With an ADN can I be a ER nurse right out of the program?

gotaluvtheER · Aug 11, 2004

I came in the ER right out of school. Here's some advice straight from the horse's mouth.

1. Make sure you will receive an extensive orientation. Especially make sure you know where everything is on the unit--nothing is more frustrating in an emergency than for you to not know where something is.

2.Take ACLS, PALS, NALS, TNCC, even if they are not all required.

3. If there's a skill to be done that you haven't done, grab a veteran nurse and have them talk you through it--watching it is not nearly as effective as doing it.

4. Don't let anybody make you feel bad about being a new grad in the ER. No matter where you work, it will be busy, short staffed, and emergencies will happen. Just know when to step back and let the veterans step in, and take that time to absorb everything you can.Follow the code team as they respond to the calls on the floor. The more codes you see, the better your ability to appropriately respond.

5. If you have time, go watch the triage nurse and note her assessment and the questions she asks. Think about what priority you would assign the pt and see if it was the same as hers and find out why or why not. Nothing terrified me more than going out to triage (and I had been in the ER for 2 years). If the pt looks fine but your gut tells you different, go with your gut. Better to err on the side of safety. Oh, and if the nurses start to complain about you bringing too many people straight back, offer to swap assignments with them. That'll shut them up. :rotfl:

Note: Even if you did work on MedSurg for a year, that doesn't necessarily mean that when you come down to the ER, you will automatically know how to work with chest tubes/vents or do gastric lavages or get an IV in a baby in full arrest in record time. No matter the years of experience you have, the ER requires its own orientation.

ManEnough · Aug 11, 2004

I know this debate creates strong arguments on both sides, but allow me to share my personal experience.

I graduated last year with an ADN and had never set foot in an ER other than a brief rotation in nursing school. I enjoyed that rotation and decided to bypass the one year of med-surg despite a lot of advice to the contrary.

I have NO regrets! I will say this. 90% of the reason I've had a positive experience is that I work for a hospital that is committed to training and retaining new nurses. My training program has been incredible and I've never once felt that I was providing unsafe care. Yes, those first few weeks/months are stressful but I hear the same things from my friends who went straight to med-surg.

Bottom line? If it's a quality hospital with a great training program and a staff committed to helping you be successful, it can be done. Proof here. :)

MrsWampthang, BSN, RN · Aug 11, 2004

I did, with an ASN, as well as my boyfriend and four other nurses that graduated with ASNs. Another guy came straight to the ER as a BSN. Now, they ALL worked as student nurses in the ER prior to working as nurses in the ER; two of the gals were policewoman in their former lives, the BSN guy retired from the military prior to coming to the ER. (He told us he was in the last gulf war and was in the war zone under fire! Nothing in ER is as scary as being shot at! :chuckle ) My boyfriend also retired from the military, but he worked as an EMT during the time he went to school as well as a student nurse in the ER. My story is kind of different. I was a medic in my former life, 12 years before becoming an RN, during that time I also worked as an ED tech in the ER so coming to ER straight out of school seemed like a natural progression for me. Working ER did seem to come easier to me than it did some of the others, but probably because I was already used to making decisions on the run, and doing things quickly.

I don't think our ER would hire any RN, ASN or BSN right out of school with no prior experience in the ER setting. ER is a specialized area, and new grads with no experience are lost right off the bat. Even with a good preceptor, it would take much longer to orient a new grad with no nursing experience than it would a nurse that had been a nurse on another floor so cost wise, I think it is more effective to hire a nurse with some type of experience, because they will be on their own sooner.

That said, I have seen nurses come down from the floors who got lost in the ER because they never caught onto the fast pace of the ER. But then, I have to admit, I would be absolutely lost on a floor, I think.

If you think you want to work the ER at sometime in the future, talk to their education coordinator. Different ERs have different reqs for new hires, so that person could give you a lot of insight into how to go about getting into the ER.

