New grad nurse in the ER & not sure if I'm progressing fast enough.

Editorial Team / Moderator · Dec 15, 2017

That is a VERY short orientation, especially for a new grad. Is there a way for you to have more time? Did you have some non-clinical orientation first and now you're on the unit? New grads need a lot of time and structure to be successful in the ER environment.

There are a lot of good tips in this current thread: https://allnurses.com/emergency-nursing/currently-on-orientation-1141025.html

Two things jump out at me - first, teamwork IS essential. You can only be in one place at one time, unless you know some magic tricks or can defy the laws of physics. Second, learn to bundle your care as someone so helpfully mentioned in the thread I linked! Go into that room prepared to do ALL those things you mentioned. If you need someone to help you, get them in there. So when your little old septic ladies come in, have your team jump on them and get the IV/labs/two sets of cultures/Foley/UA that you will need. Anticipating orders and needs is huge, and if you can get it all done at once, it will help! IVs are just going to take time and persistence and practice.

Are you getting constructive feedback from your preceptor(s)?

TheSquire, DNP, APRN, NP · Dec 16, 2017

I have to agree - 6wks is much too short an orientation for any critical care location, ED included. Are they supplementing your orientation with educational offerings like the ENA modules or classroom instruction?

lainaa · Dec 17, 2017

Wow i would be so stressed out!Someone linked my topic from last week and all the help from others w their comments have given me encouragement and hope.First off,I know everything seems so fast paced but ive learned to accept that THAT is the culture of the ER. Its going to be fast no matter what we do.If you have even 10 seconds before a patient comes try to anticipate what youll need.i usually go for the standard rainbow/type and screen/blood cultures if sepsis is suspected,ekg,etc.Sometimes I even call in lab/phelbotomist to come in when theres a difficult stick.and get as much practice as you can with IVs.I used to be so afraid of them on the floor because i was so baf at them but now im the first one people call when theres a difficult stick.go for the go to AC veins.a cool trick I learned from my crisis/resource nurse was to double tourniqet--one above and below the site im going to poke..and BAM youll (hopefully) see a nice plump vein.it really is all about team work in the ED so make use of ALL your resources.pull your float in your room if you have one,call your tech for that ekg...ive noticed if you dont speak up for help youll drown.do NOT be afraid to delegate.that has been my problem.but its so helpful when you have an ambulance rolling in,someone getting settled from the lobby and you have a septic pt where youre trying to get a line and a little old confused lady in the other.trust me.i know the anxiety from all of this.i am going through the same thing now.its scary that we have a 4:1ratio with things happening like that but ask for help.cluster care as much as you can and be proactive instead of reactive.it helps so much to be a step ahead of everything.any tips you have also would be helpful for me!hopefully everything works out on your end fellow ER friend!

Dadof2RN2Be · Dec 17, 2017

First of all, CONGRATULATIONS! You've done it!

Now onto the meat of the questions/comments. I am not a nurse, however I am a Critical Care Tech in the ER here locally, and have to agree that this is how the ER is. What I absolutely love about my job as a tech is that I get to help you the nurses out get these tasks completed. Need a urine? Ask me! Need an EKG? I'd be happy too! Labs/IV? Count me in! Team work is really a must in the ED. I do notice a HUGE difference from night shift ER nursing staff to day shift ER nursing staff, and the ability (or sometimes willingness) to work as a team! Also, give yourself some slack. You're a brand new nurse just getting the hang of things. Did you go on multiple day bike races just as you took off your training wheels? Absolutely not! You will get there! Heck, in about three years I'm sure I will be in your shoes ranting about such!

Don't be afraid to ask for help! One thing us tech's love doing is helping those that need it! But especially helping those that don't delegate every single thing too! There is a happy medium.

turtlesRcool · Dec 17, 2017

I have to agree - 6wks is much too short an orientation for any critical care location, ED included. Are they supplementing your orientation with educational offerings like the ENA modules or classroom instruction?

6 Weeks is too short an orientation - period. Even for a generic med-surg position, my hospital's standard is 12 weeks. Some people come off sooner, and others have theirs extended, but it does no one any good for a new nurse to flounder and potentially miss something really important because he or she was expected to be independent too soon.

