How I Transitioned From Ward Nurse To Intensive Care In The NHS

Something which I found difficult was how much more autonomous I was in the ICU

Emma is an ICU Nurse. In this article she shares her experience and advice and next steps on the leap from Ward Nurse to Intensive Care in the UK’s NHS.

Topics Covered In This Article

Five Year Plan

Fail To Prepare; Prepare To Fail

You Will Not Know Everything

The ‘Voice’ Of ICU

A Shift In Mindset

With Great Power Comes Great Responsibility

ICU Culture

They May Forget Your Name But They Will Never Forget How You Made Them Feel – Maya Angelou

Five Year Plan

I first decided I wanted to be an ICU Nurse during my critical care placement as a Student Nurse of only 19 years old.

When I graduated aged 22, I wrote down a Five-Year plan which included 2 years post registration on a surgical ward, some time spent travelling and finally landing my current role as an ICU Nurse.

For me personally, the experiences I had before starting in ICU were fundamental in developing and conquering key Nursing skills such as time management, communication, delegation, medication management and IV administration as well as developing me into an all-round adaptable and flexible Nurse.

However, prior experience is not a pre-requisite of the ICU and some of the best Critical Care Nurses I know entered into the unit as newly qualified.

Fail To Prepare; Prepare To Fail

When I was preparing to start my job as an ICU Nurse, I google searched “moving from Ward Nurse to ICU Nurse” for tips and advice.

The search results were poor and most advice was geared towards American ICUs.

I desperately wished to have a conversation with someone who made this major leap from Ward to ICU before I started.

I revised some pathology I thought I might come across, though unfamiliar with the setting I missed out on some crucial study.

Having now completed 9 months in the ICU environment I feel I can effectively fill this gap and share my advice for making the leap and transitioning from Ward Nurse to ICU Nurse in the NHS.

You Will Not Know Everything

The most important piece of advice given to me by my mentor when I first started - you will not know everything.

This is an extremely challenging and intense environment and so, there is a natural learning curve involved.

The first few months for me were very difficult and I felt like a new grad all over again.

There is a completely different set of terminology and language specific to critical care, which needs to be gained over time.

Our patients tend to have extremely complex multiorgan failures and oftentimes have many drips, pumps and highly technical machines attached for monitoring or treatment purposes.

When I started, I felt extremely overwhelmed by the number of alarms and the constant noise in the environment, irrespective of night and day.

Going from a ward in which you might have one or two pumps per patient to now commonly seeing fourteen pumps surrounding a critically ill patient.

The ‘Voice’ Of ICU

For the first while, I was training my ear to recognise which alarm was related to which equipment; ventilator, pumps, monitors, telemetry and gas machines. Every piece of equipment in the ICU has a ‘voice’!

Initially I found it extremely difficult to switch off from the noises after a 12 hours shift, I would be in bed after a night shift and still hearing alarms in my ears. Thankfully, now I have learned to drown out the noise but still be acutely aware of the meaning of each alarm and how that will guide my care.

A Shift In Mindset

Something which I found diffICUlt was how much more autonomous I was in the ICU.

During my preceptorship I was taught how to titrate infusions such as propofol, alfentanil and noradrenaline in line with best practice.

Although these are prescribed and ordered by the Doctors, it is the responsibility of the Nurse looking after the patient to titrate these based on the patient’s clinical picture.

It is necessary to shift the mindset from the wards, where all the Is are dotted and Ts crossed before medication administration, to the ICU where in emergent situations, this is done contemporaneously.

With Great Power Comes Great Responsibility

With the power to make adjustments to the patients’ care, it is necessary for the Nurse to have the knowledge to inform these decisions.

The medications in critical care are vastly different to the wards.

As a result, I think, it would be helpful for new Nurses to review the pharmacology specific to critical care settings.

Obviously, this will differ slightly depending on local Unit but commonly used drugs include; Sedatives, Paralysing Agents, Inotropes and Vasopressors.

As I mentioned before there is a natural learning curve that will come from experience.

However, there are some partIicular areas of physiology, I would recommend any Nurse moving from the ward to ICU familiarise themselves.

I feel that doing so, would have aided my understanding during exposure to these on the unit.

When transitioning to ICU it would also be beneficial for new Nurses to revise the pathophysiology of Type 1 Respiratory Failure and Type 2 Respiratory Failure.

It is very common for ICU patients to be Mechanically Ventilated as a result of one of these.

YouTube videos which use diagrams and examples, can be very useful in the understanding of Mechanical Ventilation.

Another area to focus on would be Acute Kidney Injury (AKI).

It is common for patients to be admitted to the ICU for this reason or for them to develop this during their ICU stay.

AKI is treated with Continuous Veno-Venous Haemofiltration (CVVHD).

This can appear complex and intimidating at first but if you understand the anatomy and physiology of the Kidney, you will have a greater foundation to build upon.

Lastly, I would advise anyone new to the ICU to do some outside reading on Arterial Blood Gases (ABGs).

Critical care Nurses are expected to draw, read, recognise and action anything which may be abnormal on the ABG.

This can be overwhelming initially, therefore its useful to make use of mentors, preceptors, senior Nurses and physicians in the supernumerary period.

The gold standard is always if in doubt; Ask.

ICU Culture

Aside from the new language and terminology, there is also a culture change when transitioning from ward to Intensive Care.

As the name suggests it is intense and at times it can be highly stressful in emergent situations.

If a patient is deteriorating or coding, the communication amongst colleagues may begin to feel almost military like.

One minute you might be at the Nurses’ desk having a chat in good spirits with other staff then the next minute someone’s life is in the balance and you and your colleagues are responsible for saving that life.

This can be a culture shock if not adequately prepared.

It’s important not to take straight-talking direct orders from seniors too personally, as these orders are necessary to verbalise tasks efficiently and effectively.

Another difference can be in the communication between Nurse and patient.

It is common for patients to be sedated and ventilated in the ICU.

This automatically alters the communication and rapport building process us Nurses are so skilled in.

Initially it felt strange to try to initiate one sided conversation, but as time goes on it is now becoming second nature.

Where possible, I try to prioritise speaking to the patient, introducing myself, reorientating them and explaining the rationale for nursing interventions.

This communication has been linked to better patient outcomes, specifically in relation to post ICU delirium.

They May Forget Your Name But They Will Never Forget How You Made Them Feel – Maya Angelou

Above all else, moving from the ward to ICU has been scary at times and I have felt ill-equipped and unconfident in my abilities to perform, however from speaking to colleagues this is a common thread.

As ICU Nurses during pandemics, we are our own hardest critics.

There will be times when you are faced with a morally distressing circumstance such as withdrawal of treatment and organ donation.

Faced with such dilemmas and when I felt ‘out of my depth’, whilst receiving valuable guidance from senior Nurses and managers who had ‘seen it all and done it all’, I found comfort in remembering that I can offer an ear of empathy to another human being during their darkest times.