Just a thought.

Pam

shell911rn · Aug 11, 2004

Hi,

I hesitate discussing new grads in the ER with ER nurses especially online b/c I know the opinions are often negative towards new grads. I just started in the ER three weeks ago after graduating in May. I worked out in the field as an EMT and also as an ER tech both for over a year. What I found is that my experience in the ER was no where near experiencing the role of the RN in the ER. The responsibility is great and overwhelming at times. My assessment skills and history taking are good, but the one area I seem to struggle in is my technical skills (i.e. IV's, blood draws, IM injections). It's not that I can't do them, it's just that I don't do them at the speed of an ER nurse and I still have many a time where I can't get an IV on a patient. I did not have much experience with these skills on Med/Surg or Telemetry which is ultimately why I decided that spending a year in Med/Surg or Telemetry would be a waste of time. I have been very stressed out the past several weeks (much more than my friends who went to med/surg or telemetry), but not b/c I'm incompetent, but b/c I first had a preceptor who wasn't comfortable precepting a new grad and expected too much from me, while not allowing me to do much of anything, and b/c I expected too much of myself. It led to an emotional breakdown in the ER, but I came back the next day and surprised both myself and my preceptor with how well I could bounce back and proved that I belonged there. Make sure you have a preceptor who has the confidence to allow you to practice your skills and doesn't let the patient know you are a new grad. There's nothing like being treated as though you are still a nursing student, when in actuality you have your RN LICENSE! We have done all these skills before at least once. Now it's time to fine tune them. Review the procedure with your preceptor before going in to the room if time permits and have him/her walk you through it. If you've never done the skill, observe your preceptor doing it first. I'm now with a different preceptor who doesn't expect too much (except at times when it gets chaotic) and is allowing me time to master my skills with guidance. I am taking an ER class for the next month followed by Basic Dysrhythmias, ACLS, PALS, and courses (splinting, cardiac meds, CHF, etc.) with our nurse educator. I chose not to stay at the hospital I worked at as an ER tech b/c they don't have an extensive ER orientation (mine is 6 months with a preceptor) nor ER courses. They place you with a preceptor and that is it. I didn't apply to any other hospital but this one and am glad I did. I'm still struggling emotionally and I have days that I feel like the most incompetent nurse in the world (quite a contrast from several months ago when I did my preceptorship for school on a tele floor and took care of 4-5 patients on my own and felt like I could handle anything). But I'm not gonna give up. My friends on med/surg or telemetry aren't gaining anything near the skills or experience I've so far been faced with in the ER. In fact, they are being babied too much in my opinion. I'm being put through a lot and I'm constantly having to prove myself to nurses, but I didn't work so hard in school to give up on my dream. Take it one day at a time and be good to yourself. Expect some days of crying. The ER is competetive, especially among new grads. Sometimes a fellow new grad is not the best support b/c they are trying to raise their own self-esteem through your failures. Sometimes your family or friends from nursing school are not the best support either. They don't understand the turmoil of spending years in school working towards a dream to feel as though it is falling apart. I'd recommend visiting the new grad board for support. Whatever you are uncomfortable with, read about at home and practice. And this actually goes for any new grad on any unit.

Michelle

Trauma Columnist · Aug 12, 2004

Michelle - you sure seem like an on-the-ball RN. I admire someone who can understand they may be in a difficult situation, but rolls with the punches and comes out on top. There is no hard and fast rule that you have to stay with your original preceptor. I'm an experienced RN who loves precepting new grads. However, I'm also a typical type A who is pretty bossy and aggressive and I realize that. So...my personality doesn't do well with the timid and faint of heart. Its so funny because I honestly didn't think I was really bossy. However, my 19 y/o son just joined the fire dept/EMS squad where I volunteer. We went on a bad MVA call together and afterward - he told me I was waay bossy! If you don't get along with one preceptor, ask for another one - that's just being assertive! Good luck!

