I am about three years into my nursing career, and during that time I have worked at four different hospitals in three different specialities. I have used three different charting systems (four if you count a different version of the same system), and have interacted with hundreds, if not thousands, of patients at this point. Here’s what experience I have and the pros and cons of each specialty:
Surgical-Orthopedic Unit: I worked in a level 2 trauma center, 397 bed magnet-status hospital outside of Houston. On this unit, you were expected to take care of four to six postoperative patients, all at different stages in their recovery. You had a list of at least two doctors, and often many more specialists, for each patient that you had to coordinate care with and communicate with. You saw many different surgeries on patients aging from 18 years old to 102 (at least my oldest patient was 102). Until the neuro unit opened about six months after I started, we received all surgical patients for any surgeries that did not go home or to the ICU. Mastectomies, colectomies, joint replacements, ORIFs, cholecystectomies, spinal fusions, amputations we saw it all. You learn how to do dressing changes, manage pain levels, and convince patients to get up and ambulate postoperatively. You also unfortunately learn about postoperative bowel obstructions caused by the bowel not “waking back up” after surgery, not ambulating, and too many opiate pain medications, indicating the need for nasogastric tube placement. You learn to monitor for signs of postoperative complications (like hemorrhaging and infection), how to communicate with surgeons (they all have their own preferences)
Pros: After working with surgeons for 10 months, working with non-surgeons became a lot easier. Learning the ins and outs of several different surgeries also set me up well for future nursing, because surgery, infection, and pain is everywhere in healthcare. I learned the initial time management skills needed for nursing, and basic prioritization. The patient receiving a stool softener is not as critical as the patient hemorrhaging out of his recent big toe amputation incision site. Having such a wide range of surgeries also rapidly increased my knowledge base of different drains, incisions, and medications. In nursing school they do not teach you a lot about surgery, so this was good information to learn.
Cons: This was basically a medical-surgical unit but just surgical. If you are a nurse, you know that working med-surg is like working in the trenches. High patient loads, lots and lots of medication administrations, many missed lunch breaks (which is a trend in all units actually). There is a high turnover rate on these units due to it being a starting point for many nurses. Working with surgeons is it’s own beast. They cut people open and fix people, so rightfully so, they can be a bit particular about how they want things done. The exact same lap chole on two different patients by two different surgeons can have a different progression of how the doctor wants their patient ambulating. One nurse even created a “surgeon cheat sheet” with what each doctor wanted for each of their surgeries. Learning what each surgeon prefers was quite the task, and often ended in me doing the “wrong” thing and getting scolded. I thought all doctors would be this..particular..but that is not the case. Lots and lots of charting, especially with 6 patients who all have incisions and drains to document.
Intensive Care Unit: I worked in two different ICUs, one a 10-bed ICU in a level 4 trauma center (in a rural hospital), the other a six-bed ICU in a level 3 trauma center. ICU nurses get the reputation of being extremely smart, extremely Type A, and slightly egocentric. This is only partially true. I worked in smaller ICUs with less capability for highly acute patients, meaning we did not have 24/7 intensivists, many speciality doctors (like pulmonologists, nephrologists), ECMO specialists, CRRT, or any cardiac procedures. In both of my ICUs we commonly took care of covid patients requiring high levels of supplemental oxygen (either on ventilators, heated high flow, bipaps, or nasal cannulas); gastrointestinal bleeds managed by fluids, blood product replacement, octreotide and protonix drips, and vasopressors; people withdrawing from alcohol requiring frequent assessment and benzodiazepine administration; patients who had had strokes and needed frequent neuro checks; patients with sepsis needing fluid support and sometimes vasopressors; patients in hypertensive crisis requiring nicardipine drips; patients in diabetic ketoacidosis requiring insulin drips; postoperative patients on ventilators or in sepsis; patients in heart failure exacerbations needed a dobutamine drip to improve their cardiac contractility; and on occasion we would have patient with a collapsed lung needing a chest tube. Nothing too serious. The largest amount of titratable drip medications I ever had was 8, on average 2-4. A big ICU does much more than this. That being said, we would have a 2-3:1 patient to nurse ratio, chart full assessments at least every four hours, chart any changes in medication drip rates, complete fluid and medication intake spreadsheets, and chart literally anything and everything we did for the patients. Even though I did not work in highly critical ICUs, my patients still required close monitoring for changes in status.
