Advice for new ER nurse

jojotoo, RN · Nov 1, 2006

Need more info. How old are you? What kind of an ER are you at? Trauma center? Community hospital? Pediatric? What exactly do you feel is lacking in your orientation?

kdmcook · Nov 1, 2006

I am fast approaching 41, it is a fast growing community hosp ER. NO traumas at this time.

The nurse/patient ratio is 1 to 4, but I am having difficulty with 2 and 3. Especially when they slam me with them back to back. I seem to be unable to think fast on my feet, with the stress of trying to hurry leading me to make mistakes, etc. Everyone seems that it will come with time, but I am getting the feeling that they aren't going to give me the "time" that I need to get up to speed.

jojotoo, RN · Nov 1, 2006

I'm 51, graduated 15 years ago. So I don't think that you are too old. Being an ER nurse is not for everyone. But that doesn't mean that it's not for you. Your peers are right - usually, everything will finally just click in to place. I think that the hardest transition for a floor nurse to make is the abrupt turnover in patients. That and learning to do focused asessments.

Does your hospital have standing orders or protocols in place? If they do, learn them. So much of ER medicine and nursing is straight from a "cookbook". It's very task oriented. "Treat 'em and street 'em". I start discharge planning in triage - "How are you going to get home?" (to those who abuse EMS and come by ambulance.) Same with teaching - "Why haven't you called your PMD?" "Why haven't you checked baby's temp and given Tylenol?"

If you wait to be "comfortable", it may be years. Even though you've been assigned a preceptor, what you need is a mentor. That will be someone of your choosing. Nobody starts out as a GOOD ER nurse. You're going to make mistakes. You're going to be slow. And you're going to ask a lot of stupid questions. But the stupidest question will be the one that you DIDN'T ask. So ask all of them. Don't be too hard on yourself. Remember your ABCs. And if at the end of your shift, everyone is still alive, we count that a really good shift! Good luck!!

ERNP · Nov 1, 2006

Just from watching and precepting a fairly significant number of nurses transfer from med/surg to ER, I wonder if the ER prioritization methods maybe what is causing you to feel this way.

Before anyone gets started... I am not saying the med/surg nurses don't have to prioritize, but it is a different kind of prioritization.

For instance, on the floor you knew you were going to see every patient that was assigned to you, all be it sometimes eventually. In ER, if the kid with an arm injury has pink fingers and the lady with trouble breathing has blue lips. I may not ever see the kid with the hurt arm and pink fingers because while I am working with the lady with blue lips one of my teammates will attempt to pick up my slack until I can stabilize the lady with blue lips. This is not a shortcoming on your part, it is good teamwork. It is one of the things that the newly transferred from med/surg always said made them feel like things were out of control. They always seemed to do better after it was explained to them a few times that sometimes there was no way to do everything and that is what the rest of us were there for.

AM-RN · Nov 3, 2006

First - welcome to the ER!

I started in ER as a new grad. I had 10 weeks of somewhat orientation (sometimes I was counted as staff, sometimes I was an orientee). To be honest, I felt pretty uncomfortable with anything/any pt that had a time sensitive illness/injury for several months.

After approx 6 months "on my own" I started to feel more comfortable and after one year I was feeling even better.

It's been almost three years now and there are still things that have me running to the more experienced nursing staff. For the most part - day in and day out- I feel confident and comfortable. There will always be new things to learn.

Taking ACLS, ENPC, TNCC, CATN, an EKG course, and a critical care course during my first year helped A LOT. And knowing your department's specific protocols will help, too.

Good luck!

EDRNIndy · Nov 5, 2006

Its a real zoo most of the time

You are lucky to run a four to one ratio

We are so short I sometime have to take charge as well as run the14 bed sub acute er area and do triage.

Speed comes in time. Focus on being accurate.

