Prologue: This article does not contain evidence-based practice or other reference-based material.  Instead, it was written based, in part, on 2 independent interviews I conducted with critical care nurses (acknowledged at the bottom of this article) and my more than 20 years of experiences on both sides of the endotracheal tube.

Do you have an interest in working with patients in the fast-paced, fairly unpredictable (yet generally organized) environment of the intensive care unit (ICU)?  Do you think you’re ready for the daily challenges (and rewards) the ICU brings?  Getting comfortable with working in the ICU for the first time (and probably for several months) will feel a bit like trying on a new pair of dress shoes, thus the inner dialogue…

Will the stiff fit and discomfort from the metatarsal assault make you want to throw the shoes back in the box from whence they came and move on to a different pair (i.e., setting)?  Or will the elation of the potential purchase (i.e., commitment), with that shiny newness and exhilaration of how you’ll feel inside overcome your tortuous stance?

Metaphors aside, working in the ICU requires a unique set of personal skills.  Really.  Assuming an appropriate level of professional knowledge (never mind experience for the moment), it’s all about pragmatics—yours and theirs.

First, yours….

Have you asked yourself, “Is the ICU the right place for me to work?”  If I may, that’s probably the wrong question to ask.  Let’s turn it around…  The question you will likely want to ask yourself is: “Am I right for the ICU?”

The ICU is demanding and a tough place to work—period.  Get more familiar with you as both a human being and as a professional; it will take you far.

This self-reflection is somewhat analogous to the question you asked yourself as you declared your major in communication disorders, when you started your graduate program, as you began applying for clinical fellowships, or even now: “Do I want to work with pediatrics, adults, or both?”  For some, the answer is easy—maybe it was never really a question at all.  For others, you may not know until you “try on the shoe.”  Your decision is probably more about your personality than it is your skill as a clinician…at least at first.  What kinds of disorders do you like to assess and treat?  What level of patient acuity do you want to see?  Do you prefer the “hit ‘n’ run” (i.e., assess ‘n’ confess/treat ‘n’ street), or do you prefer developing a long(er)-term relationship with your patients?  Can you be assertive and compassionate in the same sentence?  The answers to these questions will at least assist you in deciding whether your personal style is compatible with working in the ICU.  But make no mistake…  This decision is very personal.  In a sense, you’re investing in a professional relationship (without signing the non-compete agreement, i.e., you can still return the shoes)—you and the ICU.  We’ll get to your interpersonal professional relationships with ICU personnel in Part II.  So what’s the catch?  Well…

Now, theirs…

One of the biggest “slaps of reality” any healthcare professional needs to come to grips with in the ICU is that it is an environment in which praise does not exist, for all intents and purposes.  HUH (hear the sound of brakes screeching in the background)?!  Yes!  In fact, not only will the sounds of silence be present (and often masked by IV infusion alarms), they’re often deafening.

Professionally speaking, bolstering your ICU-specific fund of medically-based knowledge will build your self-confidence to be able to function in its dynamic environment.

Other than jails and prisons, did you ever imagine a place like this, and in a hospital of all places—a place of healing, compassion, empathy?!  This goes against most everything we’re taught as humans (never mind therapists)!  But it’s true…  The reason (read as: religion): Why should you get praised for doing your job?  The ICU is a medical setting that can change so quickly that there’s simply no time for small talk—and praise is regarded as small talk.  For all ICU personnel, once you’re done with the one issue, it’s on to the next.  So what’s the lesson here?  Simple: don’t look for a pat on the back in the ICU (but it’s a nice surprise when it happens).  In some sense, that’s a fool’s errand.  And that’s not to say that ICU personnel don’t appreciate your work or respect you as a professional—that is NOT the message here.  This is not a personal assault; rather, the medical personnel are preoccupied with 64 bajillion other things that needed to be accomplished during the last hour and those things are the subjects of their focus.  Self-affirmation is the name of the game…at least until you see your therapist, err…therapy colleagues.

And now, back to you…

So what’s the precursor to self-affirmation?  Self-confidence, of course…but to attain this, are you prepared for the challenge?  The extra hours?  The outright dedication it will take to learn, know, and be known in the ICU?  And are you prepared to learn 3 magic words that, when appropriate, will flow effortlessly out of your mouth: “I don’t know” (and in the same breath be willing to say, “…but I can find out and I’ll get back with you”)?  Assessing and treating patients in the ICU is not something that you can do “half-way.”  Be honest with yourself and take stock (nope, there’s no checklist).  Remember…this is personal.

How well do you understand the patient condition, the big picture, the trajectory of the person who is laying in the bed?  Do you speak ICU, i.e., do you understand the medical terms and acronyms, medications (and what they do), and procedures that are frequently associated with patient stays in the ICU?  What do you know about lines, tubes, and drains (e.g., why they are there; where they course from beginning to end; who put them there; how they are controlled, monitored, and maintained)?  What about monitors, pumps, and mechanical ventilators and the alarms (and other sounds) for each?  How proficient and flexible (we’ll come back to this one in Part II) are you with interruptions and speaking (and being spoken to) directly, never mind speech-language pathology-associated evaluations and treatments?

