New ER Grad Resources - Help Please??

[bitter_betsy, BSN]

I am a new grad in a and ER residency program. I just completed my first week on the floor with my preceptor and I feel overwhelmed and underprepared. My preceptor is great, but sometimes she moves a little too fast for me because I'm still trying to sort everything in my head - especially documenting because I learned 2 other charting systems in nursing school and I know zero about this one. Our time on the floor is 12 weeks in total (unless we need just a bit more assistance and then we continue in 2 week increments) , we have class every week as a cohort and homework. The problem is - there is so much I need to know right now. Some of it I know, but I want it written down so that I don't make mistakes. For example - I know the basics for IM injections BUT I need to know how much I can put where - NOW - for each age group (for example how I split up a rabies vaccine for a baby). I won't have time to look it up when I need it, so I need it available now in my "brain book". Pinterest sucks anymore because there are so many dead links and advertisements that its nearly impossible to find anything good. I have spent a good portion of my day trying to find a resource that I could purchase when I should have just spent the day looking it up and writing it down - but I was trying to save time and use resources already developed.

I would appreciate any resources that you can send my way (they don't have to be ER specific either). I want to spend my time wisely and learn. I'm so frustrated following links to articles on shoes, gossip and facebook instead of how long to push Benadryl over or what meds I can push together.

Thank you! Thank you! Thank you!

[HiddencatBSN, BSN]

I started as a new grad in the ER and it is definitely overwhelming at first. When your preceptor has a full regular assignment it’s often not possible to slow down as much as is comfortable for a new grad especially when census is especially high.

Does your hospital have you completing the ENO? If not, the ENA’s Emergency Nursing Core Curriculum and Sheehy’s Emergency Nursing are good resources.

Make yourself reference cards for things like normal vitals by age, IM locations and volumes, and every shift write down the meds you’ve given to look up at home. You’ll start to notice patterns of frequently given meds and those are the ones you want to have dosing and administration memorized for.

Does your unit have any protocols or care bundles? They’re probably written down somewhere you can review at home for the big stuff. You can also get the ACLS and PALS books and review those prior to being scheduled for the classes. If your hospital sees a lot of peds the ENPC course is good, but if you’re just getting the book get the 4th edition as the 5th edition is very pared down.

I did a ton of studying at home my first year. I worked in a teaching hospital so whenever I could I’d listen in on the attendings teaching the residents and learned a lot from that as well.

12 weeks for a new grad in an ER is skimpy. Does your unit often hire new grads and how well do they usually do?

[bitter_betsy, BSN]

@HiddencatBSN

I don't think we are specifically doing ENO - but they did say we had access to all of Elsevier. They also said that when we complete our 12 weeks that we would essentially be prepared to take the CEN. They gave us a copy of Fast Facts for the ER Nurse and we have digital access to Sheey's. I already have ACLS (and the digital book), but purchased paper copies of ACLS and PALS. They cancelled my PALS class because of covid - so I didn't get it during school. I do have to have it within a year though - so I have time.

Our program was actually 2 weeks of "orientation", 2 weeks of just following our preceptor, 12 weeks of on the floor experience (more if we need it) and then 2 weeks with another new grad as a nurse team with a preceptor assigned to oversee us / and make sure we are adjusting to being alone - and then we start. I should be on my own by Christmas if all goes well - terrifying.

In addition to that, we have 4 hours of class time per week as an ER cohort (there are 13 of us in total divided between 2 hospitals) where we have actual homework and drugs to do. After our 12 weeks, the weekly time will end and we will have monthly meetings for a year instead. We are the 10th cohort in their ER residency program.

