E.D nurses "set up to fail"

Altra, BSN, RN · Feb 24, 2012

I think that the person to ask ... is the person who made that comment.

nurs2012 · Feb 24, 2012

His reasoning is too much liability but he has no E.D experience so my question is to nurses who actually work in the E.D, if they feel the same way.

Altra, BSN, RN · Feb 24, 2012

It's good that you understand the perspective that your instructor's comments are coming from.

If by "liability" he means autonomy ... yes, this is different in the ED than in some other environments. I consider that a good thing! He may also be referring to the fact that the ED is an integral part of the community public safety system, and it never "closes beds". Even when the number of patients and their needs exceed capacity, the ED never closes, and must continually re-prioritize and strategize to provide care for all presenting patients. You have to make it work. It's often not pretty, and requires a certain amount of fly-by-the-seat-of-your-pants mentality (within clinical standards of care).

Different practice settings utilize different nursing strengths. In the ED you are often starting "from scratch" with a patient. Here is a concrete example: on a recent day when I was in triage, it was a day when patients who signed in with a chief complaint of "foot pain" ... were really "foot pain because I fell while I was reaching for my nitro pills because I felt short of breath after I got home from dialysis". :rolleyes:

There is no "typical" ED patient. They run the gamut from "I sneezed once and I'm a weenie who is afraid I've got H1N1 flu" ... to ... "my left shoulder hurts - maybe I hurt it while I was moving furniture yesterday" (which turns out to be an MI) ... to full cardiac arrest/respiratory arrest/multi-system trauma.

Also consider the psycho-social aspect of the ED - it's not for everyone. You will see every psychosocial dysfunction imaginable, and a lot you probably never imagined, played out in front of you. You will see well-dressed, well-spoken families - who have abused their children. You will see 15-year old gang members. You will interact to some degree with law enforcement and social service agencies.

Clearly I'm biased -- I love the ED. If you are considering it, really try to shadow a day or two in an ED if you can. Try to arrange for some clinical time in the ED if your nursing program allows it. And as a new grad, look for an ED committed to "growing" a new grad nurse with an orientation period of at least 12 weeks, preferably 16, as recommended by the ENA. And remember that it will take you 6-9 months to figure out what you're doing, 2-3 years to be comfortable, and 3-5 years to be really competent.

Good luck to you. :)

jbluehorseh · Feb 24, 2012

it is very hard for a new grad to flourish in this environment unless he or she has previous experience. (emt/paramedic or other) or the hospital has a good training program. one has to be on the ball at all times.one problem i see in my hospital is that we get a lot of new grads and it shows when he or she tries to send a patients to the floor. these are some example, a patient with a blood pressure of 225/ 110 with absolutely no orders or treatment in the ed. the new nurse sends us a patient with high blood sugars and blood pressures. the admitting dx is dehydration, but the patient has chf, dm, mi, and is on dialysis and do not forget elevated potassium levels. ( pt missed dialysis that day came in for not feeling well) the point of this was the patient was on d5 ns at150 for at least 8 hours. this nurse did not see the issue or connection between the treatment and the bp and high blood sugars. i find the assessment skills,very poor in with some of our new grads. this has led to my problems for patient care and safety. i say to you get a on a medsurg, or tele floor, and holm your skills and work on getting your certifications.

mybrowneyedgirl, BSN, RN · Feb 24, 2012

Some great points are made here. I agree with all of them. The fact is, it depends on YOU. I ran into my teacher the other day and she said she knew I'd do well in ER. It's not for every new grad. Honestly, I feel that they should never hire a new grad, but at the same time I am so glad they hired me. I see many tread water and few excel. If it's what you love, don't shy away. You will have to spend time at home studying your meds, patho, critical care cases, traumas. It's like still being in school. Study on your own, ask questions, watch vitals, labs, I and O's, heart rhythms. Advocate for your patient even if it means being ready to debate your case to the physician.

I LOVE the ER and cannot imagine working anywhere else. I have crappy days and crappy patients but I love the variety and the good days.

