Things a student can do to prepare for ED employment

Trauma Columnist · Nov 1, 2005

I work in a very busy level one trauma center that does hire new grads. I'm unsure we are doing them any favors. It truly takes two years to feel comfortable. However, you asked what you, as a student could do:

1. If you have clinicals in the ED, be enthusiastic, look for any and all experiences.

2. Clinicals are not about TECHNICAL skills. If all we needed was a tech in the ED, we wouldn't have RNs. The most important thing to learn as a student is assessment and prioritization. (I can't stress this enough).

3. Look for an ED that has a solid 12-16 week orientation, based on the ENA modules if at all possible.

4. Get to know the climate of the ER. Do they welcome new grads, or just tolerate them? Is there a strong (1 year in duration) formal mentor program. What is the nurse/patient ratio? The ENA endorses 4:1.

I don't want to be a wet blanket, but I think new grads find it very hard to work in the ER right out of school.

mshooha · Nov 2, 2005

I am the manager of a small ER (rural). I welcome new grads, but have found that most of the time the transition from directly from nursing school to ER is difficult.

Here are my suggestions:

1. You do no one (other nurses or patients) any favors by not asking for help if you are not sure.

2. Find the best in each nurse and emulate them.

3. Take steps toward independence, when you are comfortable (are any of us really comfortable :wink2:) take the initiative towards the next step.

4. Practice your basic nursing skills. These shouldn't be a question.

5. Accept constructive criticism gracefully and learn from it. Sometimes criticism hurts, but sometimes we don't know we are wrong, or could do it better unless someone tells us.

6. Make yourself part of the team!!!! Teamwork is essential in ER.

7. Learn from your mistakes--we all make them, and own up to them when we do.

8. Be assertive, not aggressive.

9. Understand that ER is not glamorous.

10. GOOD LUCK!!!!!!

JPine · Nov 2, 2005

Thank you for your respones. I know it's never a treat to have a New Grad in any dept. especially the ER. The hospital I'm applying to is a very large, very busy level II trauma unit. My friend's friend was a nurse in that ER and he said, "...of course having New Grads is sometimes difficult, but having only seventy five percent of the staff we need is even more difficult. New Grads are a necessary evil." He also said that his former ER had an outstanding New Grad program where the New Grads are in class one day a week, in a skills lab another day and then two days of a perceptership each week and this lasts for 16 weeks. Then we get another 4 weeks of a staight out 3 day a week perceptership.

Hopefully this will be a good experience (if I get the job). But I could see how a seasoned ER nurse would be dreading a New Grad without such a program.

Any good books you can suggest?

ClaireMacl · Nov 2, 2005

After years in the ED I still completely endorse the idea that newly qualified staff should not be employed in the department (sorry, JPine).

I knew from well before I started training that the ED was for me, done my elective placement there, everything. However, due to the advice given by ED staff, I chose a rotation program of 4 months surg, then med before specialising. I hated my surgical placement more than anyone can imagine! It was my first qualified post and I had less than no support for a very long time... then I complained and it appeared.

I then went to the medical rotation, I was 100% supported there, amazing staff, super efficient sister. I learned invaluable skills about management of patients, when to ask for help, how to know your limitations, everything!

The 8 months I spent on wards, though some were negative in the short term, helped me more than you can imagine when I got to the ED. Sure, there were new things I encountered, but I'd learnt so much that training cannot offer.

We are now not taking on newly quals in our dept due to the problems they encounter adapting to the fast pace and never knowing what comes next feeling that the ED brings.

I'm sure its different where you are, in the UK, the most you can ever hope for is a two week supernumary status, before being thrown in with the wolf, lol.

Best of luck and I hope its the right decision for you!

Jen2 · Nov 2, 2005

I graduated from nursing school in May and started my first RN job in the ED at a Level 1 trauma center. I am doing fine there as a new grad. I first however was a medical asistant, a phlebotomist, and a nurses aid for 9 years before I ever went to nursing school. During those nine years I read everything about ED nursing and critical care I could get my hands on. I was constantly questioning the doctors and nurses I worked with regarding patients.

The summer before my senior year of nursing school I externed for 5 weeks in med/surge and 5 weeks in ED. After my 5 weeks in the ED it was the staff that encouraged me to join their team. I am very happy that I did. I learn about every disease and take care of every age group, and get to practice every aspect of nursing that I learned about in school. My orientation was 12 weeks long and did not truly prepare me. I cannot say that I feel comfortable yet, that will come with time and experience.

My best advice:

If this is truly what you want to do, go for it but please try and do an externship of shadow before you decide.

Grow a thick skin. You will have nurses that hate having new grads around and will try to make you feel inadequate and that you don't deserve to be there. You will take heat from patients, families, doctors, EMS, and just about every nurse that you send a patient to upstairs ( I am being over dramatic, but it happens be prepared).

