Transitioning to ER. Any tips?

PeakRN · Aug 1, 2018

In my experience most new hire ED nurses, especially those without EMS or intensive care backgrounds, are "too nice." If someone started out new and was already getting crispy I would wonder why they want to care for people. The "ER voice," "Mom voice," or what ever else you want to call it will develop with time.

Similarly almost every new hire ED nurse takes time to keep up with the pace, this includes nurses with EMS or intensive care backgrounds. The ED isn't like any other care environment and takes time to learn. Almost every new hire we have had gets up to speed pretty quick; those who don't are often nurses who find more value in the type of patient care that can be given in inpatient units (longer relationships, more personal care, et cetera) and often want to go back to those environments. Just like long term care, med/surg, intensive care, et cetera many nurses have tried an environment that they didn't like and there isn't a reason to stay somewhere where you are unhappy. In regards to the occasional new to ED nurses who haven't wanted to stay in the ED, we are happy to work with them to find an environment that they are happier in and find their own personnel success.

I think that most of the tips and tricks you will pick up from your preceptors, however I do have a few thoughts.

Get down to what really matters, in the ED we are all about focused assessments and generally speaking only those who cannot easily articulate a good history are likely to have any kind of head to toe assessment.

Pay attention to what your preceptor is teaching you, and understand that there are many things that are very different from inpatient units (and even ED to ED). For example on adults unless there is a history of transfusion reactions in my ED we never put blood products on a pump, typically we just adjust the roller clamp so it takes about an hour to go in (of course rapid infusion is a whole different topic); this would never be tolerated anywhere else in the hospital. We give zosyn over 30 minutes rather than 4 hours, and rocephin over 3-5 minutes which I think they give over 30 minutes upstairs, and so on.

Understand that patient care is always our most important priority, but we also need flow to take care of patients from EMS or in the waiting room. Sometimes we don't get our patients food trays, give them bed baths, et cetera because we know that the floor can take care of this and we need the bed open. We are not trying to "dump" on the floors, but be able to provide care for the patients who have not yet been medically evaluated.

Most importantly be confident. I don't believe in 'fake it 'till you make it' type behaviors, but have confidence that you will be able to care for you patients, get that IV, and make a real difference. Getting fast while providing good care takes time, just like it did for every other ED nurse.

akulahawkRN, ADN, RN, EMT-P · Aug 1, 2018

When you're transitioning to work in the ED, you'll have to quickly step up to the pace. The previous poster is right about that... very right. The ED is basically one big triage facility and its job is simply to get the patient to wherever they need to go. As such, you have to be able to keep a constant watch over your patients and be ready to change priorities basically instantly. Your most stable patient could very easily become your most sick in the blink of an eye. I had a great example of this a couple weeks ago. One moment I'm getting ready to send my patient to the floor and the next I'm basically working my tail off keeping my patient from having a really bad day...

While I'm often the "nice one" in the ED, what must be understood is that I'm nice until someone gives me a reason NOT to be nice. I'll take care of the things that need to be done to keep you alive first. Then I'll take care of the things that will help keep you from becoming more sick. Then I'll take care of the things that will prevent you from having a problem develop because you're in my ED. Then I'll take care of the things that will help you become more comfortable. I do those things in that order. If I'm getting things for you that are "comfort" measures, it means I've already taken care of the other stuff and I'm not worried about you.

Oh, and about that "ED voice"... Yes, I have it. I've used it. Most of the time that I have to drop the "nice" I've only had to let out that voice only a little. It's something we all develop. Yes, my "nice" act is exactly that... an act. So is my "ED voice." It's all about getting compliance. I want my patients to do the things that need to be done so that I can get things done... so I can help get them moved through. It's all about flow. You can have a fantastic ED that gives great care to patients but if you can't move patients through the ED, you can't deliver that great care to more than a very small few. Of course hindrances to maintaining good flow can exist outside the ED as well. If your hospital has no available beds (is full) you're going to have a very tough time getting patients moved out of the ED, so they end up getting held there. I'm a darned good ED RN but I'm only a mediocre Med/Tele RN at best. That's not what I do.

What I do is focused assessments, focused reassessments, reprioritization of my patients, and everything I do is "now" and rarely is "scheduled" for a given time unless it's related to a reassessment that determines some outcome.

I'm going to echo something from above too. We do things in the ED that would rarely (if ever) be tolerated outside the rest of the hospital. Zosyn loading doses really can be infused in 30 minutes. Rocephin (and some other abx) can be given by IV push over the course of 3-5 minutes. When I hang blood, that takes about an hour per unit unless I have to give it faster. When it comes to IV fluids, we'll run them wide open... or close the roller clamp down to about a KVO rate with very little in between unless we get an order for a specific rate.

