lcb

I work in a similar ER -- a public safety net level 1 trauma with extremely high volume and acuity. I thought our ratios were bad but yours are out of the park. I made it through 2 years in the medical ER, where ratios were usually 5:1. Sometimes I would have 2 or 3 ICU boarders (waiting for their bed upstairs for days) along with 2 hallway patients, usually med-surg boarders (who were supposedly stable but could go downhill fast). I loved it at first but after a while I HATED it. The turnover was very high and after my first year I was often one of the most experienced nurses in my zone. After two years there, I qualified to transition to the trauma ER specialty unit. I started here a month ago and I LOVE it. The goal ratio here is 2:1. I have occasionally been 5:1, but only for short periods while my trauma bays are doubled because of a lot of activations coming in at once -- I've never had more than a 3 patient assignment here. I also almost never have med surg holds -- when I do have holds they're ICU and super interesting -- and our patients get upstairs MUCH faster, so my assignment turns over the way an ER assignment is supposed to do. I get to focus on stabilization, which I love, instead of passing meds for needy med-surg patients like I often had to do in the medical ER. Plus, because the trauma specialty unit requires experience, I'm now one of the LEAST experienced nurses in my unit, and there are always smart, experienced nurses I can turn to for advice when I have questions. I am so much happier. If you are one of the most experienced nurses in your ER, then you can fight for better assignments, and you should. Find a manager or a charge who will advocate for you and ask them for the assignments you want. But also, that ER sounds like a mess and you can probably get something way better. If it's anything like my ER, having that mess on your resume will give you a golden ticket anywhere you want to go. These crazy volume public hospitals have a (deserved) reputation for turning out nurses who can go anywhere and do anything. Do some research on the hospitals in your city, find threads on reddit and here on allnurses and figure out where nurses are happiest, and go there. My best friend from the medical ER recently transferred to the burn ICU, and she's a lot happier too...they have NO turnover in that unit, on average nurses are there for 10 years! That's a great sign of happy nurses. There could be a unit like that in your hospital, and after the ER, you could probably transfer anywhere you want. Ask around to find out where nurses are happy and the turnover is low.

I work at a big level 1 trauma ER in the heart of downtown of a major city. We're the only public safety net hospital in our city, and we see a huge volume of very high acuity patients. (We're probably in the top 5 busiest ERs in the country.) We have 15 fast track beds, around 60 (give or take, there's always room to squeeze in one more somewhere in the hallway!) acute medical ER beds, and 30 trauma beds with 7 bays. We also have 2 observation/inpatient boarding units of, IDK, 30 or so beds each? plus a detention unit and a psych unit, so between 200-300 patients total in the ER at any given time. We also offer scheduled outpatient dialysis in our ER so there are always people in the waiting room for that on weekdays. I don't think I've ever seen a volume lower than 100 patients total in the entire ER department. Our waiting room wait is, obviously, LONG. Can be as short as 4 hours, as long as 12. Average is probably 6-10? All 1s and 2s go straight back, they don't wait at all. 4s and 5s get moved through the fast track pretty quickly, and sometimes get discharged straight from the WR. 3s wait forever. On an ideal, perfectly staffed day, the waiting room has 5 nurses: 3 triage nurses, a charge, and a "nurse first" RN sitting at the door to catch any critical walk-ins and manage the chaos of the waiting room. Ideally there's also a patient care tech, possibly 2. There's also an EKG tech and a phlebotomist who does labs for both WR and fast track. The patient care techs mostly do triage vitals, but if there are two (that never happens though), then one will do repeat WR vitals, along with the nurse first. We are supposed to get vitals for all WR patients q. 4 hours. That rarely happens. However, it's rarely more than 15 mins to get those initial triage vitals, and if the vitals are unstable, the patient gets called back as a 2 and wheelchaired back to a bed to get seen immediately. There's also an APP who assesses patients before they get to triage. When they first come in, the nurse first does an across-the-room assessment, then if they look stable at a glance they go to registration and then to the APP for a quick initial assessment of their chief complaint. If they have chest pain, the APP sends them straight to EKG. Stable patients wait 10-15 minutes before they're called up for triage and initial vitals. They then get sent to phlebotomy for initial labs. We have a separate triage area for ambulance arrivals, which usually has 2 nurses, registration, and a provider. The ambulance triage area also has a traffic control nurse, who keeps track of where all the ESI 1s and 2s are going (we have multiple zones and multiple stabilization bays). Nobody is supposed to wait in ambulance triage, though; if they're stable to wait, the ambulance crew takes them to the waiting room. Reassessment of patients in the WR after triage is done three ways: * The tech is supposed to get vitals q. 4 hours, but like I said that is rare...probably every 5-6 hours is more average but they do get retaken. If they're changed/unstable, the tech is supposed to tell the charge nurse. Sometimes nurse first is the person doing those. * The nurse first and the charge nurse both keep an eye on the whole WR and watch for anything weird/concerning (mostly signs of an impending fight breaking out, but also something like someone falling off their chair or whatever). * The APP keeps an eye on lab results for patients in the waiting room. If something comes back super wonky (only life-threatening wonky, like an elevated K+ for someone who isn't a dialysis patient), they get uptriaged to a 2 and called back for an immediate bed. Obviously with the level of acuity and volume we have, we need to do a ton of monitoring in the WR and even with all that, we still have pretty bad *** happen in the WR. We are usually pretty decent about catching medical emergencies in WR patients, though. Usually the WR events are stuff like fights breaking out, or fires in the bathroom cuz someone was smoking in there. Those kinds of things happen regularly, LOL.

