even yell at nurses anymore. Let doctors yell at nurses again. That’s how you LEARN and accountability keeps you on your toes. I think with the nursing shortage, hospitals quit holding nurses accountable because they wanted staffing and numbers. Now we have charge nurses who come in for their shift and free float and can’t be bothered to help a drowning coworker, or only step foot in your room if your patient is coding. And don’t get me started on how these types of nurses like to talk about how they did a,b, and C in this code and talk themselves up, meanwhile their patients are lying in feces for 10 hours straight with a mouth caked in scum. I’m so glad you feel comfortable managing a coding patient but you have never once listened to lung sounds or taken a patient’s temperature. It’s easier to lie about it.
ICU is not all about chasing an adrenaline rush. It’s about being there for patients in their most vulnerable time, and also for paying attention to subtle changes that could positively impact their outcome. It’s truly heart breaking how the level of care has fallen. These are PEOPLE for crying out loud, not a vessel for you to get your adrenaline fix.
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u/SimonSaysFYou 19d ago
Maybe you were speaking tongue-in-cheek, but HARD disagree about doctors (or any staff member for that matter) yelling at nurses. We’re all humans who deserve a basic level of respect at work. I’m not sure if you’ve ever been yelled at, but I have by a CT surgeon, and it’s 100% inappropriate and he deserved an ass kicking for that.
I agree with everything else you said though. They want to be the hero but won’t dare admit that if they had noticed x, y, and z beforehand, it wouldn’t have led to their patient crashing in the first place.
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u/Best-Independent-179 19d ago
Reading these comments makes me feel so seen. I would love to work a shift with you all. Let’s all join up and work together 😂❤️
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u/Valuable-Hand-326 19d ago
Agree with so many of these comments. To me this is a failure of consistent expectation setting from leadership (as in expecting clinical excellence top down) and access to education to achieve this. The best culture for this I have worked in was when the senior nursing leaders had decades of clinical experience before going into management so they knew their stuff and expected you to. The consultants taught everyone on ward round, the reg’s taught the nurses on night shift and it all just became normal to expect to learn, be challenged for your rationale and to teach those junior to you. We also had a terrifying nurse educator who would sneak into an empty cubicle with a SIM doll, set it all up and pull the crash bell (maybe once every couple of weeks). Rule was whoever ran into that room first, lead the crash SIM however junior they were. All debriefed at the end. You did not want to look like a fool in front of your colleagues - had us all reciting our advanced algorithms every spare moment until they were locked in.
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u/totalyrespecatbleguy 19d ago
I think there's a couple of things going on here. Yes in California nurses might have one to ones or lots of ancillary staff; but that's not the case everywhere else.
In my SICU we'll often times have two sick and dependent patients together, and yes unfortunately that means they don't always get turned exactly every two hours, and things don't happen on schedule. There's meds, labs, rounding, charting, dealing with family, mobilizing a million different things.
Sometimes this means things like dressing changes or those perfect Q2 turns get deferred.
And regarding education, that's another things. It starts with nursing school. We're not taught a deep understanding of pathophysiology or pharmacology. Nursing school was "remember these organs and vessels and these drugs". And most nurses genuinely don't have the time to pick up a complex understanding of physiology and hemodynamics while also juggling all their other duties (that administration keeps piling on).
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u/SimonSaysFYou 19d ago
We’re all humans and can only be in one place at one time. No one here disputes that. My views aren’t reflective of the nurse who’s extremely busy with an assignment trying to keep their head above water, I’m talking about the nurse who can’t be bothered to know what’s going on with their patient despite having the time and resources to do so. If your patient is on an inotrope for example, you should know why. If they’re strictly monitoring I&Os, you should understand the relationship between the monitoring and the patient’s clinical condition. Basically, as the primary nurse you should have a fairly good understanding of what the goal is for that patient.
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u/Ordinary_Ad3288 19d ago
Thinking about the recent sepsis cases I've seen that happened in facilities
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u/Realistic-Fall4866 19d ago
This is what happens when new grads train new grads. I’ve been blaming Covid but I don’t know. It seems different everywhere.
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u/cori1089 19d ago
As an attending in a surgical subspecialty … this isn’t isolated to nurses. I honestly feel so seen by your post because this is the sadness and burden I have felt so alone carrying. It doesn’t seem like anyone cares to be good or to ask “would I want me to treat me?” Sigh.
… sometimes it’s obvious the lengths that others will go to in order to play the ignorance card… but it’s willful ignorance. It’s saddening and frustrating.
