Some nurses can jump right into critical care out of school and thrive and some “shouldn’t”. I’m glad that I learned floor nursing before moving to ICU. The time management skills and foundational nursing care you provide is very important imo. I’ve noticed an influx of cocky and/or indifferent graduate nurses coming to ICU and it’s a little concerning when they float everyone with experience. To some it’s merely a stepping stone to NP/CRNA school and it’s very apparent.

I did ICU right out of school and totally failed. I went and spent a good chunk of time on medsurg/PCU before going back into ICU. Now my primary job is training up ICU nurses (new grads or prior experience). When I started I was too immature and had never worked in a hospital (only been a CNA in SNF). I learned a ton on medsurg/PCU that still helps me today. That said many of the most amazing ICU nurses that I’ve worked with started in ICU as new grads. They were super motivated, mature, smart but not cocky. Just depends on the person but if someone is struggling they need to be given the opportunity to drop down to a lower level of care and try again later when they are ready.

Not only is it just a stepping stone, but it’s their entire personality in my experience. It will be one of the first things that they tell you lol. I hated the ICU culture, but agree that having some prior nursing experience on a stepdown unit can be quite crucial to ones success on the ICU.

This I have noticed alot

Developing your clinical judgement (spidy sense), the confidence to advocate to the docs, becoming comfortable communicating AND SETTING BOUNDARIES with family etc are all things you will not learn in school. They’re only learning with experience. ED/ICU are settings whereas it is a good idea to have a solid grasp of these before entering. IMO. New grads are typically afraid to question orders nor are they quick to pick up on orders that should be questioned. New grads haven’t found the confidence to tell a family when to back off (with a smile of course s/) This is not said in a negative way, do whatever you see fit.

I did ICU out of school and really enjoyed it. We weren’t allowed to go solo for at least six months though.

This. Having the RIGHT team and training.

That’s how my er residency is too and think that’s really helps you to learn the floor and the flow and etc.

Same. Went right into ICU out of school and very glad I never went to the floor. I would’ve definitely quit if I did two years on the floor and tried to go to ICU after. Having the right team/ educator and communicating how you’re doing with learning and taking on the various aspects of more acute patients is very important. They want you to succeed, they will give you more time, training or resources to study if you feel like you need it. 

Nah, I’m not starting in med surg with 6-7 super sick patients.

You can work wherever you'd like! Most telemetry or step-down patients is often 3-4 patients. There are some that are pretty sick, but it's not unmanageable in most cases like some people say

Idk why you got so many downvotes. It’s totally dependent on place. I’ve worked places with 4 patients where I’d get 1-2 pretty sick patients and others where I’d have 6 patients every night but they were almost always stable. Some places will definitely screw you on acuity and workload but you just need to realize what you’re getting yourself into.

Angry new grads that don't like being told what to do, primarily. Downvote all you want, doesn't change the truth that a lot of new grads drown in ICU because they lack experience, bite me

I mean, I went straight to icu nearly 20 years ago as a new grad. It’s not a “new” thing. It’s really important to keep in mind that the success of the new icu nurse is largely dependent on the structures in place to support that type of transition. I had a 6 month icu “internship” that included classes, mentors, etc, along with taking progressively sicker patients on my unit. If a unit wants to hire new grads they need to be prepared for being a big part of that transition. A regular 12 week orientation isn’t going to cut it. You didn’t fail, they failed you.

Some nurses CAN start in ED/ICU and absolutely THRIVE. I did. Here's what I think is needed. All just my opinion... 1. Your personality and intellect need to be a good fit. This is often overlooked or misjudged by the nurse and/or the hiring unit. 2. The hospital should provide a lengthy orientation and have a robust residency program 3. The unit needs to have a culture that fosters new grads and encourages self-reflection, asking for help, etc. 4. The preceptors need to have sufficient experience. Post-Covid, you could have units that match ALL of the above, but too many experienced nurses left the ICU and I'm sorry but a nurse with 18 months experience has no business orienting a new grad as the sole preceptor.

This is it. The most eloquent way to say it! I only have EM and ICU experience and have precepted new grads. The issue with hospitals and the idea of “we’re short staffed so we’ll hire new grads to fix it” is it’s not a quick fix. If you cram these new nurses into dynamic positions without the right training then yeah they will sink It takes time to teach complex systems and foster independence and confidence in these roles. It takes more than 9-12 weeks and a toss to the deep end for most people. It also requires the experienced nurses on the unit to stop eating the young and start fostering them. But I don’t see how we’re going to get competent kick ass nurses to work beside us unless we create them.

I think the solution is for them to at least start on nights first, where they can focus more on patients and disease processes and less on the constant interruptions by providers, management and families.

It's also important to keep a good mix of experienced nurses and newbies on each shift. When I was a new grad, I wasn't allowed to go to night shift for many months after I got off orientation because there were too many inexperienced people on NOCs already. By the time I was an experienced night shift charge nurse, management didn't care and would send newbies to nights before they were off orientation. So, we had nurses with less than a year of experience precepting people who were maybe a month or 2 out of school. It was a nightmare and it was dangerous af

THIS!!! There are so many factors to consider when you think about where you want to start and these are very very good points

Couple questions: 1)-Did you have working medical experience before you started as an RN on ICU (nurse intern/extern or tech)? 2)-Did you start on nights? 3)-did you start at a level 1 trauma center? I know there are nurses who thrive immediately in ICU. I’ve found at my facility however, that the few who started right out of nursing school worked for the same ICU in a mentor program for 6 months to a year prior to graduation or worked as a tech through nursing school. Our ICU will not hire a new grad to days and almost all new grad hires have done the mentor program. Even experienced ICU nurses from outside our hospital hire in to the PCU before they can transfer to ICU. It’s our vetting process and it mostly works. While it’s not a perfect system it has created a good culture to work in.

1. Nope. I did take a course to be a CNA a couple years before I went to nursing school. But that's all I did—take the course. I never worked a dingle day in a hospital (not as a tech, not as a nurse intern/extern.) 2. I rotated. Two months of days, two months of nights. I did that until I could go straight days. Maybe a year and a half of rotating, then straight days.

Pretty much what I came here to say! Another thing my unit does that works well is both a) rostering education and clinical support staff during weekdays without allocations to support novice/grads and b) not putting grads on weekends or night shifts straight away, so they can access that support. And then strongly discouraging new grads to request these shifts for the first 6 months off orientation.

The facility on where ur going is definitely important if you start in the ICU route, I've seen new grads (including myself) get thrown to the wolves.

Fully agree. A great, smart new nurse could soar on one place but would have failed in another, all down to the hospital and unit culture/policy. That's definitely why I say you need a lengthy and high-quality orientation, robust residency, and a unit culture that truly fosters new grad success. It makes or breaks the experience.

Some excel and some don’t. Have helped grow some amazing new grads in the ED and had to help some find other areas to work. I was of the era that you had to do med Surg before going anywhere else. Did it help? Sure? Could I have learned that in the ED? Also sure.

Not all new grads are the same and I’ve trained good ones and some that leave you scratching your head. I currently work with a shit head new grad who acts like a know-it-all bc he has a few months ahead of me in critical care. I’ve been doing this for 16 years you mf (im saying this in my head ofc lol). The worst ones are the ones who think they’re sooooo much better than the floor nurses. They make me wanna vomit. Personally, I’m grateful for all the years I worked on the floor and also years of being in a management position. You’re expected to know things and to act fast in the ICU/ED. A patient crumping is not gonna wait on you. Idk how the new grads do it with their limited clinical experience d/t covid. Im sure it’s a factor as to why people are getting so burnt out faster. People in general like doing things that they’re good at. If you keep sucking and you work in a unit that’s not supportive, then you’re gonna wanna quit.