JKL33 · Dec 18, 2017

Hello all!
So I'm a new grad nurse starting out in the ER.
I haven't had any prior experience in the ER,l.
I just finished my 4th week of orientation. We are only getting 6 weeks. SIX! From what I've heard that is short for an ER nurse and especially a new grad.
I've been juggling 3 patients but I feel like I'm at my max. The ratio there is 4:1 usually. I feel that other nurses are constantly having to come in an assist me with discharges, charting, and skills. It seems impossible to do it all on my own. Not to mention I've been through a dry spell on IVs the past 2 weeks and this has really slowed me down.
How does one finish charting, start an IV, draw labs, get a UA, EKG, all in under 20 minutes when meanwhile you are getting an EMS in one room, you need to medicate in another room so they don't seize again, and take care of a disoriented pt who can't sit up straight, vomiting constantly, and no one can get IV on her. On the other hand lab keeps calling you to let you know they need another purple top because it clotted. And CT keeps calling wondering why you don't have an IV..and the doc wants to know what's taking you so long to discharge....HOW DOES ONE ACCOMPLISH SO MANY TASKS AT ONCE!?
And I get that we help each other out in the ER, but I never seem to have time to help anyone else. Everyone seems to have to help me and I still always feel behind.
I try to prioritize by seeing my patients who enter the room first but it seems that after I'm in the room for a short amount of time, someone asks why I haven't discharge so and so. To me, that's a lower priority then getting an EKG and rapid assessment finished on a new patient but to them they want to hurry and empty the room so they can fill it asap. How can I possibly get to a new pt when I haven't even finished my initial tasks for my new one!?
Maybe I'm just slow, I'm not really sure. But I certainly hope I can keep up with this pace of the ER. I want to stay and be accepted. I don't want to be the nurse who drags everyone else down because I can't hold my own.
Well that's my rant. I'm done. Any advice would be of the greatest appreciation.

Yes - 6 weeks is not a long enough orientation for a new grad ED RN. What are the chances you should talk to them about that now? Maybe our ED peers will weigh in.

A couple of things: You are correct that, in a situation like you described above, discharging someone is not the priority as far as how you would correctly prioritize the care of your group of patients.

With regard to feeling bad that others are helping you and you're not able to help others too much - that is the way it is supposed to be right now. If others think differently, then they have an attitude problem. The time will come when you are able to check in with coworkers and see how you can help them. If anything, for now just focus on lending a hand when the techs need help with your patients.

What is your preceptor doing while you are being asked why you haven't discharged someone yet?

Keep your chin up. Work on relationships as much as anything. Take a deep breath, smile, ask appropriate questions, show initiative, thank those who are helping you.

A (hug) for you. I have much empathy for this feeling of constantly feeling behind and overwhelmed while learning your new role. You can do it.

Cat365 · Dec 18, 2017

First of all, CONGRATULATIONS! You've done it!
Now onto the meat of the questions/comments. I am not a nurse, however I am a Critical Care Tech in the ER here locally, and have to agree that this is how the ER is. What I absolutely love about my job as a tech is that I get to help you the nurses out get these tasks completed. Need a urine? Ask me! Need an EKG? I'd be happy too! Labs/IV? Count me in! Team work is really a must in the ED. I do notice a HUGE difference from night shift ER nursing staff to day shift ER nursing staff, and the ability (or sometimes willingness) to work as a team! Also, give yourself some slack. You're a brand new nurse just getting the hang of things. Did you go on multiple day bike races just as you took off your training wheels? Absolutely not! You will get there! Heck, in about three years I'm sure I will be in your shoes ranting about such!
Don't be afraid to ask for help! One thing us tech's love doing is helping those that need it! But especially helping those that don't delegate every single thing too! There is a happy medium.

I want you in my ER! Not saying the majority of our techs aren't great but I still want you.

akulahawkRN, ADN, RN, EMT-P · Dec 18, 2017

Six weeks is just not enough time to properly orient a new grad. It IS enough time to orient a new employee that's already an experienced nurse. They're setting you up for failure and they may or may not know that.

How do you "get it all done" when you have that much "stuff" to do? You prioritize. What absolutely needs to be done? What can you get done fast? Who is the most sick patient? Who can you ask to help you out?

