Top Tips for a New Grad Emergency Department Nurse

Top Tips for a New Grad Emergency Department Nurse

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emergency department nurse

**This is a guest post, written by Lynn Sayre Visser, MSN, RN, CEN, CPEN, CLNC, PHN who is a registered nurse with over twenty-five years of diverse experience including pre-hospital care, emergency department, intensive care unit, post-anesthesia care unit, and organ procurement. Ms. Visser is the author of Rapid Access Guide for Triage and Emergency Nurses: Chief Complaints with High Risk Presentations and Fast Facts for the Triage Nurse: An Orientation and Care Guide in a Nutshell, which was awarded third place in the 2015 American Journal of Nursing Book of the Year Awards in the Critical Care-Emergency category. The Fast Facts book is in its second edition which offers continuing education contact hours!  This book is available in the United Kingdom under the title Essentials for the Triage Nurse. Thank you Lynn for offering your expertise to newbies! 

Also, please note that this post is MASSIVE. There are tons of headers if you are looking for something specific, but all of the information is essential to newbies in the ED.  Lynn discusses everything from triage to EMTALA, to ED specific certifications and professional development.  So get cozy, grab some coffee, and get ready to learn all things ED!

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Welcome to the Exciting World of an Emergency Department Nurse!

You are embarking on an incredible journey. Working in the emergency department (ED) brings about every emotion you can possibly imagine. The highs of successfully delivering a healthy newborn in the ambulance bay, having a man who was under CPR sit up and ask you what happened and then reunite with his wife, and the patient who returns to the ED to tell you that you saved their life. The low’s come when you overlook subtle signs of intimate partner violence and then later learn the person died, share in the tears of a woman who delivered a stillborn baby at full term or transfer a teenager to the intensive care unit who you suspect is brain dead.

The ED is like no other unit. In essence, ED nurses are the jack of all trades and master of none. You will find that most ED nurses know a little bit about everything, but only sometimes know all the detailed ins and outs of specific conditions.

Clinical Tips and Guidance

 Goal of the Emergency Department

Practicing as an emergency nurse is much different than working on the hospital floor or other acute care areas. The goal in the ED is to identify and stabilize life-threatening emergencies and to provide quality care to ill or injured patients. The diversity of clinical conditions is unfounded. Some days you may feel like you are putting band aids on much larger human challenges, as we cannot solve lifestyle and humanitarian issues in a short ED stay. However, we can take a few minutes to provide as many resources as possible before sending a patient on their way.

Orientation in the Emergency Department

The orientation can vary significantly depending on where you accept employment. A common length of orientation may be between 4 months to a year. ED nurse residency programs do exist so seek them out.

Regardless of where you end up, you must advocate for yourself. This is your orientation. You will never get this time back. Aim to be exposed to as many experiences as possible. Adding a multitude of clinical presentations and procedures to your backpack of experience will benefit you tremendously once working on your own. When you are on orientation (or even within your first two years), saying “I don’t know how to do that” or “I’ve never seen that before, let me watch” is expected. Absorb those opportunities like a sponge.

The Emergency Nurses Association (ENA) is the authoritative body of emergency nursing in the United States. Check out the ENA’s position regarding ED orientation.

Develop a “Book of Brains”

Begin to develop what I call “The Book of Brains” while on orientation. This book can be a hand-held book or even a notes section on your phone (if phones are allowed for use where you’re working) carefully organized into medications, procedures, pediatrics, trauma, and random tips (at a minimum). You will find the categories that work best for you depending on your individual needs. The ED sees a variety of high-risk low-frequency presentations which means when you need to know what to do there is no time to waste.

The low frequency of seeing some conditions makes it hard to remember the required skills when you need them. Writing notes about the ins and outs of your facility-specific equipment can be helpful. Include the steps to setting up the equipment. For example, when setting up for central venous pressure monitoring, what are the steps to prepare the line, what ports do you flush and in what order, etc. Every person’s needs will be different depending on the types of patients seen within a specific geographical area. Collecting the inserts within packaging helps in reviewing the manufacturer recommendations and creates a more thorough note card for your book. In time, the Book of Brains will become not only a resource for you but will create you into a “go to” person and resource for others.

Checking Off the List of “Must-Have” Items for Work

  • Comfortable, waterproof shoes – yes, blood, vomit etc. may end up on them
    • Kati’s favorite nursing shoe (comes in many colors/options):
  • Compression stockings – more than likely, you will be on the move all shift long
    • Kati’s favorite compression socks (comes in many colors/options): 
  • Stethoscope
    • Kati’s favorite stethoscope: 
  • Trauma shears for cutting off clothes, bandages etc.
  • Hemostats for tough IV hubs and ports
  • Roll of IV tape
  • Name badge
  • Index card – to write down things you will look up when you get home
  • Your “Book of Brains”

Tips About Attire

Remember, first impressions are lasting impressions for both your patients and their family members as well as your co-workers. Wear nicely fitting scrubs, compression hose, clean shoes, and if you have long hair, pull your hair back.

A tip about your legs…if you don’t want jagged blue lines (also known as varicose veins) running down your leg, wearing compression hose is highly suggested. If you are in your twenties when you start your career this will be hard for you to understand the importance of this suggestion…but trust me on this…if you choose to wear compression hose, you’ll thank me for this advice twenty years from now (accepting your gratitude now).

A tip about shoes… Most ED nurses complain of foot pain at some point as the walking (almost running) in the ED is endless. Consider having two different pairs of quality shoes and rotate them either half way through your shift or every other shift. Rotating shoes gives any painful areas a break the following day and will hopefully help your foot health.

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Understanding the Triage Zone

What the heck is triage? The word triage comes from the French verb “trier” which means “to sort”. The role of the triage nurse or triage nurses (more than one often in larger facilities) is to determine:

  • Sick versus not sick
  • How long the patient can wait for medical care
  • What area of the department is most appropriate for the patient (trauma room, emergency department bed, FastTrack etc…)

Triage is often referred to as the area out near the waiting room. What is important to understand is that triage can happen anywhere at any time, even in the ambulance bay. Triage is a process, not a place. Larger facilities often have an internal triage area as well, that ambulance crews and their patients may pass through to obtain an initial evaluation that determines the best destination within the emergency department.

Most facilities use a 5-level acuity scale system. What do these levels mean?

  • Level 1 = Resuscitation
  • Level 2 = Emergent
  • Level 3 = Urgent
  • Level 4 =Semi-urgent
  • Level 5 = Non-urgent

To truly understand triage, you need a comprehensive training that encompasses classroom didactic as well as time with a preceptor at triage.

One question to ask during orientation is what type of triage system is used at your facility. The most commonly used triage leveling systems include:

  • Emergency Severity Index (ESI)
  • Canadian Triage Acuity Scale (CTAS)
  • Manchester
  • Australasian

Knowing what triage system is used will allow you time to begin to research and understand the system even before you formally begin to use it.

ESI is one triage system frequently used. If this is what you will use, take the time to order a free book and DVD from the Agency for Healthcare Quality and Research titled Emergency Severity Index, Version 4.

Additionally, the  AWHONN has created the Maternal Fetal Triage Index (MFTI) that covers triage of the pregnant woman during all gestational ages.  This algorithm was modeled after ESI. Understanding the MFTI guidelines will give you a greater understanding of concerning signs and symptoms in the pregnant patient.  Online training to further understand the MFTI is available at AWHONN for a small fee.

