New Grad in the ER

FiremedicMike, BSN, RN, EMT-P · Mar 14, 2023

I was a new grad in the ED, but had extensive EMS experience so it was a natural progression for me.

I was hired with 3 other new grads and they're all off orientation and doing fine. Our orientation is typically 6 months for new grads, it was 4 months for me. If yours is a well run program, you'll start with your preceptors in your back pocket, following you around and making sure you're fine. By the end, you'll be essentially independent but still have your preceptor nearby to bounce anything off of.

The ED I work in is a team sport, so even off orientation, we're helping each other both with patients and just generally there to answer questions and offer advice.

ACLS is easy. If the heart isn't beating, someone needs to be doing compressions and someone needs to be bagging. Epi every 3-5, amiodarone if they're ever in v-tach or v-fib. Calcium chloride if they're a dialysis patient, sodium bicarb towards the middle-end of code.

FNPxAbyss318 · Mar 15, 2023

ER Nurse/FNP here ?

Want to let you know that you are not alone! I started in the ED 7 years ago.....first and foremost never let anyone convince you that you have to be "cut out" for the ED and all ED nurses are cut throat. Unfortunately, that is a bad reputation some of the narcissistic bullies within our profession have given us. I would be worried if you weren't anxious and taking care of critical patients. Keep in mind that you are in an area of "critical care" and give yourself grace. I must say the ER is a setting that requires a love for learning and being able to manage that anxiety, while also learning to prioritize your care. As far as the ACLS--you will be fine. Most class sessions are open book and the instructors understand that most new grads are novice to this level of thinking. They are not expecting you to run a code after. Know the rhythms that will kill someone and you will be fine.

I followed a set of rules in the ED that have kept me sane:

1. Always take your break the ENTIRE 30 mins (the building will burn with or without you there)

2. Take a deep breath and figure out who can potentially deteriorate 1st

3. It's cool to go in the bathroom and cry

4. It's not rocket science--just remember the algorithm

5. Check yourself at the door and don't carry your work home

?

victoria3594 · Apr 10, 2023

FiremedicMike said:

I was a new grad in the ED, but had extensive EMS experience so it was a natural progression for me.

I was hired with 3 other new grads and they're all off orientation and doing fine. Our orientation is typically 6 months for new grads, it was 4 months for me. If yours is a well run program, you'll start with your preceptors in your back pocket, following you around and making sure you're fine. By the end, you'll be essentially independent but still have your preceptor nearby to bounce anything off of.

The ED I work in is a team sport, so even off orientation, we're helping each other both with patients and just generally there to answer questions and offer advice.

ACLS is easy. If the heart isn't beating, someone needs to be doing compressions and someone needs to be bagging. Epi every 3-5, amiodarone if they're ever in v-tach or v-fib. Calcium chloride if they're a dialysis patient, sodium bicarb towards the middle-end of code.

Thank you so much for your reply. I did complete my ACSL and have been working in the ER with a preceptor for the last 3 weeks. It has been a really tough transition and I do have doubts but I feel like that's normal. For the most part, everyone is very kind, reassuring, and knowledgeable. I have noticed that some staff have very awful attitudes towards certain vulnerable populations and it is really hard to watch. Some of the comments I have heard people make honestly made my stomach hurt. I know I'm part of the problem for not saying anything, but it just made me see everything a little bit more clearly & maybe this place isn't what I thought it was.

I spoke to one of my coworkers about it (from my previous job) and they had said that if I've seen a lot of staff act this way, odds are management will likely be the same. Have you experienced anything like this/do you have any advice on how to handle this? I have been really anxious and scared between shift sets because I feel that the environment is a bit toxic.

victoria3594 · Apr 10, 2023

FNPxAbyss318 said:

ER Nurse/FNP here ?

Want to let you know that you are not alone! I started in the ED 7 years ago.....first and foremost never let anyone convince you that you have to be "cut out" for the ED and all ED nurses are cut throat. Unfortunately, that is a bad reputation some of the narcissistic bullies within our profession have given us. I would be worried if you weren't anxious and taking care of critical patients. Keep in mind that you are in an area of "critical care" and give yourself grace. I must say the ER is a setting that requires a love for learning and being able to manage that anxiety, while also learning to prioritize your care. As far as the ACLS--you will be fine. Most class sessions are open book and the instructors understand that most new grads are novice to this level of thinking. They are not expecting you to run a code after. Know the rhythms that will kill someone and you will be fine.

I followed a set of rules in the ED that have kept me sane:

1. Always take your break the ENTIRE 30 mins (the building will burn with or without you there)

2. Take a deep breath and figure out who can potentially deteriorate 1st

3. It's cool to go in the bathroom and cry

4. It's not rocket science--just remember the algorithm

5. Check yourself at the door and don't carry your work home

?

Thank you so much for your reply! I have to ask - how do you like being an FNP? That is so cool!

ACLS was absolutely terrifying. I was the only new grad and everyone else were very experienced critical care nurses. I did manage to pass but the instructor was very keen on telling us how much she loves to fail people - that didn't help with my nerves. I've had almost 15 shifts now and I am definitely starting to feel more comfortable but after my last few shifts I have felt absolutely horrible. I do feel like because my anxiety is so high I am having trouble remembering things and just feeling crummy overall. I can't even relax between shifts because my anxiety is so bad about having to go back.

I know I shouldn't take things home with me but I can't help it. I have noticed a few nurses speaking really horribly about certain vulnerable populations and it really did make me feel sick. I didn't say anything because I know that these people are bullies and I didn't want my time here to be affected by speaking up - I also haven't really found my voice yet. I know that it's wrong that I didn't say anything but I didn't know what else to do. After seeing this behaviour it really made me wonder what is said about me when I'm not around and I just felt awful for my patients. Since I've seen this as a repeated behaviour I do feel worried that management has the same type of attitude as I have picked up some red flags from him too. Do you have any suggestions on what I could do? Have you ever experienced this?