After some time you will start to develop a sense of "this is a sick patient" from doing an across the room assessment. Listen to that gut feeling especially in the ED. I have had unmonitored non-urgent triaged patients code on me. Just about everything in the ED is ABC's and you must know them inside and out and prioitize in that order always.

You will find many nurses that love to teach allow them to mentor you. Ask them questions and watch them do their assessments. I work with some ED nurses that have been in the ED longer than I have been alive and they are awesome. However, sometimes there is just no time for a one on one teaching session and you may feel as if your mentor/preceptor is snapping at you. Never take this personal in a code situation. You gotta let things roll off your back, wait until things calm down before you ask questions, and then you just move on to the next patient.

Don't ever just do what the pysician says or orders. Look those meds up until you feel comfortable with them and always ask, "Well why are we giving this?"

I have a long long way to go, but I am in love with what I do. I hope that I can begin to feel comfortable with in the next couple of years. I still look up a lot of meds before I give them and I always go home and look up the S/S and diseases of patients that I took care of that day. I became an ENA member and subscribed to four different nursing mags and read them all the time and do the CEU's. You have to do a lot of self educating. Most importantly if you don't feel comfortable doing something or something just doesn't look or feel right to you ask for help. I wish you the best of luck and please know that it can be done, but it's up to you to get into every situation you can, ask questions, and educate yourself.

Happy-ER-RN, RN · Nov 3, 2005

I started as a new grad. also, 5 months ago. I think ER is a great place for anyone who is motivated to learn and prepared for a challenge. It was torture for the first three months for me but now I love it. I am still in training for taking traumas though. IF you have supportive staff things will be great. Honestly there isn't all that much you can do to prepare--I was a lot like you, trying to learn and do all I could to prepare myself to makeit easier once I got there but I think you just have to be there to learn how to be an ER nurse.

My husband is a paramedic and so it was helpful for me to hear his stories about taking care of critical patients--what where the assessment findings, what did he do,what drugs did he give--that kind of stuff. Barnes and Noble has a lot of books on Emergency Nursing, you can look though those. Learn about the major cardiac drugs- We give a lot of Nitro, Cardizem, Dopamine, Dobutamine, Metoprolol, and maybe code drugs--epinephrine/atropine

I felt much better as an ER nurse after taking ACLS. I felt like I could handle the worst case scenario so it made all the other patients seem so much easier to take care of. It just helps so much to know what to do when someone crashes.

Anyway, I still have a lot to learn and I still ask a lot of questions and will get someone to help me if I feel uncomfortable. That's all you have to do, just ask for help. Good Luck!:wink2:

JPine · Nov 3, 2005

I started as a new grad. also, 5 months ago. I think ER is a great place for anyone who is motivated to learn and prepared for a challenge. It was torture for the first three months for me but now I love it. I am still in training for taking traumas though. IF you have supportive staff things will be great. Honestly there isn't all that much you can do to prepare--I was a lot like you, trying to learn and do all I could to prepare myself to makeit easier once I got there but I think you just have to be there to learn how to be an ER nurse.
My husband is a paramedic and so it was helpful for me to hear his stories about taking care of critical patients--what where the assessment findings, what did he do,what drugs did he give--that kind of stuff. Barnes and Noble has a lot of books on Emergency Nursing, you can look though those. Learn about the major cardiac drugs- We give a lot of Nitro, Cardizem, Dopamine, Dobutamine, Metoprolol, and maybe code drugs--epinephrine/atropine
I felt much better as an ER nurse after taking ACLS. I felt like I could handle the worst case scenario so it made all the other patients seem so much easier to take care of. It just helps so much to know what to do when someone crashes.
Anyway, I still have a lot to learn and I still ask a lot of questions and will get someone to help me if I feel uncomfortable. That's all you have to do, just ask for help. Good Luck!:wink2:

I'll start reviewing the cardiac meds and the code drugs. I'm also gonna check into doing an ACLS class soon. Does anyone have any opinions of the book Emergency Nursing Bible? Thank you.

KatieBell · Nov 3, 2005

Got to also be honest, I am not at all fond of new grads in the ED. I am working with one now who is finding it difficult, she is doing an acceptable job. I find though, even nurses who are nice to her are stressed by working with her. As a new grad, i went to ICU because I had to (required by the ED I wanted to go to) At the time, I thought well, I would do fine as a new grad. As time has moved on, I am starting to see how not fine I would have been without my ICU experience, and I am seeing why it is a requirement in departments that can afford it. In the edn I ended up going to a different ED after my one year of ICU, but I never regretted ICU experience.