Dixielee, BSN, RN · Aug 12, 2004

Michelle, you are on your way to becoming a great nurse! You have been brutally honest with us and with yourself and that is a hard thing to do. You are right about it being very different when you are the RN and have to take responsibility for so many things. I have seen lots of techs, clerks, etc. sit back and critisize nurses when they do not feel the heat that we do. You are someone who recognizes your limitations and that will make you a safer, more conscienecious (sp?) nurse.The ones who come to the ER thinking they have the knowledge, abilities and really don't need much help are the ones I am concerned about. I still think a year or so of med surg gives you the time to fine tune your skills, builds confidence and helps you learn different procedures, hospital routines, lingo and interaction with all services with out the time pressure to get everything done STAT as in the ER. You sound like you are in the right place with people who will work with you to get you over the hump. We ALL have to get over that hump, no matter what our background might be. I think it is much tougher to be a new nurse now than when I started. The patient acquity is much higher now, there is more risk of litigation and staffing is worse than ever. I salute all the new grads and am just glad I am not starting over! Good luck, hang in there, you are doing fine!

shell911rn · Aug 12, 2004

Thank you Dixie and Trauma for your support! You don't know how much that means to me because right now I'm not hearing it enough in the ER. I'm gonna spend some time the next couple of my days off reading and practicing my skills. That has worked for me in the past to build my confidence. I long for the time when I feel comfortable in my role. All and any support is welcome. Anyone who has any tips or advice, please feel free to email me at my email address [email protected]. I wanted to come to this board a couple of weeks ago for support, but was afraid I would be told to go back to a med/surg floor or that new grads don't belong in the ER. That's not what I need to hear right now. I am in the midst of the program and I think giving up now would do even more to hurt my already blown self-confidence than if I stay with the ER and keep trying through the adversity. I don't want to give up or feel like a failure.

Michelle

Rena RN 2003, RN · Aug 12, 2004

i think success in the ER as a new grad depends on a variety of different things.

1. your personality (before nursing school, during, and at graduation). i'm a go-getter. always have been but especially during school. i didn't want to watch procedures, i wanted to participate in those skills we learned in lab. so i knew that procedure inside out in the hopes that situation would present itself. when it did, i went to my instructor and said "so and so is going on in room 212. i know this this and this. will you walk me through it if i can convince that patient's nurse to let me do it?" more times than not, i was welcomed to that room.

2. you must be humble or you will kill someone. don't be afraid to admit that you've never done something or don't know something. ASK! seek information! and learn from it. and when you have gone home, learn more from it. read, reasearch. your education didn't stop at graduation or the end of shift.

3. know your unit. if you have downtime, find a veteran RN and go through that ER with a fine tooth comb. know what all the supplies are for. know the equipment, what it's for, how to use it, how to transport it, and for pete's sake, WHERE the ON and OFF buttons are. i had a great lady that had been a nurse for 16 years take me through the trauma rooms and go over each and every box, bag, package, and roll of stuff. we didn't get to it all in one night. we did it multiple times.

4. listen. shut thine mouth and just listen. you will learn so much. listen to other nurses that have a patient perhaps unlike one you have had before. listen to how he/she handles that patient, the questions that are asked both to the patient and behind the nurses station. listen to the docs talk to each other about patients.

5. approach the doctors and asking them to teach you something. "hey, dr. so-n-so, educate me for a minute please. why are we using _______ again? all i've ever seen used is ________." for the most part, they love to teach.

6. have your peers evaluate you. i wanted to know if i was doing okay or if the other nurses thought i sucked. i went to my nurse manager and dept. educator and asked them how i was doing because i was sure the other nurses would have told them. many times, the nurses themselves won't tell you to your face if you aren't ER material but they will damn sure tell the NM. get feedback on how you can improve and we can all improve.