Another nurse I spoke with said that about half of each cohort makes it - some decide its not for them and some can't cut it. My problem at the moment is I think I should know so much more than I know right now. My preceptor feels that because I watched her for 2 weeks, that I should have all the clicks down already. "You watched me do this for 2 weeks"... maybe - but I don't learn by watching. When I acknowledge orders, she doesn't even give me time to read them. She just looks over my shoulder, tells me to click the "select all" button and move on. "We don't have time for that". But as a new nurse - I need to make time. I realize that the ER is quick, but if I don't read and actually understand - then how am I supposed to know if its normal or even right when I'm on my own. Nevermind that when you are in a covid area you have to do everything wrong. You can't scan a patients armband because you can't take the scanner into the room - so you have to scan everything outside the room including meds. Its like learning 2 separate jobs at the same time and you are expected to be able to function equally well in both areas - often in the same day.

We do have protocols and I have been trying to access them from home. There are just SO many - I don't know what to begin with. I am trying to memorize the ED specific protocols first (ie chest pain = EKG w/in 5 min kinda stuff).

I was hoping there was an ER reference somewhere that had all the notecards and stuff in it that I would need so that I could spend time learning instead of building - but I guess I'm just going to build. Today I'm taking my top 20 meds and making a cheatsheet of how long to push each over. When I ask how long to push each med over - she looks at me in a way that makes me feel like I should know. It might be in the MAR, but she doesn't give me time to look.

Maybe I'm just trying to do too much too fast. I'm not giving up. I just have to study more ?

Thank you for reaching out!!

[HiddencatBSN, BSN]

Do you use EPIC? If you do, see if you can access the playground to get more familiar with the system and practice in a slower environment.

A 50% success rate for completing orientation and staying on the unit is....low. And expensive for the hospital and unit. So I’m surprised they have this set up rather than investing in a bit of a longer orientation and keeping more of their new grads.

As far as IV push rates go, they basically fall in to 3 categories: slam it like adenosine, slow push over up to 2ish minutes, and put it on a pump because I’m not standing here for the time it takes to push this safely.

[bitter_betsy, BSN]

We don't use EPIC (I did in school). We use Meditech and it is just so different. We do have a test environment, but I'm not really allowed to be there off the clock during orientation as they closely monitor our hours.

I'm trying to see if I have access to ENO now. It doesn't seem to be something that I can purchase on my own.

[HiddencatBSN, BSN]

If you haven’t been enrolled in it you probably don’t have access, but it follows Sheehy’s.

Are you starting with a full assignment with your preceptor? Is it possible to start with focusing on 2 patients and increase that weekly until you have a full assignment?

[bitter_betsy, BSN]

We do have a full assignment (4 pts). We were in prompt care on our last shift and that helped a lot. Although we saw over 20 patients for the day, it was a lot of triaging, medicating (mostly IM injections) and discharging. She kind of dishes to me what she wants me to do next. I have a feeling she will continue to give me more responsibility on my own each shift depending on which area of the ER we are in (there are 5). Our last shift, my real responsibility was to get each patient triaged, IV started if required and discharged. I had help from her and a paramedic for the other things in the middle. In that area we had 6 patients between us and the majority of them were ESI 4 with a couple 3s thrown in.

She told me at the end of one of our shifts that we are just getting to know each other right now. Maybe she is just pushing to see where I am, what I'm capable of and where I'll complain. I don't think she is hanging me out to dry, but she does talk about going to Med Surg a lot, but then again she has shared a lot of her previous students shortcomings and how I'm not doing that - so I just don't know.

It doesn't help that I think VERY differently than she does and I can have multiple thought streams that stop at multiple places. If she is doing something - I have to wait until she is completely finished to ask a question. She is very much a unidirectional person. I get from her reaction that she thinks I'm scatterbrained. I mean I can be on occasion - but we just think differently and she sees my way of thinking as a hinderance.

We do meet for a few minutes after each shift, so maybe I'll ask her what to expect. I think her plan is based on where we are each shift (which we don't know before huddle) and maybe she has a list of things I have to do. She is keeping pt stickers with notes regarding what type of care I gave to that pt. I imagine that as time goes on - she will make it more obvious.

I tried to get into our intranet tonight and couldn't. I'm going to order Sheehy's so that I'll have it. I really can't thank you enough for your guidance!!

