Top Skills Every ER Nurse Should Possess

zmansc, ASN, RN · Dec 30, 2013

Assessment and learning how to stay calm and focus. It has very little to do with the skills most people think of, IV starts, NG tubes, etc., and everything to do with being able to assess the patient and figure out what they need, and stay calm when the **** is hitting the fan.

1fastRN · Dec 31, 2013

All those skills that are stated by the poster above are important and come with time but as mentioned, they're not necessarily the crux of being a good ER nurse. Sure, it's important to be able to find a vein on the septic/hypotensive little old lady with no veins but in the bigger picture it's not the focus.

I'd say a calm attitude and ability to prioritize. Focus on the most important task at hand, the little things can wait.

Time management is very important! You will be slow at first, but everyone is.

An assertive attitude is important. Advocate for your patients! If something just doesn't seem right, get a second opinion. If something is a little off, inform the doctor (and chart that the MD was aware). You always have to cover yourself. (i.e. Pt is hypertensive but MD doesn't want to treat BP at this time. CHART IT!)

I'll give you a recent example. I had an admitted patient (pending oncology bed) who just looked like crap. He was complaining of increasing pain and was just acting weird. He became tachy (he had been febrile the whole time but his BP shot from 105 to 140/150). I didn't know what was going on, I couldn't explain it, it seemed more than just a pain breakthrough... so I actually interrupted the ER doctor (who knew little about this patient from the previous doc) and asked our MD to come look. So she gave me an order to medicate the pt for pain and left the room. Whelp, as soon as she left the patient started seizing (no seizure history). He ended up being a super sick guy but for some reason the doctors didn't initially think so. He ended up going to ICU short after. I'm pretty knew to this and I didn't know what was wrong with him, but I just had that gut feeling.

Moral of the story, go with your intuition! Sometimes it's wrong, but worst case scenario you just bothered the doctor for a couple minutes of their time. You can always ask a more seasoned nurse for a second opinion as well. It's definitely getting better with experience but I'm impressed with the experienced nurses in my ED. A patient will come in (in mild/moderate distress) and I'll overhear a veteran nurse say, "He's going to have to be intubated." Sometime's they are wrong, but most of the time they are right. Kind of cool actually.

Other advice, communicate with your patients, even when you're running around. It really goes a long way even if you just swing by for two seconds. "Blood work came back, nothing was abnormal! We're just waiting on results on that Xray, I'll let you know when it's back. How's your pain? Are you warm enough?" Patients' and their family really appreciate being informed, and it was prevent you from having to do damage control later on.

And ASK ASK ASK! I'm always asking the nurses and doctors things. Even what seems like a silly question. Or if you want a second opinion. Your co-workers are great resources so take advantage. Never let your pride interfere with giving the patient the best/safest care possible.

Good luck!

mrnurse504 · Jan 1, 2014

Assessment and learning how to stay calm and focus. It has very little to do with the skills most people think of IV starts, NG tubes, etc., and everything to do with being able to assess the patient and figure out what they need, and stay calm when the **** is hitting the fan.[/quote']
Wow! I can't imagine working in ER & not having a calm attitude in regards for the patient. I'm also glad you clarified that it's not always about skills. I will continue to sharpen up my assessment methods. Thank you for taking the time out of your day to respond...Have a Happy New Year!

mrnurse504 · Jan 1, 2014

All those skills that are stated by the poster above are important and come with time but as mentioned they're not necessarily the crux of being a good ER nurse. Sure, it's important to be able to find a vein on the septic/hypotensive little old lady with no veins but in the bigger picture it's not the focus. I'd say a calm attitude and ability to prioritize. Focus on the most important task at hand, the little things can wait. Time management is very important! You will be slow at first, but everyone is. An assertive attitude is important. Advocate for your patients! If something just doesn't seem right, get a second opinion. If something is a little off, inform the doctor (and chart that the MD was aware). You always have to cover yourself. (i.e. Pt is hypertensive but MD doesn't want to treat BP at this time. CHART IT!) I'll give you a recent example. I had an admitted patient (pending oncology bed) who just looked like crap. He was complaining of increasing pain and was just acting weird. He became tachy (he had been febrile the whole time but his BP shot from 105 to 140/150). I didn't know what was going on, I couldn't explain it, it seemed more than just a pain breakthrough... so I actually interrupted the ER doctor (who knew little about this patient from the previous doc) and asked our MD to come look. So she gave me an order to medicate the pt for pain and left the room. Whelp, as soon as she left the patient started seizing (no seizure history). He ended up being a super sick guy but for some reason the doctors didn't initially think so. He ended up going to ICU short after. I'm pretty knew to this and I didn't know what was wrong with him, but I just had that gut feeling. Moral of the story, go with your intuition! Sometimes it's wrong, but worst case scenario you just bothered the doctor for a couple minutes of their time. You can always ask a more seasoned nurse for a second opinion as well. It's definitely getting better with experience but I'm impressed with the experienced nurses in my ED. A patient will come in (in mild/moderate distress) and I'll overhear a veteran nurse say, "He's going to have to be intubated." Sometime's they are wrong, but most of the time they are right. Kind of cool actually. Other advice, communicate with your patients, even when you're running around. It really goes a long way even if you just swing by for two seconds. "Blood work came back, nothing was abnormal! We're just waiting on results on that Xray, I'll let you know when it's back. How's your pain? Are you warm enough?" Patients' and their family really appreciate being informed, and it was prevent you from having to do damage control later on. And ASK ASK ASK! I'm always asking the nurses and doctors things. Even what seems like a silly question. Or if you want a second opinion. Your co-workers are great resources so take advantage. Never let your pride interfere with giving the patient the best/safest care possible. Good luck![/quote']
You are awesome! I wasn't expecting a great deal of information, but you have just spoiled me. I love the fact that at the end of the day, it's still the little things that count. Given some insight in the ER, I feel even more confident on getting there one day. Thanks again & Have a Happy New Year

ParalyticAgent · Jan 1, 2014

My thoughts after a 14 hour shift. I apologize for any typos! :)

1) Being able to tell the difference between sick patients and not-sick patients. This takes time. Every once in a while, you're going to think a patient falls into one category and they are actually in the other. It'll keep you humble. (Last week I had two physicians, four nurses, and two techs in the room of a patient we were all certain was dissecting. He had gallstones.)