Deciphering the Medical Provider in the Triage Zone

In some EDs, you may find the utilization of a medical provider working in triage. What does this mean? In essence, this physician, nurse practitioner, or physician’s assistant aids in the flow of the ED by performing a quick assessment and initiating patient orders while the patient often waits in the ED lobby. In some cases, the physician can discharge the patient straight from triage, saving the patient a lengthy wait time while simultaneously reducing ED congestion.

Recognizing Potential Legal Issues

The ED is a high liability area so documentation is key as well as understanding the Emergency Medical Treatment and Active Labor Act (EMTALA). Every dedicated ED that receives Medicare funding is held to EMTALA standards. An EMTALA violation results in a $50,000 fine.

EMTALA states the following:

  • Every patient that presents to the ED receive a Medical Screening Exam (MSE) to rule out an Emergency Medical Condition (EMC); this includes a woman in active labor.
  • Necessary and stabilizing medical treatment is provided.
  • Transfer to a facility with a higher level of care if deemed necessary.
  • Care is provided regardless of the ability to pay.

To avoid an EMTALA violation, never…

  • Send an ambulance that arrives into the ambulance bay (or anywhere on hospital property) off hospital property without an MSE performed by a person qualified to do so (this person would typically be a physician, or depending on facility rules sometimes a physician assistant or nurse practitioner).
  • Fail to respond to a patient who requires assistance and is located within 250 yards of the building.
  • Delay treatment while inquiring about insurance coverage or payment.

Centers for Medicare and Medicaid Services. (2017). Emergency Medical Treatment and Active Labor Act. Retrieved March 16, 2017.

These concepts are not easy even for some experienced ED nurses. Do your best to be proactive in understanding EMTALA and MSE and inquire further about this content during your orientation. You do not want to be the cause of the $50,000 fine.

Surviving the ED Transition

Accept it now. Likely your entire first year in the ED will be flooded with an explosion of emotions. Some days you may pat yourself on the back feeling rewarded by the knowledge you gained during your sleepless nights of nursing school. Other days (or nights) you may be completely humbled by all that you don’t know.

The more you see in the ED, the more you will realize how little you do know. What is critical is that you know when to ask for help from a colleague, when to consult with your charge nurse, or when to ask for a teaching moment with a physician. The scariest nurses in the ED are the ones who think they know it all. None of us do.

Recognizing Danger, Danger: Red Flag Signs and Symptoms

One of the many fun parts of working in the ED is putting the pieces of the clinical assessment and patient, family, or bystander story together and attempting to find the specific diagnosis while in the ED. Sometimes you may not know how to put all the piece together, but what you can know even as a newer nurse, are red flag findings that could potentially make the patient a high acuity level (typically a level 1 or level 2).

In the books Rapid Access Guide for Triage and Emergency Nurses: Chief Complaints with High Risk Presentations and Fast Facts for the Triage Nurse: An Orientation and Care Guide, red flag findings are listed by body system. You may find similar lists in other books, but I’m not sure where else to send you. When you do find these lists, write them down, add them to your “Book of Brains”, or memorize them. You always need to correlate the clinical findings with the story, but more often than not, the red flag findings should alert you to notify the physician in a timely manner.

Receiving Nurse-to-Nurse Report

Whether receiving a report from an ambulance crew, another nurse, or performing the initial triage as the patient walks into the department, think of yourself as a detective. Your job is to connect the dots between the story told and the clinical signs and symptoms. Listen to every detail provided. Sometimes the details that seem meaningless end up being the subtle clues needed to get the right diagnosis. Use your senses…your hearing, sight, sound, smell, and touch.

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Nurse-to nurse bedside report is the standard of care. Watch as many different nurses as possible take report and examine what they use for a report sheet and how they organize their “to do” lists. Then develop a customized report sheet to see the most important information with a quick glance.

When the report is given consider what you need to do for the patient and why you’re doing what. Ask the nurse going off shift for clarification or an explanation if you don’t understand “the why”. Refraining from asking a question because you feel it’s a silly question or something you should know will only serve as a disservice to the patient.  Inquire, inquire, inquire.  I cannot emphasize this enough.

Refraining from Judgment and Avoiding Compassion Fatigue and Burnout

If you are not cautious, judging patients within the ED can easily become part of you. The volume of repeat patients coupled with crisis after crisis results in staff coping via humor and often later coping via burnout. Judgment suits no purpose. Don’t let yourself become jaded. This statement is easier said than done if you are not astutely aware of this potential. To help avoid compassion fatigue and burnout, instill these tips in everyday clinical practice…

  • See every patient as a person; a mother, father, sister, brother, uncle, aunt, grandparent etc…
  • Remember that most of the time, a patient presenting is experiencing their own emergency. The situation may not be an emergency in your eyes, but it is in theirs.
  • Refrain from adding your own commentary or thoughts about the patient in report as this wastes time and serves no purpose. What nurse wants to start their shift poisoned by your negative?
  • Don’t work too much overtime. Overtime increases the opportunity for burnout. No paycheck is worth lowering your standard of care because you are tired and irritable.

Take time for self-care on a regular basis…

  • Exercise regularly
  • Create regular sleep habits
  • Learn something new (i.e. meditation, painting, dancing)
  • Get out into nature
  • Use your vacation time

Remember: Caring for and taking the time to rejuvenate yourself is essential in this line of work.

Assessing Your Patients

Every patient needs an assessment, but how much of an assessment do they require? Focused assessments are the name of the game in the ED. Learning to what degree of assessment an ED patient requires takes time. Use your critical thinking skills. Maybe a person is complaining of pain and swelling of both feet (no injury is reported). Will you only assess the feet? No, of course not! You certainly need to evaluate heart and lung function as well.

Be patient with yourself and be open to feedback from others. Lots of critical thinking is involved in the ED in weeding out the important parts of the patient story and determining what body systems really need a thorough exam. For resuscitation and emergent patients, a quick full body assessment should be completed as often the diagnosis is unknown and documentation of the patient baseline on arrival to the ED becomes vital to trend changes during the hospital admission.

You will see tremendous variation in the extent of physical assessments completed in the ED. Giving you a black and white system to follow is impossible. Remember: You are the patient advocate. Use your critical thinking and assess accordingly.

Determining When a Patient Should Completely Undress

You will likely find that the extent of undressing patients in the ED varies among facilities, nursing staff, and which physician is on duty. Judgment needs to be used on a case by case basis. A simple laceration to a finger certainly does not need to be fully undressed, yet a patient with diabetes regardless of their complaint would likely benefit from you looking at their skin. Sometimes the septic leg is found under the socks, or the evidence of child abuse, elder abuse, or intimate partner violence is under the shirt. If you don’t look for clues, chances are you will never find them. Follow your instincts and follow your facility policies and procedures. Follow your instincts as well as your facility policies and procedures.Most importantly, always aim to do the right thing.

Taking Over a Full Patient Assignment

Every shift in the ED will be completely different, and you will need to constantly prioritize and reprioritize as the shift goes on. Following the nurse-to-nurse report, a system that has worked for me for years is to follow a few steps. This content will not necessarily apply to all nurses. If you are working in an ED that routinely performs bedside report, you can likely skip to the 5th bullet point regarding performing a quick assessment. However, if you find yourself thrown in without the benefit of a bedside report, you will have some tips of where to start.

