Tips for a new grad ER nurse

MedicalPartisan · Mar 24, 2016

This is just one giant cluster of thoughts, so sorry in advance. No matter how level-headed and non-anxious you typically are, you will likely think there is no way you will be able to grasp it all even with all the training in the world. This feeling will ease and eventually pass. But because you're human, it doesn't matter if I, your friends, your colleagues, and everyone else attempt to ingrain this into you, you will not be able to see it that way because you're not there yet. TRY to know that you will, in time, be able to do this. ASK infinite questions. I hear nurses with 20 years of experience asking questions on a daily basis. Seriously. There will be things that you know since you're fresh out of school that even the best nurses don't know. The field of nursing will always be this way. That's why diversity is so great - EVERYONE brings something to the table. Nobody will think you're stupid for asking a question. They will think you're stupid if you don't ask a question and screw something up. YOU CAN NOT TAKE BACK WHAT YOU PUT IN YOUR PATIENT so know what you're giving. Know the 5 (I think it's 6 now) rights. Ask full name, date of birth, and allergies... every. single. time. If you word it well enough the patients won't get too annoyed. As I walk in with my meds I'll say (for example), 'Okay... my favorite question... full name and DOB? And you're not allergic to Dilaudid or Zofran, correct?' obviously this will change with an altered LOC, some patient's will agree to anything - use judgement and common sense with your interactions. Similarly, don't enter a room and say 'Mrs. Brown? 3, 1, 1957'? Even in coherent patients, sometimes they are in so much pain or not paying attention and, again, could agree to anything. Make them tell you. Be confident. Again, ALWAYS ask questions if you are unsure, BUT, the patients have nothing to do but to watch your every move so if you're nervous and questioning yourself they will become nervous as well and might even request someone else. They don't need to know it's your first time starting an IV, they don't need to know you've never inserted an NGT before, etc. If possible, and there is no safety risk, ask your questions outside the room and not at bedside. You need and want the patient to trust and have confidence in you as well. Don't ever say 'I know' to an educator or colleague. Even if the colleague or the nurse orienting your is telling you something you've known since intro to nursing, LISTEN. Be a sponge and absorb as much information as possible. If you are asked to do something, even a basic task, that you are not comfortable doing, SAY SO! You will not be judged for it. You can legitimately say (outside of the room), 'I'm not comfortable or completely confident as I've not done that before/in a while so I'd like to observe you to ensure I'm doing XYZ safely and correctly. Can you show me? Or Can we do it together?' If you've already been told how to do something or what to do in a scenario, DO NOT BE AFRAID to say, 'we went over this last week, I just want to be sure, for XYZ we are supposed to do this, right...?'. Sometimes it sucks when you forget something you've been told, I hate asking again, but never proceed if you don't know. Treat your colleges like GOLD. I'm not necessarily talking about just fellow nurses, I'm talking about techs, LPNs, and even the housekeeper. Appreciate them. Always say thank you. Appreciation goes so far and people will be more willing to help you. Even if the housekeeper is changing the trash at the other side of the nurses station that I couldn't care less if it was full or not because I'm not over there - I still ALWAYS say thank you! Your techs will be there for you when you need them most, so again, treat them like gold. You're busy, the techs are busy, everyone is busy. So do not delegate simply because you can. You are not above a bed bath. You are not above getting family coffee. That said, do not be afraid to delegate these things when need be. There may be a time when you have to ask a tech to clean an incontinent patient - that person MIGHT feel like you're the 'RN above them making them do the dirty work' but the goal is utilizing everyone to their max within their scope. The tech can't do a neuro assessment, they can't push meds, etc. So if you have tasks that MUST be completed by YOU, sometimes you have to delegate the 'dirty work' and you can't be afraid to do so. But what you can do is express your appreciation before and after their task, and at the end of the shift. Never be afraid to report things you find unethical or dangerous but don't be a tattle tale. Just use your judgement. For example, we had a patient the other day who was intoxicated and faking seizures and one of the nurses decided to push some 'nackle' (NaCl) (saline) to help with his seizures. This nurse didn't call it that, but they said 'this will help, just try and relax'. Miraculously, the patient felt much better and the seizures subsided. Nowadays, I'm pretty sure this is illegal. You can't tell someone you're giving them something and it's either A, a placebo, or B something else (ie. 'blood pressure med' that will secretly calm the patient EVEN if the sedative was ordered. The point is, this is against policy and not okay. You just have to use your judgement if you feel like you should report something. Was the patient harmed in ANY way? No. Was the act unethical? Eh... Maybe... Was it against policy? Yes. Would I personally report them? No. If you did, you would not be in the wrong whatsoever. But things sometimes can come back to bite you so just be careful. Again, though, NEVER be afraid to advocate for and protect your patient in other types of situations.