Altra, BSN, RN · Feb 24, 2012

it is very hard for a new grad to flourish in this environment unless he or she has previous experience. (emt/paramedic or other) or the hospital has a good training program. one has to be on the ball at all times.one problem i see in my hospital is that we get a lot of new grads and it shows when he or she tries to send a patients to the floor. these are some example, a patient with a blood pressure of 225/ 110 with absolutely no orders or treatment in the ed. the new nurse sends us a patient with high blood sugars and blood pressures. the admitting dx is dehydration, but the patient has chf, dm, mi, and is on dialysis and do not forget elevated potassium levels. ( pt missed dialysis that day came in for not feeling well) the point of this was the patient was on d5 ns at150 for at least 8 hours. this nurse did not see the issue or connection between the treatment and the bp and high blood sugars. i find the assessment skills,very poor in with some of our new grads. this has led to my problems for patient care and safety. i say to you get a on a medsurg, or tele floor, and holm your skills and work on getting your certifications.

though this is not a floor vs. ed thread ... i find it interesting that you pin deficiencies in physician orders on the nurse. many a time when giving report i have found myself saying, yes, that really is his blood sugar ... that's why he's being admitted. if it was a fast fix, we'd have done it and discharged him.

back to the regularly scheduled thread ... :)

VICEDRN, BSN, RN · Feb 24, 2012

His reasoning is too much liability but he has no E.D experience so my question is to nurses who actually work in the E.D, if they feel the same way.

Hee hee. Of COURSE I don't think so.

VICEDRN, BSN, RN · Feb 24, 2012

His reasoning is too much liability but he has no E.D experience so my question is to nurses who actually work in the E.D, if they feel the same way.

Hee hee. Of COURSE I don't think so.

VICEDRN, BSN, RN · Feb 24, 2012

Will add that the teaching attendings have recently informed me that new E Med guidelines do not include treating asymptomatic elevated BPs in the ER as it is bad policy (creates revolving door problems and unrealistic expectations) and dangerous for patients (possible strokes, rebound hypertension, etc). If patient is asymptomatic and non-compliant, there remains no reason to treat them in the ER. (thought 225 systolic would leave me wondering if we maybe just could, you know, at least give them a clonidine....)

Skylar86 · Feb 25, 2012

Some great points are made here. I agree with all of them. The fact is, it depends on YOU. I ran into my teacher the other day and she said she knew I'd do well in ER. It's not for every new grad. Honestly, I feel that they should never hire a new grad, but at the same time I am so glad they hired me. I see many tread water and few excel. If it's what you love, don't shy away. You will have to spend time at home studying your meds, patho, critical care cases, traumas. It's like still being in school. Study on your own, ask questions, watch vitals, labs, I and O's, heart rhythms. Advocate for your patient even if it means being ready to debate your case to the physician.
I LOVE the ER and cannot imagine working anywhere else. I have crappy days and crappy patients but I love the variety and the good days.

i couldnt agree with you more!!

i am a new grad in the ED (i am just in my 3rd week now)

Luckily the newgrad program that I am on allows me to have 6 weeks orientation with a preceptor (an amazing nurse-- i am very lucky!) so i am not completely thrown into the deep end on my own... i recommend finding out how long of an orientation you get because i really think it is crucial. I am slowly learning how to handle 2-5 patient loads. All of the staff have been welcoming and extremely supportive given the chaotic (organized) environment!

I have had previous experience as an EMT which was a HUGE help.

My advice to you as a student is don't just stand and observe thinking that you will do it next time... just get into it!! Ask to do things.. ask other staff if they need help (if you have time to spare of course)

hiddencatRN, BSN, RN · Feb 25, 2012

Luckily the newgrad program that I am on allows me to have 6 weeks orientation with a preceptor (an amazing nurse-- i am very lucky!) so i am not completely thrown into the deep end on my own... i recommend finding out how long of an orientation you get because i really think it is crucial.

6 weeks....is that a typo? New grad ED orientation at my hospital is about 18 weeks.

To the OP: sometimes people like to have opinions on things they have no expertise or even experience in. This seems like one of those cases. The ER is not for everyone, and some folks would truly hate working there. That doesn't mean it's a bad place for everyone or that we're "set up to fail" whatever that means.