ACLS, PALS, as well as a basic arrhythmia class will be helpful to you. The Level one I worked in did hire new grads, but- we ONLY hire new grads that have worked as techs in our department. Yes, the Manager interviews others, but in the end, we have never hired anyone who hadn't already worked there. So a job as an aide would be most beneficial I would think.

What would be MOST helpful would be a year in the ICU to learn to work with critical patients- ie: ventilators, drips, central lines, chest tubes. Much easier then to deal with all this stuff in the ED after you have been tangeld up in 17 lines daily for a year. I really do get short tempered when we have people who do not understand anything about critical care trying to take care of major traumas or very septic people, or very bad MI. (And, until I started traveling, I was the point person for Paramedic precepting in the department, so I am very patient).

Oh and yes, let me second that ED is not glamerous. But who would thinking being vomited on is glamerous.

:eek:

chrisg0705 · Nov 3, 2005

Hi,

I volunteer in an ER while going to nursing school and all the nurses tell me not to come directly to the ER. They told me new grads usually don't make it and end up going up to one of the floors.

But the good news is, they say if you work in an ICU (I was told the Cardio-Thoracic ICU at my hospital has an excellent new grad program) you will learn ALOT and will transition better to the ER. That is what I am going to do after graduation.

Good luck!

Chris

EDValerieRN, ASN, RN · Nov 3, 2005

I was a new grad in a level one trauma center. Before and during nursing school, I worked on a peds/womens unit for three years as a CNA.

I love my job. We have a great new grad program. There were nine that went through the program, and all but about three of us are thriving. One is still having serious issues with prioritization, one doesn't like the disorganization, and one... well.... I just don't know about her.

Many say they don't feel like the ED is good for a new grad. I say if you are positive it's what you want to do, and you love it, and you couldn't imagine doing anything else, then don't. Be a new grad in the ER. Yes, it's tough. You see everything. Just yesterday I had a 7week old in one room with bronchiolitis, a 28 year old ICU admit with DKA in the next, and a very old gentleman with delirium/urosepsis in the next room.

You don't have to know everything to work in the ED, you just have to be willing to learn. My first month with my preceptor was horrible. I was lost and I was scared. However, I was also willing, excited, thankful, and curious. I had a preceptor for three months. This is how we did it:

Every Monday, 12 hour class over critical care/ED issues.

Two days a week with preceptor

Before passing boards: I watched her for a day. I took one patient for a week and prioritized things to do with that pt.

Week 2: Two patients, same thing.

Week 3: Three patients, same thing.

Week 4: Stuck with three patients (this is where I started getting scared).

Week 5: Full pt. load. Preceptor was doing meds and IV starts, I did everything else on all of the pts, including all prioritization (with her guidance)

Then I took boards, passed, and started over with one pt. but gave meds and did everything, working my way up. There were days I went home feeling in over my head... but they occurred less and less.

Once I was off of orientation, I felt as comfortable as I could hope for. It gets better every day. I am now confident in my own abilities, and don't worry about killing someone. I still ask for help, and I have many very experienced coworkers that have been a Godsend in certain times. This is a teaching hospital, and the ED staff are supportive of all 9 of us.

For those that say it can't, or shouldn't be done.... I respectfully disagree.

I would advise you to join the Emergency Nurses Association as a student. The membership is MUCH cheaper than it will be after you graduate. You'll get access to the Journal of Emergency Nursing. Read it. Go online and read about different conditions, especially the critical ones (Hearts, strokes, DKA, sepsis, seizures)

See if you can find a book on rhythm interpretation. Study not only the rhythms, but what the treatments are. What do you give for new onset A-fib? Why? What is the first thing you do if the monitor reads v-tach? Why? What if the pt. is stable, but has a heart rate of 30? What do you anticipate being done?

Maybe find a CEN review book, and study up on that. It'll have differential diagnoses in it, and it'll tell you about lots of stuff you may have never seen, but are bound to see in the ER.

Don't stop learning, and don't think you can't do it. You'll be awesome.

JPine · Nov 3, 2005

EDValerieRN, thank you for your encouraging post. Working in the ER is something I really want to do. I almost didn't post in the Emergency Nursing thread 'cause I knew I'd get a slew of the I'm-not-fond-of-new-grads-in-the-ER respones instead of suggestions for preparation. It sounds like you had a decent orientation. I talked with my ER contact (a friend of a friend) and he said, "if you would've applied 4 years ago I would have said to not do it 'cause all a new grad would get is a preceptorship with another nurse for 3 months. Now we've got an actual program with class time on Mondays, 6-8 hours of skills on tuesdays, and wednesdays & thursdays are the preceptor days. We've actually been surprised at how fast they progress even though it's not like having seasoned nurses, but it's better than no nurses!" He proceeded to say that they've had 40 grads go through so far and they've only had problems with 3 of them.