  • Visualize each patient while you walk by their room. Evaluate from a distance that the Airway, Breathing, Circulation and Neurological status appear intact (or any significant issues have been addressed already). If you have completed a bedside report, and no urgent needs are pending, enter the room of the sickest patient first and then proceed to the other patients.
  • Introduce yourself when you enter the room. What patient wants you caring for them intimately while not even knowing your name? That would be no one. I repeat, introduce yourself always.
  • Acknowledge any visitors in the room and identify their relationship to the patient (yes, on occasion you may meet the mistress…do not make assumptions)
  • Look around the room. Get a visual of everything going on with the patient.
  • Assess the patient, and review orders.
  • Implement any brief orders and move on. If you start taking care of every little thing that needs to be completed for your patient before moving onto the next patient, you may never see your other patients before they get taken to X-ray, ultrasound or somewhere else. What an awkward situation when one of your patients deteriorates while out of the department and you cannot report on their baseline. Food for thought.
  • Evaluate vital signs, cardiac monitor, ventilator settings, drip rates, any tubes/lines, foley catheter and so on. If this was not completed during the report, confirm that any kind of machine settings are as indicated in the report (i.e. chest tube suction etc.)
  • Prioritize tasks that need to be completed for patients.
  • Reassess after completing orders or if the patient condition changes

Keeping the Patient and Visitors Updated

Lots of waiting takes place in the ED which can be highly frustrating for patients and their visitors. While some waiting is within your control,  other waiting is not. For example, often in trauma facilities, when a trauma rolls through the door, most if not all other patients requiring CT scans and X-rays experience new delays. The trauma patient always takes precedence.

  • The best way to keep on good terms (hopefully) with your patient and their visitors is to keep them updated on what you’re waiting for. You can let them know “All tests are back but one last result that tends to take a bit longer to run” or “As soon as the trauma patient is out of CT scan you should be next.”

Communicate with your patient and their visitors so they know you are working for them, that you are doing your best to get them the answers they are looking for, and that you are continuing to monitor for their results. Assure them you will follow up with their ED physician (NP or PA) as soon as the results are all back. Keeping patients updated on timeframes, even if you don’t have all the results or answers, can change the entire experience for both you and the patient.

Identifying the Conditions that Require Time-Sensitive Treatment

A number of medical conditions exist that have associated treatment timeframes. When these timeframe goals are met, the patient will likely obtain the best medical outcome. Several of these conditions are known as being national initiatives identified as core measures. Core measures that are specifically pertinent to the ED include:

  • Acute Myocardial Infarction
  • Stroke
  • Pneumonia
  • Sepsis (not officially a core measure but imperative you are familiar with this)

Since guidelines tend to change, you should seek out the details of the specific timeframes required for each condition, national standards of care, as well as reference your facility policies. If you are seeking an ED job, this content is good to review prior to an interview. Remember: Core measures are time-sensitive conditions that you want to act on appropriately.

Calling in Resources

Most major facilities have other departments and resources that you can connect with when questions arise. Do you have a rare blood draw and you need to know what color blood tube to use? Consult with lab. Cross-checking with the lab before obtaining the sample will prevent the need for another needle stick saving the patient frustration and you time.

Do you have questions about a medication order or need help verifying a pediatric drug calculation? Call the pharmacist. Other experts who may help you with infrequently performed procedures or troubleshooting include the Intensive Care Unit nurses, Rapid Response Team, stroke nurse, or respiratory therapy. Resources are available (or will become available), but you need to ask for them. You should never feel alone.

Collaborating with the Medical Team and Other Staff

Relationships, no matter where you work, are key. Take the time to get to know your colleagues. Ask about their families or what they do outside of work. Consider asking the individual physicians you’re working with how they like the room set up when they enter, preferences of how to lay out a suture set up, materials for a gynecological exam etc.  You will find some physicians want the stool on a certain side of the bed. Can the physician move the stool on their own? Sure! But if you can make his or her day a little easier, why not? The little things often make a difference and show you care about your colleagues.

Say “hello” and “thank you” to everyone. Remember every staff member you come in contact with from the medics, environmental services staff, security team, radiology technicians and so on are a potential resource of knowledge, friendship, comradery, and support. You will build on those relationships in time. Remember: Say “hello” to everyone who passes you and say “thank you” anytime the littlest gesture is done to help you.

Scribes in the ED

Some facilities use “scribes” who assist the MD, NP, PA with documentation.  Many of these scribes are aspiring medical students or are testing their interest in the medical field.  At times, the scribes can provide you with invaluable insight as to the direction the medical provider is taking for the patient with testing and medical care.  In my personal experience working in facilities with scribes, the scribe could also become an added barrier between the nurse and medical provider if you let it.  Take the time to connect personally with the medical team also caring for your patient. Direct communication among the staff caring for the patient is always ideal.

Giving Report Upon Admission

Find a system that works for you and be consistent in how you deliver the report. Anything you do in a standardized way (keeping patient needs in mind first always) will become a habit. Be sure that systemized way is developed to be a high-level report delivery. SBAR is the standard of care for a report and includes:

  • S = Situation
  • B = Background
  • A = Assessment
  • R = Recommendation

Following the SBAR format provides clear insight into the patient course of care while in the ED. Some facilities will have report sheets to complete while others will not. As you are learning to become more confident in giving the report, you will likely benefit from writing some details down of what you plan to say. Do not be afraid to let the other floor know you are new. Ask them to hold their questions until the end of the report. This practice will help you stay more focused. Ask for feedback. Practice, practice, practice.

Transporting a Patient Upon Admission

When preparing to transport a patient for hospital admission, consider the following:

  • Initiating the first dose of antibiotics if ordered
  • Medicating the patient for pain (if indicated) prior to transport as inpatient floors are often not equipped to deliver medication immediately
  • Transporting a patient on a cardiac monitor (check your facility policies), if they will be monitored upon admission
  • Bringing an emergency medication transport box when moving unstable patients anywhere out of the department (yes, patients like to crash in the elevator)
  • Gathering a co-worker to transport an unstable patient with you (not solely due to lines etc. but rather it’s very challenging to swiftly move a crashing patient on your own, start CPR etc.)
  • Packaging patient belongings in a bag before leaving the department (and bring the bag with you!)

Discharging Patients: The Down and Dirty

The time of discharge can be a time of high liability exposure to both you as an individual and the facility, thus creating an adequate visual image of the patient condition at discharge through your documentation is essential. This time frame is when you should review the chart one last time to be sure you have documented the care delivered. One approach to documenting the discharge note is to go back to the chief complaint that was elicited when the patient arrived (also consider other complaints noted during the visit) and establish a clear picture of the patient presentation following treatment. At a minimum, you should document:

  • Level of consciousness
  • A full set of vital signs
  • Skin signs
  • Readdress the chief complaint (or complaints), and the condition of the patient at discharge

The patient will benefit from leaving the facility with written discharge instructions that include:

  • Information about their diagnosis
  • Recommended post-care instructions
  • Follow-up information with appropriate telephone numbers and contacts
  • Any supplies required for the patient at home (i.e. urine strainer, crutches etc…)

If a patient has received sedation or any medications that impair judgment, documenting that you informed the patient not to drive or operate any heavy machinery is critical. Inquire with the medical provider as to when the patient can re-engage in such activities. If the patient is leaving the ED before that timeframe, ensure they have an escort for a safe ride home.