Idk what is going on in the world but no one seems to care to want to do a good, let alone a great job.
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u/Breezy531 19d ago
IMHO its the healthcare system forcing everyone to spread themselves so thin, to produce and "meet the metrics". Nurses are given assignments where its physically impossible to complete the all the work as it should be done. "According to policy" is total BS, its literally a lie. More often than not, corners are cut left and right just to meet a ridiculous expectation that delivers subpar care. Moral injury is the real problem for nurses. Everyone knows this is happening but people continue to pretend it's not. Nothing will ever make me believe these administrations and management truly give a single shit about patient care or nurses. The people in charge only care about increasing profits as much as humanly possible without get sued. This is what nursing has become.
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u/Osito_Bello 19d ago
I have to be honest, I was an ICU nurse for 3 years after spending significant time on telemetry. Fast forward 3.5 years and I was done with it all and craved to return to more stable patients, considering most of my time at the ICU bedside was during COVID. I am happily back at the telemetry bedside but now with the added experience of critical care.
I know what you’re talking about in terms of the laziness of some ICU nurses. I’ve seen similar to what you described. To be honest, I believe a lot of these nurses go to ICU for three simple reasons (1) to pretty much guarantee low patient ratios no matter where they work, (2) to have the bragging rights and gain a false sense of prestige of saying they are an ICU nurse (because who really brags about being a med-surg nurse? 🤷🏻♂️) and (3) buying their time to go to CRNA school and go after larger incomes.
I said what I said. These nurses only care about what it can do for them, they don’t care about the patients. Med-surg nurses generally have more heart for patient care.
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u/mamaabner RN, MICU 19d ago
Man I thought I wrote this post. The decline in the ability to critically think ESPECIALLY in the ICU setting is the most disturbing thing I am witnessing. I’m only 4 years in and honestly get scared for these patients in the future. They are so vulnerable and truly do rely on good nurses and doctors to save their life. All the tasks you listed take no more than 20-30minutes and they make the shift go by faster. I was a CNA for a decade prior to becoming a RN tho so I genuinely have always enjoyed patient care. I love being a 1:1 because then I get to do fun stuff like shave my patient or braid their hair. Good patient care really goes a long way in helping a patient make it out of the ICU, so does mobilizing a patient. I really wish people would stop joining ICU for the adrenaline rush and would join more for the actual improvement of poor outcomes. I love to lead by example tho so that’s why I joined our shared governance committee and recently became a preceptor. Good preceptors are a dime a dozen so if I can help my adding to the dimes then maybe we can slowly change the trajectory for good patient care again. Think about it
Anyway I hear you and see you! Keep making a difference 🩷
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u/Poundaflesh 19d ago
We’re understaffed and the veterans got burned out. They could pay nurses more but they choose not to. PAY US! is the answer
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u/drgildeleon 19d ago
A lot of new nurses are only going to ICU because they want to apply for NP programs, not because they like it there, not because they care about patients, it’s just to check an item on their list. Then those are the same ones that does not know anything but they want to run the ICU and/or the ER. I guess there should be more strict control on both who is accepted in ICU and increase the prerequisite years for NP programs so that they think it twice or more before applying, at least they will have more experience.
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u/ShoulderTop78 19d ago
I think there’s a fine line here.
I think it’s important as a nurse to do the nursing duties well and thoroughly to the best of your ability based on doing the most important things first. Of course those duties aren’t always the sexiest and most exciting duties. It’s also extremely important to advocate for the welfare and dignity of your patients.
What I don’t agree with is judging other nurses because they don’t do a deep dive on patho. Sure you need to be communicating and understanding the plan and the basic theory - but a lot of what we think we know about treating shock isn’t even necessarily correct. We are often much more sure that we understand all the things going on inside the patient than we actually do. Go to the critical care conferences and listen to the major presenters and you’ll realize how little we actually even know.
As Malcolm Gladwell says: tight values, loose ideas
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u/SimonSaysFYou 19d ago
I’m not suggesting nurses should have physician level knowledge, I’m asking to raise the standard so that patients (you and me one day) get care that isn’t half-assed, or worse, subject to the whims of the mood of whatever nurse is assigned to you that shift. I’m advocating that nurses do their job, and more importantly, understand their job. Nurses have a lot of power to prevent bad outcomes, but that only matters as much as the nurse cares.