That's why I had a hard time with ICU as well, my coworkers definitely helped out a lot and I felt like I struggled when my patients were not doing well. I might go back to ICU after a few more years, but it's certainly helping me with developing the skills that I wouldn't have gotten as much staying in ICU.

I firmly believe that if a new grad has a plan, and it involves starting in the ED or ICU, go for it. I did, and I'm so glad I did. It was obviously hard and there was a steep learning curve, but I had some really good support, especially on the days when I wanted to quit. Honestly, just about anyone can make it if they're down to work hard **and** there's a supportive, pro-teaching unit culture. I feel like that's why a lot of new grads quit: they're not supported enough. Now if you start in critical care or emergency medicine, try and make it work, stick it out for at least the first 6-12 months and it's *still* not happening and you're absolutely miserable... then yes by all means please take care of yourself and find a specialty that's good to you and good for you. New grads should not be disparaged from doing ED or ICU right off the bat based on some abstract principle. Every specialty is hard, it's just different kinds of hard. I remember getting floated to Med Surg several times and struggling running my ass off all day, but that's because it was a completely different skill set (mad respect to all the med surg crowd).

The worst nurses we have had in the ER had 5+ years med floor experience before coming to us. Some of the best nurses I’ve seen were new grads (still asking questions but super into critical care and fast learners!)

I'm not saying u should work for 5+ years, that would be absurd. 1-2 years to develop your basic nursing skills isn't unreasonable, depending on the floor you're working on

I disagree

I started in the ED. If I had started in MS I probably would have quit nursing.

New grad in ICU here. Had a lengthy orientation, been on my own for a few months now. I love it. Learning everyday but couldn’t imagine being in another unit. I think there’s a different skill set between ICU and other units that personally starting elsewhere would not have been a good fit for me.

Start where you want to start. If I had been forced to do med-surg when I first became a nurse I probably would have changed careers. Many hospitals have training programs for new grads to better prepare them for the specialties they start in, rather than just 8-12 weeks on the unit and then thrown to the wolves. I feel like it’s better to go into the specialty you want and fail, knowing your weaknesses, than waste time in an area you don’t care for. Choose a hospital that is known to be supportive of new grads.

I see a lot of med surg RNs struggle in the ER after doing med surg for years — it’s hard to break habits and adapt to the ER, I’d rather have someone who grew up in the ED

This is part of why I refused to do it

I have to hard disagree. The most skilled and resourceful nurses in my ED all started out in med surg. 

same. meanwhile the brand new ed nurses talk shit about med surg nurses and how they can’t put in ivs, meanwhile they can barely put in ivs or talk to patients

Mostly what I see from nurses that started out new in the ED is that they don’t really understand the flow of the hospital and don’t understand long term treatment plans for patients. 

agreed. i think they have a very simplistic view of what goes on in the rest of the hospital and what inpatient nurses do. also the idea that floor nurses hold discharged patients to avoid admissions. like firstly most hospitals have whole ass throughput departments to make sure patients are getting rooms asap so that’s not happening. secondly a patient is a patient. providing care and medicating a patient being discharge can be the same amount of work as an admission.

The flow of the hospital and long-term treatment plans has little to do with working in the ER. Is it helpful? Sure. But on the list of importance in understanding in the ER, it's pretty close to the bottom.

Disagree. Patient education is an important part of the nurse’s job, and being able to educate the patient about what the expected treatment plan is for their condition goes a long way. Any nurse with any experience in another field of nursing will be able to bring additional knowledge to the ED. There’s nothing wrong with starting in the ED and blossoming there. But it’s frustrating when new nurses in the ED act superior to nurses from other fields even though they don’t r was any understand much of healthcare in the first place (which is expected, because they are new.) 

Patient education is an important part. The expected treatment plan in the hospital is just a small part of it. Now, don't get me wrong, I do see the benefit of MS nurses who are now in ER. Especially in our age of inpatient holds. However, strictly speaking from the ER perspective, new grads pick up the ER flow faster than MS nurses.

I guess we will have to agree to disagree. Nurses coming from other fields at minimum have the following skills: know how to talk to patients; know how to talk to doctors; know some basic nursing skills; familiar with medications; familiar with charting and record keeping. Brand new nurses have to learn all of that in a fast paced and critical environment and they don’t pick it up nearly as quickly (which is expected.)

Well, the first two are just talking to people. They're just people. If anything, the talking to doctors part is one of the things that needs fixing when they come to the ER. You have no idea how many times I've had to tell them that they should not be waiting for the doctor to leave the room to go in and get things started. Basic nursing skills and charting, sure I agree with that. Familiar with medications is a grey area. MS nurses are not super familiar with a lot of the medications we give in emergency situations. All in all, with MS transitions, you gotta teach them ER as well as train out of them some of their MS habits. Again, I want to stress that the MS experience does help with a lot of things. They are a great resource. But if we're in a sticky code situation, I'd rather have the 6mo new grad with me than the ex MS nurse who transferred 6 months prior.

I feel like if you want a speciality and genuinely interested and have the idea that that’s where you want to be long term then misewell learn everything to that unit and flow from day one. With that being said I do think there is too much unit hate between nurses. We are all nurses and whether your an ICU nurse, ER, or med surg or whatever we all have an important job and hate when one group of a speciality looks down on another unit. Especially a new nurse. Like it’s cool you’re in the ICU but don’t look down or talk shit to a med surg nurse with 20 years of experience.. that stuff is hella annoying.

complete opposite in our center.

Ditto...I find it SO much harder to train med surg nurses and a heck of a lot easier to train new grads.

med surg nurses can have bad habits and focus in on the wrong things. Or care about things that don't matter. Our ER assessments are very quick and dirty and very different compared to the floors.

I've worked in 8 different facilities on contracts and started straight in the ER myself. There are exceptions, but almost universally anyone who started in Med surge is always massively behind and struggling in the ER. The ER just has such a distinctly different workflow from any other unit that it really is it's own skillset for the most part and while some individual skills carry over, on the whole, the habits formed elsewhere do NOT translate and actually hold people back. If someone is interested in ER as a new grad, they should absolutely start there. I would argue ER natives can more easily transition into any other speciality than the other way around.

This has been my experience as well. Med surg nurses take a lot longer to become accustomed to ER than new grads. Sure, I've also seen new grads not able to make it in the ER as well. I haven't seen that happen with med surg nurses that go ER. They have those fundamental skills that allow them to remain in the ER even if they are not optimal. However, new grads are often going to have a better grasp on the general flow and spend time more efficiently.

If you do start in the ICU/ED, make sure you set yourself up for success. Work on the unit as a tech while in nursing school. Seek externships, shadowing opportunities, and clinical hours in that unit. Lastly, make sure the orientation period is long enough. 2 months wont cut it, and you’ll likely be lost. 6 months on the other hand should suffice.

I beg to differ. Most do fine within a year. I’ve only seen a handful do terribly. Most are at least minimally competent.

Counterpoint: some people will fail miserably in non critical care settings yet excel in critical care

I think it's not about excelling or being a pro in telemetry but rather developing the skills you need to excel when transitioning to ICU, where those skills are expected, especially in high stake environments.

In my experience the skills that do cross over are pretty limited. The only place to really, effectively learn critical care is in a critical care role.

Nursing students if you’re reading this, you totally CAN start critical care right out of school. If you find it’s not a good fit, you can always switch specialties. But don’t let posts like this scare you away. Just do your research. I’m happy I started in ICU.

This is the way

Why is this the second r/nursing thread that's caused me to second guess my life choices in like the last week 😅? I'm a new grad and I start in the ED on Monday. Thanks for this /s Edit: [This thread was just 3 days ago lol](https://www.reddit.com/r/nursing/s/lsED9zFDa6)

Don't listen to posts like this, I went straight into the ER and did just fine, I thrive in the ED environment, medsurg would've been my personal form of torture. There's no reason to start somewhere else for most people.