 

Clinical Resources

Policies and Procedures

Study your facility policies and procedures. You will be held to these standards. Knowing what is expected will help you succeed. Sure, you won’t remember everything there is to know, but knowing what policies exist and where to find these resources when you need to reference one is essential.

Books

A number of excellent books exist on the market for the newer ED nurse. These are my favorites…

Fast Facts for the ER Nurse, Third Edition: Emergency Department Orientation in a NutshellFast Facts for the ER Nurse, Third Edition: Emergency Department Orientation in a NutshellFast Facts for the ER Nurse, Third Edition: Emergency Department Orientation in a NutshellFast Facts for the Triage Nurse, Second Edition: An Orientation and Care GuideFast Facts for the Triage Nurse, Second Edition: An Orientation and Care GuideFast Facts for the Triage Nurse, Second Edition: An Orientation and Care GuideFast Facts for the Radiology Nurse: An Orientation and Nursing Care Guide in a Nutshell: An Orientation and Nursing Care Guide in a Nutshell (Volume 1)Fast Facts for the Radiology Nurse: An Orientation and Nursing Care Guide in a Nutshell: An Orientation and Nursing Care Guide in a Nutshell (Volume 1)Fast Facts for the Radiology Nurse: An Orientation and Nursing Care Guide in a Nutshell: An Orientation and Nursing Care Guide in a Nutshell (Volume 1)Sheehy's Emergency Nursing: Principles and Practice, 6th EditionSheehy’s Emergency Nursing: Principles and Practice, 6th EditionSheehy's Emergency Nursing: Principles and Practice, 6th EditionSheehy's Manual of Emergency Care, 7e by ENA (2012-03-15)Sheehy’s Manual of Emergency Care, 7e by ENA (2012-03-15)Sheehy's Manual of Emergency Care, 7e by ENA (2012-03-15)A Daybook for Beginning NursesA Daybook for Beginning NursesA Daybook for Beginning Nurses

In the interest of full disclosure, I co-authored Rapid Access Guide for Triage and Emergency Nurses and  Fast Facts for the Triage Nurse. I do not have any financial interest in these books or any of the other products recommended.  Fast Facts for the Triage Nurse is a triage specific book gives you an understanding of the front-end inner workings of the ED along with content that correlates with each body system.  Even if you aren’t working in triage yet, understanding what is going on at triage and in the waiting room is important even as a newer ED nurse. The Emergency Nurses Association recommends a minimum of one year of experience before working in the triage area (though some facilities will send you to triage sooner and others will wait until you have two years of experience). However, understand that you really begin triaging on day one as ambulance patients are placed into a room. Lots of content is covered that will also help you in caring for your everyday ED patients.

The Second Edition of Fast Facts for the Triage Nurse provides expanded content that includes new chapters on active shooter/active violence, emergency management when disaster strikes, pain management, triage competency, and endocrine emergencies.  Additionally, continuing education contact hours are offered with the book so you can knock out learning and renewing your nursing license all at once!

Rapid Access Guide for Triage and Emergency Nurses: Chief Complaints with High Risk Presentations focuses on a wide array of patient chief complaints and helps you sort through essential first-line versus second-line questions, assessment, and interventions that help you determine the patient’s level of urgency.  Considerations for pediatric and older adult populations are covered, along with pages of other quick reference information, and there are even blank pages to add your own nuggets of information. Both books cover “red flag findings” that you do not want to miss!

I am also recommending Fast Facts for the Radiology Nurse and A Daybook for Beginning Nurses each of which I have contributed to in a very small way. Nonetheless, I can recommend these books wholeheartedly. Fast Facts for the Radiology Nurse gives the ED nurse an understanding of the radiology department and the many mysterious procedures that take place in that department. A Daybook for Beginning Nurses is filled with 365 days of practical and inspirational quotes and provides empty page lines for quick journaling. I highly recommend you journal your first-year as a nurse (and then keep going).

The ER-specific books are full of a wealth of information too. Fast Facts for the ER Nurse covers information in a quick, easy to read format. The two Sheehy’s books are more like textbook reading but will provide you with the most detailed understanding of clinical conditions.

Apps

The number of Apps on the market these days is endless so you will need to find what works best for you. Some facilities will not allow for the use of smartphones on the unit at all, others build helpful Apps into their computer systems, while some organizations allow for referencing medical information via smartphones. In polling ED nurses, here are some of the favorites:

  • Davis’s Drug Guide
  • Medscape
  • Nursing Drug Reference by Mosby
  • Pediatric Quick Reference
  • Pedi Quick Calc
  • Pedi Stat by QxMD Medical Software
  • RN Nursing Essentials by Informed Publishing
  • Tidy Resus – code timer/and metronome

Professional Growth

Professional Memberships

Consider joining ENA early in your career (even before you obtain a job is an option too) as this membership will give you access to free continuing education units, professional journals like the Journal of Emergency Nursing and ENA Connection, and will open opportunities for networking as well as scholarships if you choose to advance your degree. Content in the emergency nursing journals will keep you current in understanding the challenges faced by EDs and the research that is influencing standards of care and ultimately the practice of emergency nursing. In addition, you gain access to ENA Connect, an online forum where you can ask questions of other ENA members. ENA members are always willing to help fellow ENA members.

The Society of Trauma Nurses aims to provide optimal trauma standards of care and is also a good professional membership to explore.

If you graduated as an inductee of Sigma Theta Tau International, maintain your good standing. This organization has members that are a wealth of information.

The American Nurses Association (ANA) is also a beneficial membership that brings you together with nurses practicing in many facets of healthcare.  ANA has a formalized mentoring program for both new nurses and up and coming as leaders in the industry. Online forums are available to help you stay connected and supported by and with others.

Courses/Certifications

Each facility varies as far as certification requirements. However, at a minimum you should consider obtaining:

  • Advanced Cardiac Life Support (ACLS)
  • Pediatric Advanced Life Support (PALS)

Other professional courses/certifications that may be required or to consider include:

  • Emergency Nurse Pediatric Course (ENPC)
  • Geriatric Emergency Nurse Education (GENE)
  • Mobile Intensive Care Nurse (MICN)
  • Trauma Nurse Core Course (TNCC)

More advanced courses are available as you progress in your ED career. As you gain experience, obtaining your national certifications in your area of practice is highly recommended. This demonstrates a commitment to the emergency nursing profession and is a demonstration of your knowledge base. These certifications include:

  • Certified Emergency Nurse (CEN)
  • Certified Flight Registered Nurse (CFRN)
  • Certified Transport Registered Nurse (CTRN)
  • Certified Pediatric Emergency Nurse (CPEN)
  • Trauma Certified Registered Nurse (TCRN)

The Board of Certification for Emergency Nursing, known as BCEN, is the accrediting body for these certifications. Requirements to sit for the exams can be found at https://bcen.org

Contact Hours

Obtaining contact hours is not only a professional responsibility but a personal responsibility to continue to learn and grow. Avoid taking the attitude about continuing education that “my employer doesn’t pay for it” (if that is the case). You are a professional. Take ownership of your education. Topics of courses that are invaluable for an ED nurse include:

  • Triage
  • Disaster
  • Active Shooter
  • Legal Issues
  • Documentation for Legal Purposes
  • Understanding Chronic Pain
  • Mental Health Issues
  • Pediatrics
  • Obstetrics
  • Anything related to Core Measures and so on

Embrace the ED Journey

Your progress as an ED nurse is in your hands. You can make the choice to be mediocre or you can make the choice to be the best you can be. If you’re reading this, I highly suspect you are passionate about being successful in your career. You’re off to a great start! Share your enthusiasm with those around you. Express to your co-workers how excited you are to learn. Ask nicely for “teaching moments” when the time is appropriate. Absorb every nugget of information that you can. Take time to reflect. Debrief with co-workers. Journal your experiences. Be patient with yourself. No matter what the stage of your journey, may the tips provided lessen your stress, give you direction, and help you grow as a nurse. Embrace the journey! I wish you all the best.

