Questions from a Struggling ER New Grad

EmerNurse, BSN, RN · Oct 23, 2006

Can you be more specific? What types of problems do you think you're having? What has made you want to extend your orientation?

NurseLene · Oct 23, 2006

Can you be more specific? What types of problems do you think you're having? What has made you want to extend your orientation?

My preceptor states that I am having "tunnel vision" with my patients. Like I need to learn how to better focus on all of them instead of getting tunnel vision each time I am caring for one. I need to learn to be constantly thinking about my patients, regardless on who I am caring for at the time.

I've also made minor documentation errors here and there.

No major mistakes or anything.

I have extended my orientation mostly due to the fact that I don't feel confident with the skill set that I have.

Trauma Columnist · Oct 23, 2006

May I ask what type of ER this is? High acuity, level one? Low volume, one or two RN's in a community hospital ER?"

That said, I worked at a level one trauma center, high volume (65,000visits/yr) ER for 10 years. Our new grads got 12-16 weeks of orientation *** even then, we told them that it would take at least a year before they knew what questions to ask *** two-three years to feel comfortable with whatever came through the door.

If tunnel vision is the complaint, then my first thought is that you are only seeing one patient at a time *** not considering what is going on in your other rooms. This can be partially remedied by being very prepared when you go into the room. Okay, this is a 54 y/o male who is obviously obese, with a well-healed mid-line chest incision. You can get this info from across the room. He says, "Oh my chest is killing me." So...you know he is high risk for cardiac issues: EKG/O2, monitors, Saline lock placement. You do all of this as you are talking *** assessing the pt.

Being very organized *** having some kind of plan makes it easy to make one trip into the room, take care of the initial needs *** exit, ready to do something else for your next pt.

It's not something I would expect from a new grad though. So...please don't feel that you are expected to be a competent *** experienced nurse right out of orientation.

TazziRN, RN · Oct 23, 2006

I started in the ER as a new grad too. At that facility new grad orientations are 12 weeks, a mix of classroom and floor, with a one to one preceptorship.

The facility I'm at now does not hire new grads into specialty units because we are rural and have a small staff. New employee orientation, for someone with no ER experience, is still 12 weeks, all in the ER.

As for the tunnel vision part, that's normal for new grads because that's what we did as students: we only had one or two pts to concentrate on. It takes a while to get used to the real world stuff, and it will take at least a year before you will feel completely comfortable, no matter what unit you work on. Hang in there!

EmerNurse, BSN, RN · Oct 23, 2006

Even now, I keep a notepad in my pocket that I refer to for my patient info. Since we turn over beds so quickly, it helps to keep track of which beds are pending what and what chief complaint each has. That said, part of it is just experience, you learn what you need to think of for each patient - takes time. No new grad will grab it all right away - and even after orientation, there should still be people you can ask if you have questions. That goes for ER, AND for med-surg and other floors. Real nursing isn't anything like clinicals, and that's a culture shock for most folks.

angel337, MSN, RN · Oct 23, 2006

it takes time to get used to the ER environment. and if you are in a very busy ER it can be extremely overwhelming. i was at an advantage because i was a ER tech first and then transitioned to nurse. prioritizng is key. you have to know who is more important and that will make your day alot easier. patients will complain, scream and curse but it boils down to "who needs nursing care the most?". it comes with time. if you think that going to tele or medsurg will help you become more confident, then you should go for it. good luck with what you decide, you'll be fine.

HealthyRN · Oct 23, 2006

I am a fairly new grad in the ER also. I was told that I would be allowed up to 4-6 months of orientation. I am 12 weeks into my orientation now and I am starting to feel very comfortable. However, my preceptor and I still have not covered the pediatric beds or the observation unit. My orientation has consisted mainly of clinical time, but I am required to take courses for ACLS, PALS, and TNCC.

I definately don't believe 8 weeks is enough orientation time for a new grad. What type of ER do you work in? I work in a 45-bed ER that sees ~60,000-70,000 patients/year. It is not a level one trauma center though.

What helps me is learning to anticipate the needs of the patient before I even go into the room. For example, a patient complaining of nausea and vomiting is probably going to need a saline lock, so I go ahead and get everything ready, then go into the room to assess the patient and place the line at the same time. Then, when the MD orders fluid, all I have to do is hang it. Same thing with a chest pain patient- EkG, monitor, oxygen, saline lock. It is best to get as much done as you are able to (within your scope of practice, of course) before the doctor starts adding the orders.

Good luck! I'm sure that it will start to come to you, it just takes time.