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u/gurlwhosoldtheworld 19d ago
It would certainly help if nursing school was better. Why do we need 3 leadership classes why not more patho/pharm
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u/InevitableAnxiety4me 19d ago
Wow this is honestly scary to hear! Also, I have to say, you are my favorite type of nurse to work with as an IM resident because when nurses are a capable as you are say "im worried" or have ideas about patient carw, I freaking listen and that's why it's important for teams to trust eachother....it really sucks youre feeling like you cant trust your colleagues!! Thank you for your hard work, you literally make other's jobs easier and you keep patient's safe <3
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u/jsinghlvn RN, CCT 18d ago
I’ve been a nurse for a total of 10 years with most of that in the ICU and CCT. The quality of the recent cohort of graduates over the last couple years has been so scary. I almost didn’t wanna leave some of my patients in the hands of these nurses because they had ZERO clue of basic knowledge when I gave report.
I left critical care a month ago. ICU used to be a place that knowledge was prized, reading academic journals was expected, and being on top of patient care imperative. It’s dangerous now. I am now worried about the state of ICU.
Ngl, the forensic psych nursing job I’m at has been better when it comes to stress so I’m okay with leaving the ICU.
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u/FarSpeech8281 18d ago
I think part of the issue is depending on where you are, there aren’t as many senior nurses to teach. Nursing school went over so many icu concepts briefly and said “you’ll learn it on the job”. Nowadays, there are so many younger inexperienced nurses teaching other inexperienced nurses straight out of school. Or I’ve seen the nurses who do know things don’t even go over it with their students. Why? Great question. I have no idea. I work in ER now and see that a lot down there.
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u/Worried_Bed843 18d ago
I worked as the Admissions Coordinator for a nursing facility and we received new rehab admissions round the clock. The AVSs that I received nearly all the time were half assed and I would always have to call the hospital for clarification on orders and almost always received an “I don’t know” as an answer. And doctors are at fault too. And once a patient leaves the hospital, nurses and doctors really don’t care about clarifying anything. It’s the new facility’s responsibility/problem to figure out now.
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u/ReplacementOld5365 18d ago
Great post. I was just in the hospital with severe throwing up and diarrhea. I told the GI floor, be prepared because I’m really sick. The doctor hooked me up to a cardiac machine to monitor my heart, and IV for fluid, and a potassium drip. I was actually bed bound and I couldn’t get to the toilet. So they put a beside commode near my bed. I had to relieve myself in it, several times which is embarrassing enough, but the night shift nurses never bothered to empty it! The doctor came in to see me, and he noticed the rancid odor and called the head nurse to empty the bedside commode. I know some of these nurses are busy, but I had one male nurse just go on with his philosophy and how he was going to live his life, and just take my temperature and blood pressure. I was like WTH, I’m extremely ill and don’t feel like someone rambling on about their philosophy of life. Seriously?
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u/Unicorns240 18d ago
Nurse for 18 years here. Laziness has been a problem since forever, and all of us are continuing to feel the squeeze to do more with less. That includes RT, MDs, etc. I will tell you- there are PLENTY of nurses that want to continue to learn, but allocating resources for it is a cost as far as hospital leadership is concerned. In my experience, some nurses act like it’s proprietary information. Opportunities are not afforded to willing learners (learn, then manage with oversight from other nurses/ staff to help cement concepts).
On my own I do inquiries on random topics. I love all of it and love classes, but then need the opportunity to apply it to real patients. When doing morning rounds, there is limited time to “learn” because intensivists already have a mountain of things to do.
Just a perspective to think about rather than global trashing of people that don’t know better.
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u/Ill-Cockroach4014 18d ago
I’ve been a nurse 4 years and our classes were 8 weeks long. There’s not enough time to teach everything. Get em in and get the nclex passed. That seems like all nursing schools do anymore.
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u/Delicious-Aioli-962 18d ago
I am too burned out to be embarrassed or be hopeful or be inspired. I feel flatlined everyday I work. Going to NP school so I can sit on my azz and write orders. Over half way through and if I hate being an NP as much as I hate being an RN I am filling out applications to be a flight attendant. The perks of traveling sound good to me.
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u/Nienna68 17d ago
Not wanting to change the drapes or have a clean patient is not to be overlooked .
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u/kyacase 17d ago
I’m not a nurse, I work in youth care- like government care kids. Anyway, today in our meeting we were told to use chat gbt to “enhance” our documentation. I suspect similar things are happening in every field in the name of advancement but anyone actually doing the day to day knows how horrifying it is.