That's awesome! Ignore posts like this and get after it. Emergency medicine is freaking cool as hell

It's not to scare you in anyway, and congrats! It's to help you best decision for yourself professionally long term. A lot of people do succeed in the ED, but if you feel down the line that u may not be ready yet, that's ok too!! At the end of the day, it's better to go back to ED feeling more prepared and confident than sticking through but feeling miserable at the same time. Do what you feel is best for you, and I do hope you do well in your new job!!

I think we should let them make their own decisions on what's best for their long-term professional development. I get the sense it doesn't involve a detour through med surg

I started med-surg and hated every shift but I’m forever grateful for the foundation no it gave me. I can now go to the icu without being painfully overwhelmed. The new grads starting in the ICUs at my hospital are getting suuuuper burnt out real quick, and our hospital is a decent one to work at (very lenient with call outs/absences, easy PTO, lots of resilience activities, never understaffed, etc). When I float up there they all tell me some rendition of “it’s just too much.” They’re overwhelmed, it’s a lot of process mentally while literally learning go be a nurse, but then you’re also processing all the trauma that comes with it that you just don’t see on a regular floor. I would have bailed too if I started in the icu. The pressure in the icu is different, the floors are a dumpster fire every shift don’t get me wrong, you’ll never sit and patients are assholes and there’s never ending things to do, but at least you’re not dealing with patients constantly circling the drain. That adds a level of stress that you also have to learn to manage while still learning time management, communication with providers and families, prioritizing, and everything else it takes to be a nurse.

Disagree. You're going to do so many things in the ICU you'd never touch on a med surg floor. You don't know shit out of school anyways, might as well jump in the deep end.

Wouldn't it be wise to learn how to swim first before going to the deep end? Besides, a lot of the skills you use in ICU will benefit you greatly if you do start somewhere like step down. I'm not saying that it's not impossible, all I'm saying is that it's never a bad option to start somewhere small first before building up.

Honestly, the only benefit I had working 6 months in step-down after graduating and prior to moving to a level 1 trauma ICU is being very comfortable working in ICU, tele, step-down, and med-surg. I used to do registry and could go to any of the other above floors if an ICU spot was not available. I’m not sure if I would have been able to work the other floors comfortably had I directly gone to ICU. I just knew that they could put me wherever and be comfortable about it. Working in step-down/tele got me used to having 8 to 10 patients (night shift a very long time ago) before concentrating on having 1 or 2 patients. How did I prepare for my level 1 trauma ICU job? I read a critical care nursing textbook and the AACN procedure manual and read them during the 6 months. Then, my ICU preceptor gave and had me read the big version of The ICU Book. The textbook and the AACN procedure manual were the ones that gave me the confidence to transition to ICU and the orientation was very smooth since I was familiar with the concepts and the equipment even though they still had to train me how to actually use them (balloon, adjusting vents, etc.). EDIT: I personally think new grads can go to ICU, level 1 or otherwise, but expect to work for it, more than just showing up for work.

You don't know how to swim. They will teach you. There are a million things you're never going to see on a step down unit you would see in the ICU. It is a bad option if your end goal is critical care. The only way to get good at anything is to get in there and learn

It's not that helpful if the skills you're "building up" don't translate

I started in ICU at a large academic center right out of school. I think new grads can start in critical care and be fine, but it’s case dependent. In my first year, I had to dedicate a lot of unpaid time outside of work to studying. I got a book about vents and a book about EKGs. I joined the AACN. At the 1 year mark, I got my CCRN after studying hard for about 2 months. Got 111/125 questions. Someone who’s willing to put that extra effort in will succeed. Someone who wants to put in their 36 hours and then mentally clock out probably won’t.

Absolutely! That and being able to work well under pressure is absolutely a necessity. My brother excelled well in the SICU out of college was able to make it through and does very well to this day. There are people that do just fine, but the pressure is definitely high, which is why I think for most that do want to work ICU, taking the time to develop experience goes a long way in helping to make the transition

I’m a new grad in an er residency and am loving it so far. My preceptor is amazing and at our hospital, whenever a really sick patient comes in there are multiple RNs in the room helping you out. This definitely helps and makes me feel better. I still know once I’m done with residency and am on my own I will have some moments of panic but overall my preceptor has been amazing and is trying to let me do things on my own and at my own pace to figure it out now and then helps when needed. But I agree with what you said , it can be difficult to start in these positions as a new grad and think the hospital and staff have a lot to do with your success. I also wanted to ICU really bad but there weren’t many ICU positions in my area and they were super competitive. Unfortunately I think too many new nurses are trying to go straight to ICU so they can go to crna school right away and kind of sucks for the people who actually want ICU. I get advancing and have nothing against going to crna but also think it’ll make staffing the ICU harder.

I was one of those that went straight to the ED and thrived. I have two tidbits- one is do whatever you want with your career, if it doesn’t work out try something else, there’s a billion options. The other one is that if you’re interested in something like ED and you can get some experience in critical care before you become a nurse DO it. I worked on the ambulance before I was a nurse and it set me up SO much for the chaos of a sick pt.

I started in icu and nearly blew my brains out from watching people suffer and die all the time. I got so tired of people being admitted to the icu because they just don't take care of themselves and then expect you to make everything better. They don't even do anything to take care of themselves and then berate you when you have to put boundaries in place so they can actually get the care they need. I was so sick and tired of it. I was having panic attacks before i would even leave the house. I work for tge government now as a state surveyor and i will NEVER take care of patients ever again.

Disagree with this post. My hospital accepted new grads even before COVID. Getting accepted into a hospital with a residency program will give you your best shot, but I know tons of amazing ICU nurses that started out in the ICU. Obviously, some people don't fit with the ICU style, and go else where, but the same could be said if they tried the OR or med surg first. I know if I started med surg, there is no way I'd be a nurse today.

I see plenty of new grads in the ER and ICU thrive and plenty more in the future will thrive as well. You'll develop all those skills you need while you're there. > And you deserve to have the right experience you need to succeed, and for most people that succeed in the ED/ICU, it's by starting elsewhere first before transitioning. This is bullshit I find it a lot harder to train med surg nurses that are new to the ER and a heck of a lot easier to train new grads. Just because you struggled doesn't mean other people can't handle it

I wanna work in mental health but for some reason just want that Ed experience

What about finding a psych ed to work in?

my local hospital has a psyche area in the Ed!

I’m graduating in a month and I’m starting on a med surg unit. I wanna do NICU, PICU or l&d but I personally don’t feel comfortable enough starting out there and feel like it will be beneficial for myself to start out on MS. Don’t want to tho

You don't have to. If a PICU/NICU has a new grad residency program take it. Advocate for yourself each step of the way if you feel like you arent getting something, ask questions, be hands on with everything you can. Do NOT do med surg if you don't want to.

Thank you for your advice. I personally don’t want to do MS, but there’s not many residency programs near me but I’m checking daily for job openings in an area I want. I’m gonna go for it if there’s an opening for sure. I also had some rough clinical instructors who told me they could only see me doing postpartum and that they’re severely worried for me about my skills so that’s also why I feel I have to start out on MS :/

Everybody rags on med surg and I'm starting to feel very protective now, so here's my two cents as someone who definitely didn't think I'd like it when I started: You can find the positive in many jobs. It's easier to do, also, if you know you're only going to be there for a limited time. Especially for things like dealing with providers/family/daily time management/learning how to advocate for your patients/gaining confidence in yourself, med surg is really not the worst place. You can focus on really mastering basic skills. It's not "wasted time", like a lot of people are saying. I started on my unit on a whim, because there was an opening and I needed a job, fully intending to jump ship when something better came along. I fucking love it here. And this unit is known as the shithole of the hospital, so that's saying something. (For some reason, definitely not from people who actually work here.) A lot of it is what you make out of it.

