ER Orientation question

  1. Hi all,

    I recently accepted a position in an emergency room at our local hospital. Right now, census is about 150-200 patients a day. I have about 7 months experience as a cardiac ICU nurse and i'm curious about a few things.

    1. Do most ER's have standing orders/protocols?

    2. I've been told I'll probably end up having 5-6 patients at a time once all my training is done. How does your nurse to patient ratio relate? Do you think that's a too many? (We're not a level 1 trauma center.)

    3. I'm artistic in terms of personality and I don't learn in the way most people do. Any tips for orientation? I realized in the CICU I was quite different from most of the other nurses and I tend to be really hard on myself as a result.

    4. How do you continue to learn and become confident without burdening the unit by being slower? That's my biggest concern, not being quick enough in time to show that I am mastering the job. How long do most ER's give you to develop your skills? In the CICU I worked in, I felt like while I learned a lot really fast, they expected us to be able to think like a seasoned nurse pretty early on. I am a fast learner but I also understand that fast is not always safe. What do you do in terms of staying calm and focused in the middle of a busy shift rather than feeling pressured to rush?

    I could ask a million other questions but these are my biggies right now.

    Thanks guys!
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    About HannahMarine30, BSN Pro

    Joined: Jan '17; Posts: 29; Likes: 20
    Specialty: 1 year(s) of experience in Cardiac ICU

    6 Comments

  3. by   nurse2033
    1. Probably yes. You will be expected to use the protocols when things are busy, and that's always- in the numbers you describe.
    2. That's too high. 4:1 is about right, with some patients being 1:1.
    3. Not to plug my own post but try this http://allnurses.com/emergency-nursi...f-1104760.html
    4. You will be pressured and rushed, get used to it. It will probably take 6 months to a year to get a really good handle on everything.

    We use this book in our orientation, I highly recommend you read it. Sheehy's Manual of Emergency Care - E-Book (Newberry, Sheehy's Manual of Emergency Care) - Kindle edition by ENA, Belinda B Hammond, Polly Gerber Zimmermann. Professional & Technical Kindle eBooks @ Amazon.com.

    Good luck!
  4. by   Nalon1 RN/EMT-P
    Quote from nurse2033
    Funny, I replied to that post a while back, and still think it is a good way to explain it.


    As for standing orders/protocols, it will depend on your facility. Mine does not, and it is annoying.

    1:5-6 is a lot. 1:4 is becoming the norm for many, but not all.
    A big part depends on the acuity. Some fast track areas have 1 nurse, 1 mid-level and maybe a tech with 20+ patients.
    There are times when you are stuck 1:1, and unfortunately your other patients suffer if you do not have good support.

    You know your learning style, so that puts you ahead in that part, but talk to your educator (if you have one) and your preceptor. Most preceptors are in that position because they want to be (but not all). They want you to be successful because they will be working with you when you are off orientation, and want you to be competent.

    Getting faster takes time. There is no shortcut. You will feel like you are slowing things down, that others are griping behind your back, and it is true. But it is expected. Now if after a year you are still as slow, that is a different story. It is beyond frustrating when your busting you rear and moving patients and you see "that nurse" that has had the same 4 patients for the last 5 hours and it seems nothing has been done for them (meds ordered for 3 hours, assessment not charted, screening not done, ready for discharge for a hour, etc). But if you are still new to the ER, you should get some slack from most.
  5. by   akulahawkRN
    My ED does not have many standing orders/protocols and like an above poster, it is quite aggravating at times. The previous ED where I worked had fairly extensive nursing protocols that were fairly similar to what the Paramedics use in that County with a few differences to account for resources and whatnot. Basically the idea was for a nurse to receive and triage a patient and begin providing care, order certain test/exams and so on by protocol so that by the time the provider was able to see the patient, much of the initial work had been started. Where I'm at now, the provider is one of the first people that a patient sees so they can actually put in orders quickly and many times those initial orders are in the EMR before the patient reaches a room. Where I'm at we also see between 150 and 225 patients per day. It's pretty busy.