Emergency Department NurseLynn Sayre Visser, MSN, RN, CEN, CPEN, CLNC, PHN is a registered nurse with over twenty-five years of diverse experience including pre-hospital care, emergency department, intensive care unit, post-anesthesia care unit, and organ procurement. Ms. Visser is the co-author of the 2015 American Journal of Nursing Award Winning Book titled Fast Facts for the Triage Nurse which is currently in its second edition and Rapid Access Guide for Triage and Emergency Nurses: Chief Complaints With High Risk Presentations. Her contributions to emergency nursing have been recognized by her peers with a nomination for the prestigious Emergency Nurses Association Distinguished Certified Emergency Nurse Award. She believes education and mentoring are at the heart of unraveling the exceptional nurse within us and empowers nurses of all experience levels to chase their dreams and reach for their potential. You can connect with Lynn at [email protected] (she would love to hear from you) or with the Triage author team on Facebook at TriageRN or TriageRNs.

 

A few more resources

Kati here! I wanted to provide some additional helpful resources for the ED nurse.

Godspeed, new nurses!

 

Tips for New Grads in the ICU, Be Your Own Advocate

Tips for New Grads in the ICU, Be Your Own Advocate

This is a guest post.

The purpose of this episode is to offer tips and advice to new graduate RNs starting in an ICU.

All opinions in this post are that of the guest author and not those of their employer.

As a new grad in the ICU there is a learning curve. Learning to be your own advocate will help you learn things the way that is best for you.

 

This is part three in a 3 part series. Be sure to check out part one, New Grads in the ICU, Nurse Characteristics, and part 2, Tips for an ICU Nurse, Showing Initiative.

Melissa Stafford, BSN RN CCRN SCRN is the author, and will also be our featured guest nurse in Season 2 of the FreshRN Podcasts.

 Advice #4: Know yourself and be your own advocate

  • Learning style vs. teaching style: If I’m going to teach you how to knit me a scarf, how do you learn best? Can I just talk you through it? Do you want me to give you an article to read? Do you want to watch me do it? Or, do you need to hold the needles and do the stitches? Or… do you learn best with a combination of those things? Your learning style and my teaching style may be very different, so we should talk about that at the beginning. Or, best way you learn knitting may not be the best way to learn figure skating. Talk to your preceptor about things that are or are not working, that’s how you’ll learn to adapt to each other.
    • Know your limitations. Recognize what you don’t know. Nothing will kill your credibility quite like being the ‘know-it-all’. As a new grad, it will make you look dangerous. I would recommend you have regular conversations with your preceptor.
      • Example: Your post-op patient is becoming increasingly tachycardic.
        You: “My pt is tachycardic. I’m concerned they might have internal bleeding”.
        Preceptor: “Why do you think that? The patient has a fever.”
    • This would be your opportunity to show your critical thinking skills by reviewing the patient’s other vital signs (say a low BP), or your preceptor may direct you to check the patient’s lab work, or most recent dose of pain medication.
    • It takes time for your preceptor to validate your knowledge and technical skills. By allowing this natural progression, you will only improve your credibility among your peers, which will help demonstrate your independence.
  • Ask for help. This coincides with knowing your limitations. Asking for help is not always a weakness. Sometimes it can be a key strength in safe patient care. If you aren’t sure how to titrate your vasoactive drips on the new IV pump, or, if you need a refresher on how to perform trach care, ask. Your preceptor may want you to demonstrate what you do know, but this will help identify learning opportunities.
  • Find a mentor. This will likely NOT be your preceptor during orientation (but they will often become one after you are on your own). This person does not have to be the most experienced person. But, it should be someone who has experience in the unit who can offer a sounding board after a rough day, suggestions for your performance, or how to interact with your preceptor. This would be someone who is not grading your knowledge/technical skills, but someone focused more on personal and interpersonal development.
  • Own your orientation. Orientation is an extension of nursing school, without the formal grading. Use resources like textbooks, professional nursing organization references, or reputable internet sites to look up unfamiliar things (like disease processes) on your own time. Your preceptor and manager will appreciate your self-motivation to learn! Bonus: These notes will give you something to go back to when it comes back up again in the distant future.

Advice #5: Keep your orientation organized

There will be a lot of paperwork during orientation. You will be (or should be) exposed to many types of patients during orientation. The same goes for types of equipment (IVs, vents, monitors, pressure lines, etc.) You should keep notes on what you’ve experienced, what you’ve done well, and what you need help with. I hope you’ve got a preceptor helping with this one!

Advice #6: Organized routine is key

Whether it pertains to organizing orientation paperwork (as above) or to how you run your day, having an organized routine will help things run smoother. Below are some of my thoughts for starting out.

  • Assessments: Head to toe. Getting in a routing on what/how to assess your patients will help you master the patient assessment. Furthermore, good assessments are the foundation to success in critical care. This is how you will learn to recognize changes early. Technical skills are important, but your assessment skills are more so.
  • Report: Needs to be organized/streamlined whether giving or receiving. You should have a tool (whether self-developed or a borrowed) for report. It’ll help you organize your thoughts, ask questions, and plan your day. CAUTION: Do not regurgitate the report you received as the report you are giving someone else.
    • Receive report. I need to know why my patient is here and the most pressing issues. (WARNING: you will likely not receive every piece of information you need during report. For this reason, do not rely on word of mouth for your orders. Review the chart for active orders and current MD notes)
    • Assess the patient: Your eyes should go to the patient first, NOT the monitor. Seeing your patient is dusky and short of breath will tell you way more than an SpO2 of 94%. Same goes for an awake, chatty, pink healthy patient whose SpO2 is reading 52%.
    • Assess the monitor: Are the vitals normal? Anything I need to address urgently. (WARNING: check to be sure your alarms are set appropriately, both numeric values as well as sounds)
    • Assess IV meds: Look at what is actually hanging vs. what is programmed into the pump. Also, you should have enough fluids to get through the first couple of hours. If not, address promptly. The last thing you want to do is run out of Levophed while in the midst of starting your day.
    • Go from there. You decide when charting assessments, scheduled med administrations and the dozens of other nurse tasks will get done over the next 8-12hr shift.
    • Practical application: I start my day like this:
      • Receive report. I need to know why my patient is here and the most pressing issues. (WARNING: you will likely not receive every piece of information you need during report. For this reason, do not rely on word of mouth for your orders. Review the chart for active orders and current MD notes)
      • Assess the patient: Your eyes should go to the patient first, NOT the monitor. Seeing your patient is dusky and short of breath will tell you way more than an SpO2 of 94%. Same goes for an awake, chatty, pink healthy patient whose SpO2 is reading 52%.
      • Assess the monitor: Are the vitals normal? Anything I need to address urgently. (WARNING: check to be sure your alarms are set appropriately, both numeric values as well as sounds)
      • Assess IV meds: Look at what is actually hanging vs. what is programmed into the pump (my IV insulin story). Also, you should have enough fluids to get through the first couple of hours. If not, address promptly. The last thing you want to do is run out of Levophed while in the midst of starting your day.
      • Go from there. You decide when charting assessments, scheduled med administrations and the dozens of other nurse tasks will get done over the next 8-12hr shift.

