Help! I am failing orientation.

brainkandy87 · Apr 21, 2012

Well, one major problem with you being able to prioritize and manage time properly is that you are a new graduate. You haven't seen anything in a clinical setting. Nursing school clinicals, in my opinion, don't prepare you to manage time with a full patient load, especially when you go straight from school to ER. You have to prioritize pts that you wouldn't think were a priority because you've never seen that disease or situation before.

I started on a step down/tele floor before I transferred to the ER. I could do anything cardiac and could tell you what any EKG/tele rhythm was, etc. A nurse I worked with that was an ER nurse for 20+ years told me before I went down to ER that my biggest hurdle in ER would be identifying what to do with the small stuff. And he was right. There's stuff going on in the ER that never makes it to the floor that can be emergent, e.g. testicular torsion.

Anyway, I think my best advice, coming from someone who's been through what you're going through, is to keep grinding it out. Never stop learning. Seriously, try to get your eyes on all sorts of patients, not just the critical ones. Don't just watch what other nurses are doing/asking, but also what questions the docs are asking. If you stop and listen to what questions the doctor is asking, even if it's a disease process you're not familiar with, you can identify what the doc will be looking for and anticipate what you'll need to do for that patient. When you can do that, your time management and prioritization gets easier. You're no longer waiting for orders, you're already getting things taken care of because you KNOW what will be ordered. (I'm not saying go give Dilaudid without an order though )

Good luck! Keep trying and don't let it get you down. If you feel overwhelmed, take a breath and keep your head on.

missnurse01, MSN, RN · Apr 21, 2012

you can always ask to also precept with another nurse, their style of teaching might be better for you. you can also ask for more time to orient. hopefully they will start you out with only a few pts at a time as you are learning your groove. ER can be a trial by fire, I remember well when I started! remember that this area is super focused, you focus on what is the cheif complaint, not try to remember that they had a toe amputated when they were 10. you can do it! good luck!

Robublind · Apr 21, 2012

I seen a preceptor like this before. Information overload. This is someone you want to know after orientation to ask questions. Try a different preceptor.

1) see the new pt first, discharge pt last. If you discharge a pt before you see the new pt, you will end up with 2 new pt. Do the workup on the new pt first then discharge the old pt.

2) Get a urine sample as soon as possible, like when the pt is walking in the door. I wish they would have a guy at the door handing out cup with a sign "Welcome to the Ed, we deal in pee, pay up".

3) If are in a pt room giving a med or starting an IV reassess your pt.

nurse2033, MSN, RN · Apr 21, 2012

I agree with robublind. Hate to say it but I will sometimes I hang on the that discharge patient to get some important stuff done on the other patients before they drop a new one in there. Get the easy stuff done quick so you can focus on something that will inevitably take up a lot of time. Don't be afraid to ask for help when things get brisk. Things are unpredictable in the ER but that's why we love it right? Embrace it and hang in there. I try to always run through the status of my patients in my head constantly so I don't lose track of what each should be doing, i.e. headed to CT, waiting for labs ect. Make each trip into the room count so chart vitals, reasses, give meds and so on all at the same time.

GleeGum, BSN, RN · Apr 21, 2012

i agree with the above also. what i often do during part of my orientation with new grads is have them at my side *all shift* (except lunch and bathroom) and they may help with stuff while we are doing something together but the point is that they see and i can explain why i do things in the order i do them. i explain my decision making rationale. i don't ask them to get something or do other small tasks, i use those opportunities to talk out how to not miss the small things so you don't waste time on them.

BostonTerrierLover, BSN, RN · Apr 22, 2012

I would just say communicate these things NEXT SHIFT with your preceptor, I have precepted New ER Nurses (Our ER is in a Teaching Hospital that Requires at least 1 year floor equivelent experience) and at the last day they tell me their not ready to be independent without ever telling me "Where" their worries/weaknesses/needs lied? They cannot read your mind.

Make a list of what you feel are your strengths, and then your weaknesses. Go over them with your preceptor/ER NM. ASAP!

Computer Charting?

Medication System/Administration?

Admission/Discharge Paperwork/policies?

General Process/Practice?

Triage?

Location of supplies/paperwork?

Chart Preparations?

Lab/Procedures?