    I'm in California so our ratios are set. Generally speaking I'm at a 1:4 ratio unless I get a higher acuity patient or I have all psych patients, in which case my ratio changes. It can be 1:1 or 1:5, it all just depends. I'm pretty lucky compared to some!

    As far as learning goes, developing a schema is a great way to learn what you need to do. At first you will find yourself thinking through each step. Being that you're now 7-ish months into being a nurse, there will be things that you don't really think at the individual step level, but more at the larger task level. As an example, I've been doing this for about 3 years now and when I'm starting IV lines, I don't think about all the steps, I just do it with some discrete consideration along the way. I'll first do a quick look at the patient to see if they've got small-ish veins or huge pipes and I'll look at the orders or I'll pull from other schema as to what may be required and adapt from there. I've had patients that can't take IV lines in either arm because of dialysis shunts or I have to use a single arm as a result of cancer treatment, so I adapt to that. I'll start IV lines pretty much anywhere that I can get one.

    Finally, while I'm usually pretty darned fast at what I do, there are times I fall behind my ideal schedule for getting stuff done. This may be due to getting a new patient in a room right before being ready to discharge a patient or before being able to take a patient to an inpatient room so they sometimes have to wait for me to finish the initial stuff that needs to get done. If I'm lucky enough that there's an available nurse or tech to transport a patient or a nurse to discharge a patient while I'm working on that new patient, then I pretty much dance a jig mentally and keep going. Otherwise what I do is get things started and then go to the next least time-intensive task (often discharge) and then to transport.

    What I also do, because of the nature of ED nursing, is that I help out whenever I can and my co-workers help me out whenever they can because while we're all primarily responsible for our own load, we're a team. That's the biggest thing right there. You're not alone there. Others will know you're learning how to be an ED nurse and know that you're going to be slower for a while. Speed will happen but you have to work a little at it. Just remember the old adage that slow is smooth, smooth is fast, therefore slow is fast... Do things slowly and smoothly and look for ways to economize your movement while remaining smooth. Eventually you'll be pretty darned fast and smooth but you won't feel like you're rushing to get stuff done. You'll just be naturally working at a faster pace than you realize.
  6. by   PeakRN
    1. Do most ER's have standing orders/protocols?

    Typically yes, but what they are depends on the department.

    2. I've been told I'll probably end up having 5-6 patients at a time once all my training is done. How does your nurse to patient ratio relate? Do you think that's a too many? (We're not a level 1 trauma center.)

    How many patients you have also varies from ED to ED. Typically I have 2-4, but we turn over patients quick. I have had 7-8 patients on certain nights but they are mostly drunks that are metabolizing.

    Don't assume that not being a level 1 doesn't mean you don't get traumas or sick patients. I have had more than one patient walk in (and countless homie drop-offs) with multiple GSWs or Stab wounds to the T-Shirt/Boxer zone. Trauma level also won't dictate the level of sick medical patients that EMS brings you.

    3. I'm artistic in terms of personality and I don't learn in the way most people do. Any tips for orientation? I realized in the CICU I was quite different from most of the other nurses and I tend to be really hard on myself as a result.

    Be ready to learn, the flow of information will be immense. Don't be afraid to ask for help or another explanation if something doesn't make sense.

    4. How do you continue to learn and become confident without burdening the unit by being slower? That's my biggest concern, not being quick enough in time to show that I am mastering the job. How long do most ER's give you to develop your skills? In the CICU I worked in, I felt like while I learned a lot really fast, they expected us to be able to think like a seasoned nurse pretty early on. I am a fast learner but I also understand that fast is not always safe. What do you do in terms of staying calm and focused in the middle of a busy shift rather than feeling pressured to rush?

    Feeling calm in crisis takes a while to develop, but there is also a mentality to it. I want everyone to have a sense of urgency but not panic. Rash decisions result in mistakes, and often took longer to make that if you took a few seconds and a deep breath.
  7. by   Sally Jane
    Er nurses are the best, you learn so much and your work is so important
  8. by   HannahMarine30
    Thank you! I bought the book you'd mentioned.

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