Novice ER Nurse needs help please

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I would really appreciate some input. This is the first time I'm posting so please forgive me if I'm doing it wrong. I'm a novice nurse, graduated last year and entered a 10 month orientation program at a local hospital. Novices started rotations through med-surg, tele, and then end up in home unit. My home unit is the ER and I have been there about 5 months. I was set to come off orientation and had been put on May's staffing schedule. My last week of orientation I ended up in the hosp so I was told that my orientation would be extended another week to make up for the week I missed. The last shift of that week I ran into the nurse manager and asked if I was good to go to start my own schedule the following week. She informed me that they were extending my orientation (but was not sure for how long) because they were concerned my critical thinking skills were not ready. This conversation happened in the middle of my 12 hour shift AND it was the first it had ever been mentioned to me and it had never been noted in my clinical folder. I put my big girl panties on and finished my shift. Honestly I did have a little cry in private but regained my composure and think that think I did a pretty good job. I called her back on my day off to pick up the conversation and let her know that I loved the ER, felt I had grown tremendously since I had been there, wanted to be a nurse there and would do whatever it takes. She countered with: she needed a timeframe from me on how long I thought it would take to develop my critical thinking skills and I had to write a plan and goals which are due Fri at 0700. I know I need to improve and grow but honestly feel that will come with experience. I am not making excuses for myself but have had issues with the preceptor I have had since getting on days and had been told months ago by the nurse running the orientation program that other novices had issues with this preceptor. I'm a new grad at 47 and my preceptor graduated three years ago and is 23. I hate to talk badly about her, I think she is a great nurse, but honestly don't feel she has what it takes to be a preceptor. That is not the issue I am facing now I am just extremely frustrating. What I am asking for at this point is any guidance with writing this plan. She did not give me anything to go on other than critical thinking skills. I do want to improve upon them but not quite sure how you write a plan for that. Other areas I know I need help on is delegation and confidence. I do believe part of the problem that this is stemming from is that I am the kind of person that wears her heart on her sleeve. I told my preceptor that I was going to be nervous when I came off orientation and started on my own (but I feel that is a normal fear). I just shouldn't have expressed it to her I suppose. And on one occassion last month I had my first BAT and when it was all said and done I complemented my preceptor telling her what a great learning experience it was for me that I don't know I would have known exactly what to do had I been on my own. UGH! Boy did that come back to bite me. Any suggestions for a plan?? I have a 4 week extension. Thanks for any help given. : )

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Same thing happened to me. Never again mention any weaknesses or doubts about yourself because they will use it against you. In reality they are not weaknesses but in the ER apparently they are. As far as your goals and planning I am sure a more experienced nurse on here can help lead you it the right direction. Forever think and say only positive things when working with the staff. I was always told that nurses were afraid of over confident graduate nurses, well I think that is untrue when it comes the the ER. Just my opinion.

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Check out the book Critical Thinking in the Emergency Department: Skills to Assess, Analyze and Act. This resource should be able to help you put together a plan. Good luck!

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FYI author is Shelley Cohen.

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Specializes in Cardiac, ER.

Lack of Critical Thinking Skills is a term thrown at new nurses everyday, but often not defined. I agree with you in that part of your Critical Thinking Skills comes from time,.from trial and error and you just can't speed that up. I have seen many a new grad become frustrated with this term, feeling that they need specific details on what to change or improve on. The problem with that is that this term really means that you need to take all the details that you've learned over the years, lump them together and see the whole picture.

We actually have a critical thinking skills lab in our preceptor-ship. We do exercises, often not even nursing related, to encourage you to think, ask the right questions and respond with the correct interventions.

One of my favorites is the "Help me with my car" scenario. If I called you on the phone and said "Oh my gosh Lunar, I can't get my car started. Can you help me please?" What would you do? Many of the class gives the response "I know nothing about cars, you should call someone who does!" Not bad advice,..but do you really no "nothing" about cars? Don't we all drive a car everyday. Didn't we all have to pass a test to get a license?

