We have several new grads in our ER. I'm starting to think that most nurses should have at least a year on a more general ward before learning a specialty.
I'm seeing some clueless mistakes, and lack of basic skill in pt care. That includes things like how to clean a pt and roll and change bedding. Basics about IV med administration, dose calculations, prioritizing, and realities of inpatient care. They have no idea how the rest of the hospital functions.
On top of that, some of them seem to harbor elitist attitudes, as if they are already big hotshots. Yet, they themselves seem to lack the above mentioned skills.
we did a crapload of patient care/cna-type stuff in nursing school! got hanging IV and programming pump down too! just lack IV insertion opportunities.
and i'm thinking... how the heck do these new grads get so lucky?? right into specialty...
I have been through a lot of marital/family drama, reason for late reply. When I was in a 2 year RN program, They brushed fast all the important duties, skills, CNA's do-learned this as a new grad: transfer tips, changing beds & pc care under extreme situations. I knew it was important as a student & 18 yo med secretary. Felt I was cheated with this, FF 3 yrs, became AHN on day shift, when we would get screwed staffing wise on heavy,med surg floor, I would work with my. 20+ Veterans
work Hx NA's & I would do 22beds of AM care w/them & realized how little I knew, I would buy all 4 of us lunch &, happily all ended on time. More importantly, All 4 of us worked as a team, & no friction, mostly laughs=priceless & closer workers & Who gave a damn what NA thought, they gave us a ridiculous work assignment.??
I love CNA's, very unappreciated members of the team & everyone I worked with, still have special relationships with.
As someone who has been a nurse 3 years now and who went into the ED straight out of school, I can't stress enough that this is one of those things that absolutely isn't black and white. Some new grads would be wildly unprepared and unsuccessful going straight into the ED, others do it well. In fact, some of my best mentors in the ER are now 10-20 year vets in the ED who started their as new grads. I've also seen a lot of experienced floor nurses struggle to adapt to the different pace and priorities and the autonomy in the ER.
I think it's important to talk about this because when I was in nursing school I would read these boards and think "I can't do this or I have to do that...". A lot of people have said that I HAD to do medsurg first. But I wouldn't have been happy because I know I want to be in the ED. I'm really thankful now that I didn't listen or get deterred because of some of these opinions. Instead, I worked for years as an ED tech. Every opportunity I would do hands on skills (phlebotomy, ekgs, direct patient care, compressions in codes etc etc). I found the nurses that enjoyed teaching and I asked them why they did things a certain way, I observed how they prioritized. I read nursing documentation to see how they documented... I was proactive. In school, I fought to get my final internship in the ER. Every step of the way, I was trying to build my base for that specialty. I didn't wait to just get the opportunity or not in school. I sought it out.
Not everyone wants to commit that time and energy before graduating, but i also didn't want to come out of nursing school with just whatever they decided to teach me. AND, it helped me IMMENSELY during school and clinical to be aware of how things "are really done" and to already be confident with so much. I feel 100% that the actual nursing school/classroom portion was significantly smoother for me than my classmates because I put in that outside "real life" work. It was completely worth it just simply for getting through school.
With the experience I got as a tech, at times I was surprised about some of the things I had seen and done that many of the medsurg nurses in clinical or in ACLS hadn't. I was comfortably in codes and comfortable with the way nurses and doctors and techs interact in the ER. I was used to the fast pace and mixture of patients with wildly different needs. I had assisted on central lines and intubations and chest tubes. Because so many hospitals have phlebotomy and IV teams, I had more experience with blood draws in school than most of the nurses on the floor (at least the younger ones).
One other thing that has been neglected in this conversation is the type of ER. I currently work in a big city level one trauma center. Had I started there, I do think it would have been terribly overwhelming. So I started in a really small ER that was often more like an urgent care with IVs and occasional higher acuity. After a year, I went to a larger community hospital where I saw a lot higher acuity and learned more skills. Then I applied for the trauma center. I also picked places with strong orientations. So, my point is, there are ways to go the ED route without jumping into a major trauma center but without doing medsurg.