Advice #7. Learn your alarms and use them to your advantage

There is a reason for every alarm. All alarms have to be answered promptly. Still, in an ICU there are often many alarms occurring simultaneously. It’s important that you learn to prioritize. For example, a V-fib alarm needs to be addressed before an occluded IV. Each alarm has a different sound, and therefore it is imperative that you to recognize the sounds.

Even better, use these alarms to your advantage. My favorite 2 alarms to utilize in this way are IV pump alarms and tube feeding pump alarms. On an IV pump, you can program the VTBI so that you know when one antibiotic is done and it’s time to hang another one. Or, use it to remind yourself half way through to make sure you have another bag of Levophed with plenty of time before it’s empty. Titrating your tube feeding rate to goal? Use the volume to trigger an alarm on the pump as a reminder when to turn up the rate.

Advice #8: You need downtime

Becoming a nurse is an exciting, but stressful time. Becoming a critical care nurse right out of school adds another layer to that stress. Learn to separate from the physical, mental, and emotional stress of work. You will have good days and bad days, both to varying extremes. Sometimes things don’t go your way, and sometimes is very hard to accept that. But, you cannot (and should not) be in orientation 24/7. Identify stress relievers, whether that’s exercising, bowling, painting, hanging out with friends, or shooting targets at a range. Do something fun! Home-work balance is important to your long-term success.

Bottom line: you will likely have some (or many) days where you think, “I can’t do this.. or what have I gotten myself into?” But rest assured that you can. It takes time, trial and error, and confidence in yourself to become a safe and competent ICU nurse.

Welcome to Critical Care Nursing!

  • Tips for New Grads in the ICUMelissa Stafford, BSN RN CCRN SCRN graduated from nursing school in 2000, and after a short time on a medical surgical floor transitioned to neuro critical care. During her career, she has precepted multiple nurses, taught classes ranging from neurological/neurosurgical specific subjects to general critical care medicine, been involved in shared governance and resides as chair for nursing peer review. She has received various recognition’s, including the Great 100 Nurses of North Carolina and DAISY Award. Melissa enjoys spending time with family, painting, watching sports, visiting the beach whenever possible, and vacationing at Disney World

ICU Skills Conference

Learn both hard and soft skills about ICU nursing care. From vasopressors to emotional support, this comprehensive ICU skills workshop covers topics applicable to every nurse working in critical care, as well as those sending patients to, or receiving patients from, intensive care.

Use code ICUskills for $20 off!

Tips for New Grads in the ICU, Showing Initiative

Tips for New Grads in the ICU, Showing Initiative

This is a guest post.

The purpose of this post is to offer tips and advice to new graduate RNs starting in an ICU.

All opinions in this post are that of the guest author and not those of their employer.

This three part series gives helpful tips for an ICU nurse. As a new graduate, the ICU can seem overwhelming, these tips will help you find your way.

Tips for an ICU Nurse
 

Advice #3: Show initiative

It develops rapport. Every single interaction with every single patient, family, nurse, doctor and other health care partner will be a learning opportunity. Seeking out learning opportunities shows your co-workers that you are engaged. There’s a patient getting a bedside trach or ICP bolt? Ask to be in the room and tell them you’ve never seen it before. Ask questions. Most doctors appreciate the new nurse who demonstrates the desire to learn.

RT can teach you about blood gases or lung sounds, or modes of the ventilator. PT can teach you the best way(s) to mobilize patients (a huge AACN initiative). OT can show you adaptive maneuvers to help the patient learn new ways for ADLs (like feeding themselves after a stroke). ST is not just about safe swallowing (though important)… they can teach you about other cognitive deficits and how to recognize them and help patients adapt. BE A SPONGE and soak up the opportunities. That being said, be careful not to over-extend yourself in any given shift.

Advice #4: Know yourself and be your own advocate. An important point in many ways.

  • Learning style vs. teaching style If I’m going to teach you how to knit me a scarf, how do you learn best? Can I just talk you through it? Do you want me to give you an article to read? Do you want to watch me do it? Or, do you need to hold the needles and do the stitches? Or… do you learn best with a combination of those things? Your learning style and my teaching style may be very different, so we should talk about that at the beginning. Or, best way you learn knitting may not be the best way to learn figure skating. Talk to your preceptor about things that are or are not working, that’s how you’ll learn to adapt to each other.
  • Know your limitations. Recognize what you don’t know. Nothing will kill your credibility quite like being the ‘know-it-all’. As a new grad, it will make you look dangerous. I would recommend you have regular conversations with your preceptor.
    • Example: Your post-op patient is becoming increasingly tachycardic.
    • You: “My patient is tachycardic. I’m concerned they might have internal bleeding”.
    • Preceptor: “Why do you think that? The patient has a fever.”
      • This would be your opportunity to show your critical thinking skills by reviewing the patient’s other vital signs (say a low BP), or your preceptor may direct you to check the patient’s lab work, or most recent dose of pain medication.
      • It takes time for your preceptor to validate your knowledge and technical skills. By allowing this natural progression, you will only improve your credibility among your peers, which will help demonstrate your independence.
  • Ask for help. This coincides with knowing your limitations. Asking for help is not always a weakness. Sometimes it can be a key strength in safe patient care. If you aren’t sure how to titrate your vasoactive drips on the new IV pump, or, if you need a refresher on how to perform trach care, ask. Your preceptor may want you to demonstrate what you do know, but this will help identify learning opportunities.
  • Find a mentor. This will likely NOT be your preceptor during orientation (but they will often become one after you are on your own). This person does not have to be the most experienced person. But, it should be someone who has experience in the unit who can offer a sounding board after a rough day, suggestions for your performance, or how to interact with your preceptor. This would be someone who is not grading your knowledge/technical skills, but someone focused more on personal and interpersonal development.
  • Own your orientation. Orientation is an extension of nursing school, without the formal grading. Use resources like textbooks, professional nursing organization references, or reputable internet sites to look up unfamiliar things (like disease processes) on your own time. Your preceptor and manager will appreciate your self-motivation to learn! Bonus: These notes will give you something to go back to when it comes back up again in the distant future.

You will more than likely come across many chances to use these tips; some will be easier to master than others. The ICU can be very intimidating, but remember that you are not any less valuable to the team. Everyone has something to bring to the table, and that includes you!

This is part two in a 3 part series. You can read part one, New Grads in the ICU, Nurse Characteristics and part 3, Be Your Own Advocate.

Melissa will also be our featured guest nurse in Season 2 of the FreshRN Podcasts.

