I am 6 months into my new grad orientation in a big, busy ED and I feel I am falling behind the rest of my peers I was hired with. I am wondering if I should try and stick it out or if at this point realize that maybe ED is not for me.
ED is all I ever wanted while in school and at first I felt orientation was going well, my preceptor was happy with me. Recently some things have happened and she now feels I am unsafe and not ready to be on my own (which I am supposed to be in a short three more months or so). I feel that I get caught up in trying to manage all the details (is the urine sent to the lab? did I give this med? is the chart together for admission?) that I miss the big picture, so I am trying now to focus on my patient more globally.
My preceptor has a lot of criticisms of me -- she has told me I am too slow, I don't cluster care well, I don't anticipate, I wait for orders instead of completing things first. It is true that I can be forgetful and scattered but I feel I have improved a lot since I started orientation, I still have a lot of room for improvement in that regard. I always start IVs and draw labs before a provider has seen the pt, I am starting now to try and always bring fluids and if I can, the meds I think the patient may need.
I am slow to react to what is happening in front of me -- if someone's BP is going down I don't always have an automatic reaction of hanging fluids like I see more experienced nurses do. I know that is what the patient needs but somehow it is not automatic yet.
My preceptor is particularly concerned because we had a patient who was in for a septic workup the other day. The pt was nonverbal at baseline so it was hard to assess mental status, but was awake, spontaneous eye opening, etc. BP was around 140/70 and HR was around 112. Pt had a fever of 100.6. So right there he obviously qualified for septic criteria. I started a line and hung fluids, but then when the antibiotic was ordered I hung it as a piggyback on the already running fluids. She was very mad when she found out the pt had been there a long time and had not received all the ordered fluids.
I definitely feel I made a mistake, and was in the mindset of "ok, I hung fluids, check that off" rather than stepping back and looking at the bigger picture. I honestly didn't realize, and I guess this is dumb of me, that fluids are even more important than abx in sepsis. I understand now that they are and I understand why, after my preceptor explaining to me. She and my educator are upset because we have had many septic patients before and feel I should be able to handle them with ease. It is true that we have had many septic patients but I felt I was handling the patient the same as before, and we have almost never started 2 lines on septic pts. The following day I had another septic workup and this one I made sure to start 2 lines, infused fluids through one and abx through another, but the pt pulled out one IV line and when I went to start another my preceptor said not to worry about it for now because the pt was stable. I am honestly confused as to why the first patient was not stable but the second one was (I guess lack of fever/tachycardia? But I am not sure what led her to that judgement call).
My preceptor has told me that I am going to drown when I am on my own. I honestly don't know what to do because I am working as hard as I can, trying to keep up, I research things I don't understand of my own volition at home, and I am trying to be as good of a nurse as I can be at this point. I am feeling very discouraged and wondering if at this point it's time to start looking for another, perhaps less high-acuity job. Should I "get it" by 6 months? I feel my preceptor expects me to be more or less perfect by this point and I am just not there yet.
Prioritize....You seem to know what to do, you just need to get organized. What can wait?, what can't?. When I take notes and organize my day, in my head or on my papers I have things numbered according to what is most important. I reorganize my thoughts all day, along with my notes. Hats off to you for working in the ED. It is fast paced.
Your preceptor is a JERK! To answer your question, everybody is different and 6 months in a new dept as a BRAND NEW nurse is very stressful, let alone ED!
Dont feel discouraged. You got this. Trust me. Every nurse was a new nurse. We didnt just get out school knowing how to do this.
I dont understand why she chose to be a preceptor. She seems to have no patience or tact. She should've explained to you why the second septic pt was more stable than the one from the previous day.
You'll be fine. Dont leave and if you feel you need more time dont be afraid to ask for longer orientation. Everybody is different with different learning styles.
I prrobalay shouldnt be saying this but unless you truly LOVE working in the ER I would go somewhere else. Why go through all that just to get paid the same as a regular staff nurse? You don't ever really have to deal with all the headache that comes with the ER. Patients are much more stable. Maybe its just me but I couldn't handle the stress at all lol
Perhaps it's time to change the preceptor, as many here advised. I wouldn't know much about working in ER, but will try it in the near future. I'm trying to get into the hospital, and have put in a couple of applications.
Hello! I am also a new grad ER nurse (9 months experience with the hospital, 6.5 months in the ED). I am in a community hospital ED, not a large city hospital like it sounds like you are (we see approx. 40k people a year, 25 beds in ED, 100beds in hospital) so my experience may be different for a number of reasons. In my program, the 3 of us in the department were off of orientation after 3 months. Each of us previously worked as ED Techs in this same department for years, prior to becoming nurses and starting this program.
