Change of Mindset

ChristineN, BSN, RN · Mar 19, 2013

Was just reading another post per an ED Nurse precepting a floor nurse. I am a med/surg RN just starting to orient to ED...So instead of highjacking that thread I thought this would be a good place to ask:
In what way(s) should I change my mindset vs med/surg Nursing.
{A few points are obvious, but please elaborate and I will take it in and apply it :-)} Thank you.

Hey. I am also a former floor nurse that just came down the the ER a little over a month ago. For me it was weird at first to go from a systemic assessment on every pt to doing extremely focused assessments based on the pt's complaint. I still tend to do full assessments when I am assigned critical pts or infants, and I doubt I will change that practice.

IV skills were also something else I had to work on, as on the floor there just was not as much opportunity. Fortunately when I am doing a minimum of 5-6 PIV's a day my skills got better fast.

The charting is also different than I was used too. My ER has a policy that you have to document on the pt every hour regardless of their acuity. This is very different than my floor charting practices, so it has taken some effort to remember to chart more frequently, even if it is just a quick note of "pt resting, NAD awaiting lab results"

The pt population I am most uncomfortable with our the critical ones as I never worked ICU. Fortunately my hospital is having me take a new grad ICU training class which should help in that area.

SionainnRN · Mar 19, 2013

I've found "letting go" of the mentality of "my patient" was the hardest. You'll call report for another nurse who's pt you've never laid eyes on, you'll discharge a pt you've never seen before then, coworkers will medicate your pts, it's all very liquid. Main thing to remember is move the meat!!

BSNbeauty, BSN, RN · Mar 20, 2013

I worked in the ED for a very short period of time. During my time in the ED , I had to get in the mindset of "moving the meat". It was hard for me to not do a focused head to toe assessment, like I did in ICU. When I received an ICU patient, I basically ignored my other stable patients....which was not good. Definitely brush up on IV insertion. I watched many videos and practiced as much as possible. Have thick skin. You will be yelled at my patients, and the floor nurse you give report to. Floor nurses are super busy with admissions and etc. and just don't always have time to receive report and a new patient. Be understanding but also let the nurse know that you have no choice and must give report. The charge nurse will be on your back to move the patient to the floors because it often gets packed in the waiting room. You also may have many ambos coming in as well. If you had a brainsheet on the floor, it will do no good in the ED. My brainsheet in the ED was my hand or a paper towel. While the ED was not my cup of tea, I thoroughly enjoyed my experience there. I wish I was an ED nurse because I think they are super cool people.

CodeteamB · Mar 20, 2013

1. You won't be treating everything... If buddy comes in with hypertension, cardiac history, asthma and gallstones but his CC is nosebleed, treat the nosebleed. The rest is the job of the PCP.

2. Organization is different... You won't be able to plan your day out in the morning because you have no idea what the day will bring. This does not mean you don't need to be organized (if anything you need to be more so) but you need to get good at going with the flow and changing directions as necessary.

3. Teamwork... You need to be ready to jump in and bail out your coworkers and to accept help when you are offered. If a co-worker offers to help or even just wanders in to your pod and does a task for you it can be hard as a "floor" nurse to accept (Caveat: I don't know the care model you are used to but I came from a very "Primary Nurse" setting where I was used to having "my" patients and everyone else minding their own beeswax). Trust me as an ER nurse it is not meant as a criticism or a comment that you can't handle your load, look at it as a coworker having your back.

4. Your job is to get people to leave... Also referred to as "moving meat" or "treat 'em and street 'em." Recognize that the best thing you can do for your patient is get them out of the ER (while maintaining quality care while they have to be in, of course). Your ultimate goal needs to be getting them home or to an appropriate level of care. Always keep in mind "what is this patient waiting for?"

5. Charting... Any member of your team should be able to pick up a patient chart and quickly see what has been done, what needs to be done and the patient's status within the last hour.

6. You can't do it all... So do the most important thing, and then the next, and then the next. Call for help as you need it, and don't sweat the small stuff.

