First job as an RN in the ER

danggirl16 · Jul 4, 2014

First, congratulations on your internship! I'm excited FOR you! OK, so I'm cheating because I've not been a new nurse with a first job in the ER however I have been a preceptor for three ER nurse interns and have also watched as another one was trapped with a not so nice preceptor. So, I can't tell you what it feels like but I can tell you what they have told me and also maybe some advice.

If you have worked in the ER before, remember (sounds funny but...) you are the nurse now. I say that because staff see "intern" and think they can use them as their personal assistants AND if you've worked in one of those roles, sometimes it's hard to draw the line.

Make sure you and your preceptor have an opportunity weekly to sit down and discuss how things are going. Your preceptor may think you are doing an excellent job with something and you might not feel so secure...don't be afraid to bring up what is bothering you, what you need, what you think is working well and what you think could improve.

(**add in: if you are having problems with your preceptor that you can't resolve, next step is talk to the nurse manager...your time as an intern is valuable, you don't get it back once its gone. It is imperative that you work well together and you are getting the training you deserve)

Push the envelope, step outside your comfort zone but don't make yourself sick over it. As a preceptor sometimes we push toward independence and you'll think "oh my gosh, I can't do that, I've never done that, I don't know how to do that, I don't WANT to do that!!" If you are super anxious, don't NOT do something and miss the opportunity but DO let your preceptor know how you feel so she/he can reassure you that you are not alone. This is the time to do the uncomfortable things while you have solid backup.

This goes for all areas but it is so very important in the ER because the pace is rapid and the patients are acutely aware (unless they aren't!) of what is going on: Project Confidence. Always. Yes the patients can read your name tag and know you are an intern but they have no idea of your experience. Even if you are quaking inside, move with a purpose. No sick person - no matter what they say - wants an insecure nurse, especially a new one.

If you don't know something, ASK before you do it/explain it etc. There is no shame in asking and no shame in not knowing something but there IS a whole lot more than shame if you don't ask and the patient has a bad outcome.

Wear your armor to work: in other words, don't take things personally. People will say and do things that will hurt your feelings or embarrass you but do not take it to heart. The fastest way to undermine your self esteem and confidence is to take things personally. Patients can be extremely hateful and spiteful either because they are sick/frustrated or they are just that kind of person or they are testing you. Keep your cool and remember, they do not know you...it could have been anyone.

Don't let your preceptor do too much but don't let them do too little either! I inherited one intern partway through her time and she had not yet taken even half a group. Her former preceptor was impatient and just wanted to get things done (shouldn't have been precepting) so she basically had the intern follow her for those weeks. By the same token, your preceptor shouldn't be doing so little that you are drowning and she is sitting at the desk chit-chatting.

And the last thing I can remember my last intern telling me: don't be intimidated by the other nurses. She said she felt stupid and inadequate around everyone until she realized that no one thought that way about her. The thing is, everyone else has more experience than you...it's a given. Everyone knows you are new. You will frustrate yourself to tears if you constantly compare yourself to other nurses in the department. (on the flip side, be respectful of other nurses. You might think you know everything or that you are better because you are younger or have more recent education but you will only make enemies by displaying that kind of attitude)

Relax and make the most out of your time as an intern. It is a learning experience, not a competition. The ER staff is generally a team...your preceptor is helping you prepare to be a part of that team.

Good luck and welcome to the ER!!

JMD14 · Jul 5, 2014

Wow thank you so much danggirl16. You have really good advice and I will definitely keep everything you said in mind. I start tomorrow and i'm excited but of course i'm still nervous:eek:. I've never worked in the ER, but i've had clinical rotation for 3 days in the ER (which isn't much but was enough time to know that the ER is where my heart is). I haven't met my preceptor yet but i'm hoping whoever it is, they will be nice and willing to help improve my skills and teach me whatever i'm not so competent in. After tomorrow i'll let you know how it goes! Thanks again! You're words of advice couldn't be any better. :)

Guests · Jul 7, 2014

Hopefully your preceptor will cover this early on but if not, here it is:

Be very conscious of your safety. The ED can be a dangerous place.

Patients and families can become violent with little warning. We've had nurses get their bones broken, be bitten, be scratched, be spit upon, be punched, be kicked, etc.

While the docs are responsible for their sharps, recognize that they're not 100%... be very careful when they're doing things like central lines, chest tubes, etc where their are scalpels and needles around.

Wear your PPE...

BrnEyedGirl, BSN, MSN, RN, APRN · Jul 7, 2014

Congrats JMD!!! I have been in a level I trauma ED for almost 10 years now,..I did not start out in ED but I do precept new grads as well as experienced nurses new to the ED. It can be done and done well. I hope you have an extended orientation period (our new grads get 20 weeks). It takes time to just get the feel of how the ED runs. I agree with danggirl's post. The ED has a different focus and a much faster pace than the rest of the hospital, that can be hard to adjust to at first. Another big thing I notice with new grads, there is a fine line between coming off as confident and just being cocky. I know that during interviews we look for confidence, but more than once that confidence has morphed into a "cocky, know-it-all" attitude and these people are fired post haste. The ED is fast paced and no one wants to work with the know-it-all who makes stupid mistakes. We all expect new grads to ask questions, even the same ones over and over,...I encourage my new grads to think out loud, let me know what your thought process is! Ask questions, repeat back instructions and never be afraid to say stop I'm not sure about this or that! Good luck to you!!

tarotale · Jul 7, 2014

Hello I want to tell you that you have been truly blessed to skip the medsurg part like many people and delve straight into specialty you want; I have 1yr ms experience and will start my ED internship in 1 week and so so SO excited like you! Big boys and girls play in the big league: ed, and I always admired ED.

