Am I not cut out for this?

momRNmy · Feb 5, 2014

I transferred to the ER last May after working nightshift on a cardiovascular PCU for 5 years. I really love the change of pace. It's super crazy but in so many ways less stressful than the floor because you don't know what's coming... you deal with it as it comes rather than carrying tasks A-Z on your shoulders until they are done all 12 hours. For a while there I felt proud of my job for the first time in a long time. I have a 2 year old at home have been working per diem once a week so I can be a stay at home mom while still keeping my skills and make enough to pay the mortgage every month. I don't want to work more than I have to until I have another child and both children are in school. Recently though, I was pulled into the office for a sit down with my supervisor who made me sign an action plan committing to working 2 days a week for the next 6 weeks to "increase my exposure to certain patient populations" and "reduce my dependence on ancillary staff" and then meet again to see how things are going. This presumably coming up because the medic for our team was taken for triage for the day and I had a patient that needed an IV that I had stuck twice (our hospital policy is each person only gets two tries). All the nurses on our team were in rooms and it was a ghost town so I called our charge 3 times regarding the IV which she said she would get taken care of and never did, and then went to the supervisor with concerns that I couldn't handle my team. I can't really argue with some of their logic, I don't work very often so I don't get much exposure to stroke alerts, STEMI alerts, or codes. I pull my weight on most days but on days like that one I get behind and struggle a bit, and if I feel really in the weeds I ask for help, but I do try to help others whenever I feel ahead of the game to balance things out. I had put the struggling times down to growing pains and figured that it may take me a little longer than if I was working full time but eventually I would get there. Seems like they need an accelerated timetable...I feel like they would like me to work more on a more permanent basis and that will be the conclusion of this little exercise. I know I shouldn't reduce it to this level but the bottom line of what I'm hearing from them is "work harder and faster and don't ask for help". Am I not cut out for this? Can I not become proficient in this very different area without more of a time commitment than I'm willing to give? It's been a long time since I've been made to feel so insecure in my profession. Should I jump ship and revisit emergency nursing when I can dedicate more time to it? I'll probably be looking into a job outside of the hospital should they strong arm me out...any ideas on what nursing jobs work for nurses with their career somewhat on the back burner? [/quote']
I can see their point of view on one hand and do agree that nothing replaces hands-on experience (increasing your hours). But I also think that if their assessment of your progress really is based on an occasional request for help when typically you're pretty self-sufficient, then their heads are in the clouds. Even some of the most seasoned nurses I've worked with in the ED have had their off days when couldn't they couldn't put an IV into a bucket of blood :) I think you need to decide what your bottom line is and if a compromise can be worked out.

zmansc, ASN, RN · Feb 5, 2014

The hard part about answering questions like this is there usually are two sides to every story, and we only have one. I don't mean to suggest that you are intentionally attempting to give us a misrepresentation in any way. What I mean is you are giving us your perception and others may have a different perception of what is going on.

I would suggest, you discuss this with some co-workers, find some who will give you real critical feedback not just what they think you will want to hear. Try to identify what it is you need to improve on, and how quickly you need to improve. Is it really just that you will struggle with highly involved cases that are infrequently seen in your ER, or is it that you and your team are slow on the day to day cases as well? Or is it something totally different than what you think it is because they haven't done a good job explaining to you what is going on.

Once you have a better idea of what is the deficiency, then you will be better able to identify how likely it is you will be able to meet their needs within your timetable. Remember, everyone has deficiencies, no one is perfect. So, don't take it personally that they are asking you to improve. Everyone should be attempting to improve at something. The question here isn't are you capable as a RN, it's are you able to meet and exceed their expectations as a very limited (time wise) RN in a new area. If not, then you and management should identify an exit strategy so that everyone is ok with the results.

Altra, BSN, RN · Feb 5, 2014

As an experienced preceptor, I disagree with hiring a nurse new to the ED for a per diem position. Particularly if the hospital is a trauma/stroke/tertiary care/regional referral center with high acuity. It's just not fair to the nurse, nor is it particularly productive for the department.

The volume and breadth of patients seen in the ED really require a commitment to intensive training, both on the part of the ED and from the nurse. Your manager does appear to believe that performance issues can be corrected with greater exposure/practice, and I find it encouraging that she wants to make that effort with you for the benefit of all.

Ruby Vee, BSN · Feb 5, 2014

The hard part about answering questions like this is there usually are two sides to every story, and we only have one. I don't mean to suggest that you are intentionally attempting to give us a misrepresentation in any way. What I mean is you are giving us your perception and others may have a different perception of what is going on.
I would suggest, you discuss this with some co-workers, find some who will give you real critical feedback not just what they think you will want to hear. Try to identify what it is you need to improve on, and how quickly you need to improve. Is it really just that you will struggle with highly involved cases that are infrequently seen in your ER, or is it that you and your team are slow on the day to day cases as well? Or is it something totally different than what you think it is because they haven't done a good job explaining to you what is going on.
Once you have a better idea of what is the deficiency, then you will be better able to identify how likely it is you will be able to meet their needs within your timetable. Remember, everyone has deficiencies, no one is perfect. So, don't take it personally that they are asking you to improve. Everyone should be attempting to improve at something. The question here isn't are you capable as a RN, it's are you able to meet and exceed their expectations as a very limited (time wise) RN in a new area. If not, then you and management should identify an exit strategy so that everyone is ok with the results.

