Any advice or words of wisdom for precepting new grad ER nurses?

Altra, BSN, RN · Mar 6, 2014

Your idea to put together a mini reference guide is a great.

For those without prior EMS or ED tech experience ... remember the emotional transition that comes with working in the ER. This doesn't need to be hashed out regularly, but some occasional acknowledgement that working in the ER changes one's perspective can help someone new to the environment know that what s/he is likely feeling from time to time is indeed normal.

Sassy5d · Mar 6, 2014

A good resource person AND one that checks in with other nurses to see how they feel the new nurse is doing and a friendly reminder that they were once new.

I see a lot of new nurses to ER being thrown to the wolves and it saddens me.

junejames · Mar 6, 2014

I am a new grad and start my 16 week internship in the ER very soon. The BEST thing you can offer is patience and guidance! Don't assume I know certain things.. Try and explain and let the new grad tell you what they have done before and haven't. The biggest thing I'm nervous about (besides the patients) is looking stupid. It's nerve-wrecking and intimidating going in with nurses who do this everyday. I had a really great preceptor my last quarter of school in the icu and the best thing she did for me was not assume.. She never made me feel stupid for asking and I got to learn so much because I was very comfortable with her. So.. That's my advice coming from a new grad perspective! I'm so nervous about ER because I didn't have that much exposure to it but so excited to learn!!

junejames · Mar 6, 2014

And ps- any advice for me as a new grad? Books or guides I should look into?

Cardiac-RN · Mar 7, 2014

I am a big fan of 'the little black book of emergency medicine'. Covers just about every chief complaint and work-up considerations you can think of! Great for trying to understand the big picture, why the doc is ordering what, etc. Other advice- ER nurses don't generally work with 'brain sheets' like many floor nurses due because of the rapid patient turnover (they will just write important things down on their arm, a napkin, or an alcohol swab). But in the beginning it will be a good idea to keep a small steno pad on hand to write down things as you go- protocols, important codes or phone numbers, MD preferences, etc. and review it from time to time to help the information set in the long-term memory. Consider your ED techs a great asset- they are the ones typically obtaining the EKGs, splinting, and other skills- follow them, ask them questions, and learn from them. Everyone is all working on the same team.

Another piece of advice- if someone is talking about something you don't understand- ask them to clarify- do not nod your head and act like you know what you are talking about if you don't. Because then you they WILL ask you if you know what they are talking about, and to be honest you WILL have to say that you have no idea what that is, and then you WILL look foolish. It is so much better to just say, excuse me Dr./nurse so-and-so, but I have not heard of that before. Can you elaborate or shall I go look it up?

Enjoy the ED!

Cardiac-RN

meanmaryjean, DNP, RN · Mar 7, 2014

I routinely precept new grads (not in ED, in PICU) and just remember that they don't even KNOW what they don't know. Never assume they know anything unless proven. And find out how they learn best. Some like a skill demonstrated- once they see it, they've got it. Some need you to demo and then narrate while they do it under your guidance. Just because YOU learn in a certain way, doesn't mean they do.

Thanks for doing this - I find precepting to be one of my favorite things.

zmansc, ASN, RN · Mar 7, 2014

I've precepted several newbies in our ED, and although I don't have anything formally written down, the general approach I take is:

- 1) observation and skills. During this phase the newbie will observe me, and I'll observe them. They observe me to see the level of interaction an RN and a pt have, pick up on the atmosphere in the room, etc. This is really just a short phase to make sure they are comfortable in the room more than anything. It quickly gets to them observing, the doing tasks for me to make sure they are safe in the basic tasks that are done quite often. One of the keys I try to assess and make sure during this phase is that they are not confident enough to try to wing something. I want them to get comfortable enough with me so if they have a question, they are going to come get me and have me demonstrate the task first, before they do a return demonstration and start doing things on their own.

- 2) assessments and documentation. One and two are usually going on concurrently and for most of my newbies rarely last more than a shift or two. I get the newbie to do any and all assessments that the patient needs to have even if they have been done by another RN and start documenting the assessments as well as the tasks they are now starting to do for the pt. I'm big on getting them doing assessments and looking at labs first, and then doing skills and finally taking on patients. I want them to start thinking like an ER nurse first, then acting like one, not the other way around.

- 3) Now that they are doing assessments, and assuming they are safe (but very slow usually at this point) in their skills, I will have them start taking patients. Usually take one patient that is theirs, typically a safe pt to give them, someone who is stable, will probably need an IM shot or two, or another skill I have confidence in the newbie to do. The first ones, I go ahead and do the initial assessment of before I assign them to the newbie, and I always follow up with the patient in the room to do an assessment of my own. I try to get report from the newbie as well and follow the orders and results to make sure all is being covered with that patient.

- 4) After a few shifts of this most newbies will start taking a room. I usually don't have to make this transition, it just works out that they figure out once their patient in rm x leaves, they will take the next patient in rm x. Usually they are also coming to me and reporting the status of their patient. As I build trust with the newbie, I can monitor more by getting report from them and watching orders/labs. If they have had several patients of this category and I feel comfortable that they are competent, their documentation is complete, the orders and results fit with what I'm being told, I spend less time following them and checking in with the pt to make sure I concur.