In my similarly limited experience, I totally hear what you're saying. I've found recently that it really helps me, even in situations that I feel like I understood, to read about them in my Emergency Nursing text book (Sheehy's 6th edition) after work. Even in situations that I predicted and handled well, it connects a few more dots for me every time I read about various situations.
It may help validate your progress and ease your concerns if you talk to someone in the department who you feel knows your practice thus far and also is someone who will tell it to you honestly (and is not a bullying type of coworker). Ask someone in private what they think and if they have any advice, go from there. About 2 weeks away from the end of my orientation I got REALLY nervous ("How the hell am I going to be able to do this alone!?") so I confided in a friend of mine at work. She has no interest in bullying anybody in the department, isn't the type to talk about other people, and tells it to me like it is. She gave it to me straight and it eased my concerns. She basically said... you'll never know everything in medicine and nursing, you just have to be safe and know when to ask for help. I knew (and still know) when to ask for help.
Whoa, lots going on here. I'm not sure this preceptor has the right training for the job. It takes an entirely different skill set to precept/train than we learn as nurses and it takes a lot of practice to get good at it.
Ive been in the ED for 6 months now and feel competent no matter what they throw at me but I had ED tech experience, prehospital experience, and 2 years of very high acuity critical care experience as an RN. This is after being tested with sick patients on pretty much every shift since I've been off orientation and I would still defer to my preceptor as the better nurse every time because she has a lot more experience and ER knowledge than I do (basically she is a better ER nurse than I am right now).
Our new grads get 6 months minimum of orientation with a ratio of 4:1 max, 2:1 max ICU, and then get full support from management and the hospital for another 6 months. They told our managers that 6 months might not be enough when they were where you are now but they have turned out just fine. They know what they are doing even if they didn't trust that they did. Our preceptors are not negative like yours sounds because they were selected as good candidates and trained to precept.
I guess im saying stick with it and trust in yourself and in what you know. I wouldn't give up on the ED yet, maybe just that preceptor/that ED if it doesn't improve. Also, Shehy's makes a great emergency nursing manual to help see bigger pictures and know how to treat the patients walking/rolling through your doors.
Specializes in ER - trauma/cardiac/burns. IV start spec.
Times have changed. You say a big, busy ED, what does that mean.
I had 2 weeks of orientation on days per hospital rules (that were changed to 8 weeks later however if a nurse cannot function solo after 12 weeks they are out of the ER) but after 6 days my "preceptor" (who was day charge) OK'd me to go to my designated shift which was nights. My first overdose (on my first night shift) was a pyridium overdose that no one had ever seen before not even the ER doc on duty. We both went for the medical books but I got there first. Ever pushed methylene blue on a patient? From there I was on my own. At 6 months in I was pulling occasional night charge duties and at one year the night shift nursing supervisor was calling me to help with problem IV starts upstairs and was helping cover problems that came up in the ER so they could focus on other problems. Just on nights we averaged 40 patients per hour (8 hours shift) not counting the leftover patients from evenings. No small feat with 5 or 6 nurses.
If you love the ER stay and stick it out. Read, read and read. When criticized ask what, why and how their assessment differed from yours and be prepared to just move faster. Be able to give report on all your patients at a moments notice. I once got chewed out by my nurse manager about the time I spent on an ortho patient being admitted for surgery. The patient needed a splint and because of the joint involved I did the splint myself. After she was done I asked how the physician felt, she begrudgingly had to tell me that he wrote a letter of commendation for my splinting job. She did not want to tell me about it - I made her angry when I said that making the Doc happy and ensuring the patient did not have complications from an incorrect splint was all I cared about. Sometimes the Doc's pay compliments that we never hear of, so checking with the MD is not a bad thing.
6 or 8:1 in your ED??? Wow, I thought I was being abused with 5:1!!! Wherever you go from where you are now, you undoubtedly have learned a lot. I'm a new ED nurse as well, (10 months in, new grad hire, had 12 weeks orientation, high acuity Level 2 trauma center with ~150 pt/day throughput, 40 beds - 56 if you count our hallway beds that we trot out almost every day since winter started). Some days I want to throw away all my dreams and plans because I feel like we are given an impossible task with inadequate resources..other days I am in love with my job lol. Best of luck wherever your path leads you!
Susie2310
2,121 Posts
OP, what did the physician's order say in regard to the administration of the IV fluids and antibiotics?