How did you get your ER position?

bgxyrnf, MSN, RN · Dec 25, 2017

For all those ER/Trauma nurses, how do you manage to get a Trauma RN position immediately after nursing school?

I didn't... so perhaps my journey is irrelevant to you. However, I did end up in the regional pediatric and adult Level 1 trauma center, so maybe my journey is relevant.

In my case, I wasn't in a position to be picky about jobs after graduating so I took the very first offer that came along... at a tiny critical access facility in a deep, rural community... as a med-surg nurse... with mostly low-acuity patients... and no trauma at all. Further, the job paid terribly and was more than 200 miles from home... but, I figured that I just needed to start somewhere and go from there.

Rather than looking for a specific path, I followed the universal path to success: I arrived to work a bit early every day; I worked as hard as I could... doing not just those things which were my responsibility but anything that I could see needed doing; when I had the time, I freed aids to do other things by doing the dirty work myself; I was friendly and upbeat as much as I could be; I was flexible and accommodating; I refrained from complaining as much as I could; I learned as much as I could as fast as I could; I read medical books voraciously and I paid for my own training classes: TNCC, ENPC, NRP.

After a while, I gently let it slip that I was interested in more opportunities and finally was offered the chance to orient to the ED... but only if I changed my schedule around to help with some personnel issues. I agreed and got to orient for a few shifts before the personnel issue solved itself and I was left where I was and got no further ED orientation. Still, I didn't complain but simply did the job to the best of my ability.

Several months later, there was a resignation and the ED job was offered to me. I wasn't really qualified and recognized that I might flame out badly but figured that it might be my only shot so I took it and continued my active, adult learning and sought to take criticism as well as I could... and boy did I take some from the docs who were teaching me the job (did I mention that I was the *only* nurse?) I went out of my way to connect with other people... the CRNA, the surgeon, and the OR staff... just for exposure and learning.

Eventually, the nurse whose vacancy I had filled in the ED contacted me about a per-diem job at her new employer (remember that part about working hard, being helpful, and getting to know people?) and I was ultimately offered a job there. Now I had Level None and Level 4 experience. I just kept at it and kept learning as much as I could.

After a while longer, I finally secured a job at a Level 3 trauma facility followed shortly thereafter by a job at a Level 1 facility. It took me 3 years and 100,000 commute miles but I did ultimately make it.

I have no idea what kinds of short-cuts you might find. There are not many new-grad positions in the busy Level 1 EDs... there are a few but not many.

PeakRN · Dec 25, 2017

What do you mean by a trauma position? Do you want to work in the ED of a level 1 or be a nurse that is part of the trauma program? What do you mean you have a passion for trauma? Do you like the initial stabilization, the ongoing critical care, or the (most important part) prevention and outreach that trauma programs do?

Many level 1 trauma centers have a distinct trauma program that is ran by nurses with decades of trauma/surgical ICU experience. Often these level 1 centers will send down a trauma nurse from their trauma/surgical ICU and one of the program coordinators to all of their trauma alerts. What the ED nurses and the trauma nurses do varies by hospital, but the more people in the room the smaller the slice of pie you are going to get (these hospitals also have the trauma surgeon, trauma PA, (and often) anesthesia, RT, pharmacy, and an OR RN show up; and more medical students, residents, and fellows than you knew were in the hospital show up too). The honest truth is that you will not be hired into this as a new grad, these programs often only hire after years of ED and Trauma ICU experience.

If you want to be an ED nurse new grad spots in level 1 centers are hard to come by, but they do exist. One of our sister hospitals (that is a level 1) hires about 4 new grads a year, but it is an extremely competitive process; ironically they do not see the most trauma in our system and nobody wants to work at the hospital that does. You can search out these programs and apply to them, having courses like TNCC, ENPC, PALS, ACLS, NIHSS, et cetera will make you more competitive but by no means are a guarantee (keep in mind you are applying to be an ER nurse, not to work only traumas). If you have experience as an EMT or Paramedic this would be a huge competitive advantage, but you need to have the field experience not just the certification. There isn't really a secret, you just need to get out there and hustle.

If you really want to see trauma and participate in their care I would advise one of two routes. One is to apply to an trauma/surgical ICU, you will learn the physiology and participate in their care. Traumas don't become instantly stable after we apply some band-aids in the ED and send them to the OR, they often get worse and need real critical care for an extended period of time. If these patients have enough of a cardiac or pulmonary insult they can end up on ECMO, if they go into renal failure they can end up on CRRT, they may require tubes in places you didn't know could drain, and the other countless interventions that are administered in the unit. If you really want to care for trauma patients I think that this is the better option and will better prepare you if you ever want to be part of the trauma program coordination or go advanced practice as part of a trauma team. In my opinion the adult ICU is also one of the best launching points if you change your mind and want to do something else.

The other option is to look at state numbers for traumas, compare it to the ED's annual volume (trauma is a ratio, the ED nurses who are caring for the baby with a fever or discharging a belly pain are not in that trauma room) and apply at those hospitals. I take care of more trauma (both in volume and the amount of care I give to each trauma patient) at my current hospital which is a level 4 than when I used to work at a level 1; this is a function of where we are in the city, that we have built trust with local EMS that we don't dismiss the drunk falls (this is our number one source of head bleeds) or any other trauma they bring us, and that our volume of non-sick patients is pretty low. We transfer a good number of cases to one of the level 1s in the city but we admit to their ICU or OR after talking to the trauma surgeon and we have already done the same stabilization that their ED could/maybe would have provided. I don't think that this is the better way to be a trauma nurse, but you will get to participate in more initial stabilization.

