As part of a continued attempt to find out what exactly is on the minds of critical care nurses, we (R.H.S.) did a series of informal surveys of our greatest resource: our bedside intensive care unit (ICU) nurse colleagues. We spoke with multiple nurses to learn about some of their pressing issues. It was a fascinating and highly educational experience that provided insights into recruitment and retention challenges facing our field today.
The nurses with whom we spoke had varied stories about how they ended up in critical care nursing. Some became ICU nurses after working in surgery, others in emergency medicine, still others in oncology. Although critical care physicians can also have various backgrounds (internal medicine, anesthesia, surgery), we still found the wide variety of nursing backgrounds to be startling and intriguing.
We asked what they liked about being critical care nurses. These were professionals who had been in practice for many years. They all said they still liked their jobs very much. Their answers were quite similar; they all loved the challenge of being a critical care nurse. The nurses with whom we spoke said they found it exciting to care for patients when they are at their most vulnerable; to dare to stare death directly in the face as part of a team of highly trained professionals with a plan to win! They noted also that the complex physiology of critically ill patients was fascinating. More importantly, they said the ability to use this applied physiology to help save patient lives was extremely gratifying.
Autonomy and Camaraderie
The 2 words that came up repeatedly were autonomy and camaraderie.1 The nurses said they valued their ability to function with a greater degree of autonomy than is usually seen in other areas of nursing. This is an important point for nurses considering going into critical care. There are exciting opportunities to fully enact the nursing role and maximize the scope of nursing practice without infringing on the scope of practice of other health professionals.
Camaraderie is certainly not unique to critical care nursing, but the nurses we spoke with felt that the bond that develops among critical care nurses is especially important. They said it allowed them to share the unique challenges of being a critical care nurse. They also mentioned that working closely with intensivists can be very gratifying.
We also focused on what these experienced critical care nurses didn’t particularly like about working as ICU nurses. Again, the answers were surprisingly similar. They all said they were tired; not mentally, but physically. They still loved being ICU nurses, but said some of the physical components of the job were wearing on them.
“Every nurse with whom we spoke could remember his or her mentor in incredible detail, no matter how long ago it was.”
Rarely were the psychosocial issues that inevitably arise in the ICU mentioned as a downside of being a critical care nurse. However, specifically in the surgical ICUs, a theme discussed was the difficulty that arises when a surgeon creates a potentially rosy picture of the overall clinical situation for a patient’s family, and occasionally it falls on the ICU team—specifically the critical care nurse—to explain to the family that the situation might not be going as well as the surgeon implied. From a physician perspective, this also happens when the critical care team and the attending surgeon are not “on the same page” with the family. A great challenge arises when this happens, but the consensus was that it did not happen with great frequency, and that working through these problems was very important and often quite gratifying.
The Importance of Mentors
Another vital topic that came up was nursing mentorship.2–4 Our nurses frequently characterized their initial nurse mentor as key to their success during their first few months of training. Every nurse with whom we spoke could remember his or her mentor in incredible detail, no matter how long ago it was, and could describe how central that person was to his or her entire career as a critical care nurse. Many nurses told us how much they enjoyed emulating that mentor when training others. It is clear from personal anecdotes and the literature that the importance of high-quality mentorship cannot be overstated. This mentorship edifies nurses at the beginning of their critical care careers and lives on as a sustaining component during the rest of their professional lives.
This issue of mentorship throughout one’s career (for nurses and physicians on the critical care team) is extraordinarily important: finding the right mentor and learning how to become a mentor are both issues that relate to recruitment and retention of high quality members of the multidisciplinary critical care team.
We asked if the duration of shifts (12 hour vs 8 hour) affected the difficulty of being a critical care nurse but no clear consensus emerged. Everyone agreed that 12-hour shifts are long (R.H.S. does the same as a physician), but the return is more days off each month. The nurses’ overall perspective regarding shift duration was not clear.
Keeping Our Nurses in the Field
Our overall reason for asking these important questions was to find out ways to get more nurses into critical care and retain the experienced nurses we have. In addition, we were concerned about the potential for great critical care nurses leaving bedside nursing and becoming nurse practitioners and/or nurse anesthetists. We wanted to explore the situation to see if there were ways to improve recruitment and retention for critical care nurses.
We came up with some conclusions: it used to be the norm for nurses to work a few years in other areas before working as a critical care nurse. The concept was that the nurse needed to have a command of basic nursing skills before jumping into the high-stakes, high-stress, low-margin-for-error world of critical care nursing. Nevertheless, the landscape has changed. More and more often, nurses straight out of nursing school may join mentored programs with the goal of quickly becoming a critical care nurse.5–6 As a field, critical care nursing needs to accept this paradigm shift and embrace nurses coming out of school who wish to join our exciting field.5,7–8
Our overall conclusion was that no one could prevent high-quality candidates from leaving critical care nursing to get further training and become advanced practitioners. However, we feel there are a couple of important solutions on either end of the spectrum to be explored. First, a more aggressive and structured approach can and should be taken to find nurses in nursing school who may have the aptitude, interest, and personality for critical care nursing. Find them early and “fast track” them into mentored programs to keep their enthusiasm high, then give them high-quality mentorship and training early in their careers.9
On the other side of the coin, we also feel that much attention should be focused on those who still enjoy being critical care nurses and have significant experience, but who are “burning out” from the physical aspects of the job. First, a continued use of support staff for the bedside nurse must remain a top priority.10 An additional solution is to meet with those important nurses and find ways to use their extremely valuable knowledge and years of experience, while removing some of the more physically difficult aspects of the job. An example would be to give these nurses the option of becoming “team leaders” whereby one nurse with these qualifications could supervise an entire unit of nurses with potentially lesser experience, but the supervising nurse would not be assigned to a particular patient. The supervisor could then check on the unit as a whole to make sure new nurses are getting the mentorship and supervision they deserve while simultaneously providing these highly qualified nurses with a position commensurate with their skill level and experience.
“Attention should be focused on those who still enjoy being critical care nurses and have significant experience, but are “burning out” from the physical aspects of the job. ”
Given the global nursing shortage facing all ICUs, hospital administrators and nurse leaders must be as creative as possible in recruiting and retaining high-quality critical care bedside nurses. We must listen for the reasons nurses don’t go into critical care in the first place and why they leave. Listen, listen, listen! We can’t solve the problem if the problem isn’t clear. We believe strongly, however, that with aggressive efforts to match up mentors and mentees early in a nurse’s career, combined with equally aggressive measures to keep our most important and treasured resource—the experienced critical care bedside nurse—the distressing effects of the critical care nursing shortage can be minimized.
The statements and opinions contained in this editorial are solely those of the coeditors.
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