All and all, I think this is an important conversation because it was discouraging to read these posts and think I was going to be labeled or looked down on for trying to go this path. There are ways to do it safely, confidently AND humbly.
My best advice to ANY nursing student, be proactive during school. Find those nurses who can be mentors... network, take those extra certifications, get CNA/tech experience. And for any new grad, go for your dream, but do it in a reasonable way. That doesn't always mean doing medsurg for some obligatory year. When you get out there-wherever you are- be confident with the things you know and ask about the things you don't. Be someone that colleagues can trust because they know you will ask when you need help. Find those people who are willing to answer those questions and to help guide you early in your career. No one ever know everything... this is more important to realize as a new grad. If you realize that and approach this in way that shows you are open to learning, are paying attention when people offer to teach you stuff and that you are motiivated- you can find success in the area you choose.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
The big downside to having all the new grads get med/surg experience first is that they wind up leaving those units in a year and then turnover is high. I think all in all, it's better to have people start out on the unit they want to work in. You will still have some turnover as many new grads will find out they don't want to do what they thought they want to do. But you won't have almost everyone transferring in a year.
Practical skills take time to develop speed and efficiency, no matter where you are. You probably are unaware of how slow and inefficient you used to be. At some point it feels like you could always roll patients and change beds without thinking about it.
As far as the hotshot mentality, I think there are probably 2 main factors. 1. ER is attractive to people with high self confidence, so you're going to get more of that personality type, even though many will not be like that. 2. Acting like a hotshot is a common way to cope with low experience and competence, which is what every single new grad is going through.
I think it's best to not be hard on them and give them time and opportunity to develop their skills. Unless you see unwillingness to learn. In that case, lay it down for them and be firm. "You don't know anything yet, so listen up."
I had a student nurse, a senior BSN student. The week before graduation, I still had to remind her that she had to chart the BP and pulse when giving a beta blocker and other such meds. And the intervention for pain. She has no initiative, no prioritizing skills, no interpersonal skills. Seemed to me she thought nursing was passing meds and charting. She's going to start her nursing career in ER. I worked in the same ER as a seasoned nurse. They will eat her alive!
New Grad here! I love seeing this discussion because it gives me perspective on what staff nurses are thinking. However, I am also increasingly terrified to start my two new jobs in the next couple weeks. (I start LTC tomorrow and then radiation oncology in two weeks). I realize as that these are not specialty areas but some of the comments make me feel like new grads are not welcome at all and know nothing! In my degree program we got 1,680 clinical hours in med-surg, pediatrics acute and community, LTC, mental health, community placement (homeless shelter), oncology, orthopedics, family newborn, labour and delivery, and surgical. While I have always gotten good feedback from clinical instructors and good grades, I don't think I would feel comfortable working in a speciality (ICU or ER). I have always said that I wanted to get some good med-surg experience to build upon my nursing skills. But, I am now equally terrified to start my other jobs as a brand new RN.
Oh, and I also don't know if other schools get to have a placement in ER or ICU? I don't think that is common practice...For our final focus we could have requested it (360 hour rotation), but there are only about 4 spots per 200 students...so if a new grad is lucky enough to get a job in the ER then shouldn't we all be helping each other?
I disagree. I started in ICU as a new grad and I wouldn't have done it any other way. I think what matters is who you are as a person and whether or not you can handle specialty environments. I do feel that you should be prepared to be in these environments but that shouldn't mean new grads shouldn't start in those areas. I feel that you get what you put into your education and if you don't go the extra mile to learn and become competent in skills then that is on you. I feel that it depends a lot on the nursing school that you come from and who your professors are. I think ACM did a fantastic job at preparing us for a career in nursing including specialty areas. I also feel that a new grads success can have a lot to do with who mentors and orients them. I had two really exceptional nurses orient me and that has helped me become the nurse that I am today.
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Metalchild
37 Posts
we did a crapload of patient care/cna-type stuff in nursing school! got hanging IV and programming pump down too! just lack IV insertion opportunities.
and i'm thinking... how the heck do these new grads get so lucky?? right into specialty...