New Grad in ER (Time Management and Prioritization)


I'm a new grad working in a small, community ER. I am super lucky to have a 4 month orientation before I'm thrown to the wolves, but I'm in the middle of week 8 (almost half over! Where did the time go?!?!?) and I'm feeling overwhelmed--mostly by time management and charting!

For example, today I was partnered with a temporary preceptor because mine was out sick. I was handling all patients independently and she was available for questions. I did fine all morning, but when I got back from lunch my entire day was shot!

I had an older woman with low sodium (117) who was very altered and confused. I had a pt. with CHF, a young girl who had a fractured arm that needed to be reduced via conscious sedation, and a young adult with cerebral palsy and tachycardia. I was working on getting the older woman with low sodium stabilized and admitted (every time I went to give meds or chart, another doctor would call or stop by to give orders! Many of the orders correcting earlier orders!) and got behind on my other patients; just when I was beginning to get caught up on her so I could work with my other patients, the young girl needed to go through conscious sedation. I've never done conscious sedation before which irritated the doctor and my temporary preceptor wasn't a super big help, which meant I was still behind on two other patients!

By the time 1900 rolled around, I hadn't updated the charting for two patients for nearly five hours. I spent report watching the girl who had been sedated and trying to catch up on charting. I even apologized to the oncoming nurse because the patient with CP was upset because I hadn't done anything in two hours with her. Her vitals were stable, though, even if her HR was 115-120.

What can I do on days like this to not feel overwhelmed? At the end of the day the temporary preceptor basically said that days like today are why she hates new grads in the ER, because we don't have time management down. I understand I have a lot to work on, but it's only my first week with taking all patients and using the preceptor as a resource only, and I'm learning! Now I'm feeling super discouraged. Any advice would be appreciated! Especially if you made it through this novel of a post!

Thank you!


20 Posts

Specializes in ER, LTAC, Nephrology. Has 7 years experience.

That's a tough one, and being in the ER you will come across that almost daily. You get everything thrown at you all at once and there's not much you can do except ask for help from your neighbors and communicate with the charge nurse.

Let the charge nurse know you have a conscious sedation, as those need to be watched closely but hopefully you had the RT there to really give you a hand. Set up the monitor/automatic vitals and make sure you have all the right equipment together. BVM, NS drip, good working IV and when the time comes whatever sedation they will use.

The low sodium didn't happen overnight and you can't safely fix it fast either (rrrrrealllllly long process), so since that one is an admit, ask the charge to get you a bed ASAP. Pop your head in there to make sure they don't get out of bed, make sure the fall risk band is on them, and tell your ER tech or CNA that this one needs to be watched.

Communicate with the most stable one and let them know you didn't forget about them. Let them know it's a good thing that you're not in the room all the time as it's not a good sign when you are! You are waiting for the results to be reviewed by the ER doc, and you'll let them know once you get orders.

The CHF'er is likely a flare up from a chronic condition, make sure they have a bedside commode, the call light, and administer that lasix! Keep an eye on the O2 sat and they're good to go. If their sats go down, throw them on some O2 and let RT know.

Chart as you go.. bring your WOW in with you to rooms and let the patient know you need to chart as you go, plus you can discuss the plan of care by reviewing orders with them.

GOOD LUCK. I also have mixed feelings of having a new grad in the ER, but we need nurses.


224 Posts

4 months might be a bit short, we did 6 and some still struggled after that. I mean everyone struggles at first, but some really are unsafe due to struggling.

Safety first, communicate, and ask for help. In our Ed sedation a are 1:1 until 1/2 hour recovery checks. More if the doc over sedated a bit, so I wouldn't feel like a failure.

Admits need to have all their running around done before they go up at our place, but don't need to necessarily have everything done. Anything I can do in a room myself a nurse upstairs can do so I don't fret if I'm sending some work upstairs. Sometimes you just can't get everything done. Oh well.

Your prioritization, will get better. Your efficiency will get better, and your knowledge will get better. They all grow together, as you get better at one, you find the other two follow along.

Safety first, know sick/not sick. This can change so make sure you are keeping eyes on your pts from time to time. Know intervene/intervene NOW. This also changes so keep eyes on people.

It is good to feel the way you do. Feeling like you got this 8 weeks in is a much worse place to be ;)

BSN GCU 2014.

Sent from my iPhone using allnurses


6 Posts

I could have wrote this myself. I am a year in and I still feel overwhelmed at times. I think every one does from time to time. Sometimes, the ER is just overwhelming. Many nights when I'm driving home I question whether the ER is for me. That being said my coworkers are supportive and I can definitely hold my own in a true emergency. I was a Paramedic for several years prior to becoming a nurse but its like you said... The time management and charting is the hardest part of my job. I just wanted to let you know, you aren't alone and it does get better! :nurse:


21 Posts

First of all, your preceptor was rude to say that. I'm not a new grad and I felt that way when I first started in ED.

Now, onto time organization. Honestly, you just have to relax about outstanding orders and prioritize. You had a sick group of patients so there was just no way that you would be able to get through everyone fast. Just do the most pertinent things first and push everything else out of your head. I had a patient on 7 different drips today and very very unstable and guess what? My new onset neuropathy pain patient and my elderly lady who fell of her couch just were going to have to wait. If any doctor tried to say anything to me, well too bad, who is going to argue with me tending to a critically ill patient?

Some days you will feel overwhelmed and it's also important to ask for help. Our ED has a great team and we always pitch in to help one another. I hope you have that support behind you because without it it's tough.


334 Posts

Specializes in Emergency Nursing.

To answer you're question, there's not really anything you can do to not be overwhelmed. It happens to all of us. Young, old, experienced, and new. That's the ER. You're going to have the days where all of your patients are easy and everything goes as smooth as silk. And you're also going to have days that suck and you can't keep your head above water.

Remember, one patient at a time. Prioritize. Chart as you go, so you don't get too far behind, and keep your patients updated. Like in your OP, you needed to spend time with the conscious sedation patient. Tell your other patients that. That you haven't forgotten them, but something with another patient came up so you'll be tied up for a little while and let them know what you're waiting on as far as orders go. Most will understand. Others won't. And that's fine. If they are alive enough to be angry, they're stable ;) Then check in on them as soon as you're done.

Breathe :) And carry on. Good luck!


I was a new grad, straight to the ER. Love every minute of it. 6 weeks of orientation in a Level II trauma center. It can be done. I'm still swimming. Lol


224 Posts

Good advice here. I also try not to take anything too personally. Fast paced stressful environments tend to lack some of the niceties in communication. I always try to use my manners and be pleasant, and I don't take it personally if someone else doesn't.

BSN GCU 2014.

Sent from my iPhone using allnurses


163 Posts

Thanks everyone for the comments! I really, REALLY, appreciate them! Since that hellish day, I've been doing a lot better time-management wise! I make sure I'm charting every 1.5 hours, that way if I get busy, I'm not too far behind! My preceptor even noticed that I'm doing much more proactive charting and thought it was great! Today I had a full load and got a ped's patient in with DKA! And I was able to handle it (while using my team to help give pain meds to other patients who were waiting). It felt really great to have a solid team behind me. :) Thank you all again for your help and advice! I really think it's (slowly) starting to sink in!


224 Posts

A good team can make or break anyone on a bad day in the ED! Glad you're getting along!

BSN GCU 2014.

Sent from my iPhone using allnurses