How do I get things done when I've got that kind of a load? I delegate tasks. I get the UA to help me get the patient undressed and the EKG done while I hook the patient up to the monitor. I listen to the report from EMS and ask questions while the patient is getting into the gown, hooked up to the monitor, and getting that EKG done. If I know an RN has a free moment, I'll ask them to medicate or discharge a patient of mine. That's a task off my plate. For that impossible to stick vomiting patient, I'll ask the charge nurse to find someone that can do an ultrasound IV to try to place a line or I'll ask a provider to do it because they can't get a peripheral line, they'll know right away if they need to put in a central line. That's now a task off my plate. If lab needs another draw, then they'll have to come get it themselves. I don't have time to draw a purple top for them, get it labeled, and sent it to them... That's yet another task off my plate. As to charting, I try to chart something on my patients whenever I pass by a computer that's "mine" or every time I'm in the room and the computer in the room is actually working. The charting doesn't often have to be much but it should reflect what you see or have discussed at the time, or what your patient is doing or where they've gone and why.

With time you'll get faster and faster. The problem is that as a new grad, and having such a short orientation, you just are going to be slow.

My last shift was in a fast track area. I probably saw a dozen patients during the course of my shift, 4 or 5 of them just were in my area for various procedures like laceration repairs, pelvic exams, or the like. That day I probably had an hour of time sitting in a chair and that included lunch... no other breaks because we were just too busy. With all that, I still had time to help out some of my peers, consult with the providers, take samples to the lab, and so on. I'm not that fast but compared to how I was when I first graduated, I'm Speedy Gonzales! I've only been in the ED for 3 years but I still enjoy it and other nurses sometimes come to me for advice on how to do things.

How do you get fast at things? Go slow... Remember the old adage: "Slow is smooth. Smooth is fast. Slow is fast." By doing certain tasks slowly, you'll do them smoothly and get it done right the first time. For an uncomplicated IV start, it only takes me about 3 minutes to get it done from start to finish. It's all because I first choose the site, do the chloraprep, prime the extension set while the chloraprep is drying, tear tape, get my tegaderm ready, etc... all before the chloraprep is dry. It's just a series of simple tasks done quickly. Then I do the venipuncture and put it all together fast because it has already been preset. Slow, smooth, deliberate efficient movement = fast.

I just hope that when you're done with your orientation that you won't be thrown into the deep end of the pool. There are more than a few nurses that work in the ED that believe that the ED is no place for a new grad to start. It is very possible if the orientation period accounts for the additional teaching and support that a new grad needs to not only learn to be a nurse, but to also learn to be an ED nurse. I was lucky. My orientation was 16 weeks. I have since changed employers and my "new" job orientation was just 6 weeks, but for various reasons, was really effectively about 4. By then I was already experienced as an ED nurse so most of what I needed was to know where things were and who to talk to. I'm still learning and I expect to keep learning for quite a while to come!

Best of luck to you, I hope you succeed, and welcome to the 3 ring circus known as the Emergency Department!

