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

[tpnurse95]

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.

[tpnurse95]

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!

Thanks so much for the tips. I think one of my big problems is I'm not delegating and asking for help unless its offered. I just see the other techs and nurses always seem so busy, I hate to take them away from what their already working on. But it never hurts to ask!

[tpnurse95]

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.

Thanks so much. Those are some well-needed kind words! I'm going to work on asking for help more often.

[tpnurse95]

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!

I appreciate the advice. What I'm getting from everyone, is basically I can't do it all on my own so I need to stop trying to do it all on my own. I understand many probably believe the ER is no place for a new grad, but we actually get a lot of new grads on our ER (probably because our hiring manager started out in the ER as a new grad), so she knows its possible.

I'm learning so much I can hardly take it all in, which is why I wanted to be in the ER in the first place.

But my brain is growing by the day and studying definitely is continued way beyond nursing school.

I like the advice "slow is fast"..I have noticed when I feel rushed I hardly ever get an IV, but when I'm not worrying about my other patients or what else I need to do, I can get that IV started. I will keep that in mind.

[rhkenji]

Hello,

I currently have 2 years ER experience and like you, I started off as a new grad and was only given 6 weeks training (with possibility of extension to 8, but was not granted). I work in a very busy ER with many critical patients, although 6 weeks was a short time, I was given time to grow after my preceptor ship by being assigned what we consider easy patients and progressively got assigned to more critical ones.

That said, I still feel like 6 weeks is short but I also feel like its not impossible. It's going to be easier with time, going back to learn every day/night is the hard part.

[daisy33]

hello tpnurse95,

I came across your thread as I was searching online for struggling new grad in the ER and saw your post. I am also a new grad and am feeling the exact same way. I don't feel like I am at the level of where I am supposed to be at, either. My critical thinking and prioritization is really holding me back as well as my skills. I dont know if this is because I am new or because I am slow. I wanted to ask you -- how you were doing? what ended up happening? do you have any advice to share since you last posted? I would greatly appreciate hearing from you and how you are doing. Thank you!

[speedynurse, ADN, BSN, RN, EMT-P]

I have never heard of 6 weeks as a new grad. Even our experienced nurses with an ED background get 4 to 6 weeks. Our new grad orientation is 4 months; I received 3 months as a new grad BUT that is with 3.5 years of experience as an ED tech in same department and a strong paramedic background. Never heard of 6 weeks.....so unsafe!