Good luck, hope you will love the ER.

exit96 · Mar 20, 2013

Thanks for sharing your knowledge!!! Great advice, keep it coming :-)...please and thank you

turnforthenurse, MSN, NP · Mar 29, 2013

Any tips on getting better at "moving the meat?" lol. I think I have a problem with that "floor nurse mindset" regarding patients being discharged even if they are still having pain, etc. I had a patient who came in c/o abdominal pain but had psoriatic plaques all over body. Patient received 1mg Dilaudid IV + 125mg Solumedrol IV, then started complaining of an upset stomach so the doc ordered a GI cocktail. About an hour later the doc wrote their discharge instructions and gave them two Rxs, Norco and Prednisone. Patient was requesting something else for pain, but the doc had already left. I spoke with the charge RN and she told me, "too bad, the patient is being discharged and the doc is already gone. Get them out of here!"

For the record, I'm a floor RN but I have been floating to the ER frequently as of late. The ER nurses appreciate my help and I get along with everyone I work with down there....the charge nurses have introduced me to the ER nurse manager. Overall, I love floating to the ER and I'm thinking about making the switch.

I also quickly learned that brain sheets do not go over well if you're working in the ER. My "brain" is a piece of computer paper or paper towel with notes written on them. Sometimes I use my hand or alcohol pads if I don't have anything!

Keep the tips coming, please :)

CodeteamB · Mar 29, 2013

Any tips on getting better at "moving the meat?" lol. I think I have a problem with that "floor nurse mindset" regarding patients being discharged even if they are still having pain, etc. I had a patient who came in c/o abdominal pain but had psoriatic plaques all over body. Patient received 1mg Dilaudid IV + 125mg Solumedrol IV, then started complaining of an upset stomach so the doc ordered a GI cocktail. About an hour later the doc wrote their discharge instructions and gave them two Rxs, Norco and Prednisone. Patient was requesting something else for pain, but the doc had already left. I spoke with the charge RN and she told me, "too bad, the patient is being discharged and the doc is already gone. Get them out of here!"
For the record, I'm a floor RN but I have been floating to the ER frequently as of late. The ER nurses appreciate my help and I get along with everyone I work with down there....the charge nurses have introduced me to the ER nurse manager. Overall, I love floating to the ER and I'm thinking about making the switch.
I also quickly learned that brain sheets do not go over well if you're working in the ER. My "brain" is a piece of computer paper or paper towel with notes written on them. Sometimes I use my hand or alcohol pads if I don't have anything!
Keep the tips coming, please :)

Well it sounds like you are already well on your way to being an ER nurse. I also am a former floor nurse and I kinda envy you your slower transition because for me it initially felt like hitting a brick wall.

In the situation you describe, the patient has been medically evaluated and is well enough for discharge. It is difficult to say no to a person in pain but you have provided an oral analgesia, it is now the patient's responsibility to fill that prescription and manage the pain at home. Further IV narcotics for this patient is not necessary or appropriate when discharging. Sounds like this patient had a good plan going forward and just needed some education.

As an ER nurse most of your patients will not be admitted, some will be suffering from "acopia" rather than an emergent complaint. You need to steel yourself and treat them as outpatients, meaning they are an adult, healthy enough not to require hospitalization, and they are going to be fine.

It is hard at first. For my first month or two I had anxiety every time I discharged a pt.... What if we missed something, the patient is angry and yelling at me, will I get in trouble? Now I'm more of your Charge nurse's opinion. Diagnosis: check, treatment plan: check, patient able to leave ER on own power: check, there's the door, feel better!