OK, but you all were given contact info? We’re just being given a name. No contact info and in some cases the unit is unclear. I was assigned two different preceptors who both told me they weren’t actually my preceptor, and now that hospital has rescinded my placement and I’ve been moved to a different hospital. This is my last semester and I am on the verge of quitting nursing school over this. It’s so damn exhausting.

My cohort has to reach out to our senior practicum preceptors ourselves, with no introduction. We’ve been given a name but no contact info and sometimes there’s uncertainty about the unit, we just know the hospital. We’re supposed to find their contact info and get in touch with them ourselves. The first preceptor I reached out to didn’t know anything about being having been assigned to precept. I was given a different preceptor so now I have to reach out again, but I don’t even know which unit she’s in. Is this normal for senior practicum? Do most schools do this, or does the professor or clinical instructor send an email introducing you?

hey, how's everybody doing in your externship? I LOVE the ER so much! I've known since I first started thinking about going to nursing school that I wanted to work in the Grady ER, but it's so much better even than I thought it would be. I learn as much in every shift as I learned in all of nursing school! I just got my senior practicum placement in Grady's CVICU, so I'm really excited about getting to experience "the other side" too! I definitely want to do my residency in the ER, but I requested ICU for my practicum and I'm really stoked I got it! Is anybody in the CVICU? Would love to hear what the culture is like there, I'm nervous about culture shock coming up from our ER chaos! ?

Hi all you brilliant CVICU nurses out there! I just got my senior practicum assignment in the CVICU and I'm SO excited but also SO nervous. I've been working as an extern in the ER at the same hospital, and I LOVE it, and CVICU was my first choice for my practicum because eventually I want to work as a trauma nurse and I think this will be good experience (my hospital has an entirely separate unit for our Level 1 trauma, where I work is the medical ER and you need two years of experience there before you can apply to the trauma unit). I've been working on getting my ACLS and I think I can finish it before I start my practicum, and I'm also working on an online ECG course, but I'm really worried about the culture shock going from ER to ICU. In the ER, everybody's always throwing trash on the floor (yes we pick it up after the emergency is over -- usually!), everything is chaos, and I can't even get the cords on the portable vitals machines to stay untangled enough to use them -- don't even dream about organized IV lines! I have gotten to help with several codes already, and I feel reasonably solid on my basic knowledge of cardiovascular/pulmonary physiology (will brush up on that too of course), but I'm really worried about the culture of the ICU, especially in such a high-acuity/high-pressure unit as CVICU. Are the nurses as mean and snobby as the stereotypes say? Will everyone give me side eye if I drop a saline wrapper on the floor in the middle of a code? Will they act like I'm stupid if I can't remember proper medical terms for things and talk about them in plain language instead (which happens to me all the time)? What should I do to optimize my experience and learning and avoid the nurses hating me? Gahhhhh I'm so excited but so scared!

I’m brand new in the ER and an extern so I can’t answer this question, but I will say: If you ever have time, watch a good phlebotomist get a hard stick. They are amazing and have so many tricks. I was struggling searching for a vein the other day…the phlebotomist came and rescued me and I learned so much by watching her.

this is a GREAT point and exactly what I was trying to point out in the discussion. I was definitely not rude in the discussion with this instructor, at least not by my standards of politeness — I literally didn’t say ANYTHING other than to ask whether “pink” is really an appropriate term to use to describe all skin, and when she insisted it was I shut up and said nothing more — but my firm belief is that the ritualistic use of the word “pink” to describe all skin tones is in fact racist. It’s white-centering, because it implies that pink skin is normal skin and other colors are not normal. Using “pink” ritualistically (that’s a great word you use, love that way of describing it) to describe all skin tones is upholding racism in healthcare. It’s also inappropriate for the reasons you mention — it’s not an accurate assessment. Solidarity fist bump on the respiration counting. I am pretty good about *actually* counting respirations (I work in the ER so vitals could literally be anything at any time, we have no clue what’s going on with people when they come in so you gotta really look at everything), but I sometimes round up or down to chart a number between 12-20 when the person is conscious & talking & their breathing isn’t labored & their pulse ox is 100% but the respirations number is not quite within the standard limits. I’ve been thinking I’m just not very good at counting respirations, and I don’t want to flag someone and cause a panic when I’m confident their breathing is doing what it’s supposed to do, but maybe it’s just that normal is a much wider range than textbooks say!

