E.D nurses "set up to fail"

Anna Flaxis, BSN, RN · Feb 25, 2012

Personally, I don't think being set up to fail is limited to the ED.

Skylar86 · Feb 25, 2012

i have 6 weeks working with my preceptor (looking after patient loads together) then i am let loose.. if i feel i need more time with my preceptor then i am able to get it... 18 weeks sounds a bit long to be honest.

hiddencatRN, BSN, RN · Feb 25, 2012

i have 6 weeks working with my preceptor (looking after patient loads together) then i am let loose.. if i feel i need more time with my preceptor then i am able to get it... 18 weeks sounds a bit long to be honest.

Must be different in New Zealand because here 6 weeks would be a pretty skimpy new grad orientation on a specialty unit. Most of my classmates going in to specialties have orientations in the 3-6 month range. The folks I know who went to med surg units had 8 weeks with a preceptor as well.

MattNurse, MSN, RN · Feb 25, 2012

it is very hard for a new grad to flourish in this environment unless he or she has previous experience. (emt/paramedic or other) or the hospital has a good training program. one has to be on the ball at all times.one problem i see in my hospital is that we get a lot of new grads and it shows when he or she tries to send a patients to the floor. these are some example, a patient with a blood pressure of 225/ 110 with absolutely no orders or treatment in the ed. the new nurse sends us a patient with high blood sugars and blood pressures. the admitting dx is dehydration, but the patient has chf, dm, mi, and is on dialysis and do not forget elevated potassium levels. ( pt missed dialysis that day came in for not feeling well) the point of this was the patient was on d5 ns at150 for at least 8 hours. this nurse did not see the issue or connection between the treatment and the bp and high blood sugars. i find the assessment skills,very poor in with some of our new grads. this has led to my problems for patient care and safety. i say to you get a on a medsurg, or tele floor, and holm your skills and work on getting your certifications.

i agree with you, the other day i had a patient being admitted after being in the ed for 6 hours. patient was being admitted for pneumonia and i looked in the mar and noticed that nothing was signed off. i asked new grad if she forgot to sign off on the antibiotics and she simply said she just didn't have the time to start the antibiotics ordered stat. if you do not have prioritization skills then you should spend some time on the floor to learn those skills.

miss81, BSN, RN · Feb 25, 2012

My close friend started work in the ER straight out of school. She was thrilled then, but it's 10 years later and she will tell you that she would never recommend it. She will say that she can't believe that they let her work there as a new grad after all she's seen! She was smart and eager to learn, but many times new grads just don't know what they don't know! On the other hand, I had 7 years med/surg, ICU and OBS experience and an a Critical Care course behind me when I started there. I guess it depends on the ER. Ours is so busy that you don't always have time to bounce ideas of others and you have to make quick decisions using your experience and "nurse intuition" as a guide, and that intuition takes a little experience to develop. In our ER there are days that you may have an upwards of 6-8 "intermediate" patients or 3 "critical or Trauma" patients to yourself! Also, our ER does not have a good orientation program either. They did just implemented a new rule that nurses have to have 2 yrs experience before starting there.

This is just MY opinion, from MY experience in MY ER!

Pneumothorax, BSN, RN · Feb 25, 2012

sounds like your instructor is bitter to me.

ED or any critical care area is about thinking on your toes and being ready for a worst case scenario. Its about planning ahead and prioritization.

Like someone said, if you can get some shadow time & on different shifts give it a try. & ask lots of questions :)

nightengalegoddess · Feb 25, 2012

Wow. Previous poster, thank you for explaining why we get so many unstable pts with high blood pressures onto the med surg tele floor from ED. I did not know the national standards state not to treat asymptomatic high BP within ED. I had always thought ED gets them to a semi-stable state while assesssing needs for more intricate treatment. I also had thought that if we receive a currently unstable patient from ED that we were supposed to make sure they had at least been given initial treatment for the inbalance whatever it is, while in the ED. Now I understand. Thanks, I can do more research about this. For some reason there is some kind of underlying fueds within the ED, MST relationship in the current hospital I work in.....always getting highly unstabilized people to the floor without having stat orders done which were written hours earlier sometimes! This had seemed a safety issue to me. Again, thanks, more research for me to look into. Blessings! You ED people are great!

travkitty · Feb 25, 2012

I had a year of med-surg & had 8 weeks of orientation at my ER job. My preceptor says new grads need at least 12 weeks or more, depending on the nurse, of course. Many new grads are only given 4-6 weeks, though, simply because we are short staffed & need them out on their own. They didn't have preceptors with as much seniority & experience lobbying to get proper prep, though. Mine was AWESOME. I didn't know everything, but I was ready enough & my preceptor knew I'd be smart enough to ask questions & ask for help when I needed it.

My ER no longer hires new grads, though, unless they have ER tech or paramedic experience prior to nursing.

Are any of them "set up to fail?" Not in my ER. Sometimes our staffing is crappy & it's just not a fun night, but 90% of the time, if you ask for help, people willingly come to help, or instinctively know to help. We all know each EMS patient that comes in, via Charge nurse, so we can help if our patients are stable. Perhaps not all ERs are like this, but mine is, which is nice. I know, if a patient crumps, I'll have plenty of hands & brains on hand.

