Starting an ER job with no orientation?

Anna Flaxis, BSN, RN · Nov 16, 2013

I'm curious to know what YOU think.

LostnNakedNursing · Nov 16, 2013

I'm curious to know what YOU think.

I think I should say yes because I need the job but I think I'm also putting myself at risk as well as my patients. What if a ambulance brings 4 or 5 trauma cases back to back and it's just the other nurse and me? I won't know where anything is at and I would be expected to fulfill all these tasks from the get-go. At least with orientation, I could work with someone who will show me how they do things, instead of learning by error.

At the same time, I won't know where anything is nor do I even know how to document. It's quite a big jump but I'm also thinking, maybe I need that.

Sassy5d · Nov 16, 2013

I would never feel safe starting a job as a new nurse with no orientation.

Not to mention, they have a responsibility to have documentation showing you're competent with various skills. Would they just sign them off?

Esme12, ASN, BSN, RN · Nov 16, 2013

This looks like a small ER....6 beds....I would ask how long are you going to be assigned to another nurse. What is entailed in following this other nurse? Will they be showing you policies and procedures, computers, documentation, competencies, lab draws, IV' monitors? How many nurses are on duty?

They may not have a formal orientation a they are small....ask why their expectations of you are and remind them you are a new grad.

bebbercorn · Nov 16, 2013

You may be able to talk them into giving you some time... even with some experience starting in the ED I was nervous about being "fluent" in skills like IV insertions, foleys, etc that I didn't do much on my stepdown floor. The ED is a great place to be and people get overwhelmed without a strong orientation. I'd hate to see you fail because they didn't offer you some guidance!

Anna Flaxis, BSN, RN · Nov 16, 2013

Thank you for answering my question.

Just because the ED is small does not in any way, shape, or form, mean that you will not get really sick people. I'm sure you will be bypassed for traumas, STEMIs, and strokes, but those things come in through the door sometimes and you have to stabilize and transfer rapidly. In the meantime, you still have your abdominal pains, vag bleeds, and ankle pains streaming in.

It's important to know where your supplies are, particularly rescue supplies and gear, but also small stuff like bandaids. When you're trying to move patients through, it's not a good use of your time to be looking high and low for even something as simple as some roller gauze.

It's important to be familiar with the policies and procedures of your workplace. These vary vastly from facility to facility. At my last place of employment, I did lots of pediatric procedural sedations, wound infiltration with topical anesthetics, cardioversions, and so on. At my new place, anesthesia does anyone under 12, nurses don't infiltrate, and the cardioversion policy is ancient.

I think the orientation period is important because the focus is getting you up to speed on all of these sorts of things before expecting you to do patient care. It protects you and your employer because there is documentation that you have demonstrated competency of certain things.

In my opinion, by not giving you a formal orientation, they are setting you up for failure.

It's likely that this hospital is hurting financially, and cutting out orientation is one way to save a few bucks. Unfortunately, it's at the risk of patient safety, IMO.

Some people are quick studies and could jump into a situation like this and do just fine. But I would never in a million years count on this.

LostnNakedNursing · Nov 16, 2013

This looks like a small ER....6 beds....I would ask how long are you going to be assigned to another nurse. What is entailed in following this other nurse? Will they be showing you policies and procedures, computers, documentation, competencies, lab draws, IV' monitors? How many nurses are on duty?
They may not have a formal orientation a they are small....ask why their expectations of you are and remind them you are a new grad.

I don't think I'm going to be assigned to another nurse. From my understanding, there are always two nurses on the floor with one CNA and the ED doctor and I will be one of the two nurses. They were vague on how exactly will I be learning from the other nurse. The impression I received was "go out there and learn as much as you can"

LostnNakedNursing · Nov 16, 2013

Thank you for answering my question.
Just because the ED is small does not in any way, shape, or form, mean that you will not get really sick people. I'm sure you will be bypassed for traumas, STEMIs, and strokes, but those things come in through the door sometimes and you have to stabilize and transfer rapidly. In the meantime, you still have your abdominal pains, vag bleeds, and ankle pains streaming in.
It's important to know where your supplies are, particularly rescue supplies and gear, but also small stuff like bandaids. When you're trying to move patients through, it's not a good use of your time to be looking high and low for even something as simple as some roller gauze.
It's important to be familiar with the policies and procedures of your workplace. These vary vastly from facility to facility. At my last place of employment, I did lots of pediatric procedural sedations, wound infiltration with topical anesthetics, cardioversions, and so on. At my new place, anesthesia does anyone under 12, nurses don't infiltrate, and the cardioversion policy is ancient.
I think the orientation period is important because the focus is getting you up to speed on all of these sorts of things before expecting you to do patient care. It protects you and your employer because there is documentation that you have demonstrated competency of certain things.
In my opinion, by not giving you a formal orientation, they are setting you up for failure.
It's likely that this hospital is hurting financially, and cutting out orientation is one way to save a few bucks. Unfortunately, it's at the risk of patient safety, IMO.
Some people are quick studies and could jump into a situation like this and do just fine. But I would never in a million years count on this.