This post is a disaster. I just worked 13 hours and am delirious so I apologize as there is no structure here, haha. I'm actually a new grad myself. Graduated in December, NCLEX in January, and I was hired in February. That said I've worked in the ED here as an emergency registrar for 8 years so I was comfortable in the environment and knew the logistics. Even so, my first two shifts were completely overwhelming. And not that I thought for a second 'all my years here' meant I knew how to be a nurse, but I definitely didn't think I'd be as overwhelmed as I was. Day three, things seemed a lot better. Day four, I felt even 2x better than day three. That's not to say that I 'know what I'm doing', I will be learning my entire career, but the feeling of 'okay maybe, one day, months and months from now, I will be able to do this on my own' is already surfacing. Because on day one, I didn't see it ever being possible. I'm now on my 7th shift as a practicing nurse and the fear of never being able to 'do this' is already gone. I know I will be able to get it all down with time now.

TL;DR: Ask questions. All day. If you're not 100%, ASK. Also, once it goes in, you can't take it out. If you have to check the order 4 times before your comfortable giving it, do it. Be confident. Confidence and experience are not synonymous so being confident doesn't mean you're acting like you know it all. Advocate for your patient - if something doesn't feel right, it probably isn't. Treat every one you work with, down to the housekeeper like gold. Show your techs appreciation because they might be 'too busy' when you need them most. It's not your job to analyze John Doe's visit history and assume he's not really in pain. If there's an order, it's safe and appropriate, he get's the pain meds. But he's a drug seeker! Well... you're still giving the meds when it comes down to it, so spare yourself the negativity and self-caused stress and cynical perception and just do your job. Next though: Patient adds chest pain to their triage complaint because they know how to 'work the system' and get back the quickest? Ridiculous. But guess what? That frequent flyer drug seeker that you're now ignoring just so happens, out of all 25 visits this year, to actually be having a STEMI this time, but he's here ALL the time so you'll never know... until it's too late. You're going to ***** and complain - it's inevitable. But do it at the right time and place, and do NOT let it compromise your care. Also, hospitals are statistically-ish the number ONE workplace for gossip. Avoid it. You never know what relative of admin or management you're working with... and it's simply just not necessary. It's STUPID easy to get sucked in. No matter how sh***y your day is, it's absolutely not fair to take it out or let your patient suffer as a consequence on what may well be one of the worst days of their lives. Fake it. Then go home and drink or pray or meditate or whatever you have to do to let it out and return to work sane and refreshed. You most likely WILL be overwhelmed. You're not incapable of learning. You will get it. With time. Nobody can say anything to prevent this feeling of being overwhelmed from happening but I'm telling you, YOU WILL EVENTUALLY get it. Sometimes you will feel stupid, it's okay. But feel stupid, learn from your mistake, and move on.

I think once I go to sleep and wake back up I'll revise this and add more but make it so much less of a cluster. I honestly don't remember half of what I said up there, and frankly, I'm too tired to proof read right now. CONGRATS ON PASSING AND LANDING THIS JOB! Night!

rubyagnes, BSN · Mar 24, 2016

Omg this is the most helpful and amazing response--- thank you!!! Can't believe you wrote this after your shift lol I'm very excited to learn and keep learning and hope I can put my nerves aside so I can absorb everything!

rnjetta12 · Mar 24, 2016

I am starting ED in 3 weeks and I am so happy i read this post. Thank you soooo much...

MedicFireRN · Mar 24, 2016

If you're using an EHR as a new grad I would definitely advocate printing out MAR orders. I'm also a new grad RN in the ED (been a medic for 6 years and did work ER in that capacity for a while as well as working 911) and my preceptor has been a nurse for 35 years. She has an amazing memory and is able to pull multiple meds for a pt without the MAR in front of her. I'm not that person. You do what YOU need to do to be a safe nurse. If you have any questions ALWAYS ask. I ask a lot of questions! I print the MAR so that I make sure I'm pulling the right meds at the right time from the Pyxis. Don't be afraid of needing to look things up, they are going to be more worried if you don't ask questions or look things up.

Always be sure you're always re-triaging your people in terms of knowing who is the top priority at that time. Identify nurses that you respect that can be a sounding board for your questions even once you get off orientation. Also get to know your docs :) They all have preferences and they are great resources. Also listen to your patients! They know themselves well. I think it's easy to get jaded but sometimes their requests are simple, like nausea meds with abx. Most docs will accommodate that. At the very least you can advocate and document that you listened to their requests.