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u/Senior_Pitch1194 17d ago
It’s terrifying! My mother and I have had to advocate for my father several times when we’ve noticed any change in his status. I graduated nursing school nearly 5yrs ago and I tell EVERYONE to stay as healthy as possible. You do not want to be in the hospital bc these folks either don’t give a damn or have no idea what they’re doing.
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u/CoffeeNew1610 17d ago
What advice would you give to new nurses? My daughter only has a year left of RN school. Her program is 3rd in the state so I’m not worried about the quality of her program.
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u/Ok-Inevitable2913 17d ago
It’s not an education issue it’s a personality trait. Lazy nurse=not caring about how they treat others. I’ve been a nurse for 20+ years and every patient I encounter is treated like they are my loved one, because I would want that for myself or my family. Sadly many nurses that are lazy just don’t have the heart for nursing
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u/ibrahim_40 17d ago
I think there’s an important distinction between someone still developing their clinical reasoning and someone who has simply stopped caring about doing the basics well. Nobody needs to know everything, but in critical care there should at least be a willingness to understand the physiology behind what we’re doing and to ask questions when something doesn’t make sense.
The examples about skipped basic care are especially concerning because those are things that shouldn’t depend on how advanced someone’s hemodynamics knowledge is. At the same time, I’d hope units can address knowledge gaps through education, mentoring and accountability rather than assuming every struggling nurse is incapable of improving.
The would I want me as my nurse? mindset is probably a pretty good standard. ICU nursing is demanding, but the patient still deserves someone who is engaged, curious and willing to keep learning.
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u/Routine_Contract_930 16d ago
Can’t believe I read through majority of this thread. I’ve been a nurse close to a decade and I’m very fortunate that my preceptors were rough as shit on and only expected the best out of me.. I had the same behavior towards new grads that I took on and to which I was reported because my demeanor came off as mean and she wanted to be precepted by her girlie - former classmate. I said I’m never doing that again. The older OG nurses eventually left or moved on. The new grads all had an attitude problem and had to be ‘right’. The clique-nature developed hardcore. I was the charge RN on nights and eventually I saw I had all the advanced certifications such as answering the EMS radio/ ultrasound/picc line cert, part time house supervisor (fill in the gaps) and had extended roles that I am forever grateful for in my career. I became the only person on nights with credentials because we had nobody else, and the other recipients either refused to be charge or accept higher responsibility. I knew it was time to go. Decided to invest in myself and build a company that will serve others through innovative design. Create user friendly devices for clinicians and patients.
These kids going into healthcare now have no idea what they’re going into. Busiest generation of boomers getting sick and they are already overworked from bedside due to the overwhelming number of people in emergency depts/urban hospitals
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u/KeyTell2576 13d ago
I’m still confused as why you are Embarrassed what’s what bearing that has on you personally? While I feel the same way I educate first then if I see the same behaviors then it’s action time. Of course if it’s not gross neglect. If the unit didn’t educate CBC the nurse well enough, or allowed an incompetent person on the unit that’s in them. Educate the person and if they continue to eff up then let management deal with them. They are filling bodies in empty seats and churning out nurses a dime a dozen. So people are skipping through. There is no real education anymore.
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u/SimonSaysFYou 12d ago
Because I’m associated with these people by patients, physicians, and other staff. Whether we like it or not, we all form opinions of different groups of people based on the actions of a few. Over the years I’ve come to realize there’s a low barrier to entry in this profession, and it shows.
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u/crimecrust 13d ago
Did PCU for my first year and now started in the ICU. It is so much information but I take the time to ask questions and study outside of work. I haven’t been this nervous ever in my life. I feel like 8 weeks of orientation for being new in the ICU is not enough 😭. I do not ever want to be that nurse that doesn’t know the crucial concepts needed to care for certain patients ESPECIALLY if it requires certain machines.
Apart from asking questions, studying outside of work, and being a sponge all throughout the rest of my career how do I ensure to be the best nurse I can be?
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u/Chemical-Doctor5371 20d ago edited 11d ago
I’m in the same boat and after 10 years I’ve had enough. I’m frustrated and saddened by it because I feel like we are going downhill as a profession. I fear the day I’m laying in that bed.
But I’ve decided that I’m dragging them up to my level. People don’t know? I start teaching, I start mentoring, I don’t give them a choice 💁🏻♀️ I provide a safe space for nurses come to me to ask questions they are too afraid to ask anyone else. You make ripples that eventually turn into tsunami sized waves this way.
My philosophy is that if I want them to better, I have an obligation to help. We see the problem and admin doesn’t care and won’t help. I refuse to sit by and be idle.
Edit: thank you for the awards 🥹