[JKL33]

3 hours ago, bitter_betsy said:

My preceptor feels that because I watched her for 2 weeks, that I should have all the clicks down already. "You watched me do this for 2 weeks"... maybe - but I don't learn by watching. When I acknowledge orders, she doesn't even give me time to read them. She just looks over my shoulder, tells me to click the "select all" button and move on. "We don't have time for that".

Well that's just silly to put it nicely. Tell her you need to read them. Be kind about it, but come on, you're signing your name to that. That's what signing off orders is - acknowledging that you saw them.

Anyway, back to the first part of your post. I agree with getting familiar with Sheehy's, but you do not need to know things like how many pokes for rabies shot in an infant. There are hundreds or thousands of little pieces of info like that and no one knows everything without looking it up...you will be setting yourself back if you focus your time this way (trying to make little cards for everything). See the forest right now; you cannot focus on each one of thousands of trees.

Right now you are freaking yourself out due to the sheer volume of tidbits that you don't know. It's a lot. But it simply cannot be learned instantaneously, or even during your orientation. Learn where to find info as best you can.

You said you think your preceptor might view you as being a scatterbrain. You probably aren't--but you do need to see the big picture and then focus in on one thing at a time (for now). You probably don't need to worry about 50% of what you are worrying about right now. You do need to b r e a t h e.

Everything's gonna be okay...

??

[bitter_betsy, BSN]

@JKL33 this whole # of pokes for rabies literally came from her. I have spent the majority of the day on IM injections because she asked me how much can go into a deltoid and I said up to 2ml. She said no its 1ml. I have pulled out all my texts and notes and its right there in black and white in my text book 2ml. I am trying to find research journal data to back me up and I certainly wouldn't put 2ml in a skinny female deltoid, but Dwayne Johnson could handle it. I admit that just about everything I have found on the internet says 1ml but my text and pharm notes all say 2ml.

She has me out in the weeds making me crazy right now! Well I'm responsible for me so I'm making me crazy but the result is the same! I appreciate you coming to set me back on track! I should probably stop and go to sleep as well so that I can be together for tomorrow!! Thank you for taking time out for me!!

[HiddencatBSN, BSN]

How many shots an infant gets for rabies will depend on their weight and whether they’re getting immunoglobulin or not, and which brand of immunoglobulin used. So there’s no way she has that memorized herself and if she thinks she does, I have questions about her familiarity with peds.

IDK, I’ve precepted for years and memorizing different weight based dosing by ML given isn’t on my radar for something as infrequent as rabies. Tylenol and motrin, sure. Benadryl, zofran, morphine, ketamine? Yep. Seriously I think I’ve given immunoglobulin for rabies less than 10 times in 10 years.

[bitter_betsy, BSN]

@HiddencatBSN do you have an outline for what you use for your preceptees? I feel like maybe I could use some overall direction to realistically keep me on task if I find myself in the weeds again. I've thought about purchasing the CEN online module but only because our residency coordinator told us that by the time we finish we should have all the knowledge to pass the CEN while my preceptor keeps saying that I should be preparing for the TNCC because it will give me the best overall knowledge. I just want to do well and succeed with as few tears as possible this first year. Yesterday at home, I spent the majority of the day watching videos on IVs. I feel like we didn't get nearly enough teaching on the subject - like where to even find a vein other than the ac. Today was spent on IM stuff.

Sheey's has 2 books:

Manual of Emergency Care and Emergency Nursing Principles and Practice. Both are 7th edition. I don't mind buying both, but which one should I start with?

[JKL33]

2 hours ago, bitter_betsy said:

She has me out in the weeds

? Yes she does. This is weeds territory. Honestly I don't really like the sound of what's going on. Nobody cares how much goes in the deltoid. Use the VG unless you're giving a tetorifice shot. Then you won't be an idiot like I was once upon a time when I put solumedrol in someone's deltoid. Wasn't pretty.

Minutiae is not where you should be focusing right now.