New Grad Blues in the ER...

Published

Hello allnurses community! Love the postings here! I'm a new grad and have been working in the ED for 5 months now. I had the worst night ever! I had a pt with CVA who we ended up giving tPA. However, as the night progressed post tPA administration, the pt's respiratory status seemed to be deteriorating. The pt began to desat, his RR shot up, the pt became more and more restless and agitated, and suddenly the pt became extremely diaphoretic and had audible rales...he ended up with aspiration pneumonia d/t dysphagia. When the pt started to desat and I noticed I had to suction him more and more often, I had asked the ER MD multiple times to come take a look at the pt, only to be told to put a NRB on the pt. Well in the end, we ended up having to tube the pt and it took another nurse to yell at the MD to come in and take look! I'm so frustrated. First of all, does anyone know of a good way to prevent these types of complications post ischemic CVA? I've been searching journals and haven't found much.

But the bigger issue for me...is it normal for new grads to feel the like the dumbest nurse that ever came down the pipe when things like this occur? Is it normal to feel so incompetent when other nurses have to "take the reign" of your own pt? I totally feel like I could have done more to avoid these complications but I don't know what. I know I have my lack of experience working against me, but I hate feeling like this. My charge nurse was extremely supportive and told me not to worry that we all [meaning all ER nurses] have been where I am now in a hot mess and sometimes things like this just happen no matter how proactive you try to be. I just feel like I have a few good days where I just start to feel confident and then WHAM! I get a curve ball like this thrown at me. I probably shouldn't take it so personally but I honestly just want to give the best possible care I can to all of my pts. The new grad period of a nurse's career is so littered with ambiguity and uncertaintly. I watch other nurses I work with and they seem so confident and orchestrated. Will I ever reach a point where I will be just as confident? Help from other new grads and experienced alike please...and thank you!!! All pointers/criticism/advise welcome! :eek: :confused:

Up Vote Up Vote ×

This is completely normal. Gaining confidence takes time. If you were a new grad in my department and you acted "too cool" I would be scared. It's usually the new grads that act like they know everything are the ones that are providing terrible care or are going to screw up big time.

Emergency Nursing is something that takes time to pick up, sort of like running a marathon. Nobody says "hey, I think I'm gonna run a marathon today", they train, learn their skills, get comfortable in their own skin. Being "good at it" isn't like dumping water on yourself and getting soaked, it's more like walking through the mist and one day noticing that you're all wet.

The only secret is to keep going, learn as much as you can and keep asking questions.

Don't give up,

W.

Up Vote Up Vote ×

I'm also a new grad but haven't started my position yet (starting in a week and a half) but I wanted to tell you something my mentor has told me several times. It's normal to feel like you have no idea what you're doing and to second guess yourself. You jump in with both feet doing the best you can and learning from everything you encounter (exactly what you are doing by trying to figure out what happened and if there's a way to prevent it). She said there will come a time, usually about 9 mos in, that all of a sudden you don't feel like an idiot anymore and you don't have that knot in your stomach when you go to work. I'm looking at the first year (at least) almost as a second preceptorship. I know I have a ton to learn, although it drives me crazy when I can't do things well the first time! It's all part of the process. It sounds like you have supportive coworkers which is a wonderful asset. Try not to beat yourself up too much! Every nurse has started where you are, even though some forget.

Up Vote Up Vote ×
Specializes in Critical Care.

Good grief, cut yourself some slack! :-) You are a new grad, in a tough, fast-paced environment. It will take time to get your feet underneath you. I was a new grad to the ICU and I completely understand what you're going thru. It will get better...just stay diligent in your willingness to learn and sponge off staff who are willing to teach you. When things happen to your patient and other nurses come in for the save...watch as much as you can. After the event has stabilized, do a "debrief" as I like to call it...ask them "was there something I should have done differently? is there an assessment I should have made that I wasn't aware of? is there a policy/protocol that applies here that maybe I'm not aware of?" Those kinds of questions will reassure staff working with you of your willingness to learn and they should be willing to help you improve your practice.

If you haven't already done so, may I suggest you check on joining the Emergency Nurses Association? While I don't have first hand knowledge of resources they may have available, I know the AACN (Assoc. for Critical Care nurses) has tons of resources...books, pamphlets..you name it. I would guess ENA is the same. It may help you to have resources available to you. I did a lot of reading when I first started and to be honest, I continue that practice. I'm always looking something up..I get about 5 different journals a month as resource. It really does help! Keep it up. Took me about a year in the unit to stop the panic, little bit longer to feel confident. Now I know I can handle anything thrown at me....not that I"m super nurse but I've good a base of skills to rely on and honestly...if a patient is crashing you can always keep doing compressions till you can figure out a plan of care! :-)

Up Vote Up Vote ×
Specializes in ER, Trauma.

