Questions from a Struggling ER New Grad - page 2

by NurseLene 34,200 Views | 31 Comments

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... Read More


  1. 7
    Quote from KiNKy sLiNkY
    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.
    Honestly, I think it is a good thing you're terrified. Th epeople who walk into the ED feeling like they're king/queen of the ED nursing world are the people who terrify ME! A few things to remember....first, obviously someone thinks you're a good candidate to work in the ED, or they wouldn't have hired you. Second, you will eat, sleep, breathe, and work emergency nursing for the whole fellowship/orientation time. It is important that you take this opportunity to do your best - study at night, keep lists of questions you have, etc. I developed a pretty good system during my fellowship where I kept a little notebook, and took notes about disease processes/conditions/patients I took care of each day. Little things like "sickle cell patients - O2, fluids, pain meds, ESR" etc. That worked for me because I learn that way though.
    Best advice? Make a friend or two in the fellowship and study together, but also destress by going out for dinner/drinks together. I found it really helps to have a good friend either in your dept or in the same field - someone who can relate to what you're going through. It is so important that even though you're spending so much time learning during your orientation that you also take time to take care of yourself - massages, time with family, etc.
    Even when you get out of your orientation, give it time. And if you feel like a fish out of water still when you're SUPPOSED to be on your own, speak up and ask to have a few more weeks. Chances are they'll extend it.

    Good luck!
    Katers*, Maikafer-RN, jncRN, and 4 others like this.
  2. 1
    I started in the ER out of a 6 week med/surg rotation. I had been an lpn in ltc for about 7 years prior to this.

    I had problems with sooooo many things when I first started. I look back and laugh at myself now My biggest challenge was to realize that not everything is actually an emergency. That just because my pt wants me to do something emergently does not mean I have to do it emergently:lol I start with the most critical pt. I get everything done for this pt that I can. Iv started, ekg, labs, radiology, urine etc...Then I move on. But, you have to remember what you have going on in all your rooms at the same time. I just keep taking inventory... If I have someone with a very minor complaint they get the back of my inventory. I will get to them as soon as I possibly can.

    another thing that was hard for me was delegating. I have finally started to tell the tech assigned to my rooms "when you see the chart go up for d/c go ahead and get me end case v/s" Or "will you get bed 2 to the commode for a urine sample while I get the IV started in 3"

    I certainly hope what I am about to say won't offend you...But, Do you seriously love the ER? One of my very best friends wanted to be an ER nurse the entire time she was in school. When she graduated she got a job in a busy ER. They gave her many opportunities to orient. They let her rotate to ICU and med/surg-they extended her orientation time. It finally became obvious that she was not made for the ER. She was much better at ICU/Tele. She made the switch and is blissfully happy
    jncRN likes this.
  3. 1
    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 dont 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
    jncRN likes this.
  4. 7
    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
    Fritz71, Saflanut, Maikafer-RN, and 4 others like this.
  5. 0
    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.
  6. 1
    Quote from NurseLene
    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.
    jncRN likes this.
  7. 0
    Quote from traumaRUs
    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!
  8. 0
    Quote from Kinky Slinky RN
    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!!
  9. 0
    Quote from Roller
    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?
  10. 0
    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 orientd 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).


Top