Reality Check: Being a New Grad in the ED

Hellloooooo! It’s been a hot minute. Since I last wrote, I graduated from nursing school, started my residency, and passed my NCLEX! Woohoo! I wish I could say that the NCLEX was the last stop on the nursing struggle bus, but really starting to feel like it’s stop number 5 out of 100.

I accepted my dream job. I had a picture of how it was going to be. I spent over 300 hours in the ED during nursing school, so I thought that I would have *somewhat* of a smoother transition into practice. I WAS SO WRONG. Being a new grad in the ED has proven very difficult for me.


Canboc Stethoscope Carrying Case for 3M Littmann Classic III/Cardiology IV Stethoscope – Extra Storage Taylor Percussion Reflex Hammer, Reusable Medical LED Penlight

One, the ED I’m working in now is a little bit over twice the size that I had experience in, plus, it’s a Level 1 Trauma Center. New grads don’t really touch the trauma bay, and I didn’t expect to for a couple of years anyway. However, my coworkers are super great and are very supportive of learning opportunities! So I have spectated in the trauma bay a few times for some interesting cases.

Secondly, I don’t know where the heck anything is. I’m still getting lost, it takes me twice as long to find supplies, and ALL OF THE EQUIPMENT IS DIFFERENT — The pumps are a different brand and can only handle one primary line and a piggy back – no adding channels…gotta get another pump…????, the tubing is different (as well as the way to prime), the IV angiocaths are different (I do need way more practice with sticks, though), the blood culture bottles are a different shape and color, the medication dispensing system is different, the labeling process for specimens is way more complicated (the hospital recently transitioned to EPIC, so I’m not sure they’ve caught up with what other hospitals are doing), labs are drawn from different colored tubes and therefore the order of draw is different, mixing antibiotics is more complicated, requires an extra step, AND an extra piece of equipment that I’m not used to either. I could go on…but all of these little things are slowing me down immensely.

Thirdly, I am getting different instructions and directions from each nurse I interact with, so if I do something that isn’t quite what that person does, I am also slowed down because they want to explain what they are doing and why. Most of the time, I learn something new and am very excited to have a more efficient way of doing a task! But sometimes I just want to tell them that my preceptor instructed me a certain way and I would like to keep that habit. For example, I am already familiar with EPIC, but this hospital just transitioned. There are a dozen different ways to find information in the EHR. I have my favorites saved and my hands literally have two years of muscle memory to find certain pieces of information very quickly. I’m having trouble finding the balance here. I love and appreciate each piece of advice, but in the end I am responsible for my license and charting, and as long as it accurately reflects the patient’s condition and care within facility policy and the board, it’s six of one and half a dozen of the other. If you’re reading this and have advice–let me know!!

Let me get to the fun parts!!

Yes, the transition has been tough, the patient load is insane, and I feel like I got hit by a train. But I have learned SO MUCH in the three weeks I’ve been in patient care. I’ve seen a lot of new cases such as Cushing’s triad, clamshell emergency thoracotomy, ROSC, subarachnoid bleeds, and open fractures. I’ve also been able to reenforce and improve my knowledge and skills when it comes to the common cases I saw in my internship such as RSI’s, STEMI’s, strokes, and sepsis.

Being a registered nurse is really, really fun. I love seeing immediate improvement in a patient from an intervention or medication that I gave. Everyone is so supportive, and although I am a new grad, I feel like a part of the healthcare team. No one has treated me poorly or looked down on me (at least not to my face or that I know of). I’m really struggling with time management and clustering care, but my preceptors are supportive and patient.

The skill that I feel most confident in right now is my “customer service” skills. I can talk to anyone. I can stay calm in front of patients and do my best to explain what is going on. I can grab that extra blanket or take 15 seconds to take deep breaths with my patient. But I can’t wait to get better at it!

The only advice I feel qualified to give right now as a 3-week-in new grad in the ED is:

  • Don’t be afraid to ask questions! I feel like I ask a question every 5 minutes…
  • Be confident in what you know, but have the attitude that you can always, always improve and learn something new.
  • You can advocate for your patient right away! If something doesn’t seem right, grab someone for a second look.
  • You are going to feel like you are drowning, but my supervisors and preceptors have been telling me that it is a normal feeling.
  • Write things down (checklists, SBAR, questions, etc.).
  • Write out goals for each shift and take 2 minutes to share those goals with your preceptor.
  • Be appreciative of every learning opportunity and be respectful!
  • Learn some positive phrases such as, “Could you clarify this for me?” or “Could you remind me how to _____?” instead of “I don’t know.”
  • If you need to cry, do it in the bathroom or in your car!
  • Get to know your techs because they know more than you and can help you. I can’t tell you how many times a tech has saved my butt already.
  • ASK QUESTIONS. I already said that, but I feel that it is the most important for me right now.

I wrote this post about the transition before I graduated nursing school. It talks about some of the barriers new grads have with adapting to their new role. I re-read it today from a new perspective and thought it was really interesting. I am most definitely in that “first 3-4 months” where the grad nurse feels anxiety and self-doubt in the new role of a registered nurse.