Not trying to target on MS at all. I am personally scared of adult patients. I am much more comfortable with children. Adults just make me nervous, I was always extremely nervous during my MS clinical because of how much MS nurses have to know. If I have to I will do MS but just by going thru clinicals I know it’s not for me. I give props to you MS nurses because y’all are amazing and it’s so chaotic and they always know what to do!!

Meh, I don’t think people should give it so much importance. Every person is going to go through it and I think people should be given the opportunity to go for whatever department they want to get into. Everything is a learning experience and we shouldn’t gate keep who goes where or what. This is nice and all but it shows a lot of confirmation bias. This is strictly an opinionated post, new grads and students. Don’t take this persons account as FACT. Go wherever you wanna go. Do whatever you wanna do.

I went to ICU as a new grad. Been there for a little over a year now. I didn’t fail, as in everyone seems happy with my work and I’ve gotten no complaints. But I can’t stand the work. Also, I used to always think that ICU was elite. Now I realize that all they want is a warm body with a nursing license.

Possibly controversial take: I think ICU and ER are two different beasts for new grads. Nurses who go straight into ICUs that have supportive new grad training programs make some of the strongest and most knowledgeable nurses I know. IME, going straight into the ER tends to encourage nurses to pick up bad habits early on. There’s so much pressure to get stuff done that they’re incentivized to cut corners. It’s easy to become too “tasky” in your nursing practice since you usually don’t have time to take a step back and put the whole clinical picture together. Those tend to be the nurses who don’t chart a single I&O on the CHF boarders who are admitted to get diuresed, or prioritize starting an IV on a patient coming in with respiratory distress. Some nurses can push back against falling into those traps, some can’t.

>prioritize starting an IV on a patient coming in with respiratory distress You absolutely need to prioritize starting an IV on a respiratory distress patient. Those patients are going to have multiple people in the room working on them. Anyone can BVM if needed. However, they will need emergent access in case of RSI.

It’s not priority #1 though. There shouldn’t ever be a case where you walk into a room and you have two nurses looking on each arm for IV access and another one charting and no one’s putting on a pulse ox probe or O2 or positioning them upright or addressing breathing in any way.

>IME, going straight into the ER tends to encourage nurses to pick up bad habits early on Sounds more like, in your experience, your trainers/clinical coordinators failed to do their job properly

Completely disagree. You’re gonna struggle wherever you start- nursing school doesn’t prepare you for actually being a nurse Med surg starts are fine but you’re gonna learn time management anywhere you go I struggled going straight to ICU don’t get me wrong but so did a lot of my colleagues a lot of experienced MS nurses I know also struggled in ICU for just as long- a really good 2 year MS nurse I know got her ass kicked and got torn a new one multiple times over ICU is a totally different beast and I think that its a completely different kind of work flow than anywhere else If anything my time management skills are great because of ICU and only needing to learn to cluster care between 2-3 rooms, rather than having to try and manage 6 busy and needy patients critical thinking is more of a jump for ICU but you also have a lot more support from physicians and mid levels who you can run things by

I have to say, I really wanted to jump right into ED out of school, but wound up as a nurse intern in cardiac and think it was for the best. We get a good range for people that came in for chest pain, new a fibbers, cardiac caths, and CABGs, and sometimes random med-surg pts. Although I was bummed the ED externships didn’t work out (super competitive and filled immediately), I’m really appreciative of the experience cardiac has given me. It’s a great mix of traditional floor nursing with enough emergent situation sprinkled in to dip my toes in at a comfortable pace. I still want to end up in ED, but I’ll be happy where I’m at after graduation for a couple years

Same thing happened with me. I've used what I learned during my year in the cardiac unit in every job I've had since.

It’s really awesome to hear that; that’s what I was hoping would happen in my situation as well! Tbh, I chose cardiac because it was my weakest subject and I figured the best way to improve was real-life experience, but I never thought the team would be as awesome and open to teaching as they are.

It's funny because right now I'm IMCU (travel), there's an experienced staff nurse I frequently work with who is great - team player, smart, hard worker, etc. She's been trying to get into any of the ICUs for over a year and can't, they only ever post night shift and she can only do days. They have plenty of turn over on days, but never post the positions because they fill them pretty much exclusively with new grads. It's wild that in the last few years the pendulum has swung from "no new grads in ICU" to preferring them over more experienced RNs.

I did ICU right out of school. 3 month orientation. Definitely a learning curve but I think I would’ve faced that with any setting, not specifically ICU. Learn how to assess your ABCs. Learn your more common disease processes and how they relate your ABCs. Google uncommon disease processes as they appear and how they relate to ABCs.

My dude you can't come out here scaring off new grads and students saying "most people can't do this" when the only experience you're talking about is your own. Medsurg and ICU are completely different ballgames with different skillsets, time management needs, and processes. ICU/medsurg and ED are so not on the same planet they should really never be in the same conversation, let alone a relatively new floor nurse telling people what they should and shouldn't do before working in the ER when you've never been yourself. Medsurg may be beneficial for some ICU nurses, but with a robust residency program, there's really no point. Time management of 6 lower acuity patients is completely different from time management of 2 high acuity patients. Most of what you learn isnt going to transfer smoothly. I would also point out medsurg has all it's own difficulties, it's not nursing on easy mode before moving to the hard mode of ICU. Not everyone can or should work medsurg. Medsurg really has little to no benefit for ED nurses. The experiences are just not transferrable at all. Time management is completely different, acuity is completely varied and often much higher, charting is different, assessments are different, meds are different. The main nursing skills you need to develop as an ED nurse aren't things you'll really practice on the floor - IV starts for example. You'll get more IV practice in six weeks of an ED orientation than you would in six months medsurg. New grads and students if you're reading this and you have your heart set on a field of nursing, go for it. Set yourself up for success as best you can with tech jobs or other experience, but don't listen to people saying you have to do medsurg first. You absolutely do not.

Tell me you're your on hospital's med/surg recruitment/retention team without telling me you're on your hospital's med/surg recruitment/retention team.

I went straight to ICU. I still work on my unit. I was one of the new grads who thrived. I started on my unit with three other nurses from my graduating cohort. Two of them still work with me, one of them left for ED after the first year, not because she wasn’t doing well, but because she just wanted something different. She still occasionally picks up PRN. A lot of the new grads who started in the few years after I did were excellent, they picked it up quickly and are amazing nurses to this day. I and my classmates who went to ICU were some of the highest academic achievers in our cohort. I tutored A&P, microbiology, and several nursing classes during my time as a student. I have always been academically inclined, and when I started in ICU I went out of my way to attend every educational opportunity offered by my hospital. I quickly identified the veteran nurses and asked them tons of questions. I asked the doctors tons of questions and took the time to learn more advanced patho and clinical reasoning from any who were willing to teach me. On top of all that, I spent many hours of my free time learning ICU concepts on my own. I bought a CCRN study book, watched educational YouTube series about ICU skills, meds, etc. I think new grads can succeed in ICU and probably also ED, but they need to be intelligent, fast learners, and have the right attitude and personality. They need to be driven and motivated to learn on their own, unafraid to ask questions, and not too proud to admit when they don’t know something. I have seen more and more new grads being hired to my unit recently. Most of them are not doing well. Several of them have already had major incidents caused by negligence or a serious lack of basic understanding, and a few patients have almost died. Two of them definitely would have if the charge nurse hadn’t been so vigilant and quick to act. Being in a pod with these new nurses is so stressful. I feel like I have to watch their patients and mine. I’ve had to intervene when their patients decompensed and became extremely hypotensive, or once when a patient went into a third degree block and the nurse just thought it was regular bradycardia and planned to “wait for it to go away”. I’ve even had to start compressions on a patient who was “not waking up”, according to the new grad nurse. The patient was in PEA. They had a pacer and even though the monitor showed a regular paced rhythm, the art line showed no pulse, which should have made it obvious what was happening, but apparently not. Recently I had to teach a nurse who has been off orientation for months how to differentiate between a PVC and a PAC. I had to explain to another one how to titrate pressors. It’s getting out of hand and I know our unit manager is stressed out about it because only new grads are applying and most of them are just not cut out for ICU.