Lets see if we can get this car started. We start out by coming up with all the "obvious" reasons a car might not start....out of gas, dead battery, some of the more experienced people mention things like alternators and fuel pumps. We start with what we think is an easy fix and ask, "do you have gas in the car?",.."yes, I put $47 worth of gas in it yesterday and it drove fine then",...ok,.."well is it possible that someone stole you gas?",....."well,..my gas tank has a lid with a lock and it doesn't appear to have been tampered with",...ok then,...well probably not out of gas,.."Is the battery dead",...."how can I tell if the battery is dead?",...hhhmmm,.."how old is the battery?",....."I put a new battery in 6 months ago",...ok,..well it shouldn't be that,..."Is the battery attached to the car?",..."I pop the hood and yes it appears to be connected properly",......this goes on for over an hour with the class coming up with all different scenarios of why this car isn't starting.

Then finally people start asking more detailed questions,..."What happens when you try to start the car? Does it make a strange noise? Does it try to start at all?",.....as we continue to ask questions,..we realize that the key doesn't even turn in the ignition and that lo and behold,..I've grabbed my husbands set of keys!

Now this process usually takes two hours of class time. What turns out to be a silly mistake,.easily fixed,.took 15 college graduates 2hrs to figure out! The point here is the process. Asking the right questions. Observing. Using our deductive reasoning and finding a solution.

This thinking process is exactly what you as a nurse uses everyday to care for pts. Is every chest pain an MI? Of course not,...but you know how to figure it out,....you know what to do,.....start that line, draw those labs, get the EKG,..put the pt on O2 and a monitor,....from there you can start asking all the right questions,.....where is your pain,..what were you doing when the pain started,..how long have you had this pain,....etc

I try to tell all my new grads to think ahead. Learn to anticipate what you need to do to help get the answers. A great way to do this is to listen when the doc examines the pt. Listen to what questions he/she asks,..what type of physical information does he obtain,.what labs seem most important? Look at those lab results. Learn why the first three pts are sent home with pepcid and the next one is rushed to the cath lab.

Hang in there. Tell your boss that you are going to be more aware of not only what the doc orders for your pt,..but what info he expects from you and what info will be most useful in any given situation, and that you are going to try to be better at anticipating what needs to be done to speed up this whole process.

Becoming a great nurse takes experience. Make the most of your time so that you get the best experience that you can.

Best of luck to you!

(wow,..sorry this was sooooo looong..:) )

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Thanks so much for your support and input. Problem with getting the book is I need to turn in a plan for myself by 700 tomorrow morning. I live in a rural area and I'm sure the only way for me to get the book in online = won't have it today. I will definitely look into book to use as my own resource... at this point I am still in need of input for how you write this "plan" I have been working on it for the better part of today, searching on the net as well. No where can I find clear cut suggestions. Everything I find says a nurse needs critical thinking... but no where does it say how you improve upon it. UGH But I am determined!

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Lack of Critical Thinking Skills is a term thrown at new nurses everyday, but often not defined. I agree with you in that part of your Critical Thinking Skills comes from time,.from trial and error and you just can't speed that up. I have seen many a new grad become frustrated with this term, feeling that they need specific details on what to change or improve on. The problem with that is that this term really means that you need to take all the details that you've learned over the years, lump them together and see the whole picture.

We actually have a critical thinking skills lab in our preceptor-ship. We do exercises, often not even nursing related, to encourage you to think, ask the right questions and respond with the correct interventions.

One of my favorites is the "Help me with my car" scenario. If I called you on the phone and said "Oh my gosh Lunar, I can't get my car started. Can you help me please?" What would you do? Many of the class gives the response "I know nothing about cars, you should call someone who does!" Not bad advice,..but do you really no "nothing" about cars? Don't we all drive a car everyday. Didn't we all have to pass a test to get a license?

Lets see if we can get this car started. We start out by coming up with all the "obvious" reasons a car might not start....out of gas, dead battery, some of the more experienced people mention things like alternators and fuel pumps. We start with what we think is an easy fix and ask, "do you have gas in the car?",.."yes, I put $47 worth of gas in it yesterday and it drove fine then",...ok,.."well is it possible that someone stole you gas?",....."well,..my gas tank has a lid with a lock and it doesn't appear to have been tampered with",...ok then,...well probably not out of gas,.."Is the battery dead",...."how can I tell if the battery is dead?",...hhhmmm,.."how old is the battery?",....."I put a new battery in 6 months ago",...ok,..well it shouldn't be that,..."Is the battery attached to the car?",..."I pop the hood and yes it appears to be connected properly",......this goes on for over an hour with the class coming up with all different scenarios of why this car isn't starting.