Like I said, this is a huge shift in thinking, it was hard for me, but you get there eventually an start to trust your instincts more. That being said, if with this patient your spidey sense was tingling for some reason you should trust that instinct too, the physician and more experienced nurses may disagree as in this case and that's part of learning, but it never hurts to ask for another opinion.

turnforthenurse, MSN, NP · Mar 30, 2013

Well it sounds like you are already well on your way to being an ER nurse. I also am a former floor nurse and I kinda envy you your slower transition because for me it initially felt like hitting a brick wall.
In the situation you describe, the patient has been medically evaluated and is well enough for discharge. It is difficult to say no to a person in pain but you have provided an oral analgesia, it is now the patient's responsibility to fill that prescription and manage the pain at home. Further IV narcotics for this patient is not necessary or appropriate when discharging. Sounds like this patient had a good plan going forward and just needed some education.
As an ER nurse most of your patients will not be admitted, some will be suffering from "acopia" rather than an emergent complaint. You need to steel yourself and treat them as outpatients, meaning they are an adult, healthy enough not to require hospitalization, and they are going to be fine.
It is hard at first. For my first month or two I had anxiety every time I discharged a pt.... What if we missed something, the patient is angry and yelling at me, will I get in trouble? Now I'm more of your Charge nurse's opinion. Diagnosis: check, treatment plan: check, patient able to leave ER on own power: check, there's the door, feel better!
Like I said, this is a huge shift in thinking, it was hard for me, but you get there eventually an start to trust your instincts more. That being said, if with this patient your spidey sense was tingling for some reason you should trust that instinct too, the physician and more experienced nurses may disagree as in this case and that's part of learning, but it never hurts to ask for another opinion.

Thank you so much! Yeah, I had anxiety when I started discharging patients....I work nights so on my home floor (progressive care) we very rarely discharge patients, so I wasn't use to doing discharge teaching or any of that stuff. That quickly went away, lol.

I'm also still trying to get into the whole "focused assessment" thing. It still feels strange not doing a full head-to-toe assessment whenever I'm in the ER. Question though - if a patient comes in with say, a stubbed toe, do you still listen to heart/lung/bowel sounds? I do this on everyone at least. I also have the urge to put everyone on a cardiac monitor (since on my home floor, everyone is on a monitor!) but for things like a stubbed toe or abscess, I know that isn't needed.

I did find it strange that the nurse before me who received two patients c/o SOB, both with elevated troponins and an extensive cardiac history didn't get placed on a cardiac monitor...just BP and pulse ox. Needless to say, they were placed on one when I took over.

CodeteamB · Mar 30, 2013

Thank you so much! Yeah, I had anxiety when I started discharging patients....I work nights so on my home floor (progressive care) we very rarely discharge patients, so I wasn't use to doing discharge teaching or any of that stuff. That quickly went away, lol.
I'm also still trying to get into the whole "focused assessment" thing. It still feels strange not doing a full head-to-toe assessment whenever I'm in the ER. Question though - if a patient comes in with say, a stubbed toe, do you still listen to heart/lung/bowel sounds? I do this on everyone at least. I also have the urge to put everyone on a cardiac monitor (since on my home floor, everyone is on a monitor!) but for things like a stubbed toe or abscess, I know that isn't needed.
I did find it strange that the nurse before me who received two patients c/o SOB, both with elevated troponins and an extensive cardiac history didn't get placed on a cardiac monitor...just BP and pulse ox. Needless to say, they were placed on one when I took over.

My dirty ER secret? I will do a head to toe assessment on anyone in a bed. Clothes off, full baseline neuro, heart lung and bowel sounds, inspection and palpation of thorax and one million questions. I take maximum 15 minutes to complete this (on a slow talking vague historian). I have never regretted doing a full assessment. The day your abdo pain crumps and is found with a blown pupil and wet lung sounds you will be glad you know which is baseline and which is new.

That said, no way a stubbed toe is making it to a bed (unless they area bed bound octogenarian, and then I have a whole new set of questions). In fast track I will ask and chart "denies concerns" for all major unaffected body systems and a focused assessment on the problem area.

Sounds like you have the right idea on cardiac monitors, doesn't hurt to have it on and you leave your butt in the wind if you don't (especially with symptoms suspicious for cardiac causes).