The best laid plans...

[utadahikaru]

Hello all, my plans are crumbling and I'm looking for some solid suggestions on what steps to take next. I've been working in the ER for six months and I'm completely miserable. Basically, I feel like the ER expects too much from nurses. I feel very comfortable taking care of 3 patient rooms, but my hospital assigns each nurse 4 patient rooms. Most days I feel like I'm just barely keeping my head above water.

The fact is, I've always favored the Tortoise more than the Hares. Even when I was a student nurse I scored well on my exams, but I was also always amongst the last few students to finish. I'm not saying that I can't manage 4 patient rooms, I can, but it takes all I've got and it's completely exhausting. I feel that the best thing for me to do right now is to transition into another nursing specialty where all day sprinting isn't required to get the job done.

If anyone has a good suggestion, I'd like to hear some suggestions. THX :)

[JBudd, MSN]

Honestly, our floor nurses carry more than 4 patients. We try for a 4:1 ratio but sometimes end up with more; when one is critical sometimes there isn't a lot of back up if the rest of the team has heavy pts as well, still responsible for your other 3.

ICU or CCU does 2 or 3 to 1, but hard to get into ( at least here). They tend to be rather heavy duty 2 or 3 pts, in the ER you might luck out with some lighter pts.

6 months is kind of early to feel totally comfortable with being in the ER; it usually takes at least a year to really get the hang of it all. But you're right! we do tend to be hares

[emtb2rn, BSN, RN, EMT-B]

4:1 is the suggested ratio by the ENA and is how we staff in my ED. That said, 5-6:1 is more common. IMO, being a hare is critical to success in the ED as things happen so quickly and unpredictably. You have to stay caught up if not ahead of the game or you'll sink. Not being mean here, just stating what I believe to be the reality of this specialty.

Good luck.

[SubSippi]

But the hare loses...

[Emergent, RN]

Neither a tortoise, nor a hare, are actually good analogies for ER nursing. Hares aren't too smart, and are always running away from something. Their fleet of foot is motivated by fear. Tortoises plod along, and their only protection from danger is their thick shells.

An ER nurse is more like a border collie. Intelligent, hard working, observant, quick to change directions and respond to changing situations. She is part of a team, able to take direction, but also able to assess situations and react to them.

[Hpy_Vly_RNBSN]

4:1 in the ER seems kinda like an easy load The ER at my hospital is a 7:1 ratio... Floor nurses here have a 5:1 or 6:1 Even med surg is busy running room to Room. Maybe Dialysis nursing would be more your speed.

[Anna Flaxis, BSN, RN]

emtbtorn, do you have a copy of the ENA Staffing Guidelines? Because this is what the ENA has to say about staffing:

"Staffing based solely on nurse to patient ratios or paid hours per visit is limited in scope without consideration of the variables that affect the consumption of nursing resources.4,12 To identify safe, effective, realistic best practice staffing in emergency departments, the Emergency Nurses Association (ENA) identified six key factors that were critical in the projection of staffing requirements, the development of staffing models, and accurate budget preparation.12 These factors include patient census, patient acuity, patient length of stay, nursing time for nursing interventions and activities by patient acuity, skill mix for providing patient care based on nursing interventions that can be delegated to a non-registered nurse, and an adjustment factor for the non-patient care time included in each FTE.12 The staffing guidelines and tool that were developed are applicable in all types of emergency departments, flexible and dynamic, and easy to use and understand.12"

Source: http://www.ena.org/SiteCollectionDocuments/Position%20Statements/Staffing_and_Productivity_-_ENA_White_Paper.pdf

It seems to me that the ENA's position isn't really as simple as a suggested ratio. Maybe there are factors in the OP's situation that make a 4:1 ratio impractical. I've certainly been in the situation of being one on one with a critical patient, then after taking them to the ICU and checking on my other three a couple of hours later, finding that nothing has been done for them. To me, this seems unsafe. Just because that's the way it is in a lot of EDs does not make it okay. Just because some ED nurses are okay with unsafe staffing levels does not mean there is anything wrong with the OP.

To the OP, as pointed out by a previous poster, six months in, you should not feel "comfortable". There is a lot to learn, and it takes time to develop your skills to a high level. However, I don't feel like you should be "completely miserable", either. If you are miserable, then there is a problem, either with your work environment or that you aren't particularly suited to this area of nursing, or a combination of both.