Then finally people start asking more detailed questions,..."What happens when you try to start the car? Does it make a strange noise? Does it try to start at all?",.....as we continue to ask questions,..we realize that the key doesn't even turn in the ignition and that lo and behold,..I've grabbed my husbands set of keys!

Now this process usually takes two hours of class time. What turns out to be a silly mistake,.easily fixed,.took 15 college graduates 2hrs to figure out! The point here is the process. Asking the right questions. Observing. Using our deductive reasoning and finding a solution.

This thinking process is exactly what you as a nurse uses everyday to care for pts. Is every chest pain an MI? Of course not,...but you know how to figure it out,....you know what to do,.....start that line, draw those labs, get the EKG,..put the pt on O2 and a monitor,....from there you can start asking all the right questions,.....where is your pain,..what were you doing when the pain started,..how long have you had this pain,....etc

I try to tell all my new grads to think ahead. Learn to anticipate what you need to do to help get the answers. A great way to do this is to listen when the doc examines the pt. Listen to what questions he/she asks,..what type of physical information does he obtain,.what labs seem most important? Look at those lab results. Learn why the first three pts are sent home with pepcid and the next one is rushed to the cath lab.

Hang in there. Tell your boss that you are going to be more aware of not only what the doc orders for your pt,..but what info he expects from you and what info will be most useful in any given situation, and that you are going to try to be better at anticipating what needs to be done to speed up this whole process.

Becoming a great nurse takes experience. Make the most of your time so that you get the best experience that you can.

Best of luck to you!

(wow,..sorry this was sooooo looong..:) )

This post was absolutely perfect. Why not give us a class like this while in school perhaps the last semester. I would have taken that class in a heart beat.

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RN-Cardiac!! Are you kidding me? Apologizing for it being a long reply?? That was exactly what I needed. Thank you, thank you, thank you! I hate to admit it but I have felt so beat down since my conversation with the ER manager, and have felt so alone... your reply was a breath of fresh air for me. The fact that you took to time you did to answer me means the world to me. Your right trying to "define" critical thinking, let alone trying to write a plan for it is very frustrating. I know I am a good nurse and don't believe my fears are unfounded. My mistake was expressing them to coworkers. Won't make that mistake again. I loved your car scenario and will definitely use your advice. Thank you again so much for showing me a random act of kindness. You never know how such things can touch a person's life. : )

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Specializes in CT stepdown, hospice, psych, ortho.

So include in your plan that you are going to read critical thinking for nursing books (go to amazon and do a search and pick a couple that have high ratings) and start going over case scenarios on your day off, ask for a bi weekly meeting to discuss your progress, request a couple of weks with a different preceptor "in order to gain perspective on how yet another nurse organizes her day and responds to various situations", see if you can find any CEU courses on critical thinking or ER nursing or common situations in the ER that you aren't comfortable with yet and also incorporate those in your plan. I know at my last hospital we had an online university with CEUs and various courses that weren't required but you could register to complete at home (on your own time of course and without pay) but some of them were very good. I took several of them about topics I hadn't addressed in a while in my various nursing roles and found them really helpful reviews. I would just suggest coming up with a workable plan that includes timeframes and some goals for yourself and also the way you plan to evaluate your own progress and have your manager evaluate you as well. I'm sure she will have her own input as well but it will look better if you have a well thought out plan to present to her and then ask her what additions she would like to make so that both of you are confident that you have a plan for developing the necessary skills. Best of luck. I've never done ER but it seems like it would be very difficult for a newer nurse because there are so many things that you have to do on the seat of your pants. Let us know how it goes.

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Specializes in student; help!.

It's totally fair for you to ask what they mean by "critical thinking skills". In fact, you have to, or the whole scenario is left up to you to decipher. Ask for examples, situations in which you did not display the thinking they want to see, and how they'd like you to be thinking. Just laying it out as something you need to solve with no clues as to WHAT you're solving is a cop-out and bad management. You cannot fix what's wrong if you don't know, SPECIFICALLY, what they want you to address. "Critical thinking" is too vague. Is it that you're not assessing pts correctly before speaking to the doc about the case? Did you miss a s/s? Did you make a med mistake that could have been avoided if you'd asked one more question? If they can't/won't help you with this, I'd look for another position; this is not a job you want to keep. They'll do the same kind of thing again and again until you leave or they fire you. It's not limited to hospitals, either.