I always recommend new grads do a year of med/surg before going to the ER. You've been there 5 months already, so by my standards you've succeeded! Many new grads are overwhelmed and moved out much sooner. As for your co-workers, ask them how long they've been ER nurses. Many years I suspect. You need to remember every one of them was a new grad at one time and had to learn like you are now. If you like the ER, keep working and learning and before you know it a new grad will be asking how you got so confident and orchestrated. After 30 years in emergency medicine I still have days when I depend on the experience of a coworker, and days when I am bothered by an experience. It means I'm still learning and still want to do better for my patients. Good luck, may all your patients be compliant and all your orders legible.

Up Vote Up Vote ×
Specializes in Urgent Care.

Being a new grad can be hard. I have heard from many co-workers from a newer nurse of 1-5 years to experienced nurses 15+years who tell me the "1 year" mark is crucial. Once we hit the 1 year mark, things will just click and the blues will be much less. Well, the times you feel "stupid" maybe think differently...maybe say to yourself, I just learned something and it will get better.

Hey, I am still a new grad and I am trying every avenue to keep my spirits up and keeping myself from feeling stupid. Doesn't mean I don't still feel it at times and I do think it's just part of being a new grad.

And really, you are in the ED my friend...much much to learn! Keep up the good work :)

Up Vote Up Vote ×
Specializes in Trauma Surgical ICU.

I have been on my floor for 5 months also; a very high acuity renal floor.Pts can go south very quick as well and we never know what will happen next. I ask questions, ask for help, clarification, and more questions.. We are still learning, everything is still new to us and we don't have that experience to guide us in the right direction YET, but it will happen..

Keep going, keep asking questions. Hang in there..

Up Vote Up Vote ×
Specializes in Emergency, Cardiac, PAT/SPU, Urgent Care.

To answer your question about the patient - what was his LOC like? What was his GCS score before he started to deteriorate? Was the HOB elevated before this happened, or was he completely supine? Things that could be done in the future that may help to prevent the above-mentioned outcome are 1:1 care or at most, a 1:2 patient to RN ratio (almost impossible in the ED, believe me - I know!) on such a critical patient so that frequent neuro checks could be assessed in order to notice any change in mental status. Also, keeping the HOB elevated can help to prevent aspiration of secretions (although in certain situations with stroke patients, this is not recommended, and no matter what you do may not prevent it), as well as checking and rechecking his gag reflex if he seems to be having trouble swallowing. If the patient was alert and oriented - providing him with a Yankauer to administer suction to himself is also helpful (if he still had good function of one arm).

Try not to be hard on yourself, it is a learning experience. Never be afraid to be assertive (in a polite but direct fashion) with a doc if you feel your patient is deteriorating. Usually, just looking at them directly and saying in a very straightforward manner, "Dr. So & So, I really need you in here now!" is all it takes. Best wishes to you! You will be a great ED nurse.

Up Vote Up Vote ×
Specializes in Critical Care.

I'm a new grad in a level 1 trauma ED. Been there since March, but am in a nurse residency that gave us the benefit of working through 7 critical care units to find one that "matches" to us. Being a new grad nurse is a challenge and, a sI can relate, I will say that everything you're feeling is expected. If you didn't feel stupid, you aren't learning. I've talked to some of the nurses in my ED that have been there for years and because of the nature of the ER, they say there are STILL times that they feel stupid... and it's simply because in the ER, there is no real consistency. Unlike on a floor, you cannot predict or "assign" the appropriate patients to a new graduate. You can't take some of the same precautions on a floor for a new grad in the ER. The ER just doesn't work like that. You treat 'em and send them off. It sounds like that you did the best that you could do and that you had people around you to support you... and that, at this point, is the best thing for you. You'll continue to succeed as long as you rely on those around you to help you grow into this RN role. It'll be worth it once you know you've hit that moment... that "click," things are comfortable.

Good job, I say! Keep working hard and know you're not the only ER grad feeling those things. PM if you ever need to...

Up Vote Up Vote ×
Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.

I just hit the two-year mark last month ... it gets better! Really. :)

Up Vote Up Vote ×

Thanks for all the great insights and encouragment everyone!!!! I'm not giving up yet! I accept this will probably be the hardest year of my career but I'm just going to keep learning and keep asking questions. At least I feel better than I did 5 months ago when I first started and lately I've been getting more and more highly critical pts...just more and more learning experiences!! And I still love it!!! Thanks everyone!

:yeah:

Up Vote Up Vote ×

The pt was very lethargic, almost stuporous and suddenly he became restless, HOB was always elevated, I noticed he was pulling at his NRB and his sats were dropping before he really tanked and I was suctioning more often...if memory serves his GCS on arrival was 12-13, in no condition to self-suction...NIHSS upon arrival was 18-19 and quickly deteriorated to 23. A pt like this is supposed to be 1:1 but I'm sure you know how that goes...Thanks for your encouragement and words of wisdom!

Up Vote Up Vote ×
+ Join the Discussion