New Grad to Busy ER


Hey folks,

I landed a job in a busy city ER immediately after graduating nursing school (no previous medical experience other than 1-1/2 year as PRN float pool PCT during nursing school). I underwent 2 months of classroom training as well as 5 certifications. Afterward, I went into preceptorship for 8-12 weeks and each week I took on one more patient until reaching 5. I have been on my own for about 6 months, and I have throughout the day between 4 and 7 patients (more often than not, it leans toward the larger number of patients).

The location of the hospital is close to downtown and is in a large, "under-privileged" neighborhood. Therefore, many patients that come in are frequent fliers seeking drugs, and it seems that most have an agenda to come in and give staff a hard time during their entire stay. The pace is so fast, that I feel I am not learning much as I hardly have time to review lab and imaging results and interpreting them to the patients and their families. I also feel that, due to the consistent frequency of difficult to deal with patients, I have become very stern (and far from compassionate) with all patients that come in under my care. I perform my duties with a bundle of AMA papers in my scrubs pocket, and honestly, would rather patients to leave than stay most of the time. One room is a patient with complications of an abortion, regretful of her decision and crying, the next room is an uncontrollable HTN from a dialysis patient that is in that condition because they "didn't feel like going to dialysis" and is going on cardene drip, the next room is a drunk patient seizing, the next room is a sickle cell "crisis" yelling at me for dilaudid (which we do not carry), and the last room is telling me what meds they want as if they are ordering from a menu.

I come in hitting the ground running, I leave running (and when I hit the parking lot, it's like a sprint). I dread coming to work, I am getting depressed at home, and want to quit so bad. My wife makes plenty money for me to pay back my contract of which I am only obligated for another 15 months or so. However, as a man, I am having an internal battle of maintaining my word to obligate myself for the 2 year contract and not quitting just because it is extremely demanding or just quitting since the pay-back is not an issue.

I am a combat veteran and getting shot at in Afghanistan was far easier than working in this super-fast paced ER that treats an ungrateful community while maintaining professionalism (the compassionate care part is long gone at this point).


1,142 Posts

Specializes in ED, Cardiac-step down, tele, med surg.

I think you need a vacation. Also, you've got too many patients. Are you in NY? I work in CA and our ratios are 1:4 for regular ER patients, and 1:2 for ICUs (most of the time). You've got to try to review your labs on your patients because lab might not call you for a critical. I've had that happen. I felt the way you did at 2 of my ERs and found another job, presently working at a better hospital that is not overwhelming all the time.

If you can't do that, I would try to add more self-care to your live. Don't take on extra shifts, don't stay if they are short. Go in for your shift, take your breaks, put up a filter between you and the patient. Compassion from a distance. Also, security is your friend. If someone is giving staff a hard time, have them escorted out. It's okay to be stern and also maintain your empathy. If you find you no longer care, that's a red flag you should listen to that you need a break. I've had patients scream and yell at me because they weren't seen fast enough, meanwhile the patient in the next room was in cardiac arrest. I explain to the patient we are going as fast as we can and they will be as soon as possible, go to the doctor if they want to leave AMA maybe the doctor can see them quickly, or just sign the AMA. No problem for me. Also, our hospital has started decreasing the use of dilaudid. We rarely give that, more often morphine and fentanyl. That has decreased drug seekers significantly.

Take care of yourself.


6,593 Posts

I also think that self-care is in order.

The only way to survive is to change yourself. Being able to put things into perspective is really difficult, and IME not too likely during early years of career when one is stressed about learning, about doing a good job, and about upholding the nurse's roles and responsibilities as dictated by the Code of Ethics. But you certainly can give it a try now that you've identified a problem.

