New to ER

zmansc, ASN, RN · Mar 11, 2015

I am sure this has been asked a lot but I am more venting then asking questions (although your input would be great).
I have recently moved to the ER from BHS. As most know BHS is very limited on clinical nursing (IV, cardiac rhythms, breath sounds, ect). At this point I feel that they are expecting more from me than what I am providing. I struggle with reading rhythms and I am refreshing my memory on breath sounds. Is this normal for me to feel this way? Also, how can I better myself so that I am a better nurse? My plan at this point is to take notes on what I am lacking and and reviewing the info in the book.
Thanks for listening and any comments your provide.

Who is they? Your coworkers? Mentor? Your supervisor? I would talk to them. Ask if you are progressing according to plan, or what you need to do differently to improve. I have mentored a RN who moved from our BHU to the ED, she was initially not very team oriented and we often found her sitting at the nursing station when she could be helping others. After a open and frank discussion, she learned to be more team oriented and willing to try to help and after a few weeks of this new attitude the perception of her in the unit changed dramatically.

I'm not saying this to disparage BHU nursing in any way, it just happens that at OUR BHU team nursing is not how they do it, so this was something that was fairly foreign to this particular RN. Once she was given appropriate guidance she adjusted. I'm also not suggesting that you don't participate in your team, but there might be something that you don't know that you don't do that a simple conversation would help you identify and make an adjustment and the sooner you do that the better off you and your colleagues will be.

At the same time, she expressed that we tended to train by the sink or swim method more than she was comfortable, which was a valid issue. We do tend to train with the "do what you know how to do, and if you don't know how to do something, get someone to help you" method alot, especially with "experienced" nurses even if their experiences have very little overlap with what they will be doing in the ED. Because this was an issue, she and I sat down every couple of shifts and discussed things that she felt uncomfortable about, I gave her some homework and I took some homework, and we would spend as much time as possible during the next shift or immediately before on occasion to discuss what she had learned or to teach her specifics about that subject. This was mostly for things like assessments, drips, etc. Basic skills like IVs, Foleys, NGs, etc were typically things that were picked up during the shifts (watch one, do one, teach one).

I think this relates well to your idea to take notes and research when you get home, which I applaud as a great idea. My suggestion is that you express to your mentor and supervisor that you are trying to do this, and that you would be willing to have them give you ideas of things to research on your own time to help you get up to speed.

Altra, BSN, RN · Mar 13, 2015

It is absolutely normal to feel like a new grad again when changing specialties. And studying all over again, just like a new grad, also comes with the territory. I love that you're committed to that.

I would hope that ER orientation for someone coming from another specialty would include a dysrhythmia course and then ACLS and PALS. If this has not been offered, can you ask your preceptor or manager if your hospital offers this?

Alternatively, ask to spend a day with a monitor tech, and make the most of that learning experience. Really pick their brain -- and I would bet money that they will direct you to some great resources for your own study time, too. You might also ask to spend a half-day or so with an IV Team nurse, or being precepted on IV starts in the same day surgery area.

Be ready to learn from everyone in your department - nurses, physicians, techs, medics, and unit clerks. (And it's always worthwhile to spend a half-day with a unit clerk, too - trust me, you'll learn much) Not sure of the rationale for an order? Ask. Why does the triage protocol for x symptom include such & such order - what will it contribute to management of symptoms or to narrowing the diagnostic differential? Have no idea where x supplies are kept? Ask the tech who does stocking - they'll be glad you asked proactively.

Any areas of system by system assessment or pathophysiology that you would like to brush up on - let your preceptor know these. Ask the docs, too - most are happy to teach.

We all feel disjointed when we're out of our comfort zone, and it will take a while to feel like you're up to speed. Give it some time, and be responsible for your own learning.

Welcome to the dark side! :)

kward6 · Mar 13, 2015

Thank you both this is a lot of help. I am pleased to hear that my feelings are normal. I will continue to study and ask for help.

brkndoll18 · Mar 15, 2015

I'm in the same boat... I've always been a pedi nurse now I'm going to ER. Eek! Open and honest communication. And if you need something or don't understand, ask.

renzlao, MSN, APRN · Mar 18, 2015

I'm in Canada and our orientation is a 6 month paid university course.

I worked in medsurg for more than 5 years and pretty much new in the ER. What I learned with my course is to do my primary assessments (ABCDEF) when they arrived and get everything secured. I don't move on unless I address airway, breathing circulation, quick GCS, Expose and Full set of VS. I can then do history taking after securing these stuff and my focus assessment later.

PG2018 · Mar 19, 2015

This is interesting. I'm actually leaving an ED to go to a BHU until all my APRN stuff comes in. Frankly, I'm tired of general nursing, but I entered the ED seven months ago. I don't staff the trauma rooms and tend to stick with the urgent care stuff out of preference. I don't like skill-oriented nursing or hands on tasks. If someone handed me a chest tube or arterial line collection of stuff it'd be like me trying to put a jigsaw together. With regards to the BHU I'm going there to see how the other half works. I've covered inpatient as a psych NP intern, butbu really don't know how the nurses fill their day. I know they seem to stay busy though.

kward6 · Mar 19, 2015

Pt can tend to keep the nurses busy, such as you ask if they need anything else and they say no. However, after 5 or so minutes they will ask you for PRN meds, ect. There is also a LOT of charting on BHS, I have never worked on a unit that charts so much and the most frustrating is that its all repetition. The inpt unit I work on contains very stable pt. A typical days starts off with giving AM meds/bhs assessment, team meeting,charting, noon meds, charting, evening meds and in the mix discharges and admits.

kward6 · Mar 23, 2015

Renzlao does your ER have an intake nurse that completes history before coming to you?

renzlao, MSN, APRN · Mar 23, 2015

I am not sure what an intake nurse is. Are they the same with triage nurse? So basically this is our flow (lets say potentially unstable patient).

Presents to ER registration then to triage nurse. Triage nurse decides if its stable enough to wait and get assess initially at rapid assessment unit or to fast track. If we have beds available, potentially unstable patients go directly to my bed with EHS or triage nurse giving me some history. While i am listening to history I am doing my primary assessments and securing my ABCDEF. Once that is done, I do my history of presenting illness and pertinent negatives then do my head to toe or focus assessments. I usually asks help from another RN with my "C" for an ECG or blood work if its not yet done at RAZ.

Renzlao does your ER have an intake nurse that completes history before coming to you?

kward6 · Mar 23, 2015

it's basically an assistant to triage. Pts presents to the er the triage nurse rates it emergency (ESI). At this time the pt gets assessed by the intake nurse who is up front with the triage nurse. Intake nurse does vitals and background information then presents it to the appropriate pod. It the pt is fast track or ACE they go straight that area.

renzlao, MSN, APRN · Mar 23, 2015

Oh I see. Our triage does that for us either going to acute beds or fast track.