7. bounce like a ball baby. you are gonna screw up. there will be something somewhere that you miss, overlook, or do incorrectly. vent or whatever to get it out of your system and then bounce back. take responsibility for what you do then go on with your job. learn from yourself.

8. find a facility that embraces new grads. mine did. they nurtured me along. they were willing to teach me, mold me. the sent me to all sorts of classes. they instituted a monthly ED class presented by another RN or MD so the new people would have the ability to learning something that perhaps they didn't know. they never said "i don't have time" or "you should know that."

i've been in the ED a year and i've loved every minute. i still make sure to learn something new everyday. i get on well with my co-workers and the docs. my patients love me. and i STILL find stuff that i do not know. but i never stop learning. and it's always something new every day.

Dixielee, BSN, RN · Aug 12, 2004

You made some great points. It sounds like you found a wonderful, nurturing home and I bet your patients get the care they need as well. You stated, "I STILL find stuff that i do not know. but i never stop learning. and it's always something new every day." I'll tell you a secret...I have been a nurse 30 years and I still feel the same way! It is a never ending story of learning. Even though I may not learn a new procedure or technique every day, I learn something about human nature. Glad you are doing well.

CSLee3, ASN, BSN, LVN, EMT-P · Aug 12, 2004

I agree that you should get some med surg experience....unless:

BIG facility with ER internship

Former LPN/Paramedic w/experience

Otherwise, go ahead and soak up all you can from med surg...there is so much to learn. If you don't fit into the criteria above, you might drain or pull the other staff down for their knowledge. just IMO..............good luck with your career...

MrsWampthang, BSN, RN · Aug 12, 2004

Hi,
I hesitate discussing new grads in the ER with ER nurses especially online b/c I know the opinions are often negative towards new grads. I just started in the ER three weeks ago after graduating in May. I worked out in the field as an EMT and also as an ER tech both for over a year. What I found is that my experience in the ER was no where near experiencing the role of the RN in the ER. The responsibility is great and overwhelming at times. My assessment skills and history taking are good, but the one area I seem to struggle in is my technical skills (i.e. IV's, blood draws, IM injections). It's not that I can't do them, it's just that I don't do them at the speed of an ER nurse and I still have many a time where I can't get an IV on a patient. I did not have much experience with these skills on Med/Surg or Telemetry which is ultimately why I decided that spending a year in Med/Surg or Telemetry would be a waste of time. I have been very stressed out the past several weeks (much more than my friends who went to med/surg or telemetry), but not b/c I'm incompetent, but b/c I first had a preceptor who wasn't comfortable precepting a new grad and expected too much from me, while not allowing me to do much of anything, and b/c I expected too much of myself. It led to an emotional breakdown in the ER, but I came back the next day and surprised both myself and my preceptor with how well I could bounce back and proved that I belonged there. Make sure you have a preceptor who has the confidence to allow you to practice your skills and doesn't let the patient know you are a new grad. There's nothing like being treated as though you are still a nursing student, when in actuality you have your RN LICENSE! We have done all these skills before at least once. Now it's time to fine tune them. Review the procedure with your preceptor before going in to the room if time permits and have him/her walk you through it. If you've never done the skill, observe your preceptor doing it first. I'm now with a different preceptor who doesn't expect too much (except at times when it gets chaotic) and is allowing me time to master my skills with guidance. I am taking an ER class for the next month followed by Basic Dysrhythmias, ACLS, PALS, and courses (splinting, cardiac meds, CHF, etc.) with our nurse educator. I chose not to stay at the hospital I worked at as an ER tech b/c they don't have an extensive ER orientation (mine is 6 months with a preceptor) nor ER courses. They place you with a preceptor and that is it. I didn't apply to any other hospital but this one and am glad I did. I'm still struggling emotionally and I have days that I feel like the most incompetent nurse in the world (quite a contrast from several months ago when I did my preceptorship for school on a tele floor and took care of 4-5 patients on my own and felt like I could handle anything). But I'm not gonna give up. My friends on med/surg or telemetry aren't gaining anything near the skills or experience I've so far been faced with in the ER. In fact, they are being babied too much in my opinion. I'm being put through a lot and I'm constantly having to prove myself to nurses, but I didn't work so hard in school to give up on my dream. Take it one day at a time and be good to yourself. Expect some days of crying. The ER is competetive, especially among new grads. Sometimes a fellow new grad is not the best support b/c they are trying to raise their own self-esteem through your failures. Sometimes your family or friends from nursing school are not the best support either. They don't understand the turmoil of spending years in school working towards a dream to feel as though it is falling apart. I'd recommend visiting the new grad board for support. Whatever you are uncomfortable with, read about at home and practice. And this actually goes for any new grad on any unit.
Michelle