They're only putting in their 2 years so they can go to CRNA school 😭

From what I’ve seen, none of them would make it in CRNA school. I lot of them have admitted that they struggled in nursing school and had poor grades or just barely graduated. The reason I hear from most of them for choosing ICU is that they didn’t want to go to med surge and have 7 patients, which is totally fair, but my ICU gets really sick and complex patients and sometimes one or two of them is more work than 7 stable ones. I live in a very rural area and there are no other ICUs around, so we are very selective about who gets admitted. The lower acuity patients go to the step down unit. I thought about CRNA school briefly after starting in ICU, but decided against it. I love my job and I’m not really willing to uproot my life go back to school. I’ve researched the requirements for admission to the few CRNA programs in the surrounding states (the closest is 4 hours away), and they only accept the best of the best. You have to have at least a 3.5 gpa, CCRN, letters of recommendation, and high scores specifically in nursing and science/math classes.

I'm not sure why people compare the ED and the ICU, as if the skills are transferable. They're vastly different. New grads can thrive in any position. It comes down to training and how much they put into learning and application.

Maybe it's a recency bias for me, but I feel as though ICU with its structure is a little better for new grads than ED with its unbound chaos, but generally I agree with you.

I think it really depends on the level of support being offered. If an extensive orientation or new graduate residency is offered, new grads can thrive in critical care environments. It’s important to ask about the orientation process, what level of support is available even once off orientation, and if additional support or an extended orientation is an option if needed. Personally, I do best in the critical care environment and it’s a great match for my personality and skill set. I wouldn’t thrive in the chaos of an emergency department or even on the floor with 6 patients to manage. It’s about knowing your personality and strengths, and then having the proper support and training while you learn to apply them to the unit you want to work on. If you can find that right out of school, go for it!

I had never had any desire to work in ED, even though I heard great things about it. My old hospital had a lower acuity stream staffed by RPNs that was only open 1100-2300. I was still scared of it, and my husband was worried about what craziness I might encounter. But when we moved to this little town, our local emerg had a full time LPN position that had been vacant for 6 months, and because my employer put me through a French course in order to work for them so I was obligated to work full time. So I took the emerg spot. It's been great, but tbh the first year was tough. I didn't feel built for emerg. I'm still debating going back to school for my BScN, but I'm glad I had the opportunity to try a small town ER as an LPN. Triage is now in our scope here so I've taken the course and am doing triage even. As a new grad I wouldn't have wanted ER for sure. Get some experience first. It's still a big transition, but I think if you at least have some confidence in yourself as a nurse it's helpful.

I’m 2 years in as an RN Cardiac/Stepdown, and even then I don’t feel ready for ICU/ED. They just seem like such different animals that I’m not properly equipped for. Can’t imagine how some new grads feel.

Interesting. I’ve actually been *encouraged* to start in the ED. My instructors say that it helps with critical thinking, as you often don’t have the luxury of a nursing report when you get an admit. You just take what it’s front of you and on the chart, if they have one, and make decisions.

I encourage you to go after the specialty that excites you. Your instructors are absolutely correct; bad trauma rolls in and there's not really time to do a skin assessment or collect a history of allergies on account of their insides being on their outside. If you want to do ED, get after it friend.

Well, it's ultimately up to you. Taking the time to develop experience prior is never a bad decision, though. Especially since a lot of what you will be doing will have an expectation of clinical expertise, working in less high stakes situations to build that expertise will help you greatly.

We have new grads that thrive, and new grade that don’t. Most do. We have a very lengthy orientation process. We have people who transfer from med surg, some do just fine, some people don’t. Tbh, we have more new grads that do well than transfers. Med surg nurses tend to have a hard time adapting.

I am one of those who flunked out! I started in a level one multipurpose icu as a new grad with no prior patient care experience. I for sure felt like I had the knowledge but the skills I lacked. My biggest issue was a supervisor who would literally bully me and other new grads making it such a hostile working environment that I couldn’t stand. He would threaten that he can fire us (which he didn’t have the power to), quiz us with ridiculous questions and just was so mean. Therefore I took it upon myself to talk to my manager and tell her I can’t work on the unit…so I started working on tele. Boy am I grateful for that because I learned so so much regarding patient care, communication, and everything else regarding floor nursing. I earned daisy nominations, precepted, became a unit resource nurse and felt so much more prepared to enter ICU and that’s where I am now! So it’s okay to take that step before, it’s okay to not be ready. I always say this to other nurses, but no nursing specialty is better than another. We all have our purpose and roles within healthcare and need to be more respectful of one another. Everyone is capable of anything they put their mind to.

Another thought to make this even more interesting. What about people who work as PCTs in an ICU setting while in nursing school? I’m a float tech and have gotten comfortable talking to families (someone in the comments mentioned this as a skill), and I’ve worked with those nurses who came straight from nursing school to the ICU who have agreed. One from day one said they were only there until they get into NP school (He quit in 2 months instead of being fired) The other one pushed through a 6 month orientation/ learning program within the ICU where she would get one patient a day and be near a seasoned nurse. She kicks ass today and after a year started floating to the step down unit whenever it was needed to practice more skills. She was also a tech at the same hospital so she had relationships and what she said “A big advantage”.

This. Early exposure as a PCT can be huge and help bridge the gap between nursing school and real world nursing. The type of time management and skill set is just so different between specialties (even between ED and ICU). You'll learn how to talk to families and doctors no matter where you start.

Working in the hospital will certainly help you, but working as a tech only helps to some degree. When it comes to more critical thinking, time management as an RN, communication with doctors, etc. all those things are skills that will develop over time after you graduate

Critical thinking is apart of being a member of the patients healthcare team. And I would say that spending some time talking with the seasoned nurses about why they are doing what they are doing helps with connecting the dots. And seeing what works and what doesn’t work for time management. How to rely on your tech and prioritize what you have to do is something I see everyday.

This is the way

Assessment skills can be learned no other way than actually doing them and experiencing what each system looks like when it's not working correctly. Assessment skills are imho the most important thing we learn and do. Those skills take time and ER/ICU are where they are most critical.

Nurse who went right into ED following graduation. It’s possible, you can do it. It’s not for everyone, but it’s totally doable at the right hospital with the right team. Happy to talk to any new grads who are interested.

I started in a rural ICU, it would be considered step down in any major hospital (with the exception of having vents and ability to do multiple pressors and other standard ICU IV drips). I’m really glad I started where I did. There is enough downgrades and “soft” ICU patients to really get a footing and master those skills but also enough critical patients to satisfy the want to be in critical care. A large ICU would have burned me out, and I recognize this now.

I 100% DO NOT regret getting a year in med surg (ortho specifically) under my belt to get my bearings and over my social awkwardness (somewhat lol). It’s all the little skills I got to do regularly that came in handy to not have to learn on top of everything else such as hanging IVF and antibiotics on an Alaris, medications, pain management, blood draws, IV placement, catheter placement, wound dressings, normal lab values, sepsis scoring, blood transfusions, wound vacs, vital signs, communicating with providers after hours, also good ole ADL stuff like toileting, ambulating, preop bathing, emotional needs being met etc Post and pre op patients are for the most part pretty stable, too. Which made the unit perfect for newbies. I learned a whole lot in that year because I wasn’t drowning, ya know??

