Questions from a Struggling ER New Grad

nursebearfeet · Nov 12, 2006

I hate to say it, but the ER is not a great place to start your career. I have nothing against new nurses, I was one once. ( a long time ago) The ER is a world to it self. Nurses in the ER tend to "eat their young" more than in other places. Also, time management is a skill that is learned with time. It is essential in the ER. Our orientation is 3 months or until you are completely satisfied in your ability to swim or at least tread water. You should be developing a peer network, people who will not gaffaw when you don't know some thing or need reminding.

My advise is that when you get report be thinking of all of the things that could possible go wrong with your group, head them off. IV's, monitors, UA/ UPREG, x-ray's, CT scans . anything you can get started before the md sees the pt helps, as long as your facility allows it. If a person comes in and complains that they were watching the football game when all of a sudden they got dizzy and had a severe headache on the left side then their fingers went numb and they had a hard time speaking to the scanner they go with IV lock in place immediately. It's hard to learn to juggle, but you will with time. if you are swamped with a critical patient the other nurses should be picking up your slack, it's the only way an ER can function. Take a deep breath, allow your self to gain some confidence, don't be afraid to get a team of nurses that you lean on, people who you can always go to in a hurry and ask any thing!!

good luck

er_guy2003 · Nov 13, 2006

Well, I'll put my 2 cents in also. I currently work in a 42,000 visit per yr ED with only 17 beds. We have a great staff including doc's, rn's, tech's, unit clerks, etc. We turn over a tremendous amt of pts daily with only 17 beds, which is reflected in our press ganey scores. So, why am I telling you all this. I think first it starts with organization, and great charge nurses, and a great nurse manager, which I have at our facility. It is a very difficult transition from school, to a specility unit, in particular, the ER. As I sure you know, the ER can be very fast paced, crazy at times actually. Learn your protocols first, learn who you can rely on to ask questions too. You'll need to learn to prioritize, and to delegate. I recently re-vamped our entire orientation, and we now sit down once a week with our new employee, the preceptor, and either myself or the mgr. There is a tremendous amt. of feed-back from all parties. (Here's what you're doing good, and heres what we need to work on). And like the other replies, learn the across the room assessment, assess and do you hands on stuff at the same time, ask for help when needed, and chart. I also agree with this: Most orientees never think they are ready to be "cut loose", and would be more than happy to be on orientation forever. But trust me, if you have a good preceptor, they will know when you are ready. And again, give yourself a bare minimum of a year to even begin to feel comfy, but never, ever, ever, too comfy. We all learn everyday. Good luck

Roller · Jul 8, 2008

Hi Angel,

I was just skimming through and read your note to the new ER grad. I too was a tech for 11 years in the ED I worked at. We were Level II and saw about 50,000 a year. As a tech, I didn't have too much of a problem, but I found that I had a hard time making the transition. I'm now working a Med/Surg floor and miss the ED very much. I'd like to go back, but I was told my skill set was dangerous. This broke me, but I still want to get back to ED. Any words of encouragement or wisdom.

Thanks, Roller.

MassED, BSN, RN · Jul 12, 2008

NurseLene said:

Hello ER Nurses!
I started in my ER in August and have extended my orientation twice (it was only supposed to be 8 weeks and I am going on my 11th). This hospital is relatively new at starting new grads in the ER and I'm not sure if this is a long enough orientation.

So my questions are: how long are your hospitals' orientation programs and what do they consist of?

Mine was a mix of ER classes and clinical floor time.

I don't feel like they could have whipped me into an ER nurse in 8 weeks, but the other new grads seem to be doing fine. I was a CNA, unit secretary and nurse extern in telemetry and ICU as a nursing student. ER was new to me.

I should have followed my gut and gone to a telemetry floor first. I know that tele floors are busy as well, but a different kind of busy than ER.

I read previous threads about new grads in the ER, so I know almost everyone concurs that new grads should go to a floor first.

But until I transfer out, I would appreciate tips on how to survive and thrive in the ER..(books to help me, what helped you..etc.)

Thanks in advance.

Buy the "Emergency and Critical Care Pocket Guide" by Paula Derr and Jon Tardiff. It's fantastic with algorithms, assessments, lead placements, strokes, meds.... it's a great tool for new or older nurses alike.

MassED, BSN, RN · Jul 12, 2008

traumaRUs said:

May I ask what type of ER this is? High acuity, level one? Low volume, one or two RN's in a community hospital ER?"
That said, I worked at a level one trauma center, high volume (65,000visits/yr) ER for 10 years. Our new grads got 12-16 weeks of orientation *** even then, we told them that it would take at least a year before they knew what questions to ask *** two-three years to feel comfortable with whatever came through the door.

If tunnel vision is the complaint, then my first thought is that you are only seeing one patient at a time *** not considering what is going on in your other rooms. This can be partially remedied by being very prepared when you go into the room. Okay, this is a 54 y/o male who is obviously obese, with a well-healed mid-line chest incision. You can get this info from across the room. He says, "Oh my chest is killing me." So...you know he is high risk for cardiac issues: EKG/O2, monitors, Saline lock placement. You do all of this as you are talking *** assessing the pt.

Being very organized *** having some kind of plan makes it easy to make one trip into the room, take care of the initial needs *** exit, ready to do something else for your next pt.