Once you have some experience with trauma in the unit or ED you can work on getting your TCRN as well as CCRN or CEN and then you'll have much more mobility with getting into the trauma job that you want now. Or you may find that you want to go advanced practice and now you have experience to go to school for it, or find some other direction in your career that you have not yet discovered.

Alexxoxox, BSN · Dec 26, 2017

How would I get into a Trauma/Surgery ICU? Is it possible to get into one right after graduating?

PeakRN · Dec 26, 2017

Look at which hospitals hire new grads into their ICUs and start applying, but make sure they have a robust training program. ACLS and TNCC would definitely help you get your foot in the door. If you are willing to travel that generally helps. Don't be afraid to reach out to managers, someone who goes the extra mile to talk to them looks much better than a resume that just shows up. And remember that there are some great trauma ICUs at level 2 trauma centers, and even remote level 3 surgical ICUs will be keeping some pretty sick patients. Once you have critical care experience it is much easier to move to a different ICU.

NurseyMcNurserson · Dec 26, 2017

I'd say your best bet is to work as a tech or unit secretary in that department. Be awesome, get to know the managers and other staff, then apply for an internship position when you graduate.

Editorial Team / Moderator · Dec 26, 2017

I was (am) a paramedic and I worked as an ER tech, and I made myself an asset so they wanted to retain me as an ED RN when I finished my ASN. I continued my education and achieved board certifications (CEN and CPEN) and finished my BSN. Then I was chosen to commission into the Army as an ER/trauma nurse. My time in Afghanistan with a Forward Surgical Team (FST) really shaped my love of trauma, though I had also worked in Level 2 for a bit as a civilian nurse and knew that I loved trauma. It's also a large part of paramedic education, and I was an International Trauma Life Support (ITLS) instructor for a bit for prehospital providers. I also obtained the TCRN board cert in 2015. I am now 100% in a trauma role as an educator, and I love what I do. I also teach TNCC, which is a great course; I am kind of on the fence about newer nurses taking TNCC, I feel like you need some actual time as an RN first.

Definitely consider which part of the trauma interests you most, from resuscitation (ED) to physiologic restoration (ICU) and even rehabilitation (inpatient rehab). What experiences have you had that make you say that it is your passion?

SpankedInPittsburgh, DNP, RN · Dec 26, 2017

I didn't. I had to work as a floor nurse for a year & then applied to the critical care class offered in our hospital. After that I was assigned to the ER at my request

PeakRN · Dec 26, 2017

Since we are talking about trauma I want to throw out my thoughts on new nurses taking TNCC. TNCC is not an easy course by any means, and having more experience will help you to get more out of the class. Being able to actually understand what your assessment findings and interventions are will help when you are learning the trauma nursing process and the why behind it.

That being said TNCC is a 'core course' and does not replace ATLS or any of the other advanced trauma courses, nor having your TCRN. I view ENPC in the same way, it does not replace taking further education or having your CPEN and it is very much an introductory course. Having TNCC did not stop me from taking the other trauma classes or eventually getting my TCRN.

The system I'm a part of which has hospitals that range from level 1 through 4 as well as some non-trauma center hospitals requires TNCC before RNs can participate in trauma at any of our trauma centers. We also push further trauma center education related to each hospital, for example my hospital specializes in pediatrics, high risk OB, and transplant/oncology so our CE is geared towards that. Our level 1 center pushes their process of very rapid stabilization and taking the patient to the OR. One of our level 2s is right on a section of the interstate that has a ton of high speed MVAs so they get a lot of education on that.

Some systems will have their own introductory courses for trauma, especially large independent trauma centers and the military, but they also eventually have staff take TNCC. I think that this is a great option, but for smaller hospitals or systems that have a large disparity in their trauma cases between hospitals it is much more difficulty to successfully implement, it is much easier for us to teach TNCC to everyone at the beginning.

The Lady Kate · Dec 27, 2017

I was a floor nurse first at level 2 community hospital. I made my connections but unforntunately that particular hospital did not take any nurses that don't have prior ER experience, even floor and icu experience. So I applied to the busiest and biggest trauma center (a level 1) in my area to get experience and they took me since I had floor experience already. They do not hire new grads. If I were you I would just make connections now and apply to any ER that has new grad residencies. Good luck to you!

Editorial Team / Moderator · Dec 27, 2017

Some systems will have their own introductory courses for trauma, especially large independent trauma centers and the military, but they also eventually have staff take TNCC. I think that this is a great option, but for smaller hospitals or systems that have a large disparity in their trauma cases between hospitals it is much more difficulty to successfully implement, it is much easier for us to teach TNCC to everyone at the beginning.

Yes, I developed a trauma course for new hires at our center as well as an initial push of training for the current staff. We ultimately require TNCC for nurses in certain areas (ER, ICU) and it is optional but encouraged for others (OR, PCU).

I have had some new grads come through my TNCC courses and completely rock it. I have also had experienced nurses bomb the course (but that usually has to do with lack of preparation, though I stress to them that it's not an easy course). Our nurse residents are now getting TNCC and ENPC early in their residency, before they go to their respective areas. Not a fan, but I don't make the rules.

Do you teach TNCC, PeakRN?

PeakRN · Dec 28, 2017

Do you teach TNCC, PeakRN?

No, I prefer to do our prehospital outreach and community prevention programs.