RunnerRN, BSN, RN · Oct 23, 2006

I started as new grad in a lvl 1 as well, and had a lot of tunnel vision problems at first. Does your ED have any protocols/standing orders? If not, use your critical thinking skills. Anyone with CP is cardiac until proven otherwise, so they get a SL, cardiac monitor, O2 2L, and EKG. Abd pain is easy - get into a gown, pee in a cup, and start an IV.

My manager often says that ER nursing is not terribly difficult....and a lot of the time it isn't, it is just a time management issue. But when it is hard, it is very hard.

Ask your manager/preceptor to get some case studies together for you to go through. If you learn well by reading, I would suggest Sheehy's Manual of Emergency Care, or Introduction to Clinical Emergency Medicine. I eventually had to can the sweet loving nurse crap and focus on getting my stuff done. You know if you're walking into an abd pain pt's room, you're going to be starting an IV. Get your stuff together before you walk in the room (or just after you walk in) and start the IV as your doing the "talking assessment" - while you're getting the where, why, and how of everything. Pop the IV in, draw your labs, then do your physical assessment.

When you get all your stuff done at once, you can afford to have some tunnel vision - that way you know your CP pt has his EKG, is on the monitor and O2, and has an IV in if something goes wrong.

Good luck!

Kinky Slinky RN · Oct 23, 2006

Hey!! I will be graduating in December, and I am TERRIFIED!!! I have signed on to THE busiest Level 1 Trauma Center here in Dallas.. The ER has about 145,000 visits per year... Our orientation is 16 weeks... The first three weeks are strictly classroom time to get everyone on the same page apparently... I'm scared!! Thankfully two other classmates have signed on to this hospital as well.. I am TERRIFIED but I am pretty sure they will prepare me enough to function on my own... Any suggestions that would help as well?? Thanks.

RunnerRN, BSN, RN · Oct 24, 2006

Hey!! I will be graduating in December, and I am TERRIFIED!!! I have signed on to THE busiest Level 1 Trauma Center here in Dallas.. The ER has about 145,000 visits per year... Our orientation is 16 weeks... The first three weeks are strictly classroom time to get everyone on the same page apparently... I'm scared!! Thankfully two other classmates have signed on to this hospital as well.. I am TERRIFIED but I am pretty sure they will prepare me enough to function on my own... Any suggestions that would help as well?? Thanks.

Honestly, I think it is a good thing you're terrified. Th epeople who walk into the ED feeling like they're king/queen of the ED nursing world are the people who terrify ME! A few things to remember....first, obviously someone thinks you're a good candidate to work in the ED, or they wouldn't have hired you. Second, you will eat, sleep, breathe, and work emergency nursing for the whole fellowship/orientation time. It is important that you take this opportunity to do your best - study at night, keep lists of questions you have, etc. I developed a pretty good system during my fellowship where I kept a little notebook, and took notes about disease processes/conditions/patients I took care of each day. Little things like "sickle cell patients - O2, fluids, pain meds, ESR" etc. That worked for me because I learn that way though.

Best advice? Make a friend or two in the fellowship and study together, but also destress by going out for dinner/drinks together. I found it really helps to have a good friend either in your dept or in the same field - someone who can relate to what you're going through. It is so important that even though you're spending so much time learning during your orientation that you also take time to take care of yourself - massages, time with family, etc.

Even when you get out of your orientation, give it time. And if you feel like a fish out of water still when you're SUPPOSED to be on your own, speak up and ask to have a few more weeks. Chances are they'll extend it.

Good luck!

scrmblr · Oct 28, 2006

I started in the ER out of a 6 week med/surg rotation. I had been an lpn in ltc for about 7 years prior to this.

I had problems with sooooo many things when I first started. I look back and laugh at myself now:) My biggest challenge was to realize that not everything is actually an emergency. That just because my pt wants me to do something emergently does not mean I have to do it emergently:lol I start with the most critical pt. I get everything done for this pt that I can. Iv started, ekg, labs, radiology, urine etc...Then I move on. But, you have to remember what you have going on in all your rooms at the same time. I just keep taking inventory... If I have someone with a very minor complaint they get the back of my inventory. I will get to them as soon as I possibly can.

another thing that was hard for me was delegating. I have finally started to tell the tech assigned to my rooms "when you see the chart go up for d/c go ahead and get me end case v/s" Or "will you get bed 2 to the commode for a urine sample while I get the IV started in 3"

I certainly hope what I am about to say won't offend you...But, Do you seriously love the ER? One of my very best friends wanted to be an ER nurse the entire time she was in school. When she graduated she got a job in a busy ER. They gave her many opportunities to orient. They let her rotate to ICU and med/surg-they extended her orientation time. It finally became obvious that she was not made for the ER. She was much better at ICU/Tele. She made the switch and is blissfully happy:)