New to Er...Feeling a little incompetent

soapaddictOH · Apr 11, 2008

I would give yourself at least 6 months to a year to be really comfortable in the ER. I worked ER full time for 3 years and then left for PACU. I went back to ER prn and while I'm okay with protocols and meds, just getting back into the groove of the pace is taking me some time.

I really want to go back full time, I didn't realize how much I missed ER until I left. I'm in the burn unit now and I like it, but it's not ER.. I don't feel at home!

ozinurse · Apr 11, 2008

The good thing is that you identify that you have deficits, and you are endeavouring to do something about it; read, ask and experience. The scariest new practitioners are those who think they know it all.

From my own experience the first three months are keeping your head above water. One of the most important things at this time is time management. This is difficult, whist you are trying to learn about all the new things that you are administering and doing, and the different presentations.

Prioritising is the other. Especially when things seem to be getting out of control, sometimes you need to stop and regroup and work out what needs to be done right now, compared to what can wait.

I would discourage new entry clinicians from pursuing the overwhelming urge to learn to do cannulation, abg's and other technichal skills until you have the previous under control. Otherwise you are trying to encompass something else that can be time consuming into your time management.

I had several stages of acute anxiety when I started in ED. The intitial 3 months, then another one a few months later, when you can start to pre-empt what needs to be done, as well as the technical skills, and then try and compress them into your current patient management. Then you go through move into resus and triage, in-charge etc, etc.

Just remember - primary survey - Airway, Breathing, Circulation and Disability determins the acuity of the patient. Work with the presenting problem and think about possible causes and possible effects. From that you can determine the appropriate assessment and management.

There will always be something new. Personally I reckon if you aren't learning something new or being challenged, it is possibly time to move on.

All the best. Keep at it.

bill4745, RN · Apr 11, 2008

After 12 years of ICU, I made the move. It took several months before I felt competent, and two years until I felt good enough to consider myself a 'real' ER nurse, and able to orient new staff. It is the best move I made-there is never boredom in the ER. After almost four years I still learn something different or solve a new problem every shift. Hang in there; you'll be fine.

graceomalleyRN, RN · Apr 11, 2008

I'm not a nurse yet, but can someone please tell me that "3-4 weeks orientation, on and off" is not the usual case?!!

Aren't there all sorts of new skills required in ER that you didn't have in Med-Surg? This just seems woefully inadequate to me...but what do I know?

ecnav · Apr 11, 2008

I'm not a nurse yet, but can someone please tell me that "3-4 weeks orientation, on and off" is not the usual case?!!
Aren't there all sorts of new skills required in ER that you didn't have in Med-Surg? This just seems woefully inadequate to me...but what do I know?

You're correct. They'll just keep 'restarting' her orientation... dashing her confidence and spooking her. Really ought to start off on a tele unit for a few months before introducing the ED. That's mostly for the new nurse to get their sea legs so to speak. When the basic skills start to become second nature, then move to the ED.

SDS_RN, RN · Apr 11, 2008

I have only been in the ER for about 5mo now only had a little over a year of experience on a surgical floor and when I made the transition I felt the exact way you do. I still have days that I feel like a total moron:confused: but I have been starting to feel a little more at ease w/ each passing day. I do love being in the ER but I still have a lot to learn yet. Keep doing what you are doing and it will get better. I told one of my coworkers recently that I may ask stupid questions sometimes but I would rather have it done right than do harm to a pt.

There are still many things that I haven't encountered in the ER and it scares the daylights:no: out of me but at the same time I'm excited to take on a new challenge and learn something new. I was terrified of chest pains when I first started because I never had to deal w/ that on the floor but now that I've had several I am feeling more comfortable w/ it and I think that's how it will be w/ almost anything that comes in. The more experience you get the more comfortable you will feel.:wink2: I posted a thread similar to yours here awhile ago and the other nurses on this site are very supportive and can give you some comforting advice. :nurse:Hang in there because it does get better. Wishing you the best. :up:

northshore08 · Apr 11, 2008

OP, it is great that you are recognizing how you are doing. Personally, I feel bad that you were dumped off after 3-4 weeks of "off and on" orientation. In my experience, successful precepting of new ED nurses has involved 1:1 orientation for at least 6 weeks using ENA orientation materials and close guidance. Since this is not the case for you, here is what I would do if I were you.

1. Get online to www.ena.org and find their online orientation program. If your employer will not supply this for you, join the ENA (to lower the cost of their products) and buy it for yourself. You may be able to convince your employer to help you with this. Study, study, study. Knowledge will help you feel more confident. You're obviously going to have to be self-directed in your learning from now on.