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This may be of some help:

http://http://books.google.com.au/books?id=LG2XHbEpWz4C&pg=PA607&dq=Critical+Thinking+in+the+Emergency+nursing&cd=7#v=onepage&q=Critical%20Thinking%20in%20the%20Emergency%20nursing&f=false

I dont know if this will help you but one thing i have learnt is initiation of procedures i am not sure where you live, but here in Australia at the hospital were i work at we are able to initiate certain procedures for patients such iv cannulation, xrays, ECGS and blood tests. So say you are called to the triage desk to bring in a patient, you get there and the triage nurse tells you that there is a patient who has presented to the ER, they have driven themselves in and have had crushing chest pain. This is how i would go about managing them just by what i have been told first i would think differentials stemi, nstemi, chest infection, pneumonia, pneumothorax, pericarditis, pleuritic pain, muscular, just some of the things it could be. Next:

I do my primary survey i begin this just by looking at them and when I bring them to their bed, ill quickly palpate their radial artery for 15 seconds, is it present? Tachy? Brady? Pop on some o2 via hudson mask, Get them undressed, start putting ecg dots on, while i am doing all this i am asking questions, about their pain, getting them to describe it and when it started, what it feels like etc., I can visualize their chest so i can assess their breathing, the rate, are they breathing rapid, shallow, deep, labored, there undressed and im putting the ecg dots on so i can see the rise and fall of there chest, color, symmetry, their respiratory effort, penetrating wounds? edema? Past chest surgery? By this time i am ready to print my ECG. I look at my ecg and it has st elevation in leads II, III, AVF

Already in this time up until now in such a short period i have established that my patients:

Airway: is patent he is talking describing his pain telling me that it started 5 hours ago while he was shopping for his sons birthday in 2 days, and have a pain scale as he describes it as a sudden crushing pain on a scale of 7 he states

Breathing: I'm looking at his chest while the ecg is being processed and can see that its symmetrical, rise and fall is present there is some effort as seen by the mild use of his breathing accessory muscles.

Circulation: Ive palpated his radial pulse the pulse is strong regular and 80 bpm so i can assume safely he a B/P of >80mmhg as he has a radial pulse present

I can also say his GCS is 15 as his eyes are opened spontaneously, he is orientated and is conversing with me as he has told me he was out shopping for his sons birthday in 2 days and he is obeying commands when I asked him to lay still so i can print my ECG.

In the space of a few minutes i can go to one of our doctors and tell them quick this patient is having an inferior MI , there pulse is 80 and B/P is >80mmhg as there is a radial pulse present and he has a RR of 26 with mild work of breathing. Go back give pain relief get my iv access take bloods send my bloods to path and request a FBE U+E and Ck Troponin and Initiate a mobile CXR. Hopefully by this time i have another nurse there helping me prepping the pt for cath lab.

Critical thinking thinking it is thinking ahead time managing and planning ahead and being quick to intervene properly and safely and initiate procedures. When you get a patient try to think ahead, if you get a patient say with upper left abdomen think ahead what it could be pancreatitis, viral gastroenteritis and what you can for each one etc., Working in a ER i have found is always being one step ahead and if you find you dont understand something ask questions. The question that one day will save someones is the one you never asked no matter what it was. Experience will come but dont allow yourself to become intimidated and loose confidence in yourself and your abilities.

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Do not mean to be a downer here, but, as good and knowledgeable as any new grad can be, the ED is daunting. I am a 15 year plus ER dog. I have seen the shear volume and acuity chew up and spit out many new and promising ED nurses. Burn out rate becomes very high. It is a great place to work. It is also an area where you have to crawl before you walk and than run. In the ED you do run. I started med surg one year, ICU one year than ED. This was after 3 years as an orderly in the ED finishing school. I am sure you have better critical thinking skills than you may have been led to believe. The problem with the ED is that many times you do not have the time to think, you have to know and react, this comes with experience. Do not give up your dream, but perhaps your plan could be something like tele level for 6 months to increase your organizational skills and gain that valuable insight needed in a busy ED. Good luck to you.

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