WOW, @soontoretire2020, it’s WILD to hear how much hospitals have changed. I can’t even imagine the situation you’re describing when you first started — so different from today!

Ah, thanks for all the support — I wish I’d checked this thread again before my comments were due! After talking with other students who saw me in clinical and a friend who’s a nurse and had a similar experience as a student, I decided to let it go. I really didn’t want to do anything in my response that would potentially support her statement that I don’t accept feedback, and after talking with other students who were with me in clinical, I feel pretty confident that this was just one person not liking me and that I’m not really gonna be able to learn anything valuable from her. (As others said in this thread — if she wanted to offer constructive or useful feedback, she would have said something when an incident happened, not called me names after the fact like that!) Also, there was an incident — which to me was so minor I had forgotten it — where I questioned her use of white-centering language to describe skin (she INSISTED that in report we should always say skin is “pink and well-perfused”…I asked “wouldn’t it be more appropriate to say “skin color is appropriate for ethnicity? Because not everyone has pink skin?” and she insisted no, you have to say pink, and the discussion moved on). But yeah, me essentially implying that she was being racist in front of all the other students is probably what she meant when she said I was argumentative and uncivil. I’m not ashamed and I would do it again. ??‍♀️? After talking with my friend who’s been a nurse for years, I realized that it really doesn’t matter — I got a passing grade overall, and she probably just wanted to punish me for questioning her. But trying to discuss it now is likely not gonna benefit me — it’s not even gonna show up on my transcript, and the program director would undoubtedly take her side, because it would basically be my word against hers on whether I was argumentative or not. I certainly DID argue with her when she insisted that everyone has pink skin, because that’s some white-centering racist BS, and if that’s what this was about then that’s not about me. I decided it’s only gonna exhaust me to to try to get clarification, and it’s not gonna benefit me, because if she actually had valuable insight to offer me about my behavior and ways I could improve, she would not have dropped it on me unexpectedly like this— she would have discussed it constructively when I still had a chance to improve. After final grades are in, I might email the course professor and just let her know that this instructor dropped this criticism on me out of the blue, and that I felt I couldn’t ask for clarification without sounding like I was confirming her accusation that I don’t accept feedback. That prof is a sweetheart, and I think if I offered her that info in good faith, in a kind way, she might share it as constructive criticism with the instructor, which I think would be helpful for future students. I don’t feel comfortable saying anything to the instructor because I feel like any interaction I have with her, she’s gonna perceive as argumentative and uncivil…seeing as I have no clue still what I did to get that on my eval. But most likely I’m just gonna let it go. It doesn’t actually affect me at all, and there’s a limit to how much I can advocate for future students.

I am a rising senior and I just got my first poor clinical eval. The problem is, I have no idea why. She did pass me, my overall grade is satisfactory, but she said in the eval that I'm argumentative, unprofessional, uncivil, unwilling to do tasks she delegated to me, and that I don't accept feedback. I'm dumbfounded because she didn't ever once give me feedback during the clinical. The clinical was only 4 days and we didn't have a midterm eval. Never once did she say one word to me about my performance. I honestly didn't do anything in the entire clinical other than change bed linens, take vitals, and give a few oral meds (under her direct supervision, of course). This criticism is totally out of left field. I honestly have absolutely no idea what she's referring to -- like, I'm wracking my brain and I can't even think of what interactions I had with her that she interpreted this way. Was it because I asked her for advice on how to better count pediatric respirations when she told me to go back and count them again? Was it because I asked if I could finish a task I was in the middle of for my assigned patient before I followed her orders to change the bed linens for several other patients on the floor? So my question is: Should I ask her? The clinical is over and I don't expect to ever see this instructor again. I feel like even asking what she's referring to is going to sound like I'm being defensive and, you know, "not accepting feedback." But obviously I can't learn from it when I literally have NO IDEA what I did that she didn't like. Feel like I'm damned if I do, damned if I don't. Should I ask for clarification, and if so, how would you word it? Or should I just let it go? I'm supposed to put my own comment on the eval and I have no idea what to say. I feel like if I say anything along the lines of "I truly don't know what interaction/incident/behavior on my part this is referring to," then -- again -- I'll sound defensive, thus proving her point. But if I say nothing then I'm afraid my professor will think it's true and that I agree with it, which I definitely don't (at least not without further clarification seeing as I truly don't even know what I did!). The professor for this class is the one who does placements for senior practicum, so I DO care what she thinks.

Bianca, did I meet you today? Were you the person who’s going to ICU? I’m the one who asked nonstop questions and is gonna be in the ER. ? I’m so excited!

THANK YOU, yes that’s extremely helpful! Gonna email my prof and see if anything can be done

I emailed to try to find out orientation week schedule cuz I have a clinical day on June 8. ?? Which I can probably get moved if I ask NOW....but I need to know the orientation schedule!

Have you guys heard anything from HR yet? It’s been over a week and I’m worried they didn’t get my confirmation or something! I’m holding my breath to hear what unit I’m on.