New Grad in ER with unsafe practice - Advice please?

[R!XTER]

As a licensed new grad in the NYC area my biggest fear right now is of course, not getting a job. A clinical instructor I am close with offered to help me get a position in a local ED (ED IS MY DREAM!!) where her husband is attending MD. When I did some research, I found that this hospital has less than satisfactory ratings by patients and national standards. One nurse I know who works at a different hospital nearby told me she has heard that there is some unsafe practice going on - she did not provide details.

I've already contacted the head of department who is supposed to call me this week to set up an interview.

How do I approach the possibility of remaining unemployed (I can see that student debt in my peripheral vision...) vs. working in a less-than-desired and possibly unsafe environment? I am especially concerned being that it's a first job and therefore will probably influence the way I practice forever, not to mention that I really really do not want to risk losing my license!

HELP?!

R!xter

[NocturneRN]

I would DEFINITELY interview for the job. New grad jobs in the ED are hard to find.

I started as a new grad in a community ED 9 mos ago. I am thriving. I would ignore the advice that says you should do med-surg for a year before ED. You can start in the ED, if you don't like it, you'll know right away and you can find another job. Some are made to do ED, others are not.

Questions to ask in your interview, as a preliminary screening for safe practice/policy:

1) what is the nurse to patient ratio? ENA recommends 1:4

2) what happens if there are call-ins? what is the acceptable maximum nurse to patient ratio? at what point to you get nurses from other floors to help?

3) are there "task/float" nurses available? are there paramedics assigned to certain nurses or teams of nurses? what is tech staffing like?

4) is there central monitoring for patients who need to be cardiac monitored? is there someone to watch the monitors?

5) what is the policy and procedure for psych patients? do they have sitters available?

6) what is the policy for rooming patients from triage? is the nurse notified immediately? are patients placed in a gown and put on the monitor by the transporting tech?

and, just a few pointers.....

The key to surviving as a new grad in the ED

1) Study, study, study: I subscribe to medscape and do continuing education all the time- they have case studies on there that pertain to the ED. I bought a book that I would highly recommend called In a Page: Emergency Medicine by Caterino & Kahan. I reference my old NCLEX study guide for how to do certain procedures. If I take care of a patient with a certain diagnosis that I am not familiar with, I go home and look it up. I do research on nursing interventions for a patient that I wish i could have taken care of better.

2) Identify and cozy up to a mentor QUICKLY. Find someone who is willing to help you learn how to place NG tubes, tricks on starting lines, etc If they reference the policy and procedure for the hospital, or better yet: evidence-based practice, you know you have a winner! If you take care of a patient with a GI bleed (for example) for the first time, say, "hey, so-and-so, am I missing anything here?"

3) if your hospital has protocols, become familiar with them quickly. It will help you anticipate your orders. If you don't know why a certain med/imaging/lab is called for, look it up.

4) help others whenever you can. Buddy up to the RN who is the best at placing lines and help her with her grunt work. Then she'll start those hard sticks for you. Its politics yes, but its also teamwork!!!

Great suggestions! I'd like to add: use the ER doctors as resources, too. When I first started in ER, I was frequently encouraged to go in and listen when the doctor explained the care plan or answered questions. (Time permitting, of course!----this isn't always possible if you work a busy shift in a hectic department!) It's a huge help in understanding what they're ordering and why, and also in understanding why the doctor pursues a particular course of action.

Another good question is to find out what kind of standing orders the unit has. If you have generous standing orders, you can get a lot done on your patient right away, without having to wait for the doctor. Good for the patient, good for unit flow, and good also for sharpening your assessment skills. ;>)

[WonderRN]

Great suggestions! I'd like to add: use the ER doctors as resources, too. When I first started in ER, I was frequently encouraged to go in and listen when the doctor explained the care plan or answered questions. (Time permitting, of course!----this isn't always possible if you work a busy shift in a hectic department!) It's a huge help in understanding what they're ordering and why, and also in understanding why the doctor pursues a particular course of action.

Another good question is to find out what kind of standing orders the unit has. If you have generous standing orders, you can get a lot done on your patient right away, without having to wait for the doctor. Good for the patient, good for unit flow, and good also for sharpening your assessment skills. ;>)

Great add about the docs.... I was going to add that after I posted too, but thought I had already said too much There is one doc I work with that I used to always place myself strategically in the room during his H&P so i could learn from him. He is very thorough. And now my scripting is just like his! And whenever I don't know why we are doing something for a certain patient, I ask him, because he is very welcoming of questions and likes the fact that I want to learn.

And just like NocturneRN said, I always always always place my Iv and draw blood during my history gathering (its my multi-tasking) because we have protocols in place for most common complaints that include labs and saline lock. I make sure I draw extra tubes too (this is common practice by all ED nurses) incase the doc adds orders on later (i just label them and place them at the bedside). Then, like NocturneRN said, I stay one step ahead of the docs.