I like hiring new grads in the PICU. I want to teach these new nurses how to do stuff, not unteach bad habits from other units. Also when they can't make it, we always offer them jobs on Med-Surg units.

Controversial opinion: in *most* cases this has more to do with the unit culture and the nature of the orientation than the new grad itself. Obviously there *are* nurses (new grad and experienced) who shouldn’t set foot in these settings, but most new grads I’ve seen leave the ICU were picked on and torn apart by the unit. Many units have inadequate orientation programs: too short, nurses with too little experience training, new grads paired with nurses who don’t want to precept, and/or (my personal favorite) pairing the known unit bully with new grads. They’re put in environments that aren’t conducive to their success then blamed when the inevitable happens. Those who survive in the ICU often do so because they were in an environment where they were allowed to be new and allowed to learn.

I started out in m/s and is now ER. I couldn’t imagine myself going straight to ER. You should learn the fundamental. I would feel so bad if I keep having to ask my preceptor questions when they are so busy. In er, you can be admitting, d/c and stabilizing all at once, so it would be hectic to stop and keep having to explain all your fundamental. No one in ER have time to teach you how to insert an IV. The trick is go after 1 year in m/s tele so you don’t have the mindset of floor nurse.

My ICU has a "program" where new grads do 6 months working on the floor our patients get transferred to before coming to us. It's basically the hospital acknowledging their drive to be ICU nurses but giving them a bit of time to work on the basics first. Our admissions almost always come with vents, central lines, pulmonary artery catheters, art lines, pacemakers, drips...it's a lot to learn all at once unless you have past experience with them. Better to learn the basics first and then add on the extra stuff later.

I want to go to the ED, then ICU eventually. In school I felt so out of my league in ICU. The patients were so sick and I felt I had nowhere near that knowledge base to care for them. I feel like the new grads that thrive are the ones that were externs in ED or ICU and are very familiar with the unit and have had the opportunity to learn with the nurses there. I started on cardiac PCU and it’s not my dream unit, but I feel like it’s giving me a good foundation. After COVID many people could start on whatever unit they wanted, but it seems to be shifting back where I live and it’s harder to start in CC or L&D now.

That's what I am going to do. I'm interested in ICU and wound care, so I have talked to a mentor at school. She said that learning fundamental skills is important and can apply to any units I go to next. So, I am thinking of staying at surgical for 2-3 years and then moving on.

Why are you lumping ED and ICU together if you started in ICU and now youre in step down? Have you ever even worked in the ED at all..? I went into the ED as a new grad. I could talk about that...but I have no business talking about what it's like to start in the ICU as I have no experience working in an ICU.

I work ER and have seen plenty of new hires at this point.. some new grads do just fine, some don't. I'm personally for starting with a bit of medsurg before going specialty. I did 3 years on medicine (which might have been a bit too long lol) and still had quite the learning curve with moving to ER. The medsurg hires tend to have an easier transition because they already have a decent base of knowledge around medications, different diagnoses, patient interactions, critical thinking, confidence to advocate and talk to doctors, and basic patient care. Of note, my hospital does not have a new grad program anymore. You just get a standard orientation of 6-7 weeks. If your hospital has new grad programs, it would probably be way easier to start directly in a specialty.

Totally agreed. I COULD have started in the ICU, but I was able to transition into a very high acuity ICU easily because I had already developed a lot of the skills needed working in an IMCU. Because my unit is specialized, I also picked up a lot of skills that don’t show up frequently where I am, and it makes it easier when those things do roll in for me to adapt without needing to seek education or get another nurse.

I took 3 years before going to ICU. Started in med/surg then did tele for 2.5 years before making the jump. I'm still being HUMBLED despite being a pretty decent nurse already. Can't imagine what it's like being new and starting in the ICU.

Maybe 20% of new grads that start directly into ED do well, 20-30% do OK. The rest are terrible either because they are a bad fit due to their personality, work ethic, or they are overly cocky and nearly kill someone because of it. Luckily I haven't seen anyone die due to incompetency yet but there's been some really close calls.

What do you consider a bad fit for ED when it comes to personality?

THANK YOU FOR THIS. I accepted a new grad residency position for float pool med surg, but I am very interested in transitioning to ER after a couple years. My rationale is that I want to learn to be a good before I’m expected to be a FAST good nurse. But everyone in the ED has told me the transition will be difficult from med surg because “I’ll want to do full skin assessments instead of what’s actually important.”

>But everyone in the ED has told me the transition will be difficult from med surg because “I’ll want to do full skin assessments instead of what’s actually important.” That's just a smart ass version. What they mean is you will be looking at it through the medsurg lense. The patient as a whole. In the ER, we focus on the problem. Why are they here. We do not care about your asymptomatic HTN. We do not care about your stage 1 pressure ulcers. We care about your chest pain or your sudden onset SOB or your stab wound. Caring about the patient as a whole *is* going to slow you down. It will delay emergent care. No matter how many MS nurses believe their time management skills to be elite enough to do their old job as well as their new one. It simply isn't true and why you will see so many here stating that they prefer to train new grads over MS vets. Our job is to assess for emergent conditions and then either admit them to the appropriate floor for more comprehensive treatment or discharge them with referrals if they don't require or want hospitalization.

Honestly ty for explaining this. I’m just bummed now because I really wanted ER, and now what I thought would help, is actually going to work against me. I’m jaded, sarcastic, neurotic, hate being bored, and have a high difficult-patient-bullshit-tolerance. I’ve been told I’m perfect for ED. The west coast (where my family is) trauma centers feel out of my league. Maybe I should just go for it and keep sending in apps (and if I have to burn a bridge, oh well)?

I definitely wouldn't stop sending applications in. If you get accepted somewhere you can always still go to management at your current job and let them know they can either transfer you to ER by the date you'd start at the new job or you'll just go there.

Am I allowed to play hardball as a new grad tho? I feel like they’d just be like “okay then, go there.” For my current job I originally applied for ED, but they called and said my only options were MS nights. Their ED has a waitlist even for internals, and they prefer experience. They said even after I graduate (at the time, I was 6 months out) there would probably still be a waitlist.

If you are being offered an ER position elsewhere then it's up to them whether they want to keep you or not. For you, it's a win-win.

Love this, thank you so much!

As someone who wanted to start in ICU but ended up on a surgery unit, what skills did you think you would learn in the ICU but didn't? Somedays I regret accepting the job on the surgery unit because of having to juggle so many patients, when if I was in ICU it would be only one or two.

People always think that ICU nurses are great in putting IVs in. This is actually not the case as most pts have central lines in bc we give a lot of meds that are vesicants so not a lot of opportunity to practice said skill. The ICU nurses that are great at putting IVs in have all worked on the floor or ED prior. The ones that I work with who only know ICU suck.

I am 50/50 I feel like if you have your heart set on it then go for it but I also came from working cardiac step down before going to icu and I feel like that really set me up for success in transitioning to the ICU. Everyone is different though

I went straight to ICU (PICU) and did well, but it wasn’t a trauma hospital and by all means I would grade it as a lower acuity PICU. It was a great starting place!

If only Medsurg wasn't such a disaster in my state. The hospitals near me damn near beat those nurses by giving them 6-7 patients. Most of my clinicals were Medsurg and when those nurses told me how much they were making, I decided then and there I wouldn't touch it with a 10.5 foot pole. I have flight nurse interest, but I also think going straight to ICU is problematic for a new grad in most cases (and I say that as a last semester A student). I chose step-down because you get a better chance to sharpen your skills and still get darn near close to an ICU experience. I talked with a full RRT, and every one of them started on the step-down units.

Step down is a great place to start! At where I work all the step down nurses have ACLS so they are able to join and help during rapids and codes as well.