Much of the time our natural reaction is to take things in a way that is simply too personal. It's very common to react to patients by feeling, "How dare you (pt.) act like this is my fault?" or "You will not speak to me that way!!!" or "I don't need this!!" And although we know the things they're complaining about are not our fault, per se, we react as if all those things are our fault. We get defensive. You know? Those are some natural internal reactions when being treated poorly. And when administrators constantly nitpick about what we could be doing better or what we're doing wrong collectively or individually, our profession has a very lengthy history of taking on the blame for all of those things, too, although in reality we control absolutely nothing other than our own individual actions and reactions.

So what do we do about this. My suggestion is to practice being non-reactionary. Re-focus on the patient. It is their situation, after all - not ours. When we're done caring for them, we are going to move on. If we know that we're doing our best, then we can't legitimately take responsibility for the rest of it. So we work on seeing ourselves separate from the situation. The only frame of mind that is required is, "I am here to help with what you are going through today." That's it. Let other pressures melt away. If you can get to a point where you're there to help that patient with the situation they (not you) are dealing with, you're good to go.

Patient suffering with sickle cell crisis: "I'm sorry you are facing this situation today. The doctor should be in soon so that together you can make a plan that is best for you."

Ab patient suffering with physical and emotional crisis: "I am here to help you as you're going through this."

Dialysis patient suffering of dialysis: "I'm sorry you've been feeling so poorly. I'm your nurse and I'm going to work on stabilizing your blood pressure and hopefully helping you feel a little bit better."

Drunk patient seizing: (to self) "I will help this individual the best I can; this condition is not how most people envisioned their life going..."


It feels really good to stop accepting (internalizing) inappropriately-placed blame. Start practicing your "I'm rubber, you're glue...." mindset." ;) Get the emotional reactions off the table so that you can focus on doing the ED nurse role, which is to attend to whatever circumstances our patients presently find themselves in.

It's possible that another job is in order, but no matter where you go I predict that it will be necessary to incorporate some of the above ideas. Release your tension, put a smile/pleasant look on your face, stand up straight and carry yourself with purpose. Literally the only thing you have to do is try your best to help people with their problems.

Best to you~


560 Posts

Dont be to hard on yourself. From one veteran to another, you sound like every ER nurse Ive ever met (at least those who work in busy inner city ER's).

Stick it out. Like you said. Its tougher than Afghanistan, so prove to yourself you can take it. Then take all that ER experience (on paper) and do something better with flight nurse, or applying for an ER RN position with the DoD, or go back on active duty as an officer, or apply for an ENP program.

In the meantime, find something to channel your anger into. Personally I use the gym. My anger, frustration and cynicism turns into bench presses and pushups and 5 mile runs. Im in better shape now than I was on active duty.


547 Posts

Specializes in Adult and pediatric emergency and critical care.

I think that you have received some great advice so far.

Your ED sounds like a very toxic environment, and unfortunately is not dissimilar from many urban EDs. I love my ED because we are a tertiary referral center and even though we are down town most of the drug seeking/violent/shelter seeking/et cetera patients go to the other downtown hospitals; personally I know that I wouldn't work in those other EDs and would sooner work in rural medicine or an intensive care unit.

The day you resent your job is the day you need to talk to your manager. If you can stick it out that is great, but the ED isn't for everyone and there is nothing wrong with being a great inpatient nurse. In our hospital we allow our new grads to transfer to the ICU, Peds, and Tele if they don't want to stay in the ED without backing out of their contract, I would see if yours would allow the same.

From a ED leadership perspective I'd far rather have an ED nurse go to the ICU (or any other unit/floor) and be happy there, and help the ICU to better understand why the ED is the way it is, than to have an unhappy ED nurse or worse a nurse that leaves our hospital or nursing all together just because our ED was a poor fit for them.

Do what is right for you and your family. You don't deserve to become a person you don't want to be and your family will always come before work. I wish you well, and the fact that you have the perspective to realize that this environment isn't working for you already tells me you are a great nurse.

Specializes in ER.

There should be national standards for staffing. Seriously. 7 patients? So how much time can you spend with each one each hour? Even if you never have to go grab supplies/meds/etc, it is less than 10 minutes with a patient each hour. It is probably 5.