Oh, and if I get to sit for a bit and actually get to check my department email or work on CE topics, that's a rare thing. It means I'm all caught up. The pace is often just unbelievably fast. If you see me sitting at a desk computer, it's because I'm checking lab results, imaging results, or reviewing orders. Then I'm up and moving again because I need to help keep the flow going.

What else do I do all shift? I also jump in and help my other nurses get their tasks done and they'll jump in and help me get mine done too. That can mean doing anything from getting the patient on the monitor to starting a line, helping out with getting a foley placed, to inserting a NGT, to wiping a butt. I've cleaned rooms that aren't "mine" because the room needs to be cleaned and the nurse assigned to that room is too busy with something else...

Does this seem like a lot? It is! Hang out in the ED for a while and you'll quickly understand why ED nurses are the squirrels of the hospital...

Editorial Team / Moderator · Aug 1, 2018

Even after 18+ years of EMS and 10+ as an ED RN, I am very nice. But I caution people: don't mistake my kindness for weakness. Period.

You are going to feel slow and stupid at first. That will pass. Enjoy the journey. :)

akulahawkRN, ADN, RN, EMT-P · Aug 1, 2018

Even after 18+ years of EMS and 10+ as an ED RN, I am very nice. But I caution people: don't mistake my kindness for weakness. Period.
You are going to feel slow and stupid at first. That will pass. Enjoy the journey. :)

If you're not feeling slow and stupid at first, you're probably not learning. As to the rest, yep.

amzyRN · Aug 1, 2018

Don't be afraid to ask questions. Find learning opportunities and jump in to help. Never sacrifice safety to go faster, ever. Never be afraid or embarrassed to ask questions and admit that you don't know something. There are various skill levels in the ED because the knowledge base is so broad. So you might get a really sick patient that you don't konw how to take care of and their life will be in your hands and you will have to ask for help. Does that mean you are stupid? No, it means you are smart enough to know that your ego is not more important than someones life. Everyone starts as a beginner and the most skilled ER nurse was once a novice, so as mentioned above, enjoy the ride. There is a flow and order of operations in the ED though, your preceptor will help you learn that. Once you have that down and basic skills and know how to get the answers you need, it's just a matter of time before you perfect your skills. There will always be something even the most skilled ER nurse does not know.

kclady · Aug 2, 2018

Good clinical assessment skills, always remembering which patients are top priority( hint: it's not necessarily the ones throwing the biggest fit), good intuition and good assertiveness skills are all essential in the ER. If it's a big trauma center expect a lot of staff turnover. Good luck.

akulahawkRN, ADN, RN, EMT-P · Aug 2, 2018

Something I forgot to mention... while I'm a darned good ED RN and I've got a wealth of knowledge from previous careers/jobs (Sports Med and Paramedic), there are times I still feel stupid. Not dumb... just there's so much to know and so much I've learned and so much I've forgotten and so much that has changed over the years.... yeah, it's just easy to feel stupid at times. So when that happens because I've got a patient that's got something I know isn't right but I can't put a finger on it, I ask. I'm in a small-to-medium sized ED now (~30 beds) and there's enough staff around that somebody has seen whatever it happens to be and knows how to deal with it. So... I learn how and I get better.

And when I know something, I'm happy to teach/refresh others about it so they learn and get better too.

Feeling stupid is often a sign I'm still learning. If I stop feeling stupid about something, I've probably learned it all... and I don't ever want that day to come because that's the day I need to retire because I've become truly dangerous at that point.

amzyRN · Aug 3, 2018

There are lots of "nice" people in the ER. A lot more than I anticipated actually. People go out of their way to help me and other team members when in need. One thing I've rarely observed in the ER though is someone who is afraid to speak up and set boundaries. Some people do it politely and call security or quietly say "no I'm not doing that doctor-you put the order in"-with a smile. However you do it, you'll have to set boundaries with patients and colleagues or you won't survive in the ER. This is a skill that is learned through with practice, so don't let that discourage you.

JKL33 · Aug 3, 2018

I left the hospital about 5 months ago for community health. I hate it. I crave the patient interaction and the acute care. I am starting a new position in an ER and excited to get back into the swing of it.
I'm terrified. I am having doubt of my capabilities. I wonder if I'm too nice. I wonder if I can keep up. I wonder if I will move fast enough...
Any stories, tips, tricks?

Nice is bad. Kind is good.

Frankly, nice isn't too helpful in much of life, not just the ED. It just means that you didn't tick someone off.

Kindness is more genuine, and can (should) accompany assertiveness and boundary-setting.

Ditch nice, aim for kind and assertive.

Good luck!