Tips for New Grads in the ICUMelissa Stafford, BSN RN CCRN SCRN graduated from nursing school in 2000, and after a short time on a medical surgical floor transitioned to neuro critical care. During her career, she has precepted multiple nurses, taught classes ranging from neurological/neurosurgical specific subjects to general critical care medicine, been involved in shared governance and resides as chair for nursing peer review. She has received various recognition’s, including the Great 100 Nurses of North Carolina and DAISY Award. Melissa enjoys spending time with family, painting, watching sports, visiting the beach whenever possible, and vacationing at Disney World

ICU Skills Conference

Learn both hard and soft skills about ICU nursing care. From vasopressors to emotional support, this comprehensive ICU skills workshop covers topics applicable to every nurse working in critical care, as well as those sending patients to, or receiving patients from, intensive care.

Use code ICUskills for $20 off!

Tips for New Grads in the ICU, ICU Nurse Characteristics

Tips for New Grads in the ICU, ICU Nurse Characteristics

This is a guest post.

The purpose of this episode is to offer tips and advice to new graduate RNs starting in an ICU.

This post contains affiliate links.

All opinions in this post are that of the guest author and not those of their employer.

New Grads in the ICU may find themselves overwhelmed and feeling afraid. This guest post deals with tips for new grads in the ICU to help you acclimate.

In the beginning… Hopefully you did your homework by learning what to expect in a critical care unit. Bonus points for you if you had the opportunity to observe nurses in a critical care setting. Extra credit + Bonus points if you were able to do an extending preceptorship/internship during nursing school. Those students who did that will have the best idea of ICU reality.

Still, all is not lost if you didn’t have those opportunities. Or, even if you DID have these opportunities, reality as a student nurse is very different than reality as a credentialed nurse. Which leads to…

Come in with an open, actively engaged mind

You will have to pull together/brush up on every skill you learned in school and then add many more. Expect to be overwhelmed for a while. Seriously. A minimum of 6 months.

Be aware typical ICU Nurse Characteristics

  • Assertive – We have a reputation for being “bossy,” but there is more to that. We have to be advocates for our patients (or sometimes families). Sometimes we need to be more direct with doctors when the patient is showing early signs of decompensation. Maybe the doctor orders a chest x-ray for a patient who is short of breath and confused, but we think the patient may need a blood gas to check for hypoxia not detected by simple pulse oximetry. Or, a patient’s family expresses concerns regarding aggressive treatment when the patient had previously indicated they did not want “life support”, and you need to help the family communicate this to the MD.
  • Detail oriented – This is more than Type-A or control freak personality, although there really is no denying its presence. ICU nurses need to know their patients… their lab values, their x-ray results, what medicines the patient is on, their head-to-toe assessment. We need to know it all because it helps us anticipate complications and respond quickly.
  • Critical thinkers/problem solvers – Successful critical care nurses have a good grasp of pathophysiology. This helps us recognize early changes and anticipate/direct the necessary treatments.
  • Intense – Here is where I’d say the term “adrenaline junky” applies. Many critical care nurses thrive on challenging situations. We want the sickest patient with the most invasive lines. A code blue? Let’s go! (As long as it’s not our patient, whose AM assessment we still haven’t documented because there was too much stuff to do!)
  • Autonomous – We are self-directed, independent workers. We thrive on doing as much for our patients as we can (within our scope) BEFORE we have to call a doctor.

You will likely come across many nurses with these characteristics; some will be easier to interact with than others. Identify those with whom you feel comfortable and take the others with a grain of salt. We recognize that experienced nurses can be intimidating, but remember that does not make them any more or less valuable to the team than you. Everyone has something to bring to the table, and that includes you!

More resources for new ICU nurses

This is Part I in a 3-part series. Check out Part II, Tips for New Grads in the ICU: Showing Initiative and Part III, Tips for New Grads in the ICU: Be Your Own Advocate

Melissa is one of the co-hosts in Season 2 of the FreshRN Podcasts.

Become a member of the American Association of Critical Care Nurses (AACN) here.

   

Tips for New Grads in the ICUMelissa Stafford, BSN RN CCRN SCRN graduated from nursing school in 2000, and after a short time on a medical surgical floor transitioned to neuro critical care. During her career, she has precepted multiple nurses, taught classes ranging from neurological/neurosurgical specific subjects to general critical care medicine, been involved in shared governance and resides as chair for nursing peer review. She has received various recognition’s, including the Great 100 Nurses of North Carolina and DAISY Award. Melissa enjoys spending time with family, painting, watching sports, visiting the beach whenever possible, and vacationing at Disney World

ICU Skills Conference

Learn both hard and soft skills about ICU nursing care. From vasopressors to emotional support, this comprehensive ICU skills workshop covers topics applicable to every nurse working in critical care, as well as those sending patients to, or receiving patients from, intensive care.

Use code ICUskills for $20 off!

Understanding Alternative Medicine! Before Patients Ask to be Cupped like Michael Phelps

Understanding Alternative Medicine! Before Patients Ask to be Cupped like Michael Phelps

This is a guest post.
This post contains affiliate links.
For more information on my partnerships and affiliates, please see my disclaimers page (link in menu).

The closest that most hospitals get to alternative medicine is a TV channel for guided imagery. Understanding alternative medicine can help you as a nurse.

What? Your hospital doesn’t have a Traditional Chinese Medicine Practitioner for patients who need cupping, acupuncture, or herbs for dampness and wind? The closest that most hospitals get to alternative medicine is a TV channel for guided imagery. You know the one—it shows lush scenery as beautiful music plays to distract patients while a trembling nursing student with an IV needle learns to differentiate tendons from veins.

Understanding Alternative Medicine!

First of all, nurses need to realize that there is a wide spectrum from fraudulent to miraculous for this topic. Many CAM (complementary alternative medicine) modalities are validated by research but simply don’t fit into the fast pace of our conventional health system, while other approaches are heavily marketed but have little evidence of usefulness. For more on that, you’ll have to read the book The Grecian Garden: A Natural Path to Wellness. Public interest is exploding to the point that many multi-level-marketing companies are trying to jump on the natural health bandwagon–usually with inferior products. Which ones do you want the scoop on?

Branches of Alternative Medicine

It is true that there simply isn’t enough data for the health products lining the walls of grocery stores, and people are wasting billions of dollars yearly on supplements that only complicate their health problems. There is much more to natural health than keeping GNC in business, however. To simplify, CAM consists of natural products and various practices often blended together. These practices can be biologically-based therapies such as herbal medicine; mind-body therapies such as meditation; manipulative and body-based therapies such as Rolfing (focuses on the fascia); energy therapies such as therapeutic touch (everyone’s favorite nursing diagnosis); or systems of care such as Ayurvedic medicine (Hindu approach incorporating mind, body and spirit).

Research is sparsest for energy therapies, which use lasers and magnets and emphasize the avoidance of electromagnetic frequencies and radiation. Despite the difficulty in quantifying the effects of energy medicine, it is a system of care. Another popular system, homeopathy, is based on the philosophy that like cures like. It delivers extremely diluted substances to achieve healing. Naturopathy is based on the theory that diseases can be successfully treated or prevented without the use of drugs, by diet, exercise, and therapies such as massage.

On the opposite end of the spectrum from energy and homeopathic approaches is functional medicine. Although functional philosophy resembles CAM in its individualized approach, the treatment methods used in functional medicine vary from vitamin and herbal supplements to advanced genetic testing. Functional medicine may also incorporate unique treatments with conventional pharmaceuticals, such as long term IV antibiotics for chronic Lyme Disease. Despite successes in combining traditions, the differences in historical development, ideas and practice settings make it difficult to combine conventional medicine and CAM. It’s sort of like those yogurts with a handful of dying probiotics tossed in. It doesn’t taste as good as regular yogurt, and the bacteria population isn’t diverse or robust enough to actually change a health condition. And, you’ll still have to urgently visit the restroom exactly when all your patients gleefully press the call light.

