ED after ICU?

Kyrshamarks, BSN, RN · Apr 25, 2018

17 preceptor in 6 months? something not right there.

Sour Lemon · Apr 26, 2018

Hello!
I need some perspective. I'm a semi (?) new nurse. After starting int he PICU and a 6 month orientation and 17 preceptors, I decided to leave due to safety issues, lack of support, and bad unit culture. The unit kind of broke me down and destroyed my confidence as a nurse.
I'm now in the process of finding a new position with my eyes set on ED nursing; however, I fear that if I don't do well there, I dont think I can recover as a nurse. Am I aiming too high? I know that ED nursing has a specific personality type and need thick skin.
I really love the ED due to the mixing of different clinial presentations and psych patients.
Please give me your feedback and experience starting anew in the ED from a bad prior experience.
Thank you!

It could go either way, but I'm under the impression that ER can be chaotic. If you've already had a chaotic experience, didn't relish it, and feel like your next experience is going to make or break you, maybe something safer would be better? You could always transition to ER after you find your footing.

pkstien · Apr 26, 2018

FNKA, I had a similar experience to you. As a new nurse, I had started in a MICU and just wasn't fitting in and decided to leave after a few months. I was really disappointed and lost a lot of my confidence, too. I really wanted to stay in the ICU setting, so I ultimately decided to stick with it and found a different job in a different city- and I flourished! Of course, I didn't transition into ER nursing, so I can't say what it's like to be an ER nurse. But if that's what you would truly like to pursue, then I say go for it! Just because you had a bad experience the first time around, doesn't mean you will the second time. Hope that helps!

Guest219794 · Apr 26, 2018

Your question really has nothing to do with the type of unit.

You will be best off going into a unit that is well prepared to train new nurses. Some ERs are, some aren't.

ruby_jane, BSN, RN · Apr 26, 2018

You will be best off going into a unit that is well prepared to train new nurses. Some ERs are, some aren't.

^Bravo!^

Prioritize going into a unit where their main goal is to safely precept you into a competent nurse. Acuity in the ER and the ICU are both pretty high. Were you having a problem adjusting to the acuity? I know I did on the medical ICU where I started. As you look around, identify your strengths and weaknesses. Need help prioritizing? Try to find a CE course about prioritization. Join the professional nursing group of the area you want to specialize. Mr. Ruby Jane worked at a small rural ER right out of nursing school. He didn't get to see all the different kinds of trauma (those went to the level 1 trauma center over the bridge) but he became an excellent ER nurse.

My preceptor used to say "The ICU's not for everyone." She said it in the most patronizing way possible but she was right. It's not a reflection of you or your nursing skills. Good luck.

FNKA · Apr 26, 2018

Hello! Thank you for responding.

I didn't have problems with the acuity. I actually loved the high acuity, but the unit culture and lack of a proper orientation made it really hard for me. I also think my prioritization needed work; i often found myself running around all shift regardless of what was happening.

Maybe the ICU isnt for me; it sure isnt right now. I think I'm just worried that after my confidence has been shaken pretty badly that starting in another high intensity area with a large chance of failure will hurt my career.

FNKA · Apr 26, 2018

Thank you pkstien!

Im sorry you had that experiene as well. Would you mind telling me how you transitioned? I'm trying to weigh my options going forward.

Although I know that the second time likely wont be as bad, I know that ED nursing tend to have a certain personality type and need of thick skin.- to be honest, my skin is pretty thin after the stint in the PICU

JKL33 · Apr 26, 2018

Hello FNKA,

Sorry to hear of your experience.

I know that ED nursing tend to have a certain personality type and need of thick skin.- to be honest, my skin is pretty thin after the stint in the PICU

This will affect you wherever you go. That's both good and bad, meaning that if you can kind of put it behind you a little bit, your options are open. It's only a bad thing if you let it dictate and pre-decide how you approach your next situation.

I know what people think about the ED, but the truth is that it requires the same emotional skills as other places, things just move at a faster pace on a shorter timeline. We do have hearts in the ED, we keep them in an accessible place like our pocket instead of on our sleeves. Which frankly is not a bad way to roll in nursing. We are there for the patients; we have to learn how to get in there and do our best for them whatever their circumstances (or ours). Treat people (coworkers and patients) the way you'd want to be treated, and if they can't rise to the occasion that's not your problem.

The ED isn't the destroyer of new nurses. As hherrn said, it's important to make a good decision about the unit itself. If an ED has a strong orientation/precepting program, then you just get in there and be determined to learn while going with the flow. Be a good observer of people and be committed gaining the skills and knowledge base and you'll do well.

