Questions from a Struggling ER New Grad

Can you be more specific? What types of problems do you think you're having? What has made you want to extend your orientation?

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.

I started in the ER as a new grad too. At that facility new grad orientations are 12 weeks, a mix of classroom and floor, with a one to one preceptorship.

The facility I'm at now does not hire new grads into specialty units because we are rural and have a small staff. New employee orientation, for someone with no ER experience, is still 12 weeks, all in the ER.

As for the tunnel vision part, that's normal for new grads because that's what we did as students: we only had one or two pts to concentrate on. It takes a while to get used to the real world stuff, and it will take at least a year before you will feel completely comfortable, no matter what unit you work on. Hang in there!

Even now, I keep a notepad in my pocket that I refer to for my patient info. Since we turn over beds so quickly, it helps to keep track of which beds are pending what and what chief complaint each has. That said, part of it is just experience, you learn what you need to think of for each patient - takes time. No new grad will grab it all right away - and even after orientation, there should still be people you can ask if you have questions. That goes for ER, AND for med-surg and other floors. Real nursing isn't anything like clinicals, and that's a culture shock for most folks.

it takes time to get used to the ER environment. and if you are in a very busy ER it can be extremely overwhelming. i was at an advantage because i was a ER tech first and then transitioned to nurse. prioritizng is key. you have to know who is more important and that will make your day alot easier. patients will complain, scream and curse but it boils down to "who needs nursing care the most?". it comes with time. if you think that going to tele or medsurg will help you become more confident, then you should go for it. good luck with what you decide, you'll be fine.

I am a fairly new grad in the ER also. I was told that I would be allowed up to 4-6 months of orientation. I am 12 weeks into my orientation now and I am starting to feel very comfortable. However, my preceptor and I still have not covered the pediatric beds or the observation unit. My orientation has consisted mainly of clinical time, but I am required to take courses for ACLS, PALS, and TNCC.

I definately don't believe 8 weeks is enough orientation time for a new grad. What type of ER do you work in? I work in a 45-bed ER that sees ~60,000-70,000 patients/year. It is not a level one trauma center though.

What helps me is learning to anticipate the needs of the patient before I even go into the room. For example, a patient complaining of nausea and vomiting is probably going to need a saline lock, so I go ahead and get everything ready, then go into the room to assess the patient and place the line at the same time. Then, when the MD orders fluid, all I have to do is hang it. Same thing with a chest pain patient- EkG, monitor, oxygen, saline lock. It is best to get as much done as you are able to (within your scope of practice, of course) before the doctor starts adding the orders.

Good luck! I'm sure that it will start to come to you, it just takes time.

I started as new grad in a lvl 1 as well, and had a lot of tunnel vision problems at first. Does your ED have any protocols/standing orders? If not, use your critical thinking skills. Anyone with CP is cardiac until proven otherwise, so they get a SL, cardiac monitor, O2 2L, and EKG. Abd pain is easy - get into a gown, pee in a cup, and start an IV.

My manager often says that ER nursing is not terribly difficult....and a lot of the time it isn't, it is just a time management issue. But when it is hard, it is very hard.

Ask your manager/preceptor to get some case studies together for you to go through. If you learn well by reading, I would suggest Sheehy's Manual of Emergency Care, or Introduction to Clinical Emergency Medicine. I eventually had to can the sweet loving nurse crap and focus on getting my stuff done. You know if you're walking into an abd pain pt's room, you're going to be starting an IV. Get your stuff together before you walk in the room (or just after you walk in) and start the IV as your doing the "talking assessment" - while you're getting the where, why, and how of everything. Pop the IV in, draw your labs, then do your physical assessment.

When you get all your stuff done at once, you can afford to have some tunnel vision - that way you know your CP pt has his EKG, is on the monitor and O2, and has an IV in if something goes wrong.

Good luck!

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.