- 5) Concurrently with 4, most newbies will start to take a second room, and then a third. As they increase their speed of skills, and have shown me that they know how to do more of the less frequent skills, their ability to do more rooms concurrently picks up. Two seems to take a while to get a hang of, the prioritization seems to be a key change that takes a while to get over. I don't push them to take more and more rooms, I want them to be good and slow instead of sloppy and fast. I want to reinforce the habits of checking the lab results, monitoring the patients, spending time with the patient before they pick up the speed too fast.

- 6) Also concurrently with all of the above, were a community hospital, so the bigger stuff does not happen every shift for us. So, if we have a big trauma, or something other that is rare, I will take the newbie's patients, and make/let them go watch/observe/participate in the care of that patient.

- 7) Full load. I rarely have to push the newbie to pick up the pace to be able to handle a full load. They seem to do that on their own as they get more comfortable with their role and the speed they need to be able to do the task. I will alternate having them try to take a full load in the clinic rooms with shifts where we take the cardiac or trauma rooms and hopefully have them take some of the more complicated trying patients, so they get comfortable with hanging multiple drips, having multiple nurses starting multiple IVs at the same time, etc.

That's the general overview of the progression I try to take the newbies through. Some fly though all stages rather quickly and I wonder if I've missed something with them. Others take more time in one stage or another and I have to remember to be patient with them. I've never had (knock on wood) someone stall out and not make it to being able to work on their own. I have had to address and teach things I thought should have been covered in nursing school, but that's just part of the process.

1fastRN · Mar 7, 2014

As a new grad (working in ER one year now) I'll offer my 2 cents from the orientee perspective.

1) Start out working side by side with them or letting them shadow you for the first few shifts. Let them get in the groove and work on skills like Ivs. Initially focus on tasks they will need to solidify. A preceptor of mine had me work and entire shift starting lines on every new patient. I wasn't great at first but the more I did the better I get. If they fail, bring them in with you and let them watch you get the line. I learned a lot from watching the experienced nurses get those tough sticks.

2) Quiz them on things. Why are we doing this? Why are we giving this med? Make sure they understand what they are doing and not just carrying out orders. What do you have to monitor after giving this drug? What labs or tests do you anticipate with a patient who presents this way? What's your priority?

3) Try to get them to think of the big picture. This goes back to number two. Encourage them to critically think and anticipate what the doctor is going to order.

4) Throw them in uncomfortable and hectic scenarios. Is someone else being intubated? A code taking place on someone else's patients? If you can, "pull them" from the current assignment and throw them in that critical situation. Have them draw up the meds for intubation or a code (with guidance) so they get practice in these fast paced and critical scenarios. It's stressful but helps them a ton in the long run. I had a preceptor like this... I would get so stressed but it made me prepared for these situations when I was on my own. She would pull me to work on a patient getting TPA. She'd say, "Nurse X's pt is in SVT, you're going to draw up and push the adenosine." "This pt is being intubated. Ask the MD what drugs she would like. You're going to draw them up and give them." At the time I felt so unprepared and stupid but she wanted me to be a good nurse and now those situations have become routine. I owe her so much for advocating for me in this way!

5) Let them drown. Of course, if something is unsafe you should intervene. Pt care shouldn't suffer. I had some preceptors who pretty much just spilt the assignment with me or would help out to much. This may seem like a favor but it's a hindrance. As a nurse you're probably used to running around and well, being a nurse. My favorite preceptor would watch me drown on those busy shifts. It forced me to get my speed up and keep up. It sucked at the time but I knew I'd be on my own soon enough. I quickly got up to speed. Better to drown on orientation when you have a safety net rather than being babied and completely overwhelmed when you're on your own.

6) Provide honest feedback but also support. Give your orientee your phone number if you feel comfortable. My favorite preceptor exchanged numbers and offered to discuss things or allow me to ask questions post shift. Don't lie or sugar coat things. We don't know what we can work on if you're not telling us. Being overly nice isn't what we need. We need constructive criticism with a little "pat on the back" at times so we aren't completely discouraged. We want to feel comfortable expressing our concerns so please try to encourage a friendly preceptor-orientee relationship!

turnforthenurse, MSN, NP · Mar 7, 2014

And ps- any advice for me as a new grad? Books or guides I should look into?

I like Sheehy's Manual of Emergency Nursing and Fast Facts For The ER Nurse.

Thank you so much for your suggestions, everyone! :)

Mommynator · Mar 12, 2014

What a great plan! Unfortunately, I was thrown to the wolves in the ER, six preceptors who did things differently and confused the living daylights out of me. I wish all preceptors were this systematic. I think I could have stayed in the ER if I'd had you for mine.

turnforthenurse, MSN, NP · Mar 12, 2014

What a great plan! Unfortunately, I was thrown to the wolves in the ER, six preceptors who did things differently and confused the living daylights out of me. I wish all preceptors were this systematic. I think I could have stayed in the ER if I'd had you for mine.

I think that is the problem my orientee has. She has been on orientation for several weeks now and sounds like she has had several different preceptors... and she seemed confused on the way to do things because different preceptors have told her different things.

There was one thing that really bothered me, though. I had a critically ill patient come in by EMS... we ended up having to incubate and do a lot of other things. My orientee was nowhere to be found. At the very least I would have expected her to observe in the corner. When I was new I wanted to watch everything and was always thinking what could be wrong with the patient, what would we do to fix the problem, etc. Even today I'm the same way... if I'm not assigned to trauma and we get a trauma or critically ill patient through our door you better believe that I am in the room ready for action.