Thanks for your response! You brought up everything I'm concerned about. The nursing did say it wasn't in their budget to train me as they usually do but I'm thinking why are you hiring a fresh out of school new grad if that's the case.

I'm still thinking about it but I don't think it's worth the risk.

Footballnut · Nov 16, 2013

The biggest question is - do you want to be an Emergency nurse? It is a commitment and a steep learning curve, especially for a new grad. If you want to be an ED nurse, you can most likely do this with some hard work and planning on your part.

More information would be helpful. You could be working with another nurse without being counted as part of staffing which actually would be an orientation of sorts. If you are needed to be able to carry a patient load immediately you will need some time to learn the minimum basics of functioning in the department even if you have the support of the other nurse. My guess is that they will start you in an area of the ED that is potentially less demanding.

This sounds like what we did years and years ago. Nurses received minimal orientation to the department and then spent the next 2 years or so learning to be an ED nurse since it took that long. The requirement for getting into the ED was that you had to have prior nursing experience. Not everyone made it after getting into the ED. Even with 2-3 weeks of orientation nurses needed quite a while to become proficient. We had to tough through some problems due to staff not being ready to do the job and needing time to learn it.

I had two days of orientation to my department (years and years ago) but I already had nursing experience and skills from other settings to carry me. I was fortunate enough to be able to work with staff who supported me while I was learning to be an ED nurse. However it still took more than just time in the department for me to get good at what I was doing. I needed a knowledge base specific to being an ED nurse.

Currently we give our new grads an 18 week program that includes skill building, classroom time, debriefing and mentoring, clinical time, goal setting and various certifications. They often comment to me that it feels like still being in school. We want them to be ready to function in our fast paced department and they usually are after the focused time that we give them. They still have learning after that, but they are ready for many things. Some of our grads are the type that can figure things out quickly and would do ok with a moderate orientation but many are not. In any case, we want them prepared. We don't want them to have a "trial by fire" experience while they are becoming ED nurses.

I am hoping that you are ACLS certified at least. Go to the ENA website and look at the educational opportunities/publications available because you will need them. There are Emergency nursing core curriculum classes, trauma classes, pediatric classes, etc. Many of these classes are offered locally at different places around the country as well as online. I would also recommend reading an ED nursing text like Sheehy's as soon as possible. https://admin.ena.org/store/item.asp?ITEM_ID=475&DEPARTMENT_ID=104

Check with your manager to see what resources and classes are available to you to learn to do your job. Also determine how supportive the nursing and medical staff will be during your learning curve. They will need to be your clinical resources. You can do this with the right environment and commitment on your part. It is about equivalent to adding a couple of more quarters to your nursing education and will you will need to give it time like you are still studying in school. It will also involve some expense on your part depending on what your hospital is will to pay for.

All the best as you make this decision!

WAheartnurse · Nov 16, 2013

Footballnut- I think you might have misunderstood her posting. She is not going to receive minimal orientation with some support and training from others. She has no experience. From my understanding, she is to start day one expecting to be part of the staff and be working as a full member of a very limited ED staff. Not even an ED tech (a CNA has a much narrower scope of practice). The other nurse will be doing all the work plus teaching you- I would be very upset if I was that nurse. This is absolutely UNSAFE.

This is a disaster waiting to happen. Absolutely crazy. There are only a few scenarios where this might be marginally acceptable. If you had done an extensive preceptorship in that ED in nursing school or if you had worked as an ED tech in nursing school. That would give you some background.

I am working in the ED after 2 years step-down experience. I was given an entire month of training which was excellent. I might have been able to manage with one week, maybe, because of my other experience. Still I have many other staff to absorb my weakness and my slowness and my many question asking. You do not. I also had little peds experience and you need a lot for the ED.

If I was in charge of the hospital I would not keep a manager that would install such a liability. It shows a glaring lack of judgement on her part (the manager's). To attempt to save a few dollars and potentially have to spend so much more if you make a mistake or if more care has to be done because of your experience is really questionable.

I would demand a few weeks training AT LEAST. Do not be so desperate that someone is harmed because you have no idea what you are doing. It is completely different that floor nursing- which is the only thing I was trained to do in nursing school.

And then remember- you will be working for a manager and a hospital that is so strapped financially that it would do this. What else will it do?

Esme12, ASN, BSN, RN · Nov 16, 2013

I don't think I'm going to be assigned to another nurse. From my understanding, there are always two nurses on the floor with one CNA and the ED doctor and I will be one of the two nurses. They were vague on how exactly will I be learning from the other nurse. The impression I received was "go out there and learn as much as you can"

This is a problem then....as a new grad you are going to be vulnerable to mistakes and being overwhelmed.

Are they JACHO accredited? There needs to be some orientation to comply with regulations.