Will I ever keep up the pace???

nurse2033, MSN, RN · Apr 30, 2011

Your progress sounds OK. Don't try to be perfect but get the important things done. Part of handling this job is prioritizing tasks to what "must be done" versus "what would be really great to get done". Don't feel you are failing as a nurse if you aren't getting a head to toe skin exposure for example. Accept that the floor will be handling small things like skin issues that you don't have time for. Stick with "keeping the patient alive and safe" and let go your desire to send every patient upstairs with a bow in their hair. IVs go in the AC because they're quicker, and the floor nurse will curse you every time they bend their arm, but not your problem. An NG might be quicker than an OG but again, stick to what works faster and better for you. It's not your job to make the floor happy, just keep the patient going. Keep going! This is a long slog for everyone, and everyone gets overwhelmed at times. This is why we love it! If it was easy we'd be bored.

PHATRN49 · Apr 30, 2011

I have a question for both new(er) and seasoned ED nurses! First, let me say that I'm still floating on cloud nine that I succeeded in getting my RN and that I have a great job! On top of that, I'm very fortunate to have been selected for a 6-month residency program. I'm 10 weeks in and have a wonderful preceptor! What's even better is that I love 99% of the people I work with :)The ED in which I work is a trauma II unit in an inner city hospital.
The problem? I feel like I started out strong, but that I've hit a plateau and have been disappointing her lately. I'm up to 3 patients, but I'm having a hard time with that and my preceptor often needs to pick up the slack when the bottom falls out, as you know it will several times a day in the ED . I run around like a chicken with my head cut off and I'm dripping with sweat! I do realize some of my problems:
1. I get bogged down with the small stuff...sometimes because I still need to work on delegation, or because we have no tech...and much of the things the techs do, I'd like to take the time to do (like IV's because I need the practice)
2. I have it all under control until 5 medics come in within minutes and I need to cover other nurses' patients while they work a code and then need a couple hours to document or admit a pt
3. Lots of little things that need double, and sometimes, triple charting:uhoh3:
At first she gave lots of feedback, but she's been quiet lately. I really feel like I'm letting her down and I've been doubting myself lately, like can I really cut it here???
The other two new grad residents are carrying what they "think" is a full load, but I find that they may be a bit overconfident and downright unsafe...either with patients or with their license. I now see why it may seem like nurses eat their young...some of these younger ones are so cocky and have that "I know it all" mentality, which is scary:eek:...They also "order" the techs around to hook a patient up to the monitor or clean a bed when they obviously have the minute or two to do it themselves.
Should I be this concerned that I'm 10 weeks in and can barely manage 3 patients? I love this job and want to succeed, but maybe I'm just not quick enough. Where should I be now and how can I improve???
Thanks for any advice and for listening

You are a new grad and safety is first. ED is a very swift unit and things are always moving and changing. So you have to be able to think and act quickly but always safety first. Getting use to it takes sometime, and you have to learn to prioritize ! It's a matter of finding what works for you and practicing it. One thing that I use to do was on my down time when it was quiet, I would familiarize myself with everything and store in my long term memory where things were located. Don't be afraid to delegate, because it will make your job a lot easier.

Reflect on what you as a person like: If you don't like fast past and steady change, then the ED may not before you. Another thing that helped me was that I had several years of Meg-Surg experience before tackling the ER. In med-surg you assessment and time managment skills are developed and the ER is a breeze then. So since you have not had any previous nursing the ED may feel very overwhelming. Don't stress it's takes a while for a nurse to find there niche.

WonderRN · Apr 30, 2011

You are doing fine. I was a new grad in ED, and I hit a slump too. It is partially because my preceptor was watching the computer for orders and would intervene when she became impatient instead of letting me work it out. I don't think you REALLY learn how to manage 4 patients until you are on your own and figure out how to manage by yourself.

My preceptor was a little frustrated with me at the end. In fact, my manager pulled me into the office and told me that they were afraid "the ED was not the right fit for me" my first day off of orientation. Not because of anything I did persay, just it seemed like i was overwhelmed. I told her to give me 2 weeks and I would show her I could do it, and I did. I was one of first new grads they hired, so I don't think they knew quite what a new grad needed.

BTW, 1 year later I was pulled into the office and told that i was being nominated for the Rising Star award because as a new grad, I was thinking critically and intervening for my patients. I established a rapport with the docs and would clarify orders that I thought were questionable or make suggestions that made a positive difference for the patient. They could tell by my charting that I got it. I was also helping others when I had the time and starting hard sticks- I was becoming an asset to the ED.

Things come together with time.