It's not something I would expect from a new grad though. So...please don't feel that you are expected to be a competent *** experienced nurse right out of orientation.

good info. OP should focus on prioritizing and reshuffling priorities as the needs change. For the OP, you need to get in, get out, get it done. Once you have an idea of each patient that are in your care, decide which c/c is the priority and start there. Delegating to CNA's for things such as EKG's, obtaining urine specimens can help to limit distractions. Sometimes you may not have an aide to assist or any other nurse to call upon for assistance. You jot down a quick to do list of those things that can wait a moment or two then get back to them when you're done starting your IV, getting labs, giving meds, etc. Just don't get into a room and linger. Get in, get out. If you keep a sheet to jot down times and meds or interventions, for instance "room 7 at 1430 Tylenol 650mg" and chart it later so it doesn't interfere in your flow, if you're not able to chart just then. Flow will come with time. Constantly thinking of what is next is also a skill that comes eventually. Anticipating the docs and initiating ER protocols also can help you immensely with flow. Try a quick cheat sheet to keep you organized, if needed, to see the big picture with all of your patients. Good luck, I'm rooting for you!

MassED, BSN, RN · Jul 12, 2008

Hey!! I will be graduating in December, and I am TERRIFIED!!! I have signed on to THE busiest Level 1 Trauma Center here in Dallas.. The ER has about 145,000 visits per year... Our orientation is 16 weeks... The first three weeks are strictly classroom time to get everyone on the same page apparently... I'm scared!! Thankfully two other classmates have signed on to this hospital as well.. I am TERRIFIED but I am pretty sure they will prepare me enough to function on my own... Any suggestions that would help as well?? Thanks.

good luck, sounds fun! 3 weeks of classroom time is great and will be helpful. Sounds like a thorough orientation. I wonder how they'll structure the time in the unit. I would advise to absorb info, ask questions (as appropriate) take lots of notes and stay focused. Really sounds like fun!!

MassED, BSN, RN · Jul 12, 2008

Hi Angel,
I was just skimming through and read your note to the new ER grad. I too was a tech for 11 years in the ED I worked at. We were Level II and saw about 50,000 a year. As a tech, I didn't have too much of a problem, but I found that I had a hard time making the transition. I'm now working a Med/Surg floor and miss the ED very much. I'd like to go back, but I was told my skill set was dangerous. This broke me, but I still want to get back to ED. Any words of encouragement or wisdom.
Thanks, Roller.

"skill set" was dangerous? What, exactly, does that mean?

mom23RN · Jul 12, 2008

Boy, that's tough. Honestly, there are some people who ER is just not cut out for. I don't know if that's you or not (may take some serious conversation between your perceptor and yourself). I remember being "thrown to the wolves" and learning very quickly. I had no formal orientation to the ER as a new grad. I worked the unit behind ER and got pulled out when things were crazy and voila, all of a sudden I was an ER nurse (I think I might have had two weeks of one-to-one).

I do remember a nurse that did an orientation a few years later. She oriented for about 8 months, the whole time almost all the nurse telling the manager that she was "not it"; in other words just not meant for the ER. At the time staffing was difficult and they were looking for warm bodies and they kept at her. I believe she's still there today, and while much more comfortable in her position..... the staff STILL complains about the things she does and says that she just doesn't have it (7 years later).

MAISY, RN-ER, BSN, RN · Jul 12, 2008

12 week orientation-definately not enough! Had 20 weeks in our ER and that was barely enough! Not many new grads stay....it's a hard place to start, but with the right preceptors you can learn to be a good nurse.

Maisy

Roller · Jul 16, 2008

It was mentioned that during a code when I pushed an "Epi" that I didn't push with a flush and that left the medicine in the line and not to have it's effect. Another time I forgot about giving a contrast and it interupted care for about 4 hours. The patient wasn't critical. She was being ruled out for an Appendectomy which she didn't have. I'm not exactly sure why my managers felt that way. Maybe I wasn't ready and should have gone to tele floor, like I wanted. Oh well, 20/20 hindsight, and I'm working on my skill set. Thanks.

azguyrn · Jul 22, 2008

Echoing the other responses, it comes down to anticipating what you and the provider will need for the patients you're assigned. Anticipating what you'll need (supplies, labs, poss. dx) will make everything flow smoothly. Usually, you pick that up with experience. Along with anticipation comes with prioritizing. Focus on the most important stuff (airway, breathing, circulation).

likemike, BSN, RN · Jul 24, 2008

ENA. ENA.

I joined in my last semester of school.

I go to local, state and the national scientific meeting.

I read the journal, go to the web site and am very active in ENA.

For one thing, you get away from the chaos for a break.

Another thing is that knowledge is power, I take what I learn to the bedside and sometimes know more than my colleagues. It makes me far more comfortable.

I understand that a lot of colleagues are just tired and do not want to go to these events. Yet I see the same Nurses attending ENA events, and they are excited about learning cutting edge evidence based practice.

It is normal to be scared, patients try to die in front of us on a regular basis.

So don't stop just cause you finished twelve weeks or whatever of orientation.

We are life long students and scientists.

And if ED Nursing is not for you, so what. There is life outside the ED, you may just need to find a better unit, or perhaps a different ED.

Some colleagues feel that if you are not a rockstar Level 1 trauma Nurse you are nothing.

Whether you work in a knife and gun club or in a community ED with a little less chaos, you are still an ED Nurse.

Keep studying, work on CEN and please recruit new members to the best Professional Organization in the US.

ENA rocks.