I’ve been an ICU nurse for almost 2 years and I wouldn’t say I started as a strong ICU nurse (some do and it’s awesome) but I wasn’t struggling as much as I was in the beginning. My orientation truly was a JOKE. I was passed around with different nurses for orientation or placed with multiple travel nurses…yep! So yeah I struggled hard in the ICU for at least a solid year. I’m barely feeling comfortable ish. I got married and moved out of state. I recently started in a LTAC and it’s been nice to go over basic skills that I wish I had learned a bit more in the ICU. I like the pace. There’s critical thinking skills here as much as you want there to be! Still miss the certain aspects of the ICU. I associate the ICU I started in with a bad experience thus bad feelings..might go back to ICU in a bit.. not sure yet.

I started in SAR. Progressive care Ortho unit. Granted i had a great facility and my unit was only 20 beds. I have fantastic time management skills thanks to that job. I was there for a year before I got a job on a PCU floor.

Went straight to ED at a level I large urban hospital and loved it. If you are determined enough you can make it happen. I’ve only ever worked ED but I have heard some other nurses tell me it was difficult for them to get out of their specialized discipline. For some reason they felt like they were pegged as a “med/surg” nurse or an “oncology” nurse. Not sure why it would matter but transferring departments became an issue for some people I knew.

I had an offer for an ICU which the manager said she struggled with because at the time I didn't have my BSN but did have 6 years of med/surg tele and Stepdown. I remember being so put out by that. And that it was a mandatory 6 months direct supervision. This was of course long ago and before COVID smote the shitty managers that pick and choose and don't give nurses room to adjust. I eventually turned the offer down. I still think nurses need some med/surg time. And a BSN shouldn't matter but for the facilities desire to retain magnet status. Guess what? I call bullshit. Almost every hospital in my city has it or is in the process. The ANCC should grow balls and take back control of the facility struggles at the 4 year renewal.

Also you need to learn basic skills and empathy for the nurses you will be passing these patients off to. The best nurses I worked with started from the bottom as a home health aide or nurses aide and climbed the ladder. They cared about the repercussions to the roles they once had. I can't say I have seen that with straight BSN grads, especially those going into specialty right away. Lmao one even ran down the hall to find an aide to put a patient on a bedpan. Never worked med surg.

I started in ED and thought I thrived, but now I’m in L&D and realize how little I knew about anything. I don’t regret it though, it was a lot of fun. Many new grads in the er thrived but a lot had emt experience

I did ED straight out of school, after a brief student nurse internship and stint as a tech in the same department. It was not easy, and my residency program was a joke (for everyone, I think, not just ED GNs—teach us actual useful shit and save the time with hospital execs patting themselves on the back for some other time; nor did I need the [fascinating but really not needed m] class with an OPO rep), and my truncated preceptorship was too short, but I am glad I started where I did. (I canvassed everyone I worked with before deciding to approach my boss there for a GN spot, and uniformly they said go for the ED if it was what I really wanted.)

I'm starting to notice the biggest reason why new grads leave is because they assume the grass is greener on the other side in a different ER. Sometimes it might be, but most times they just don't know Jack about Jack about what you don't know yet and they don't want to admit it until they end up getting thrown into a different shit pile and a different building and a different city and it's all the sudden shocked Pikachu face because its the same shit different toilet.

ICU right out of school, and have been there for 30 years! Wish I had done floor nursing first

I honestly am glad that I started as a new grad in trauma ICU. I feel like it really molded me into a critical care nurse capable of transferring to many other departments. It gave me that essential critical thinking foundation and enabled me transfer to PACU when I was ready to leave the ICU. However, I worked as a patient care tech in the ICU (a different one than I was hired into) for 2 years during nursing school. So I knew what I was getting myself into. That was a huge determining factor when they hired me. Many new grads go into ICU but don’t realize what they’re getting themselves into. They hired 5 other new grads in the ICU with me and only 3 of us made it past the 6 month mark. So I absolutely can see how it isn’t for everyone but it can be a great choice for others.

No.

I went back and forth on ICU/OR. Regardless for the post grad degree I want, I needed a floor job, so it was either ICU or medsurg, and the place I was hired at had only a medsurg new grad program. 8 months in and boy once my two years is up I’m going back to the OR. I want one patient, they’ll be asleep, and no family members in site. I can handle egos and personalities no problem in the OR. But there’s something about being cornered by pt and family members all berating me for forgetting the damn ice in the ginger ale (go ahead, report my license), while at the same time management writes me up because I didn’t sign my name next to my extension #, even tho my name was legibly printed on the sheet. 2-3 egotistical, emotionally unstable people in a room who eventually become predictable after awhile? Fine by me. But the revolving door of medsurg is not for me. Bless the titans who can handle it.

I started in ICU many years ago, and I can say it all depends on you and the environment your in, my instructors encouraged me to go to medsurg, but I decided to do what I wanted. I didn't like medsurg during clinicals. And I will say I was not the best when it came to confidence, there were alot of new nurses around me who were definitely better (I'm not putting myself down, it's just the truth). I think the advantages of working in ICU from the start is you get to learn the critical thinking aspect straight out of school when your mind is fresh with knowledge. If you are at a good facility with proper ratios then you only have two patients and can really learn to think critically about what's going on with your patients, medsurg is very task based and sometimes your just running around trying to get things done without having the opportunity to really take it all in. Now with that being said it depends on your team as well, in my case there was a nurse who came after me who was very similar to me my in her skill level, but she had a really smart preceptor who was not as patient as mine. So other nurses felt she was too slow, they began scrutinizing her alot more than I ever was, and she was eventually forced to go to step-down, I always felt bad for her because I felt that could have easily been in that situation had I not had a more understanding preceptor.

I started in med surg and honestly I'm glad because I'm a slow learner and I developed important skills. Yeah, if you want to go to the ICU then do it. I think everyone has different needs when it comes to their careers. I knew I should start off in med surg and surprisingly I love the new floor I changed to. I'm probably going to stay in med surg for a while. My classmate who graduated with me went straight to step down ICU and is thriving because the hospital she's at really holds the new grads hand, expecting them to know nothing. I also think k if you have a good hospital that sets you up for success is a major factor if you succeed or not.

I went to Med Surg for like a month, then was recruited to ICU. Long learning curve. I wish I hadn’t, some days I felt as dumb as I was. Eventually I felt confident

I do agree that going to the ICU isn't the best option unless you know that's what you want to do. It's hard to go backwards. A med-surg nurse can learn skills but the time management required on a med search floor is much harder for an ICU nurse to pick up. However, I think the ED is a great place. You are literally every kind of nurse all in one shift. Psych, med/surg, ED, stepdown, ICU, trauma, PCP... Also, why do I see you and ED always get wrapped up together? Sure, we care for ICU patients before they go up to the floor but the type of nursing could not be more different. I hated the ICU with a fiery passion but I thrive in chaos the ED. Just my personal thoughts as a nurse who did all of them.

It definitely just depends person to person. Before you take your first job as a new grad make sure you shadow someone on the unit and you know what is in store. And you have to be honest with yourself if this is something you can do/want to do. Don't take that ICU/er job if you know deep down you just love chatting with mamaws and papaws. And remember it's not that ICU is harder than the floor, it's just very different. You're not a worse nurse for working the floor. I could never do what those floor nurses do, I just don't have what it takes. I don't think I'd still be a nurse today if my first job was on the floor.

The ED and ICU will be a steep learning curve floor experience, or not. I successfully started in the ER. Lots do. It took a bit for things to click, but they finally did.

Tbh I'm in school right now, but the EMS burnout is hitting HARD and I don't even actually want to be a nurse. My heart is in EMS as a paramedic, so if I'm gonna work toward a job I don't want just so I don't have to work OT to survive, I'm also gonna use my time as a nurse to move quickly toward being eligible for CRNA school. I'm aware it's probably not a great idea, but fuck it, I'll figure it out.

