Time to Train More Critical Care Nurses: Supporting Our New Colleagues

We hear your stories of hardship. Many of you are exhausted and the effects of burnout are real. We are also shaken and saddened by the loss of treasured colleagues to the coronavirus disease 2019 (COVID-19). During the past year, some of you announced your retirement and others have quit the nursing profession entirely. Unsurprisingly, recent US national surveys reported an increase in registered nurse (RN) turnover,¹  with higher rates in step-down units, emergency departments, and critical care.²  In 2019, RN vacancy rates in the United States increased to 9%, a full percentage over the previous year.¹ Despite difficult working conditions exacerbated by the pandemic, nurses reported that they were more committed than ever to nursing,²  providing us with a sense of hope for the future.

Because of the prevailing COVID-19 pandemic, the year of the nurse has been extended through 2021.³  Nurses, especially those in critical care, have been at the forefront of the media and the world’s attention throughout the pandemic. Hopefully, this energy and excitement can be used to build retention capacity, recruit, and train more critical care nurses.

Every nurse has a role in recruiting and training new critical care nurses. Consider the pipeline of nurses who may be eligible to work in critical care. Can some of the nurses who worked alongside you during the pandemic be recruited to work in your unit? We also need to keep the pipeline full of nursing school applicants, nursing students, nursing students with clinical placements in critical care units, as well as new critical care nurse hires. Does your institution currently allow senior nursing students to complete clinical training or practicum placements in your critical care unit? If not, partnering with nursing programs at local academic institutions may be a good strategy to increase the pipeline of possible applicants. During the pandemic, some hospitals recruited nursing students to provide basic nursing care under the direction of critical care RNs and alleviate some of the burden created by the pandemic.⁴  We should open our arms to nursing students who are excited about becoming critical care nurses. The transition into clinical practice following graduation is enhanced when nursing students are socialized into environments where they feel part of the professional team.⁵ 

New trainees require increased knowledge, advanced clinical skills, enhanced clinical judgment, and critical thinking in this fast-paced, highly acute environment. A strong focus is also placed on interdisciplinary collaboration and communication skills. There is much to learn. Additionally, some critical care units are willing to commit the additional time needed to train new graduate nurses. Being a preceptor can be difficult and emotionally draining, but it can also be an incredibly positive and uplifting experience. As you read this, are you thinking about some of the excellent preceptors who have helped to shape your nursing career? Many of you are already excellent preceptors. We see you in action in the clinical setting and hear your stories through the American Association of Critical-Care Nurses and social media. Nursing preceptors are typically experienced nurses who exemplify the profession and provide role support and learning opportunities for new trainees. Preceptors assess learning needs, develop mutual goals with their assigned trainee, and work toward meeting these goals within a defined time period.⁶  Support from institutional leaders is required to help preceptors obtain the necessary skills for the role, such as the ability to provide meaningful constructive feedback to trainees.⁷  The pocket guide Fast Facts for the Nurse Preceptor is a concise, practical resource for preceptors.⁸  As critical care nurses, we share the goal to foster new trainees as they aspire to excellence; they will become our trusted colleagues and may someday care for us and our family members.

I distinctly remember the challenge of transitioning from an expert medical-surgical nurse to suddenly becoming a novice critical care nurse. Even for experienced nurses, a career transition from expert to novice in a new specialty area can be intimidating. Can anyone relate to counting the number of intravenous infusions hooked up to your first critically ill patient? In a highly acute environment, the learning curve is steep, even for nurses who are highly engaged and ready for the new challenge. Purposeful matching of preceptors with trainees is highly recommended to achieve optimal outcomes.⁹  Preceptor personality traits associated with positive graduate nurse outcomes include openness, conscientiousness, and emotional stability.¹⁰  Another consideration is the cost of turnover. In 2019, the turnover cost per RN was $44 375,¹  which may not capture additional training requirements for critical care nurses. The entire team should be committed to fostering a positive orientation experience. A healthy work environment is also key to retention of the valued, experienced nurses who already work in critical care.¹¹  In addition to satisfied nurses, healthy nurse work environments have been associated with improved patient outcomes, such as a decrease in 30-day mortality for older adults receiving mechanical ventilation.¹² 

Recognizing the importance of a positive orientation period, it is disheartening to hear the common adage “nurses eat their young.” A story was shared in American Nurse about a nursing instructor who experienced verbal abuse from her clinical educator when she was a nursing student.¹³  Years later, a brave student made the instructor aware that she was also using inappropriate behavior toward her students. The nursing instructor expressed gratitude to the student and was able to modify her behavior. This story suggests that some nurses may model known routines and actions and perpetuate abusive behavior without being aware of it. They may continue to use inappropriate behavior or language based on how they were taught. Nurses need to be aware of these behaviors and commit to creating a positive career transition for nurses entering the world of critical care.

I felt energized after becoming aware of the campaign Nurses Support Their Young, started by Blake Lynch, known to many of you as Nurse Blake.¹⁴  The campaign calls for nurses to “advocate for a culture of kindness, civility, and compassion at your workplace.” I love the premise of this message, because learning is facilitated in a positive, caring environment. Nurse Blake is known for his ability to find humor in some of our entrenched nursing routines and remind us what it is like to be a new nurse or a nurse in a new environment. Challenges such as locating the restroom and obtaining codes to locked storage areas can seem bigger than life and are on the periphery of our patient care role.¹⁵  In fact, nonpatient care challenges can occupy a fair bit of our time, but they still need to be addressed.¹⁶  In a video on the best hospital jobs, Nurse Blake discusses critical care nursing opportunities (see minute 20).¹⁷ 

Nurse Blake interviewed one of his nurse mentors, Brigit, an emergency department and former intensive care unit nurse, to discuss the role of fear experienced by new nurses and nurse trainees.¹⁸  Brigit and Blake agreed that some amount of fear is healthy because nurses have people’s lives in their hands. Brigit encouraged new nurses to ask lots of questions and try to understand the rationale behind their practices. Ongoing curiosity and understanding will help to promote safe nursing practice. Preceptors may find that fielding numerous questions during the orientation period can be draining, but we need to remind ourselves that this is an opportunity to promote safe nursing practice.

Nurse Blake joined me in this editorial to discuss his campaign and offer some tips on how to maintain a positive environment as you train your new colleagues and support them during their onboarding period to become excellent critical care nurses. Nurses from around the globe have posted insightful and motivating quotes on social media, linked to the Nurses Support Their Young campaign (#NurseSupportTheirYoung). At the time of writing, more than 15 532 nurses have joined the campaign. According to Blake,¹⁴  “Together, we have the power to create an intergenerational, lasting, meaningful change.” Selected words of wisdom and inspiration from our global nursing community in support of young and new nurses are shared below:

• “No need to harden them, nursing is hard enough.”

• “We don’t need thicker skin, we should just be nice and support each other.”

• “Be the example of who you want by your side in the chaos and hope they set an example for someone else.”

These messages exemplify the positivity, kindness, and support required to train new critical care nurses.

Despite the exhaustion and frustration expressed by many nurses as the pandemic persists, we must continue to devote time and energy to recruit and train new critical care nurses. We need to foster their desire to provide excellent patient-and family-centered care. Let us continue to share our passion for critical care nursing with new trainees. Nurses must support their young (critical care trainees of all ages) and each other to maintain a healthy work environment. As nurses we have a unique opportunity to work closely with people during their moments of critical need. We make a difference every day. Each of us has an important role to play in training our future colleagues, whether it be recruiting, precepting, or simply offering kindness and support. Mindful, supportive training today will lead to excellent critical care nurses—our future colleagues. All In!