JKL33 · Dec 19, 2017

Six weeks is just not enough time to properly orient a new grad. It IS enough time to orient a new employee that's already an experienced nurse. They're setting you up for failure and they may or may not know that.
How do you "get it all done" when you have that much "stuff" to do? You prioritize. What absolutely needs to be done? What can you get done fast? Who is the most sick patient? Who can you ask to help you out?
How do I get things done when I've got that kind of a load? I delegate tasks. I get the UA to help me get the patient undressed and the EKG done while I hook the patient up to the monitor. I listen to the report from EMS and ask questions while the patient is getting into the gown, hooked up to the monitor, and getting that EKG done. If I know an RN has a free moment, I'll ask them to medicate or discharge a patient of mine. That's a task off my plate. For that impossible to stick vomiting patient, I'll ask the charge nurse to find someone that can do an ultrasound IV to try to place a line or I'll ask a provider to do it because they can't get a peripheral line, they'll know right away if they need to put in a central line. That's now a task off my plate. If lab needs another draw, then they'll have to come get it themselves. I don't have time to draw a purple top for them, get it labeled, and sent it to them... That's yet another task off my plate. As to charting, I try to chart something on my patients whenever I pass by a computer that's "mine" or every time I'm in the room and the computer in the room is actually working. The charting doesn't often have to be much but it should reflect what you see or have discussed at the time, or what your patient is doing or where they've gone and why.
With time you'll get faster and faster. The problem is that as a new grad, and having such a short orientation, you just are going to be slow.
My last shift was in a fast track area. I probably saw a dozen patients during the course of my shift, 4 or 5 of them just were in my area for various procedures like laceration repairs, pelvic exams, or the like. That day I probably had an hour of time sitting in a chair and that included lunch... no other breaks because we were just too busy. With all that, I still had time to help out some of my peers, consult with the providers, take samples to the lab, and so on. I'm not that fast but compared to how I was when I first graduated, I'm Speedy Gonzales! I've only been in the ED for 3 years but I still enjoy it and other nurses sometimes come to me for advice on how to do things.
How do you get fast at things? Go slow... Remember the old adage: "Slow is smooth. Smooth is fast. Slow is fast." By doing certain tasks slowly, you'll do them smoothly and get it done right the first time. For an uncomplicated IV start, it only takes me about 3 minutes to get it done from start to finish. It's all because I first choose the site, do the chloraprep, prime the extension set while the chloraprep is drying, tear tape, get my tegaderm ready, etc... all before the chloraprep is dry. It's just a series of simple tasks done quickly. Then I do the venipuncture and put it all together fast because it has already been preset. Slow, smooth, deliberate efficient movement = fast.
I just hope that when you're done with your orientation that you won't be thrown into the deep end of the pool. There are more than a few nurses that work in the ED that believe that the ED is no place for a new grad to start. It is very possible if the orientation period accounts for the additional teaching and support that a new grad needs to not only learn to be a nurse, but to also learn to be an ED nurse. I was lucky. My orientation was 16 weeks. I have since changed employers and my "new" job orientation was just 6 weeks, but for various reasons, was really effectively about 4. By then I was already experienced as an ED nurse so most of what I needed was to know where things were and who to talk to. I'm still learning and I expect to keep learning for quite a while to come!
Best of luck to you, I hope you succeed, and welcome to the 3 ring circus known as the Emergency Department!

Nice post.

As for whether or not the ED is appropriate for new grads, you're right, it all depends upon the support and orientation that is being offered. When either of those things is inadequate, it's not the best place for them, for their own well-being. It makes me sad to see new grads get shorted in these ways because I feel a first position is an opportunity to lay either an excellent foundation or a shaky one where the person struggles for years because of too many gaps that were never filled in.

tpnurse95 · Dec 20, 2017

That is a VERY short orientation, especially for a new grad. Is there a way for you to have more time? Did you have some non-clinical orientation first and now you're on the unit? New grads need a lot of time and structure to be successful in the ER environment.
There are a lot of good tips in this current thread: https://allnurses.com/emergency-nursing/currently-on-orientation-1141025.html
Two things jump out at me - first, teamwork IS essential. You can only be in one place at one time, unless you know some magic tricks or can defy the laws of physics. Second, learn to bundle your care as someone so helpfully mentioned in the thread I linked! Go into that room prepared to do ALL those things you mentioned. If you need someone to help you, get them in there. So when your little old septic ladies come in, have your team jump on them and get the IV/labs/two sets of cultures/Foley/UA that you will need. Anticipating orders and needs is huge, and if you can get it all done at once, it will help! IVs are just going to take time and persistence and practice.
Are you getting constructive feedback from your preceptor(s)?

First off, thanks so much for the feedback and the link!

I plan on requesting an extra 2 weeks on orientation if I'm not feeling up to par by week 6. My preceptor is great and she does provide helpful tips and tries to help me prioritize but I'm always falling behind. I've voiced to her that I don't feel that I'm progressing fast enough and she doesn't agree nor disagree..just kinda gives me the "I'm listening, I'm here for you nod."

I did have some non-clinical prep before through a nurse residency program, and although it prepped me on skills and refreshed my memory on nursing school basics, hands on care and multitasking is a whole new ball game.

I think I just need to start asking for more help and be ohkay with accepting the help.

tpnurse95 · Dec 20, 2017

I have to agree - 6wks is much too short an orientation for any critical care location, ED included. Are they supplementing your orientation with educational offerings like the ENA modules or classroom instruction?

I went through a nurse residency program before hand. This included simulations, PALS, TNNC, ACLS, and a week long class on EKGs.

Although it expanded my knowledge base tremendously, it didn't prepare me for all the juggling I'd be doing in the ER.