I suggest you stick it out until that magical one year mark, then if you are still unhappy, consider transferring to another unit. Keep in mind, though, that as pointed out by a previous poster, floor nurses often carry a heavier load than ED nurses do, and inappropriate staffing levels are a problem throughout the entire healthcare spectrum, not just unique to the ED. I think you'll find that all day sprinting is pretty much the norm in almost every area of nursing.

[zmansc, ASN, RN]

Wimps! At our facility we have one RN who handles the entire hospital, ED, Med Surg, ICU, L&D, BHU, & OR all at the same time. We also have to be able to start a picc line with our toes and place NG tubes with our teeth since we may be doing procedures on as many as five pts at a time. They prefer tall nurses too, so you can reach into several rooms at a time to do your procedures. And no techs, manual vitals q5min for all pts. In all seriousness, I don't really like the whole ratio comparison thing, there are a lot of variables that go into how many pts are safe to take at any one time. My primary job the ratios are either 3:1 or 4:1 depending on the rooms your assigned. We can get higher than this when we have a couple lvl 1s taking up much of the staff and some really sick pt's getting stuck in the hallways. I've had as many as 8 pt at a time when the other nurses were taking really high acuity pts. That was actually much easier than a routine day with 3:1 because all the providers were busy with the high acuity pts so my 8 pts didn't get any orders written for them for quite some time. So, to me, comparing ratios is a little ridiculous.

OP, I agree with the poster who suggested that at this early in your career and time in the ER, I would expect you to still be struggling with 4 pt at a time. The prioritization and time management aspects of ED nursing takes time, and requires a great deal of not only knowledge about the pt and their condition, but also ability to predict what the provider who is on duty at that time will want so that you can be prepared for the situation as it unfolds. At this point, I would expect you to still be gaining speed on many skills, just getting to the point where things are starting to slow down a bit and you are able to make sense of why the providers are ordering certain things for pt x, but different things for pt y. The labs and diagnostic tests should be starting to make better sense to you.

All of these things will help you to increase your speed and ability to manage your time better so that over the next 6 mo, as you get more proficient and your time management improves, you will be better able to handle the forth patient. I would not let it worry me too much. Remind yourself that everyone progresses at a different speed and gains abilities in different orders, so when someone tells you they mastered x, y, and z in their second day on the job, just remind yourself that you are you, and you will learn this at your rate.

Now if you truly hate everything about the job, then by all means feel free to find a job you love. Every nurse should find a job they are passionate about and practice the hell out of that job! But, I would not stop at 6 mo because I'm too slow for 4 rm at a time and say ER is not for me.

Hope that helps.

[emtb2rn, BSN, RN, EMT-B]

emtbtorn do you have a copy of the ENA Staffing Guidelines? .[/quote']

Mea culpa. No, my manager (who's pretty up to date generally) mentioned that ratio and I didn't verify it before posting.

I like border collies but if we're going to debate which animal is truly representative of an ER nurse, I'm going to go with a honey badger.

[LakeEmerald]

Hang on for another six months. You'll be a much more desireable candidate for whatever position you apply for. Regarding being exhausted, you may not have had time to get your head straight. It took me 2 years to be able to set aside that frenzied feeling and to be able to put aside the negative pressure and let the good stress energize me. That being said, it's not for everyone. OR is much more controlled, I think. Whatever you do, stay 6 months to have a good record and impressive experience.

[turnforthenurse, MSN, NP]

I agree, hang in there. It's tough when you're new. Most new nurses do not feel comfortable until they are about 12 months in... and the ER can be a difficult place to start. You may actually begin to love the ER once you begin to feel more comfortable.

[1fastRN]

When I first started, a nurse told me every new ER nurse spends the first year drowning. Completely true.

Stick with it! Nobody is perfect off that bat, but from what I've seen you either "get it" or you don't. Maybe ER nursing isn't for you, but the great part about nursing is there are SO many directions to go. So I say give it some time and then reevaluate if you're still having trouble. There's a lot of pressure in the ETD so your feelings are normal.

I always found it kind of funny when the feedback I would get was that I needed to "be faster" after just a few weeks on the unit. Well duh, I was new! It's more important to learn things correctly at your own pace at first....speed will come. Keep your head up!