I think that it is super important that you maintain a cautious confidence. The overconfident new grads you work with WILL crash and burn: there were a bunch of those at the hospital I just left. In fact, when several of them were on their own, they were pulled BACK on orientation because they didnt know WHY there were doing what they were doing. They were just checking off orders. For example, one of them was going to give nitro to a pt who was hypotensive, and another was SUPER late on giving her hyperkalemic cocktail meds- she didn't even know what they were for.....

As a new grad, I went home and studied commonly used meds to learn them better (but WILL always look up one i don't know BEFORE i give it) I would try to better educate myself on the nursing interventions for a certain disease process and what orders to expect. This helps for a few reasons because 1) less time spent looking it up a work/asking other folks about it, 2) less time redoing something, 3) it inspires confidence in you that your are capable. For example, if you know that a pt with a small bowel obstruction will need a NG, you will have all the stuff ready at the BS when the order comes along- the appropriate supplies etc- because you set up for yourself when you had 5 minutes down time.

My best suggestion to you is this, Get your iv and labs drawn ASAP. It puts you ahead of the game. That is, as long as there is a culture that allows nurses to do this before the official orders are in. If I am behind, I talk to my patients while I place their line, and document when i get done. I at least get my line, a systems focused assessment, and a short note done before i leave the room. I usually come back and hit the systems that I missed before (as necessary)- get more details-, do meds lists, etc when I hang meds.

If the doc orders a whole slew of things at once, I do it piece mail in order of importance. Like blood first, come back and hang my AB in 15 mins after I go see the next one. That way I don't get stuck in a room for too long.

And like others have said, prioritization is key. Some things just have to wait. It is sometimes an hour or two before I can cath the little old lady from the NH.

Find a buddy on your shift that will help you when you get behind, and do the same for him/her. Call your charge nurse if you need help and are not able to find it.

Don't let floor nurses get to you. When you give report, don't let them chew you out because the line is in the AC or because there is no foley in the incontinent patient or because the line was put in by EMS. Some of them have NO idea what the ED is like. i let stuff like this bother me for entirely too long, until finally my skin became thick enough, i guess.

If you have any more questions, just let me know. I have survived for nearly 2 years now :)

nurse.sandi · Apr 30, 2011

:heartbeatOP do not give up. Keep trying. Try to improve on your critical thinking skills. It seems you probably are in the fight or flight stage most of the time. It takes time to acquire all the knowledge and skills you need in the ED. I think you are probably doing a great job. Be patient with yourself. Remember to prioritize. Yes it is hard to work without an assistant. Has anyone talked to you about what your short term goals are? If not set one or two for your self and work on those. Maybe you should just come right out and ask your preceptor what she is thinking? But be prepared for her answer. Her attitude may not have anything to do with you. Good luck.

GM2RN · Apr 30, 2011

What you are experiencing is normal, and WonderRN did a good job of laying it out for you. Give yourself at least 6 months to 1 year to start to get really comfortable, but realize that even when you are considered "experienced," you will still have those times when "the bottom falls out." That is the nature of the ED.

The only other thing I would add is don't assume that your preceptor is disappointed with you. It may be that she is just giving you some room to find yourself and figure things out on your own in this new environment. Talk to her and find out what is on her mind, and see if she has any tips to help you.

Traum-a-Rama · May 1, 2011

Thanks, guys!!! I really appreciate the feedback...I'm really trying here, cause I really, really want to be successful here. I didn't always want the ER; I kind of found my way here by accident, but now I can't imagine working anywhere else! What I love most is the sense of comraderie and teamwork among the staff (well, 99% of them!) I think a good team can make it or break it for you in nursing, you know?

To answer one of your questions, our ED allows us to enter our own orders or begin treatment in expectation of doctor's orders...besides the obvious, like always get my EKG STAT on the chest pain pt, get my line and labs, etc., do you guys have any more tips for time management???

cadency · May 10, 2011

Some of the time management things will come with time; does your ER have set protocols? That helped me so much when I started that I began to anticipate what I would need for my abdominal pains and even my headaches. I could get most things done before the doctor even came to see my patient. (minus meds, of course)

Someone else said it best; focusing on what absolutely needs to be done versus what would be great to be done. How does my patient look when the triage nurse walks them by me and into my room? Getting the skill of being able to assess who doesn't look right when they walk in will help as well. My walky-talky sore throat patient can wait while I prioritize care for my chest pain patient. Learning to "triage" your tasks is important and it is okay to go slow while you get there.

I had 12 weeks of floor orientation and had to be able to take a 4 patient load by then. It's doable and if you need to ask your preceptor to hands off, that is okay. It's scary and ER nurses have a hard time to keep hands off during precepting. They are used to getting things done and doing it their way - not watching you do it. My preceptor finally started to float around and make sure everyone was okay while coming back to check on me every little bit. Taking that leap is sometimes the only way to get there.