It usually takes a good year to two to get up to speed. Soon you will be the senior employee because most people cant keep up with the pace and its too easy to find another job somewhere else that pays the same in nursing.

pjsleepy, BSN · Nov 5, 2006

Help, I just started a new ER position and having much difficulty with the role transition. I am still a fairly new nurse with 2 years Med/Surg and needed a change, and some new learning experiences. An ER position at another hospital was offered to me and I took it. I am about 1.5 months into training and am really struggling. I am having a hard time with the super fast pace, and so many things to learn. There has been a big turn over of staff for some "secret" reason and preceptors are apparently hard to come by. I feel like they are rushing me thru training in order to get me out on the floor to meet staffing needs. I am afraid for my pt's safety and my license. The other new orientees, there are four of us, feel the same way. We have tried talking to our nrs manager, education specialist, team leads, everybody, but so far have gotten no where.
I worry as well that being an "older" nurse, that maybe I am just too old for the pace, especially learning a new pace. Initially I was excited about the position, but lately have been feeling very anxious and having a lot of self doubt. I have started having stess symptoms, anxiety, depression, general maliase and overall feeling sick and I think it is because of this job.
Any advice would be greatly appreciated.

Do you have multiple preceptors or just one? Did you have any exposure to the ER scene before you took this job? What is management telling you when you have brought up your concerns? You are probably doing better than you think you are. 2 years of med-surg probably gave you excellent assessment skills. When I first get a new pt I run through differential diagnosis in my head (like dr's do). What could this person possibly have? What do I need to be doing? That can be the tricky part. You'll learn that the ER standard of care is mostly the same with the exception of a few idiosyncrises from doctor to doctor. DO NOT BE AFRAID TO ASK QUESTIONS. And I mean ALL THE TIME. Ask everyone (nurses, doctors, techs, unit secretaries, etc). Even something that seems really silly, ASK! I also really like ERNP's post about prioritization. ER nurses, for the most part, help each other out. We've all been the nurse with a critically ill or injured pt and 3 others we just can't get to. My suspicion is that med-surg has made you super organized and methodical. The ER, on the other hand, is semi-organized chaos on it's best day. Would sitting down with all the other preceptees and your nurse manager together to address this issues help?

jbird125 · Nov 5, 2006

Welcome to the field, although i work across the pond so to speak one of the other posters is right, focus first on geting your assessments right, then speed will come, you will find it easier to cut to the chase when taking a patients history.

In our department there is a ratio of 1:6 or 1:8 if we are pushed, and in the trauma bays there is a ratio of 1:4.

I found the way to start to speed up was to go into one patients room, attach them to the dynamap, set it going and go next door and take the hx of the next patient, then swop over, it is bloody hard though.

Best of luck, i think you have joined the best field in nursing, although i will conceed that i am biased on that.

nursebearfeet · Nov 12, 2006

If being in the ER is your dream, don't give up. Transitioning is tough. It's OK to lean on your peers. We all do and should. It's good nursing care. You cant do everything at one time. Time management is one of the most important aspects of the ER, after basic knowledge and skill. It's usually as simple as ABC's. Sickest first. Your peers should be more than willing to help in crisis situations. if you are getting nowhere with management and your peers refuse to help, look for a new ER. Don't risk your license if it's the entire ER that's floundering.

Jennifer, RN · Nov 12, 2006

When I first transferred from the floor, I couldn't keep up with the pace. I was used to delivering a completely different level of care.

Give yourself 6 months, if you haven't started to feel a little more comfortable (of course, it will take you longer to feel proficient), then transfer to another unit.

bbrned · Feb 7, 2007

please don't give up on trying. I am the educator for a very busy level I trauma center. we hired 5 new grads this year. they are having a hard time, but turn to me for assistance. I take time with them to evaluate where the problem lies, and if I can help resolve it. it may be a difficult relationship with a preceptor- they are tired of orienting new folks- it may be a skill issue, time issue, prioritization issue, etc... it is important to define where the issue lies first. if your administration is unwilling to guide you, going higher. that should be addresses. you deserve the best orientation to guide you in your quest. keep in mind that you won't find a true level of comfort for at least a year, and even then, something you have never seen will come through the door. hang in there. I have 15 years er experience, and you are welcome to contact me at any time, if there is some way I can help you.

I also recommend that you er get the orientation manual from ena, it is very useful.