What she said!

Ruby Vee, BSN · Feb 5, 2014

As an experienced preceptor, I disagree with hiring a nurse new to the ED for a per diem position. Particularly if the hospital is a trauma/stroke/tertiary care/regional referral center with high acuity. It's just not fair to the nurse, nor is it particularly productive for the department.
The volume and breadth of patients seen in the ED really require a commitment to intensive training, both on the part of the ED and from the nurse. Your manager does appear to believe that performance issues can be corrected with greater exposure/practice, and I find it encouraging that she wants to make that effort with you for the benefit of all.

What she said, too!

utadahikaru · Feb 6, 2014

Agreed, The ER is hard even if you are doing it full time. Every hour on the job is an hour of education and an opportunity to hone your skills. If you had 10 years of ER experience and you wanted to work 1 or 2 days a week, that would probably be ok. But you have very little ER experience, so it seems rather unreasonable to expect yourself be able to carry your weight in this new environment that you are only half heartedly dedicated to learning.

Editorial Team / Moderator · Feb 6, 2014

Agree with those above me up there. Nurses new to the ED setting need constant reinforcement of those ED paradigm cases. If you are not getting exposure to strokes, STEMIs, and codes, you are missing a huge part of the ED bread and butter. In my opinion, they did you a disservice by hiring you per diem without ED experience. I think the only people who should work per diem in an ED are experienced ED nurses. I think you already have a sense that you need to look elsewhere if your nursing career is on the back burner for now. Good luck, whatever you decide to do.

wannabecnl · Feb 6, 2014

I was not only a new PACU nurse working per diem but a new nurse, period. I am and will always be grateful that they have given me this chance, but I will say that doing it per diem was probably not the best for the same reasons you are listing here. PACU is a more controlled environment than the ED, but they are similar in that a particular kind of case (or skill to be used) may come up once in a year or three times in a week, and you can't plan for that in your training and orienting. Working per diem once a week reduces your exposure and also your opportunity to repeat a skill until it is comfortable. My sense is that on the floor, especially if the floors are dedicated (ortho, neuro, etc.), you're seeing the same types of patients frequently and thus doing the same types of assessments and treatments with them, thus developing expertise. You probably have expertise in CV that will help you in the ED, but there are other issues you have probably never had to assess and treat.

If you really love what you are doing, I would encourage you to take the mgr up on the offer to work 2 days a week for 6 weeks. It's a difference of 6 days. Please believe that I know what I'm suggesting; I put off nursing school for years so that my kids would be in school every day before I went, and your highest commitment is to your family. I get that. I also know that those 6 days might change your career. I oriented for 16 hours a week at the beginning, but I just wasn't getting enough different patients to gain independence. At the end of orientation I worked 30 hours a week... for 5 weeks. Without that time, I would have probably been let go. With that time under my belt, I was able to move forward. It's now a year later, and I can take pretty much anything that comes out of the OR. You are already ahead of me, and I think by showing that you are willing to train a little more right now, you'll be able to make this ED position work for you in the future.

Atownshend · Feb 7, 2014

I feel like all of this is confirming my fears. I did do 12 weeks of orientation half of which where full time and half were 2 days a week. I really don't want to have to leave this job but I'm almost afraid that they are going to be looking over my shoulder looking for reasons to make me work more, or worse fire me so they can fill my position with someone willing to work more hours. I was told when I was hired that the ideal per diem employee for them would work overtime every week, but I made no illusions as to how much I was willing to work from the get go. The hospital I work at now is a level II trauma center and the busiest hospital in the area. I could've chosen the slower ER 5 minutes from my house in the same hospital system but I chose this one because I wanted as much exposure as possible in the limited amount I have. Would transferring to the smaller non trauma center hospital be an option that makes any sense? I don't want to feel like a burden instead of an asset. I knew that that particular day was a bad day but I haven't had many days that feel like that. And when I asked if they felt my performance was consistently poor they said no it was more about my exposure limitations. I definitely don't want to go back to the floor and I really like the ER. I don't even know what else I would or could do once a week if the ER doesn't pan out for all parties involved. I feel like they've taken away my sense of joy and competence in my job. Now I'm constantly second guessing my performance because I feel like there is something I'm missing that makes them feel I'm not good enough. I just don't know. I guess I'll just do what they want and go with the flow and deal with any issues as they arise. Really, what else could I do?

Editorial Team / Moderator · Feb 7, 2014

I don't want to feel like a burden instead of an asset.

I think that hits the nail on the head, to be quite honest. Realistically it takes a nurse new to the ED a good amount of time -- and that's FULL-time time -- to become competent and confident. Ask yourself if you feel confident about taking care of anything that rolls in your ED doors - those strokes, STEMIs, and codes. Have you thought about going somewhere with lower acuity, like an urgent care?

Armygirl7 · Feb 7, 2014

Well if you can commit to working 2 days X next 6 weeks then do it! More will be revealed after that and you and the manager may feel differently with the information gleaned over the next 6 week. Try not to take any evaluation too personally - think of it like an athlete - the batting coach needs to watch your swing for a few weeks and maybe you need to make some adjustments that will benefit your practice and your patients. Doesn't mean you can't hack the big leagues just means you need more practice or a changee in your stance or grip (sorry for all the baseball analogies!!)

Good luck!