I don't want to start a fight with this, but after working the floor 2 years, ER was a breath of fresh air! I felt like I found the fountain of youth. I felt the same way in Intercity Level I Trauma Centers- all the way to Rural Critical Access Hospitals. What I am saying is, You will find floor Nursing just as Overwhelming, but it sure does let you get alot of Nursing Practices Mastered, so when you do go to ED- you just have to learn the cultural/procedural differences.

That said, It depends on the person as to if they need that year or so of floor nursing, but for a new grad without former ED experience- I think that is a little risky (but to each his own- I don't want to press my beliefs or feelings on someone else's life), but you will definetly need OPEN and FREE communication between you and your supervisors to succeed!

Good Luck!

:redbeatheBoston

amzyRN · Apr 22, 2012

Thanks so much everyone. I meet with my preceptor and nurse educator soon to discuss strategies to help me. I am going to make a list of all my strengths and weaknesses and talk with my preceptor about going over his reasoning more thoroughly, like why exactly he does things in a certain order, how to bundle tasks more effectively, and the order of discharging. I guess if they are interested in hiring me, they might have to extend my time. There has been a lot of people not passing orientation recently, it might be a good opportunity for them to modify their own methods of orientation, so they can retain staff and cut costs.

LynnLRN · Apr 22, 2012

Some people just need a more structured work environment. ER is not for everyone.

amzyRN · Apr 22, 2012

That's true ED isn't for everyone, especially many new grads. I might be one of those people that needs a year or more of med/surg (or something else) to improve my confidence base and basic nursing skills. I love the ED though and I've been very fortunate to be at a good facility and work with great staff, so it would be great to be able to pass. I'll try my best and if I don't pass, I will have something to strive toward.

NO50FRANNY · Apr 23, 2012

Your awesome attitude has inspired me to respond. I am one of these crusty old nurses who thinks it is really tough for new grads in emergency and hate seeing them struggle and have their confidence shot. It's just my opinion but I think a year or so of ward nursing gives you good grounding to move into a specialty. I dish out helpful hints for our new grads wherever I can so here are a few. Save yourself time by learning by heart some commonly prescribed drugs, including IV AB's so you don't have to look everything up. On the floor you have an 8 hour plan, in Emergency, it should be a 10 minute plan. Do everything that you can think of for each patient one at a time- for example, if your patient needs an ECG, vitals, bloods, pain relief, urine do the lot before you move onto your next patient where possible. Don't think, oh, I'll do that ecg after I do vitals on Mrs H, just do it. Like the little old lady who fainted, I will usually be doing her ecg before I even write a story, and her urine spec will be cooking while I write it. Ask your colleagues what they think the pt. will need, learn to anticipate.

If you know your common presentations and likely investigations you can anticipate nursing responibilities and complete tasks before being asked and there are some great pocket resources you can use. For example, the pocket book will list a presentation"PV bleeding + abdo pain 7/40"- vitals, bloods and cannula, pain relief, urine, fluids, if you know they are going to need it, get the doc to order it, don't wait- these pocket books list it all out for you until you know off the top of your head. Anticipating saves you time in the long run because doctors aren't pestering you for things, they're already done!. Tell your patients what they can expect while in the ED, tell them how long the blood test results will take, how long you think they will be in the department, they will trust you, and be less likely to hound you with questions. Pick up the pace, the tempo in ED can be overwhelming and I know for me, the hardest thing was upping my pace, just had to work faster, chat less, prioritise. You can get an entire pt's story walking them to the bathroom for their urine sample. ABC PAIN.

Can't think of any more right now, but stay positive and best of luck.

CrashED · Apr 23, 2012

The ED is a hard place for any nurse to go. The style of nursing is completely different. You need to be able to prioritize, recognize problems, emergencies and acuity. Some new RN's have trouble with it, but eventually it gets easier. I came from Acute care ICU stepdown and went to Emerg...(Frying pan to the fire!)....And one seasoned nurse told me "If you are comfortable and feel safe in your first year here, give your head a shake" it takes a year or so to get your groove on in the Emerg Dept! Whether it be a small center or a large one! Emergency Nursing is not for everyone, but don't jump ship and give up on yourself before exploring other education options and preceptors!