Pros: Admittedly it does feel very cool to be able to successfully manage a sedated patient on a ventilator with multiple drips. Being able to have the autonomy to titrate drips to keep the patient comfortable, and/or keep their vital signs within range is satisfying. Being able to have the knowledge to know what adverse effects the medications can have on the patients and understand how the systems work as whole is cool. You are always learning new information that can often be life or death knowledge. You have the same 1-3 patients for the entire shift, and sometimes for several days or weeks at a time. You get to see people progress from very ill to less ill. You get to focus on the detailed minutiae of just those patients, instead of being pulled elsewhere.
Cons: You can have the same 1-3 patients for days, if not weeks, at a time. Which, depending on the patient, can be rough. Your patients do not always improve, and you do see more death and severe illness than on a med-surg unit. There is so. much. charting. And if your ICU does not have 24/7 doctors and specialists, it can sometimes feel like the care provided to your patient is not enough. A good bit of responsibility always falls to the nurses, but especially so in a rural ICU where there is no doctor rounding at nights, and you are the sole set of eyes on that patient (besides respiratory therapy, who is amazing). I feel like I lost some of my time management skills, especially when I worked nights in the ICU, because if your patients are stable, you have plenty of time to carry out tasks.
Emergency Department: I worked in a level 3, stroke certified trauma center. This speciality is the one I liked the most out of all the ones I tried, however by far the most stressful and unsustainable in today’s day and age. The environment is totally different than all the other units. You have a mixture of psychiatric, pediatric, geriatric, obstetric, trauma, orthopedic, and critical care nursing all rolled into one department. And there are many more things you will see than listed above. Literally any person at any age with any ailment can come into an ED. You are often the first point of contact for a patient coming in from the waiting room, or you receive ill patients from ambulances. Your role as an ED nurse varies as well: some days you are the triage nurse who initially assesses patients walking in, sometimes you have all “boarder patients” (those who are admitted to the hospital but cannot move out of the ED due to the hospital being full) which means you could be a med-surg or ICU nurse for the day, some days you are in charge of the psychiatric patients, some days you function as a regular ED nurse with (hopefully) 4 ED patients who are constantly cycling in and out. Sometimes you work as the waiting room nurse, who gives medications, places IVs, performs covid swabs, draws labs, and discharges waiting room patients. You have the opportunity to learn so incredibly much in the ED, from new skills and assisting in new procedures, learning how to balance multiple patients with completely different presentations and ages, quickly identifying “sick versus not sick”, and just the overall exposure of it all.
Pros: as listed above, the chance to learn how to work with literally any patient population, age, and presentation. Time management skills and prioritization skills are taken to a whole other level in the ED. Ideally you will not have the same patients for an entire 12 hour shift, and variation abounds. Your work day will hardly ever be boring. The physicians and nurses you work with are of a different breed, and are usually fun to work with. The experience you gain here will take you many places. And you don’t have to complete nearly as much charting as on other inpatient units. There is always always more to learn, which I like. You become much better at IV insertions and blood draws, simply because you do them so often. If you like interacting with lots and lots of people for brief periods of time, this could be for you. This job really exposes you to everything, from a learning standpoint but also from a life standpoint.
Cons: absolutely no predictability. You typically will not form lasting relationships with your patients, unless they are frequently in the ED. It is organized chaos, and you will be on your feet the entire shift. You must be incredibly flexible, good at managing stress and rolling with the punches, otherwise you will be incredibly drained at the end of each shift. You deal with a lot of negative patient encounters, especially as wait times increase due to staff shortages and hospitals well past maximum capacity. You will see patients crash and die and deal with incredibly ill people who deserve 1:1 care, while other patients are angry that they have not been seen in a timely manner in the room next door. It is an extremely demanding job, physically and mentally. I could write an entire article (and maybe I will) about the exponential uptick in stress and demands placed on nurses over the last two years. Not to mention all the other healthcare workers. Times have changed, and I am so glad to not be a new nurse during them.
Overall I’m thankful for the exposure and experience to these three types of nursing. They have all been difficult in their own ways, and I cannot say I see any of them as a long term career option. But the knowledge gained from these jobs has been invaluable, and I have high respect for nurses who work years at the bedside in the hospital.