I remember being pretty nervous as intern at even a MS unit where people are generally more stable than pts in the er, so my pt care experience will really help me on at least how to interact with pts and families , but you a brand new RN into the den of wolves!! I won't lie to you so yes be ready to be nervous and I can only imagine pts and families only more frustrated and wild in the ED.

I'm blessed to be pretty confident but as browneyedgirl says, always ask about everything. I didn't even know how to prime a tubing when I started and I asked about anything everything I wasnt sure of.

My personal recommendation to you in this field however. You will meet lots of people, some respectful and some very disrespectful. If it's your manager, MD, PA, NP, and someone above your hierarchy, take the crap within reason (which will be most of cases unless they are hitting you or telling you to do something illegal) . But if someone equal to or below ur hierarchy gives you funny attitude, you confront that bs right there and then (no cursing or yelling however, but be very clear and firm you aren't to be messed with). But still be initially respectful to everyone starting from janitors to doctors, until someone under your hierarchy give you a reason not to. I see that a lot of nurses are little wishy-washy about this and don't project it, and it only works to your disadvantage; some lab techs will throw away your blood sample if you put wrong date, and all you need to do is breath fire down their neck to change them to say "can u come down to re-label this lab?". Cockyness is definitely bad but being a pushover especially at ed is probably a bad idea. This really helped me in my practice and allowed my coworkers to trust me as a comrade since confidence is a desirable trait.

I hope I didn't sound crazy giving this advice lol, but to me, social skills were as important as skills in a way at work. I had become friends with some providers, nurses and charge nurses, and that makes the job so much easier.

I hope you have great time in your internship and work with the best preceptor. Mine is 13 wks and ed is a privilege to be at!

JMD14 · Jul 9, 2014

All of you are so helpful! I really appreciate the time yall have taken to help me out! Last sunday was my first day on the floor. Before starting the shift I felt extremely nervous and started doubting myself. However, not even ten minutes after I clocked in, I felt wayyy better and more confident. My preceptor is awesome and very helpful. That was definitely a relief! I couldn't have had a better day, I got to practice a lot of skills and if there was anything I wasn't sure of, my preceptor would explain each step to me and demonstrate it as well. I even got to respond to a code blue. Overall I'd say I had a great day and with the help each one of you have given me I will feel a lot more confident from now on. Thanks guys!

RN2014g · Jul 16, 2014

Thank you for this post. I just passed my boards and start in the ER Thursday night. I have a passion for ICU and ER nursing. I've done some clinicals in the ER, but I am terrified right now. I know what to expect for med-surg since 90% of my clinical experience is there, but 4 days in the ER as a student was not enough. Like a few of you have said, I am starting to second guess myself and my abilities. The unit manager fought to get me in the ER since they do not normally hire new grads, so I guess they saw something they like during my time there. I hope this goes smoothly. Reading your advice has helped calm some of my anxiety.

JMD14, any tips or advice now that you have been there a few more days?

GinRN777 · Jul 18, 2014

Watch the experienced nurses. Realize that the more you know, the less you know. Jump into every opportunity to start that IV, insert that NG tube, and trust your instincts. I can't tell you how many times I had that "gut feeling" - epiglottis in an 18 yr old- yes it happens and no she wasn't drooling!!!

Congrats on making it into the ER - I love every minute.

JMD14 · Jul 22, 2014

Thanks for the posts guys. I have now worked 8 days in the ER and absolutely love it. RN2014g, I started with an extremely nervous mindset and felt like I wouldn't be able to do what it takes. However, after a few days I began catching on and loving it. Don't ever underestimate yourself, as long as you are willing to learn and step up to the plate then you'll do good! It takes time to build confidence, but everyone has to start somewhere. Just think about the experienced nurses who have been working as a nurse for years; every single one of them were once a new grad nurse who felt exactly how we do. No one expects a new nurse to start their first job knowing everything. The best advice I can get is to ask questions for anything and everything you don't know. I got lucky enough to be paired with an awesome preceptor but even he gets annoyed with all the questions I ask. It's just something you have to do, they are getting paid extra to prepare you to be a competent nurse so ask all the questions you need to regardless of your preceptor's attitude. It's your license, not theirs.

LJ85, ADN, BSN, CNA, LPN · Aug 2, 2014

I have an interview with a panel of ED nurse preceptorship next week. Does anyone recommend any specific questions to ask them?

JMD14 · Aug 3, 2014

There is a number of questions I wished I would've asked as soon as I left my interview. Here's a list of what you might want to ask:

1. What is the Nurse to patient ratio? Is it a set ratio or does it change?

2. What computer system does the ER use (epic, meditech, etc.) or is it paper charting?

3. How long is orientation and how long will you be with a preceptor.

4. What type of scheduling system do they have (is it a matrix where you work specific days each

week or is it random)

5. During orientation will you get paid the rate at which they hired you or do they pay you a

stipend during orientation (stipend is a set pay rate some hospitals pay orientees for the first 3

months or until orientation is over)

6. Do they help pay for school (if you are planning on getting your BSN or Masters)

7. Do they accept overtime.

I'll think of more as they come to me. Hope this sort of helps for now.