2. Continue, as you have been, to ask your co-workers about things you are unsure of. When a new co-worker asks me a question, I have never felt that I wasted my time sharing knowledge or skills.

3. Use your downtime at work (if you have any) to get into your rooms or the trauma/resus rooms and learn all the stuff that is there. Do the same thing for infant warmers/bassinets, rarely used equipment, etc. You will be surprised to know that many of your coworkers are unsure about these things as well and you will have a short little inservice right there in the trauma room. If you don't know how it works, open it up and look at it and get someone to show you, or read the directions. You will get more help from your coworkers if they see you are serious about learning. And the next time some doc calls for that whatever thing, you may be the only one around that knows how to use it.

Stay strong, and become the ED teacher that you needed. And remember how it was for you, and pass it on. You will become that person sooner than you think.

RedSox33RN · Apr 11, 2008

I've been in the ED since December, and up until last week, we did not have preceptors. We were with someone different each shift, and in different zones (large ED), but we did not have our own patient load either. We also had classroom time every week to learn protocol, trauma equipment, etc. Or even just vent and ask questions about stuff we saw in traumas, etc.

We now have our preceptors, and will until the end of June. We have a schedule of how many patients we should be taking by a certain week. Right now, I just have one, but even by last week, I felt the need to be having more, but I'm following the plan. I do help out the other RN's in my zone, maybe learning new drugs that they happen to be giving or hanging (just last week I learned about titrating Lopressor, the parameters for giving and holding it, and then boom - had my own pt that needed it!) or just doing a procedure I haven't done since nursing school, like an NG tube (hadn't done that in a while!).

Honestly, I can't imagine only 3-4 weeks. I feel overwhelmed the night before a shift now, and worry I'll make a fool out of myself or something. Are you able to ask for more time? I was told that if by chance we don't feel comfortable being off orientation at the end of June, it could be extended by a few weeks if needed. If you are not comfortable, I would certainly talk to your manager.

crb613, BSN, RN · Apr 12, 2008

Thanks to all of you! I appreciate the advice! Thanks for the link northshore 08 & I do what you suggested....I always stock the rooms/bays when I get the chance so I will know where everything is at & what it does.

One thing that has got me is all the diff. doctors & how they operate. I had one pt the other night having slight epigastric pressure....I started an IV, put her on the monitor, 02, drew labs ( I always draw labs when I start an IV) got an EKG....informed him about her , he gave no orders....over an hour ( or more) later he finally went to see her & had a fit because I had not ordered the lab test, asa, nitro sl. The other doctor that had been on rotation would have seen her asap....more likely than not ordered a GI Cocktail & went from there. I am just a little confused as what to go ahead & do & what not to.....they are all so different. :bugeyes: Ever since that happened with doc #1 it seems like he has tried to make me feel dumb. The next pt of his I had w/cp I did all the above mentioned.....guess what??? he wanted a chest x-ray too! :no: I just want so badly to learn & be confident in what to do...and when to do it! Thanks to all of you for making me feel a little better! :icon_hug:

SDS_RN, RN · Apr 12, 2008

That was a struggle for me too was getting used to just doing things w/out notifying the doc first because on the floor you can do absolutly nothing w/out an order first. I sort of know now what the ED docs prefer now and if I don't I just ask my more experienced nurses what they do.

Does your facility have a CP protocol? All of our CP get put on the monitor, cardaic lab panel, CXR, EKG, O2 4L. I guess I haven't given any meds for CP w/out the docs permission though and our docs are pretty good about seeing a CP almost immediatly.

I like to think that the more I see and do the better I will get at it and will feel more confident when I have to do it. You will catch on just hang in there and keep learning.

northshore08 · Apr 12, 2008

Every new place you have to learn the docs and what they want/allow you to do. That just takes time. It's especially hard if you come from a place that is more aggressive; sounds like the first doc took you for granted, then got upset that you did not do "everything." I bet if you had done "everything," then he would have grilled you as to why you did this, why you did that....Just do the protocols for now. If you do not have them, your hands are tied, just document that you reminded the doctor of the pt and their condition.

I had a doc once years ago---we got a trauma pt from MVC with obvious steering wheel mark on his chest and c/o chest pain. I got an EKG, and suffered the consequences for the rest of the shift. I stood up for myself and advocated the standard of care for my patient, but that doc was self-absorbed and not used to having a CEN taking care of business. I worked with this doctor for many years and ended up having a good relationship, but I will never forget that incident.

Good luck to you...I am orienting in a new ED now as a matter of fact, and currently backing off and "following the protocols." :typing