Best of luck ~

JKL33 · Apr 26, 2018

One more thing regarding orientations:

I notice you mention above some prioritizing concerns.

Well the ED is all about that. It's the core of our careflow. And for all practical purposes, the re-prioritizing is fairly constant.

I suggest getting details about the orientation program for any position you consider. Personally I favor a system where new nurses get good and comfortable with lower acuity patients before taking on higher ones.

I know there are is a preference for getting every orientee up to speed on nearly everything (including triage) ASAP during the orientation process, but when that is the overall motivation/goal I haven't noticed it being very safe and it's definitely not good for (most) new nurses. It tends to produce a situation that is either overwhelming to the point of despair or a situation where people learn to "talk the talk" while not knowing what they don't know (unsafe).

Guest219794 · Apr 26, 2018

It really is unrelated to the specialty-

I started in ER, and got a substandard orientation.

I transitioned to an ICU with an excellent precepting/education program. Worked full time 2 years, earned my CCRN. Tried to love it, but did not. I would have if all my PTs were critical, and I didn't have to torture defenseless old people.

Back in the ER for the past 11 years, no interest in another specialty.

bgxyrnf, MSN, RN · Apr 26, 2018

It's really hard to help judge your likelihood of success given three unknown (to me) factors:

1) The details of your PICU experience and why it was such a poor fit. Six months of orientation is excellent; seventeen preceptors, not so much. I do think you need to take a good hard look at yourself and what role you, your attitude, your behavior, your skills, your judgment, and your personality played in the unsatisfactory experience because I find it hard to believe that there weren't at least a couple of excellent preceptors among the 17. A red flag is always raised for me when I hear the "unsafe" label applied by a newbie or someone who's discussing why they are leaving their first job. I'm not saying that that isn't a legitimate criticism but it is also used sometimes to deflect criticism and responsibility away from oneself onto the unit.

2) The characteristics of the ED that you might enter. I have worked in four different EDs at various levels from the tiniest, rural, critical-access facility all the way up to the academic level 1 with a dedicated level 1 peds ED attached. I'm not sure that I would describe any of them as terribly "supportive" though there were and are some very supportive people within each of them (me, included). While I am firmly of the belief that new nurses can be successful starting in the ED, it is a higher-risk proposition than most because of the pace and, occasionally, the acuity that you may be expected to handle without support. While every department has had the stated intent to support the newer nurses, that sometimes falls to the wayside as things ramp up and EMS is stacking up in a holding pattern, you have legitimate sick people waiting for hours in the WR, and you're short-staffed. Then you'll have an overwhelmed charge nurse or triage nurse directing patients to your room who are perhaps much more critical than originally thought and there you are, trying to cope.

I had a situation once with an acute GI bleed (those are among the 'scariest' patients because they can look OKish right up until they exsanguinate) who decided he wanted to leave though deemed to lack capacity, in need of multiple interventions, and a doc (legitimately) getting stressed because things weren't getting done quickly enough. I pushed back, showing him how buried I was and how hard this guy was to work with. His response (again, totally legitimate) was, "maybe you need to get some help from your colleagues." I pulled him out of the door and waved my arms across the empty pod and said, "do you see anybody who's free to come help?" He immediately understood and came in to help me out himself... while leaving his other work going undone as were my other tasks with legitimately sick patients. What made this situation difficult was that it was a gradually evolving case rather than an abrupt bleeding varices brought in code 3 hypotensive and tachycardic. Had it been the latter, I probably would have had some help when I needed it. Anybody who's spent any years in the ED has multiple stories like this. As one friend puts it, "How many times have I walked around wondering if this is the shift that ends up costing me my license?" which is, IMO, a bit overdramatic but does capture the feeling at times.

ED docs and nurses can be a pretty grizzled bunch and you'll need to pull your weight and get up to speed as quickly as you can.

When I started in the ED, with less experience than you have, I was way out of my league and I fully recognized that it could end up costing me my nursing career given the potential for catastrophic failure. I was willing to take the risk and I had the confidence that I could do it but you need to be very clear about the risk that you're taking and what you're going to do to mitigate it.

3) Your characteristics... as you can see in #1 & #2, it really does come back to you and your ability to learn and integrate and self-motivate and collaborate and investigate and...

Making the leap to the ED was the wisest choice that I could have made in retrospect but it wasn't easy and there were a number of times that it could have gone really bad but didn't due to some combination of having the right person around at the right time, some good judgment on my part, and... simple dumb luck.