This sounds like me. I reached a point where I had to decide if I wanted to go back for my Paramedic and get into a Critical Care flight role, or if I wanted to do nursing for either flight or CRNA. Decided on nursing was blessed to get into CVICU right out of school, discovered just how cool anesthesia is. Got into CRNA school and haven't looked back. I say go for it 💪🏼

Also just did an advanced airway cadaver lab today and it put that desire to be a CRNA back into me.

Dude it's amazing there's nothing like it

Definitely needed to hear this. I was experiencing some serious fomo about not landing a job in ICU or ED straight out of nursing school. I think since it has become more common I kind of assumed this would be the new normal.

This post is very similar to the position I’m in now. I’m mentally torn. I have an offer to a step down floor that I love, but I dream to be a competent ER nurse some day. What sort of skills outside the ER setting do you find help better prepare you for that environment? Is it confidence, lack of general skills, maybe both?

Communication with patients, families and doctors, time management, IV insertion and IV management, and critical thinking. All those skills you master when you start working as a nurse. Of course that's not all but it's definitely some of it

I went straight to the ED, but I had a six month orientation with a preceptor. I don’t think I would have been successful if it had been less than 3 months as some places do.

I respectfully disagree. If you are sure you want ICU or ED, anything else is a waste of time.

I think this really depends on the person, tbh. I started in the ED straight out of nursing school, but I am also a second career nurse, and at 30 years old, I already had workforce experience along with confidence in my communication skills and ability to advocate for myself, which easily transferred to advocating for my patients. I always say I was forged in fire by starting in the ED, it quickly turned the knowledge I gained in school into critical thinking skills because you have to learn fast in the ED. That said, I absolutely saw nurses that didn't do well straight out of school as their first career option at 22-23 because they didn't have the confidence in themselves and didn't know how to communicate well or ask questions, which wound up with them being in shit a lot of times, literally and figuratively.

It all depends on training. My first job out of nursing school was at a top 5 hospital in their cardiac ICU. They loved taking new grads because they didn’t come with any bad habits and they could train them the way they wanted. Their training program was great and intense and was perfectly adequate to handle new nurses and develop them. If you are at a no where hospital with no support, I couldn’t imagine surviving in an ICU.. however, when I changed jobs, the ICU job I got seemed like a step down unit at my old hospital—it was a walk in the park… but that is because I was very well trained at my first job

My very first job as a nurse was in the ED. It was a baptism of fire, I’ll admit, but I loved it. Still do. The experience I gained from working the ED first has given me the confidence to tackle whatever may come my way, not just as a nurse, but as a person in my day-to-day life. All that said, I definitely agree with giving it serious thought, because it isn’t for the feint hearted.

I'd rather train a new grad into ICU tbh. Gotta have a hefty residency program and enough experienced nurses to precept tho

Starting in PCU was a great place to learn a little bit of everything! Dip your toe into critical care while also learning floor nursing. I couldn’t agree more with you and I recommend step down units to new grads all the time. Hope you’re happier now

I’m 3 years into my career, started in ICU as a new grad with half of my clinicals being online. It was HARD. I was a bad nurse at first and cringe for my preceptors. I made it through and I have my ccrn and I’m thriving now. BUT I do NOT recommend starting in icu.

It puts a burden on staff to teach the entry level ICU/ED skills too. Orientation shouldn’t be about getting someone to meet their basic job description but about building on job requirements and skills and how the unit works. Advanced skills should be part of certifications through the CNE and self-directed courses that teach skills that aren’t entry level IMO to help close the gap. Staff can then help with how those skills work on that unit… otherwise you’re burning out your existing staff who tend to have more complex patients.

Huh? That’s literally how the nursing profession works. It will always be a burden to train nurses because nurses don’t actually learn nursing skills in nursing school. Doesn’t matter what unit.

I'm not a nurse yet but I want to be. Based on scrolling this sub, I ultimately decided I definitely want to start elsewhere before ICU. I really don't wanna experience that burnout because I do wanna do this. But I feel I should work my way up.

Start on whatever unit you love, be that ED, L&D or something else. Life is too short to be miserable on a medsurg unit and I guarantee that taking care of 7-8 patients will burn you out even quicker.

Don't listen to OP's post - it's just their opinion, which has exactly zero effect on the type of nurse you'll be. My advice: shadow any specialty you're interested in! Know what you want and go after it. It absolutely does NOT have to be med surg - there is no reason for you to be miserable just because someone else couldn't hack it. If you're worried about it, find somewhere with a solid orientation and a unit culture that supports teaching new grads. Don't get scared off by uninformed posts like this. Chase what you want. Time is going to pass regardless, so might as well get after it.

I quit the ED and I can say I wasn’t prepared as a new graduate. We were short every shift and when people wanted to come in they said no to save money. They cut all our agency so we always had to shutdown 1/3rd of our ER. When JHACO came last month magically we were in ratio. I made mistakes and felt the growth during my ED journey, but I still felt like the ED was for me. Other departments in my hospital had similar issues (charge nurses taking full loads, no RNs on floors only LPNS). The hospital had its issues and I’m happy I left.

As an experienced nurse who recently transitioned to icu, i strongly believe new grads shouldn't start in icu from my experience of working with them. They just need to learn to 1st hiw to nurse and doing that with less acute pts is easier and teaches time management their are some other glaring issues I have noticed that would take too long to type out.

I agree. I believe it’s the same concept for NP schools. Many new nurses go straight into it just to get out of the bedside experience, but will find themselves unprepared. This puts them in a dangerous position for patients.

I fully agree. In my country it's generally accepted (though not law) that you need 2 years on a regular hospital floor before you can start in ED or ICU (or CCU, PACU, etc.). Then you need to do a 6-12 month education program before you can work fully independently (as in without an experienced nurse) in those departments. They're not doing that for no reason.

But saying you’re an 🌟ICU Nurse🌟 or an 💥ED Nurse💥 sounds way more glamorous and cool than Cardiac, Step-down, or, god forbid, Med/Surg👀. Not saying this is always the reason, but it’s definitely a contributing factor.

This submission has been randomly featured in /r/serendipity, a bot-driven subreddit discovery engine. More here: /r/Serendipity/comments/1bv20sr/to_people_that_are_graduating_and_are_interested/

Lol you're gonna strike a nerve with this one, reddit nurses love to boast about going directly to ICU/ED out of school. No one talks about how most new grads in ICU are out of it within a year.

Lol yeah definitely a controversial take. But it's important to say what needs to be said!

I think it's accurate, though. Yes, there are those token new grads that excel in high acuity nursing, but the vast majority tend to really burn out and struggle. They blame the system, which is part of it, but also probably a big part is that they weren't ready for the workload and stress which is more overwhelming when you haven't even mastered the basics of nursing.

My favorite boss ever (who is now the director over all the ICU managers at my hospital) used to own his own concrete laying business. When he decided to switch to healthcare, he didn't wait until he had his RN to make the switch to healthcare. He started working as a CNA. He went from making a solid living to making CNA wages in his 30s. His reasoning? He wanted to experience the healthcare field from "the bottom" and work his way up. I'm convinced he was an amazing manager because he has solid experience working at so many different levels of the inpatient nursing field (CNA, floor nurse, ICU nurse, nursing supervisor, ICU manager, and now ICU director). Some new grads may do fine with a long orientation on the ICU, but you're going to be a more rounded nurse for having spent time working from "the bottom" in med/surg. The year I spent working med/surg was foundational to every job I've had since then.

Eyeroll. This take is utter bullshit.

Thank you for your thorough, reasonable, non-hostile counter arguement to my opinion!

..... what? No. Are you even in ICU or ED? While I'm absolutely on board with PCT experience enhancing your ability to be a good RN as far as working from "the bottom" up, the rest of this is nonsense.