Alternative Medicine Philosophy

CAM providers view symptoms as clues to underlying causes rather than problems to eradicate. This relates to working with the body to heal itself and finding root causes of illness. Even if taking an herb or nutritional supplement for headaches proves as efficacious as aspirin, a CAM provider may delve deeper into dietary and emotional issues rather than just recommending white willow bark.

Of greater concern than choosing natural products for artificial ones is the substitution of unproven therapies for effective ones. Nurses may perceive natural approaches to health with suspicion after caring for failed attempts at natural home births in the neonatal ICU or communicable, preventable diseases in the pediatric ICU. Because CAM systems are rarely effective in divisible portions (which would ignore their holistic philosophy), part of the problem is the attempt to take a Western approach. The quintessential example is substituting a homeopathic remedy for a vaccination. Although both homeopathic remedies and vaccines purport to contain tiny amounts of a toxin, they are not equivalent or even remotely comparable.
The CAM community also perceives problems with Western medicine. For example, the concept of masking symptoms of indigestion with pharmaceuticals rather than making dietary changes to address core issues is incompatible with CAM philosophy. Finding the line between empowering patients and depending on lifestyle changes to improve health, or relying on science and medicine to cure disease, requires critical thinking and an appreciation for biomedical ethics.

Now about that Patient…
Understanding how patients perceive both CAM and traditional healthcare improves nursing communication with all patients. Advocacy and empathy are most important, since CAM depends on patient empowerment and involvement in care. Also, any answer choice on the NCLEX that mentions advocacy or empathy is probably the correct answer. As nurses learn about CAM therapies, they should remain objective while providing the best care available for their patients. There probably isn’t a cupping policy at your hospital. That doesn’t mean you need to write one, or consult some obscure protocol to see if Phenergan is compatible with ginger essential oil. How do you deal with these issues at your hospital? I realize I haven’t defined all the terms I used in this nice chat we’ve had, so feel free to ask questions in the comments (such as, “Uh, so what works and is too late to get a refund for my magnetic energy bracelet?”).

alternative medicineNick Angelis, CRNA, MSN, is the author of How to Succeed in Anesthesia School (And RN, PA, or Med School) and regularly writes or presents continuing education articles on a variety of boring or fascinating topics. Thankfully, he also has a thing for fiction, non-fiction guides for students and clinicians, and satire closely resembling non-fiction. Nick works as a nurse anesthetist in the Florida Panhandle and enjoys playing several sports poorly. You can connect with him on Twitter or Instagram.

Melanie Angelis, MS CAM, is the author of The Grecian Garden: A Natural Path to Wellness and the owner of Nourished in Eden. Melanie began her career as a teacher, but after researching her way to health naturally from a variety of puzzling conditions, she pursued a Graduate Certificate in Holistic Nutrition and Masters of Science in Complementary and Alternative Medicine from American College of Healthcare Sciences. She offers educational workshops and works individually with clients to improve their health with many of the modalities mentioned in this article.

Sources:
Angelis M. “Therapy for Wellness.” In: The Grecian Garden: A Natural Path to Wellness. Pensacola, Fla.: Indigo River;2016:133-136.
Angelis N. CAM vs Traditional Medicine. Advance for Nurses. Retrieved from NursingAdvanceWeb.com

Assisted Suicide:  A Nurse’s Perspective

Assisted Suicide: A Nurse’s Perspective

Physician-Assisted Suicide_

This is a guest blog post written by fellow nurse author, Susan Allison-Dean, MSN RN.  This can be a pretty emotionally-charged topic and was interested to hear about her research during graduate school.  Check out her post below and please comment with your thoughts and if you’ve personally done research on the ethics of this!  Please, be respectful, professional, and appropriate with your responses as many have very strong beliefs and feelings about this topic.  

The issue of assisted suicide, otherwise known as active euthanasia, is hot in the news again. Earlier this month, California Governor Jerry Brown signed legislation to make assisted suicide legal. The California law will permit physicians to provide lethal prescriptions to mentally competent adults who have been diagnosed with a terminal illness and face the expectation that they will die within six months. Last year another Californian, 29-year-old Brittany Maynard, made headlines when she elected to move to Oregon, where assisted suicide is legal, to end her own life. Maynard had been diagnosed with terminal brain cancer and wanted to “die with dignity”. Governor Brown and Ms. Maynard made their decisions using the ethical principle of autonomy – the right to self-determine a course of action.

It was the principle of autonomy that led me to select active euthanasia as the focus of my graduate ethics paper back in the early 1990’s. If I were in a hopeless medical situation, I would want the ability to get out of it, I remember thinking back then. Our professor also required us to choose a health ethics topic that was current. Dr. Jack Kevorkian was all over the news for his efforts in offering patients assisted suicide. I admit, this was an added benefit, I thought.. there would be plenty of sources to put a literature review together. Unbeknownst to me, a classmate across the room chose the same topic, with the same thoughts.

Flash forward to the end of the semester when each of us presented our ethics topic. Much to my surprise, I found that after a rigorous review of the active euthanasia literature and the ethical principles involved in this topic, much to my surprise I concluded that I was not in favor of active euthanasia. It was the principle of utilitarianism – a theory that supports what is best for most people, which led me to this outcome. The utilitarianism theory states the value of the act is determined by its usefulness, with the main emphasis on the outcome or consequences. An issue of great concern cited in multiple ethical journals regarding active euthanasia is the slippery slope effect.

Once intentional killing begins, however well intended it may be initially, it opens the door for humans to extend this practice. Those who may be deemed a ‘burden’ to society may fall victim to non-voluntary or involuntary euthanasia. It may also unknowingly pressure people who are not well to feel they ‘should’ kill themselves. Ironically, the other student in my class came to the same conclusion.

During the course of our analysis of this topic, we both found that we were in favor of passive euthanasia. Passive euthanasia means that when a person can no longer naturally sustain himself or herself for whatever reason, they should be allowed the right to die a natural death. This incurs by actively removing, or withholding, life-sustaining equipment. An example of this is refusing or removing a feeding tube or ventilator. Passive euthanasia leaves the decision of death in the hands of a higher power-God, The Universe, Mother Nature, etc.

Ethical decisions are not easy because there is no ‘right’ answer. Nurses are often on the front lines of these difficult, emotionally charged situations. Understanding ethical principles and being active on ethical committees can help each nurse to understand why he or she comes to certain conclusions and respect those who come to conclusions that are different.

1413210650Susan Allison-Dean, MSN RN is a nurse who retired from traditional practice in 1999, after working 13 years as a Wound, Ostomy, Continence Clinical Nurse Specialist.  She has authored several clinical and horticulture articles and was a contributing author to the bestselling book, Touched By A Nurse.  She is passionate about the sea and loves exploring tropical islands.  She extends this passion by doing volunteer work benefitting dolphins and whales.  Sue splits her time between Armonk, New York and Cary, North Carolina, with her husband and English bulldog, Bubba. Check out her website here.

And please check out Susan’s two books!  Woo hoo!  Go nurse authors!  Clicking on the image will take you to Amazon to learn more.  

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