MedicalPartisan · Mar 24, 2016

Also listen to your patients! They know themselves well.

Agree 100%. My patients teach me so much. They live with (whatever) day in and day out so they are much more knowledgeable than me in many cases. They generally love being able to tell you all about it, too.

LadyFree28, BSN, LPN, RN · Mar 24, 2016

Get an (or a couple of) emergency nursing books and start self studying; I have Sheehy's and ENA's Core Curriculum for Pediatric Nursing (I work at a Level I PediER).

Also be prepared to get a ACLS, PALS, books; I am sure you will become certified in those.

Be willing to learn from everybody; take what you need, analyze it and then shape to your practice.

Once you learn about ESI levels, tailor your practice and monitoring to help with keep up and anticipating what your patients need.

Also remember your critical thinking hat-don't forget to think outside of the box.

nursingismycalling25 · Apr 2, 2016

I graduated December and started working as a new grad in the ER. I have learned so many things which I saw many named on one of the first replies already. What I would like to add is I print out my pts triage sheet when they arrive before they are sent to their room I take that in the room to write assessment findings, allergies, pain level etc so if I get pulled to a code or trauma coming in then I have my assessment etc on paper because sometimes you get more than one pt back to back. On that triage sheet I also write meds and take it w/t me to the Pyxis, and I write IV site and gage and critical labs and when the blood cultures were done and what time I hung antibiotics etc. it sounds like a lot but it really helps when the pts is admitted and I have all the info for my hands off report or when transferring to ICU I take my paper with me or if the Dr's have a question everything is right there on 1 sheet of paper, really simple notes.

MedicalPartisan · May 14, 2016

Omg this is the most helpful and amazing response--- thank you!!! Can't believe you wrote this after your shift lol I'm very excited to learn and keep learning and hope I can put my nerves aside so I can absorb everything!

How has it been going in the ED for you guys?

AZQuik · May 14, 2016

Best I can offer is this: The ED is a great place to start and learn humility. You will see the same "problem" presented in 10 different ways, sometimes in the same week. So you get a lot of latitude for not knowing everything. There is just too much to know.

Learn the work ups, ask yourself "what are four different "problems" this pt might get diagnosed with for X presentation.

No room for ego in the ED. Learn who has worked where, and who you can go to for questions. You will have them. I've had nurses with 20 years under their belt ask things. It's what we do. If someone gives you grief for it, mark them off you resource list. Don't hate on them, just know that's not someone that wants to help and move on.

Work hard.

Have some fun, this is what you've been working for. Enjoy the moments you find enjoyable. Relish in your successes. Learn from your failures. This is emergency. The come in asking for you to heat up their roast beef sandwich (for the 5th time this week) while you are mixing an epi drip (cuz you are on the 6th code of the night)

Always remember, if they die, and you did everything by the book (which has a lot of gray) they were probably dead when you got them.

And finally, find out that one thing that gets to you. Acknowledge it, and respect it. It will likely always get to you in some form.

Enjoy the ride!

rubyagnes, BSN · Jul 11, 2016

@medicalpartisan, rn Wow, so things have been busy! So busy that I just saw this post :) I'm really enjoying the ED Definitely learning a lot. Sometimes I feel like "yeah, I've got this" and then a moment later it's like "whoa, what just happened..." So the ups and downs have been a little exhausting. I just worked three 12's in a row (which ended up being 13's) I've found documenting is the hardest for me. I definitely update all of my interventions in a timely fashion, but I'm not so good about writing notes and using the "correct lingo" I'm worried that I might write something in a note that conveys something negative somehow...

I also still have some hiccups in giving meds because I overthink the meds and get worried about things like adverse reactions or unknown allergies. I'm definitely paranoid :/ My preceptor says being worried is a good thing because it can keep me in line, but I definitely want to try to gain more confidence while being careful and concerned. I know these things come in time but my worries have been the hardest part.

The best part is just working with patients. Even the more challenging patients, I feel good about walking in, giving them a smile, and asking them how they feel/what I can do for them. I'm sure my documenting and technical skills will improve. I can't wait for the day where I just care for my patients independently and can leave a shift without worrying that I did something wrong.

Anyway, I've heard these feeling are all normal so I guess things are going well! :) Thanks for asking and I hope you're doing well :)

Jmarty31 · Jul 13, 2016

Be stern, and ask questions when need be.