I also grabbed this pocket guide called Emergency & Critical Care Pocket Guide. It’s a cute little flipbook that fits in any of my scrub pockets. It has basic information about common emergencies, ACLS charts, medication compatibilities, and more! I love being able to just grab it and learn something new.

Check out my previous post about essential emergency room supplies. Not much has changed about what I brought during nursing school versus what I bring to work now!

I also highly, highly recommend Hoka One One shoes. Listen, y’all. I had constant foot and back pain during and after my clinicals in nursing school. These shoes were recommended to me while I was in school, but I couldn’t afford them. After I got my first big girl paycheck, I ordered these shoes, and I feel like I am walking on a cloud. My pain has decreased and I can last much longer without feeling pins and needles.

Save up some money, buy some good nursing shoes and compression socks, and save your back and feet. You’ll thank me later!

Long story short, ER nursing has been a wild ride so far. I could go on and on. The bottom line is, if you are going straight from nursing school to the ED, get ready! It’s a lot. I’m only three weeks in, so please take anything I say here with a grain of salt. Not everyone will have the same experiences and I am not trying to portray that I am an expert.

Happy nursing!

Skyanne, BSN, RN


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The Transition – Nursing Student to New Grad

As I countdown the days until graduation, and even more so count down the days until I take the state boards, the mix of nervousness and excitement running through my veins is increasing at an exponential rate. I am beyond thrilled that I accepted my dream residency position at a level one trauma center. I’m having nightmares about the NCLEX and I lay awake at night fantasizing about what my life is going to be like in six months.

I know it’s been a while since I’ve posted, but I wanted to talk about something that I feel is extremely important, but neglected in the nursing programs. I want to talk about the transition. I came across an article in the Nurse Education in Practice journal from 2016 written by Jennifer Ortiz. It talks about professional confidence during the first year after graduation and the common setbacks that graduate nurses experience.

Transition Theory

There is a theoretical framework for the phenomenon that new grad nurses experience. To keep it short and sweet –

Doing: First 3-4 months – The grad nurse feels anxiety and self-doubt in the new role of a registered nurse.

Being: Next 4-5 months – Competency is increasing, but self-doubt and anxiety continue as the transition between dependence to independence solidifies.

Knowing: Final 8-12 months – The new grad has established him or herself as a professional and feels like a contributing member of the field.

I don’t know about you, but knowing that these stages have been studied and written about makes me feel better that soon I will be sharing these feelings with my colleagues.

Communication

Ortiz found that a huge lack in nursing programs is communication with other healthcare providers. In my school clinicals, I seldom interact with doctors, and I was never given the opportunity to give report or SBAR for a change in condition or critical lab result. The only experience I have with this is through the nursing internship that I applied for. Only a handful of students from my school participated in an internship; it was not a regular part of the baccalaureate program.

I have about 70 hours of clinical left for nursing school (out of almost 900), and each time I have offered or asked to pick up the phone and page the mid-level, pharmacist, or respiratory therapist, I was rejected with, “no, I need to do it,” by my preceptor. Many of those times, I was fully prepared and confident to deliver a concise SBAR. I am not bashing clinical preceptors. They need to protect their license and I fully understand that, but as Ortiz mentions in the study, “new graduates nurses recounted many difficult experiences which involved communicating with other members of the healthcare team,” even after six months.

If you are a nursing student reading this, I encourage you to elicit the help of your instructors to be more involved in multi-disciplinary communication. I regret not speaking up for myself more often. Although we practice communication in lab and with each other, I am not 100% confident in this skill.



Mistakes and Errors

Another challenge reported in the Ortiz study that has “a negative effect on professional confidence” is the occurence of mistakes. I already feel guilty for making small mistakes, like leaving too many air bubbles after priming IV tubing, or grabbing the wrong size Foley kit for my patient as a student, so I can’t imagine having a license and making larger errors. Throughout nursing school, they nearly tattoo the rights of medication administration on our foreheads, yet we always hear stories about lethal medication errors.

The fear is real. Will I ever make a mistake that results in a sentinel event? If I am being completely transparent, I’m a major people-pleaser. Years of retail experience toughened me up, but some days I feel like a failure if one little thing goes wrong. I’d like to think that I would never make a huge mistake, but it would definitely dampen my professional confidence.

One time in clinical, I put a dirty pillow in the wrong place, and my preceptor reprimanded me in front of a patient. I felt humiliated! I wanted to go home after that, and the relationship between that preceptor and I was effectively ruined.

I hope that I have a preceptor who stays on the positive side and encourages learning instead of punishment. I hope that my preceptor encourages autonomy early in the game. If you are a new grad or a preceptor of a new grad, I would love to hear your feedback on communication and errors!


Ortiz, J. (2016). New graduate nurses experiences about lack of professional confidence. Nurse Education in Practice19, 19–24. doi: 10.1016/j.nepr.2016.04.001

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