The ER tends to be a jack of all trades. I recently assisted with my first cardioversion of a wide complex tachycardia. We used fentanyl and versed. My hands shook giving the meds... but it went ok. You just always ask questions and don't be afraid to say, "I don't know how to do this." You can always grab a more experienced nurse and ask for the "see one, do one, teach one."

nfdfiremedic, BSN, RN · May 12, 2011

I think the two most important things anybody can hope to learn as a new ED nurse are time management and prioritization. At any given moment throughout the day you will need to do 5 things, and only have time for 3 of them. That's a given, and it doesn't indicate anything wrong on your part. It's just the way these sorts of busy departments are. The key is in recognizing which of those 5 things can be delegated, and which require you to do them. Then, once you've made that decision, deciding which of the remaining tasks have the highest priority.

You'll frequently find yourself in a position where you have "routine" meds or blood sugars due for an inpatient that's stuck in the ED because there are no beds upstairs, an ambulance crew walking into one of your rooms with a new patient, a phone call from a family member of one of your patients, a doc wanting an update on one of your patients, a tech wanting to hand you an EKG they just did, and who knows what else all at once. Add to this mix the inevitable code in the next room over that you go in to help with, and a whole list of other unexpected things that happen and it's easy to fall behind.

Above it all, just remember those two key things. Time management and prioritization. Make sure you always know the full list of tasks that you must accomplish, and make sure you have a mechanism in your head to keep the most important things at the top of the list. Ask your preceptor or the experienced nurses around you for guidance when you are unsure of which task to perform first, given several that seem equally important. Be prepared to accept that sometimes, all of the tasks that you need to accomplish are "very important" and you may need to look to one of your colleagues to help you in a pinch.

The people that pose the greatest cause for concern in the ED are not, and will never be, the ones that don't know things and need help. It's the ones who think they know everything and won't ever ask anybody anything.

murphyle, BSN, RN · May 13, 2011

Hi there! I remember you from your posting when you got hired into Emergency. Glad to hear you're still loving life in the wild world of the ED.

Hitting a "plateau point" in your orientation phase is completely normal. If anything, I'd argue it happens a little harder for second-degree grads because we're so used to constantly pushing for excellence - our programs gave us no time for breathing, let alone plateaus! Talk it over with your preceptor and see if he/she has any advice to offer; if not, ask the other nurses and techs around you. Be honest and sincere with them, explain that you're trying to improve your practice and would like their input, and see what they say.

On the subject of time management, I'd repeat what nfdfiremedic and Cadency already said. Advance-order early and often, and learn to recognize what's really a priority versus what can be left to do later. Some of the issue, too, may arise from what your individual ED allows you to delegate and how your chain of command works. Learn what you can ask for help with, and who you can ask for it.

(Aside: my own plateau came about two-thirds of the way into my orientation and a week or so after I'd transitioned to nights. My preceptor and I were given the psych rooms, all five of them full of drunks, suicides and overdoses, plus a Resus shift during which we activated twice, and the rest of the team was full of Priority II mayhem, so we were also assisting on central lines, pressors, vents and God only knew what else, all the while with Triage screaming for us to pull patients to the hall. By the time 0630 rolled around and the end was in sight, I was so fried you could've put a pan of water on my head and boiled eggs in it. My preceptor's sage advice to me was, "Don't sweat it, you did fine. Some nights you just get handed a bag of d***s.")

All things considered, it sounds like you're doing fine so far. Best of luck to you!! :nurse:

EmergencyNrse · May 13, 2011

Welcome to emergency medicine.

I think most people have touched on it but I think you might be a little behind the curve. Perhaps you're trying to elaborate too much on charting. It's not a care plan. "Git er done"... be as concise as possible. Work on an abridged version of what you're charting now.

Reassessments are sometimes as simple as observing the patient sitting upright and still breathing as you walk by the door. Place as many patients as will tolerate it on Q30 vitals checks and monitor(some just refused to remain hooked up). That way you can either pull vitals from the computer or at least write them on a glove as you come by the room. It saves you time.

There should be some lag time in between your assessment and results from Xray/Lab/Procedures... this is where you shine and catch up after "ambulance "surges". If you're tied up with IV's then try once or twice and ask for help. If you take more than 20 min for an IV start then you're wasting time (yes, I know there are difficult pt's sometimes).

Keep this in the back of your mind. 3 patients is nothing. At least you're at a facility that limits ratios to 4:1. East-coast hospitals will run you 7-8 patients of varied acuity. Worst I've had it is 12. Other places nurses have more than that. Not bragging... just the way it is.

K.I.S.S. is your best friend in the ER. You really do have to just keep it simple stupid...

Good luck. You're doing well. It will come...