The ICU is demanding and a tough place to work—period.  Get more familiar with you as both a human being and as a professional; it will take you far.  Professionally speaking, bolstering your ICU-specific fund of medically-based knowledge will build your self-confidence to be able to function in its dynamic environment.  And the sweet reward?  Well…you’ll grow immensely as a clinician, functioning well in most other areas of the hospital.  How do those shoes feel now?!

Coming up…

Applying for a Passport into the ICU—Part II will continue with an even more luminous spotlight in the mirror on you.  Highlighted will be 5 of the most highly-respected qualities of healthcare workers in the ICU.  Do you have them?  And don’t take my word for it.  My colleagues, 2 critical care nurses, will join me in orienting you to the ICU.  Their insights and advice may surprise you, perhaps even be a bit tough to take, but how badly do you want those new shoes?

Acknowledgements: Many thanks to Rebecca Coeyman, RN and Lauren Chasan, RN.  Your time and thoughts will serve to help many SLPs on their journey to critical care.

Links of Interest

  1. Medical speech-language pathology: A desk reference (3rd ed.) 
  2.  Medical speech-language pathology: A practitioner’s guide (3rd ed.)
  3. Society of Critical Care Medicine: Take note of the tabs “Learn ICU” and “Patients & Families,” in particular.


  1. Great post, Dr Brodsky, and looking forward to the next installment. I have to admit I was an acute care junkie for most of my career. Energized by the fast pace of the acute care setting and drawn to the complexity of the patients in the critical care area. It has been so long, that I honestly don’t remember my first trip to the ICU as an SLP, but I can picture the look of terror in the eyes of students as I walked with them into the Critical Care unit for the first time. No classroom experience can prepare students for that unique environment.

    Now, that I have settled into the less intense environment of an out-patient private practice, and have had the experience of sleeping overnight in the ICU at the bedside of a parent, I must admit, it has lost its luster. I now wonder, how an environment that should be about healing is full of detriments to the process, like 24 hours of lights, CNN and FOX news blaring from televisions to ad nauseaum, along with the assortment of other noise-human and otherwise.

    Hopefully clinicians considering the acute care setting will read your posts and spend some time in relfection.

  2. Your perceptions and observations about the ICU being a “disruptive” environment and one that may not bode well for healing because of distractions is making considerable progress in research and implementation now–thankfully! The days of 24/7 “daylight” in the ICUs are quickly becoming a thing of the past.

    The term “post intensive care syndrome” (PICS) was identified through a task force sponsored by the Society of Critical Care Medicine in 2012. Organized thinking around the burdens of physical, cognitive, and mental health status of the patient and mental health status of the family came to the fore and an eruption of research addressing these issues started.

    The environment is changing, with reduction of delirium and the ABCDE (Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility) bundle being the impetus for a lot of the change and research. Sedation is being reduced. Patients are becoming more physically mobile in ICUs (even on ventilators, whether with an oral endotracheal tube or a tracheostomy tube), benzodiazepines are being reduced, shades are being drawn, doors are being closed (to reduce noise at night) and vitals checks are being more spaced out (q2 hours are now 4-6 hours in many instances).

    Consider reviewing the following references for guidelines and current research:

    Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.

    Balas MC, Vasilevskis EE, Burke WJ, et al. Critical care nurses’ role in implementing the “ABCDE bundle” into practice. Crit Care Nurse. 2012;32(2):35-38, 40-37.

    Kamdar BB, King LM, Collop NA, et al. The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Crit Care Med. 2013;41(3):800-809.

    Kawai Y, Weatherhead JR, Traube C, et al. Quality improvement initiative to reduce pediatric intensive care unit noise pollution with the use of a pediatric delirium bundle. J Intensive Care Med. 2017 (ePub).

    Kudchadkar SR, Yaster M, Punjabi NM. Sedation, sleep promotion, and delirium screening practices in the care of mechanically ventilated children: a wake-up call for the pediatric critical care community. Crit Care Med. 2014;42(7):1592-1600.

    Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders’ conference. Crit Care Med. 2012;40(2):502-509.

    Rivosecchi RM, Kane-Gill SL, Svec S, Campbell S, Smithburger PL. The implementation of a nonpharmacologic protocol to prevent intensive care delirium. J Crit Care. 2015.

  3. Dear Dr. Brodsky,

    I am a student taking some pre-requisites for a Master in CSD. I do not have enough knowledge on how broad the field is, and never thought that a Speech Language Pathologist would be working in an ICU. I can’t wait to see the second part of this article. Thank you for sharing it with us.


Please enter your comment!
Please enter your name here