(quite a contrast from several months ago when I did my preceptorship for school on a tele floor and took care of 4-5 patients on my own and felt like I could handle anything).

Now see, not trying to bust your bubble or hurt your feelings, but you said yourself that you felt you could handle anything...on a tele floor. Why not work that floor where you do feel confident, and capable and get your sea legs and your nursing skills down pat, instead of working in a unit that constantly makes you feel inadequate. ER is not a place to work, just to prove yourself, ER needs nurses who are confident and competent. It's great that you aspire to be an ER nurse, but it sounds like from your post, you should really have started on the tele floor. ER does require that you "prove" yourself; timid, shy, new nurses that take their time mastering skills really don't belong in the ER where the pace is fast and the docs want things done yesterday. You're probably lucky your preceptor is patient, but the longer you take to master your skills and become confident, the more obvious it is going to be that you need to be somewhere that you can master your skills at a slower pace. It sounds like you have thrown yourself into the deep end of the pool without knowing how to swim well. Again, not trying to hurt your feelings, but realize there is no shame in not being ready to be in the ER. You can't keep feeling low self esteem after work; it isn't fair to you. I'm sure you are a great nurse, but I just think you would be better off working somewhere where you can feel like you are a great nurse after work. After you have gotten experience and confidence under your belt, then come back to the ER; I'm sure your orientation would be much more comfortable to you at that point. I just don't want to see you quit nursing or feel inadequate because you started out in an area that is too difficult for you. Just a thought. I'm sorry if this hurts your feelings, guess I'm just being brutally honest. If you do choose to stick it out, then jump at every chance to do your skills, both advanced and basic. Ask your preceptor if you can go in with other people if there is something going on that you haven't seen before, even if it is just to stand in the corner and watch. Try and keep in mind things you see that go well, as well as things you see that don't work out so well. Try to learn from others mistakes as well as their good tricks. Don't sit around waiting for your preceptor to ask you to do something, if you see something that needs to be done, jump up and do it, even if it is only checking someone in for another nurse. Don't make your preceptor have to come and find you. Always let her/him know where you are at all times, if you are not with them. If you have down time, go in your assigned rooms and familiarize yourself with where everything is. The biggest reason I have seen nurses fail in the ER, is they weren't self motivated. They waited to be told what to do. Don't do this! Good luck!

Pam

needsmore$ · Aug 12, 2004

shell911-

thanks for your post- i shared it this morning with the 2 gns i am mentoring/preceptoring. they were feeling better after reading it; realizing that their concerns are very similiar to yours. i still think that 1 yr med/surg is beneficial, but i work in the real world and i see that it is becoming a trend for hospitals to start hiring gns for their eds. i think that ena is beginning to support this as well (per my manager who is the state prez of ena currently in pa.) i think that we have to recognize that this may be a new trend and have orientation and mentoring programs to support this. we also need to remember that feeling of insecurity and downright fear that we experienced when we started out as nurses (no matter where we worked). we can use those memories to support the new nurses coming along. maybe we can get rid of the phrase--"nurses eat their young" during orientations. good luck

anne