FiremedicMike, BSN, RN, EMT-P · Apr 10, 2023

victoria3594 said:

Thank you so much for your reply. I did complete my ACSL and have been working in the ER with a preceptor for the last 3 weeks. It has been a really tough transition and I do have doubts but I feel like that's normal. For the most part, everyone is very kind, reassuring, and knowledgeable. I have noticed that some staff have very awful attitudes towards certain vulnerable populations and it is really hard to watch. Some of the comments I have heard people make honestly made my stomach hurt. I know I'm part of the problem for not saying anything, but it just made me see everything a little bit more clearly & maybe this place isn't what I thought it was.

I spoke to one of my coworkers about it (from my previous job) and they had said that if I've seen a lot of staff act this way, odds are management will likely be the same. Have you experienced anything like this/do you have any advice on how to handle this? I have been really anxious and scared between shift sets because I feel that the environment is a bit toxic.

There's a lot to say on this topic but I'm not there to witness exactly what you're seeing.

I guess I'd take a hard look at what's happening. Is this venting at the nurses station to blow off steam from the stress of the job, or is this actual hateful behavior that affects patient care?

Hoosier_RN, MSN · Apr 10, 2023

FiremedicMike said:

There's a lot to say on this topic but I'm not there to witness exactly what you're seeing.

I guess I'd take a hard look at what's happening. Is this venting at the nurses station to blow off steam from the stress of the job, or is this actual hateful behavior that affects patient care?

I'll also add that there are patients, that staff gets to know, the well known frequent flyers. While they deserve compassion, they also, at times, drain precious time and resources that could be directed more efficiently to other patients. OP, scan the threads on here and see that it's not necessarily meanness or toxicity. It could be frustration, if this is the case as I mentioned

londonflo · Apr 10, 2023

victoria3594 said:

I have noticed that some staff have very awful attitudes towards certain vulnerable populations and it is really hard to watch. Some of the comments I have heard people make honestly made my stomach hurt. I know I'm part of the problem for not saying anything, but it just made me see everything a little bit more clearly & maybe this place isn't what I thought it was.

I went to a conference years ago, on Ruby Payne's discussion on Generational Poverty. She was contracted with an ER (ED) and later schools to help professionals understand where the patients were coming from. I wish I could summarize when she said but it is very true. I worked Med-Surg for dozens of years and just couldn't understand the plight of those who live in poverty for generations.

Her theories hit me right in the face for what I was experiencing . Frankly it is not going to change your "group think" at your job but might just help you to understand your patient population.

Ruby K. Payne - Wikipedia

emtpbill, ASN, RN, EMT-P · Apr 17, 2023

Im in the same boat as FireMedicMike, I have 26 years as a medic before I went back to school and got my RN license. I honestly feel that if I did not have all the experience of working as a 911 medic I would probably be lost, now that's just me. I know there was an EMT that went to nursing school and started in the ER the same day I did. He didn't have any experience starting IV's doing finger sticks, interpreting EKG rhythms and he didn't make it off orientation. Last I heard he transferred to the psych wing of the hospital. Very challenging but not as heavy on the hands on skills. (please, my psych peeps, this is just my observations, I value and respect psych nurses more than anyone can know).

Now my grandson's mother just finished nursing school and started at a busy urban ER. She was on orientation for 5 months and she still sometimes asks me things. Not that I know a whole heck of a lot but with my EMS background I can offer little hints and tips.

Just watch and learn. Ask questions. Even if you think it's a dumb one, ask, you aren't the first person to ask and we all started in the same spot you're in, even the 40 year crusty old charge nurse. She, or he, was once a bright eyed bushy newbie. The only difference is that Mash was in its first season on television and you have , well, TV sucks today and I don't have time, so you'll have to fill me in on that one.

FNPxAbyss318 · Apr 17, 2023

@victoria3594

Being an FNP is very rewarding in since that I felt like I was ready for it. Being a nurse in the ED I found a sense of autonomy with the ability to anticipate orders and wanting to make more decisions as a provider.

As far as your anxiety I do recommend journaling! When I was in the ED, I would also get very anxious which would ultimately lead to brain fog. After only 6 months of reflecting on my entries I would realize the miniscule things that I would fret over--that no longer mattered. To this day, as an NP I read my journal entries from the ED and I laugh because those moments did not define me or my competency as nurse! You are learning and you deserve to give yourself grace. I have experienced all of the above working in multiple settings. You are not alone :)

Lipoma, BSN, RN · May 14, 2023

I started in the ED as a new grad and it was the most fun experience I've had. The one advice I have is have your preceptor make you shadow during weeks 1-2 (focusing on skills/tasks; IVs, foleys, NGT/OGT, port access etc). Take care of the most stable patients (1 room/1 patient) during weeks 3-4 from start to finish. During this time offer to place IVs in everyone from your preceptor's assignment to your pod mates. Week 5-7 assume care for 2 patients (1 stable, 1 semi acute/sick). Week 8-9 (3 patients; 2 acute, 1 stable), and jump in during every single code/high acuity patient that rolls through the door; respiratory distress, cardiac arrest, pediatric emergency aka your ESI 1s and 2s. By week 10 assume care for all 4 patients and act as 2nd RN for high acuity situations. Try to man the Zoll/cart with an experienced nurse so by week 14-16 you're comfortable drawing up meds, delivering defibrillation/cardioversion/transcutaneous pacing. The more exposed you are to high stress situations the more confident you become in your skillset and the less timid you are when you're finally on your own.