In a perfect world...
Where to start? As others have said, ED is very different from other areas of nursing, and each ED has its own culture and flow. For many nurses, coming to the ED can be a little shocking or eye-opening. All of the "fluff and puff" goes to the wayside. There just isn't time. Even if there is time now, in ten minutes that can all change. I'm not saying we are uncaring. You just have to prioritize your care. Then re-prioritize. Then start over again.
A few things- the disdain for psych patients. It's not disdain, really. You'll find if you work ED, psych isn't always psych. Sometimes it's "I don't want to go to jail, so I'm going to say I'm suicidal." Or "I got evicted and need a place to crash. Better go to the ER." With that said, many are truly psych patients and there's no doubt the system could be better. Psych patients, like all patients are as varied as they come. Some are manipulative. Some are just plain dangerous. And some are just sad. You said, "I would like to think about the future for the patient and not just their present needs." You have to remember, the ED is focused on present needs. ED is meant to stabilize. Stabilize and Move.
A disregard for all things not life-threatening- that is why it's called EMERGENCY DEPARTMENT. Sorry, not at all trying to sound harsh. Assessments are quick and focused. They have to be to ensure there is a room and staff available for the patient brought in not breathing or post-trauma. I don't mean that it is only important if it's life threatening, just that again, it's priorities first. Example, a chief complaint of "Elbow pain x 3 months" is lower priority than "Elbow pain and limited ROM post-fall at 0300." It's not that the 3 month elbow pain doesn't matter. It's just obviously not acute. If often makes us wonder "why now" is it an ED visit? The second CC gives us something to work with, something to rule out.
We don't do that- Not sure about this one. No doubt it can and has been used to avoid work. Human nature being what it is. I can't think of any examples. I think we do what we can in the limited time we have with our patients.
ED is awesome if you can let go of the little things, prioritize, and adapt. You'll find you have to be quite direct to get things done. I don't mean rude. Just direct. Direct with co-workers, patients, and patient's families. Some will test you. Confidence shows. Speed with empathy. We have to move the patients or the gears come to a grinding halt.
Remember this, the ED (and maybe L&D?) is the only department that can't say no to another patient. The doors are always open, regardless of staffing, icy weather, and full-moons.
I wouldn't want it any other way!