Anna Flaxis, BSN, RN · Feb 26, 2012

I agree with you, the other day I had a patient being admitted after being in the ED for 6 hours. Patient was being admitted for pneumonia and I looked in the MAR and noticed that nothing was signed off. I asked new grad if she forgot to sign off on the antibiotics and she simply said she just didn't have the time to start the antibiotics ordered STAT. If you do not have prioritization skills then you should spend some time on the floor to learn those skills.

What time were the antibiotics ordered? Just because the patient was in the ED for six hours, doesn't mean those orders were six hours old. They could easily have been written four or five hours into the patient's stay, and you have no idea what else was on the nurse's plate. That patient could have been her most stable patient of a full load. Perhaps those STAT antibiotics were NOT her top priority. She may have had an ICU patient or two that were keeping her busy, so that the stable medical patient with pneumonia had to wait. Or perhaps the department was getting slammed with medic after medic and a full lobby. That's the way it works in the ED, and I would not be so quick to judge, were I you.

MattNurse, MSN, RN · Feb 26, 2012

What time were the antibiotics ordered? Just because the patient was in the ED for six hours, doesn't mean those orders were six hours old. They could easily have been written four or five hours into the patient's stay, and you have no idea what else was on the nurse's plate. That patient could have been her most stable patient of a full load. Perhaps those STAT antibiotics were NOT her top priority. She may have had an ICU patient or two that were keeping her busy, so that the stable medical patient with pneumonia had to wait. Or perhaps the department was getting slammed with medic after medic and a full lobby. That's the way it works in the ED, and I would not be so quick to judge, were I you.

Antibiotic orders were 5 & 1/2 hours old when I got report, I looked at the orders. I looked at ED census. And I also discussed this with my carpooler on the way home from work and she told me the ED was slow that night and this is a chronic problem with this NEW GRAD who lacks prioritization skills at this point in her young career.

I am not quick to judge another person, I looked into the problem before I submitted my concerns to the nursing manager. It seems you are quick to judge me, and I was simply offering advice to someone who was asking what it is like to be a new grad in the ED. I feel new grad nurses should start out on the floors to learn prioritization, because you cannot simply ignore antibiotic orders for 5 hours. If you are too busy in the ED to treat someone, maybe you should send the patient up a little earlier to the floor (as the admission order was 3 hours old). Nor was this patient stable in my opinion as the nurse who assessed this patient, this patient required treatment which was lacking in the ED.

The antibiotic prescribed needs to be started “door to dose,” within 4 hours of arrival at the hospital. The timing of initial therapy is crucial. Data have shown that early treatment reduces mortality (This should have been one of her top priorities).

I happen to be an ED nurse at another hospital and I know how busy it can get. I also know when to ask for help from my colleagues.

Anna Flaxis, BSN, RN · Feb 26, 2012

Antibiotic orders were 5 & 1/2 hours old when I got report, I looked at the orders.

I don't believe this. If the patient was there for six hours, no way the workup was completed and medication orders written thirty minutes after they arrived, unless they were the only patient in the department and the doctor met them at the door, which I find unlikely.

Nor was this patient stable in my opinion as the nurse who assessed this patient, this patient required treatment which was lacking in the ED.

In what way was the patient unstable, and what is your definition of unstable?

As far as second hand reports of whether it was busy or not, I find those to be terribly unreliable. It depends on staffing levels, patient acuity, and a host of other factors. You can't just look at the census and know how busy it is.

MattNurse, MSN, RN · Feb 26, 2012

I don't believe this. If the patient was there for six hours, no way the workup was completed and medication orders written thirty minutes after they arrived, unless they were the only patient in the department and the doctor met them at the door, which I find unlikely.
In what way was the patient unstable, and what is your definition of unstable?
As far as second hand reports of whether it was busy or not, I find those to be terribly unreliable. It depends on staffing levels, patient acuity, and a host of other factors. You can't just look at the census and know how busy it is.

You are rude calling me a liar. I am offering advice to the OP who asked if nurses are set up to fail. I don't care if you believe it or not, and not sure what your motives are for saying I am lying. In our hospital our standard of care for patient's coming in with respiratory distress via ambulance get an xray, cultures, and broad spectrum antibiotics within 4 hours from entering the door. Our APRNs and PA's that staff the ED meet the ambulance staff at the door.

I don't know why you insist on defending a situation you know little about, other then what I have conveyed, at a hospital you know nothing about. It was poor care delivered by a new grad. I didn't just look at the census to know how busy the ER was, my carpooler is an ER nurse who worked that night. We had one admission that night. As an ER nurse myself I can tell when the department is busy.

Why would you question my definition of stable? I know from my experience that a patient is more stable when they get the medications in a timely manner and I know that mortality is decreased when antibiotics are started sooner then later from the journals and evidence based practice. I work in a high acuity department with telemetry and step-down ICU. Pt was not stable enough to go to med-surg.

Again, my point here is that a lot of new grads do not belong in the ER. I know this nurse, she precepted on my floor as a student, she wanted to be an OB nurse who accepted any position they offered her, she is too green to work in the ER. You seem to be taking this situation personally. Am I not allowed to offer advice to a student seeking all of our opinions without you being rude?