2) Prioritization. Working in the ED your to-do list is always evolving and changing based on the needs of both your patients and the department. Knowing what needs to be done and knowing what can wait is essential.

3) Being assertive without being aggressive. Sometimes doctors miss things. It's our job to advocate for our patients. Being able to state your case is essential. If a doctor isn't listening to you, document, and watch your patient. Go to your charge nurse. Go to the medical director. On the other hand, you need to choose your battles. If you pick a fight over every order, no one will listen to you when something really is wrong. There are many orders that I don't necessarily think a patient needs. My rule of thumb is that if it won't harm the patient, I will do it.

4) You need a way to separate work from the rest of your life. In the ED, you are going to see heartbreaking cases. You need a way to decompress and allow yourself to let go. There will be cases that will stick with you for a long time- this is normal. What isn't normal is having it take over your life. Have someone you can talk to who will understand. Have someone with whom you can be honest: "Work sucked and I hated my patients tonight." Sometimes just saying it will feel better. You are not a bad person for feeling this way- it will happen and anyone who says they haven't felt that way is either lying or heavily medicated.

5) Not necessarily a skill, but a good tip. My entire first year, I brought a notebook to work. Any time I was unfamiliar with a medication, diagnostic study, diagnosis, or treatment, I wrote it down in the book. When I had time, I studied what I wrote down. I learned a lot this way.

mrnurse504 · Jan 3, 2014

My thoughts after a 14 hour shift. I apologize for any typos! :) 1) Being able to tell the difference between sick patients and not-sick patients. This takes time. Every once in a while you're going to think a patient falls into one category and they are actually in the other. It'll keep you humble. (Last week I had two physicians, four nurses, and two techs in the room of a patient we were all certain was dissecting. He had gallstones.) 2) Prioritization. Working in the ED your to-do list is always evolving and changing based on the needs of both your patients and the department. Knowing what needs to be done and knowing what can wait is essential. 3) Being assertive without being aggressive. Sometimes doctors miss things. It's our job to advocate for our patients. Being able to state your case is essential. If a doctor isn't listening to you, document, and watch your patient. Go to your charge nurse. Go to the medical director. On the other hand, you need to choose your battles. If you pick a fight over every order, no one will listen to you when something really is wrong. There are many orders that I don't necessarily think a patient needs. My rule of thumb is that if it won't harm the patient, I will do it. 4) You need a way to separate work from the rest of your life. In the ED, you are going to see heartbreaking cases. You need a way to decompress and allow yourself to let go. There will be cases that will stick with you for a long time- this is normal. What isn't normal is having it take over your life. Have someone you can talk to who will understand. Have someone with whom you can be honest: "Work sucked and I hated my patients tonight." Sometimes just saying it will feel better. You are not a bad person for feeling this way- it will happen and anyone who says they haven't felt that way is either lying or heavily medicated. 5) Not necessarily a skill, but a good tip. My entire first year, I brought a notebook to work. Any time I was unfamiliar with a medication, diagnostic study, diagnosis, or treatment, I wrote it down in the book. When I had time, I studied what I wrote down. I learned a lot this way.[/quote']
Much love for your post. Thank you for not only breaking down the ED, but for also being very honest, as sometimes we can feel a certain way towards a rude patient/family member, per say. I will never forget your advice. Thanks and have a Happy New Year!

jallen326 · Jan 3, 2014

Great advice! Working in the ED is quite rough, especially for a new graduate, and learning the work flow can be even more challenging since things do change pretty quickly!

Guests · Jan 5, 2014

It's not all about the psychomotor skills but they do count for a lot.

Look for every chance to practice those thing and to become expert at them.

I'd encourage you to start studying the CEN curriculum now. Get the CEN review book from ENA and start working through the questions. You may end up having a topical interview as I did and it will help you be prepared for the question.

Remember ABC/CAB, HIPAA, CYA, and patient autonomy... one of these issues comes up with at least one of my patients every shift.

nshortrn · Jan 5, 2014

I agree with 1FASTRN..... I have only been in the ER for 3 yrs but I AM iN LOvE with it!!! I am a very active hyper person in general so I love the fast paced. The most portent skill in my opinion is to always .. Always ask questions.... Never lose the ability to be TEACHABLe!!!!

Medic2RN, BSN, RN, EMT-P · Jan 5, 2014

I agree with everyone before me. I would like to add something though. Know the laws and SOPs of your hospital. You'll find yourself in some strange situations in the ER. It will guide you as to what you should do and cover all your bases. Examples: HIPAA, mandatory reporting requirements, special paperwork required for animal bites, psych patients, death protocols, etc.

These are good things to know, especially when the place is jumping and you don't have time to learn about it at that time.

At least familiarize yourself with them.

Good luck!

1fastRN · Jan 5, 2014

I agree with 1FASTRN..... I have only been in the ER for 3 yrs but I AM iN LOvE with it!!! I am a very active hyper person in general so I love the fast paced. The most portent skill in my opinion is to always .. Always ask questions.... Never lose the ability to be TEACHABLe!!!!

Haha finally a place where our hyperactivity can THRIVE!