The Ultimate Resource for New Nurses – The FreshRN New Nurse Master Class
When I graduated from nursing school and passed boards, I was so excited to finally be a nurse. Only, I didn’t feel like a nurse. I felt alone. I felt like somehow everyone else knew exactly what they were doing and I was the only one who didn’t belong. I desperately wanted to sit down with an experienced nurse and chat about all of the ins and outs, the cool things to do and the not so cool things to do, and dive into what it’s really like at the bedside… not what my textbook says… what it’s really like.
I would have loved to ask that nurse on my unit I admired so much because she seemed to know the answer to everything, was calm and confident, and so smart, if she could meet me for coffee for about four hours every week during my orientation process. But, I have a feeling that would have fallen into the “not cool” category, right?
A little much? Yea, probably.
Even though I wanted to do that, I didn’t. I stepped out into the nursing wilderness alone and scared, unsure if I’d make it through.
From an intimidated bedside nurse to nurse educator
Well, that was back in 2010. Since then, I’ve worked med surg, step down, and neurocritical care. I’ve been a preceptor, mentor, charge nurse, and now I am an educator. Despite all of the experiences all these years later, those feelings of isolation, insecurity, fear, and loneliness are still palpable when I think back to when I was that fresh new nurse. I never forgot them.
As I started figuring things out at the bedside, I began jotting things down. You know, all those things I learned on the fly that I felt like I should have learned prior to being in the situation.
Well, the list kept growing.
How to call a surgeon at 0300… how to manage your time when everyone is doing just fine… normal post-op care… what physicians appreciate and what makes them cringe… what to do in a code when you have absolutely no idea what to do…
But, they’re not typical courses. While I appreciate theory and textbooks, those are tough to apply at the bedside when the real world of nursing doesn’t look like the textbook says it will. I was prepared for the perfect-world situations, not the real-world situations. So, my courses reflect just that: what it’s really like and what you need to know to provide safe patient care.
It’s not every single piece of information available about specific topics, disease rates, complex pathophysiology, and doctorate-level pharmacology. It’s what you need to know today to safely take care of patients in a hospital. As a new nurse, you’re in a constant state of information overload, so naturally we need to prioritize information.
No fluff, no theory – just straight to the point information telling you not only how to get through your first few months at the bedside, but how to maximize them. I don’t want you to be in a constant state of overwhelm and panic, praying you’re doing okay. I want you to be aware of your progress, prioritize your mental wellness, and feel like an experienced nurse is walking right next to you through this whole process as you make your way through the woods.
But, since I can’t physically do that with all 300,000 newly licensed nurses in the United States every year, I created an online course.
A self-guided nurse residency program
The FreshRN® New Nurse Master Class is concise, honest, practical, and real. It is the answer to every single burning question I had as a new nurse, and answers to questions I didn’t even know I should be asking.
Like,
How do I emotionally disconnect from the bedside?
How should I eat while working shift work?
How do I sleep while on night shift?
How do I take care of patients who seem to be abusing substances?
How do I handle rude providers and colleagues?
How do I manage my time when everyone is doing okay?
How do I give report to the really intimidating nurse?
How do I actually delegate? I mean, I know which tasks to delegate, but how do I ask that nursing assistant who’s been here for 10 years who knows this unit backwards and forwards and I don’t even know how to clock in?
I sat down with multiple healthcare professionals to provide you with the insider information new nurses are desperate to learn – like what level of skill does leadership expect of newbies, how to master nursing report, and navigate emotionally-charged situations like the leader everyone expects the nurse to be.
Most importantly, I want you to know that you’re not alone if you’re scared or feel ill-prepared and overwhelmed. I struggled with imposter syndrome quite a bit, which is why I have an entire module dedicated to overcoming it.
What you get
When you purchase the course, you instantly get life-time access to over 70 modules containing over 9 hours of video, 11 hours of audio, text, and downloads. Every module has text and audio options to accommodate different learning styles. After completion, you will earn 20 continuing education credits and be able to print your own PDF.
It comes with a 1-month, 4-month, and 12-month completion plan. Because it is self-paced, it is up to you to complete this as quickly or as slowly as you’d like. There is also a 30-day money back guarantee. If you dive in and decide it’s not for you, simply email me and with no questions asked you will receive a full refund if it’s within 30 days and you have not claimed the continuing education credits.
Together, we can walk through this journey from graduate nurse to successful bedside nurse. I don’t want you to brave the nursing wilderness alone. It would be my job to be your guide.
Normally priced at $297, this comprehensive course is on sale for $197 through Friday August 2.
Enroll now to make sure you get the $100 in savings!
I’ve received a lot of questions from new nurses saying that one of their biggest struggles is learning how to trust your nursing judgement. You think you know what you’re doing, but you’re not sure… and are constantly questioning yourself, doubting yourself… how do you get over the hump? How do you go from unsure newbie to confident nurse?
I posed this question on my Facebook Page to experienced nurses and they had some amazing responses.
As a new nurse, I also struggled with this and wanted to compile their responses with my own experiences. Onward!
When I had to trust my nursing judgement
“When I was forced to rely on it,” is what Micki P., RN said and I couldn’t agree more. There were times when I wasn’t 100% totally sure… but everyone else was slammed, nowhere nearby, or whatever the circumstances, and I was forced to stand on my own two feet. While I was nervous, I thought critically about the situation, and asked myself, “if another nurse came up to me and asked me this question, what would I tell them?”
When you’re right again and again
Anastasia M, RN answered the question by saying, “When my observations were confirmed with increasing frequency.”
Again, I completely identified with this. I started to notice I went from being way off base or almost correct… to being right most of the time. And it. felt. amazing.
“Hey, he feels a little warm and his heart rate seems to be above baseline. Let’s check a temp and I’ll peek at his CBC from this am, and circle back with the doc.”
“Hey her lungs aren’t as clear as before, she’s not urinating as much… maybe she needs some Lasix.”
“Hummmm… maybe we wait on getting that non-STAT chest x-ray until after the resident puts this central venous catheter in and I put the feeding tube down to save the patient an x-ray and radiology another trip up to the room…”
The pieces just sort of start to fall together and all of the pathophysiology you learned in nursing school comes together with all of that time management / patient care you’ve been learning throughout orientation.
When others come to you for your opinion
Jackie T, RN said, “When co-workers started asking my thoughts and opinions (more experienced nurses). I felt like if they thought I was good enough, that what I thought mattered, I must be then.”
Ding ding ding! YES! A few months after I started as a newbie, a new crop of nurses started as well as a few new CNA’s. I was thankful to have more new people on the unit who were hopefully as lost as I was. Yay friends! But, I noticed that when they started asking me questions… I actually knew some of the answers.
I quickly went from the most lost person on the unit to someone who knew the unit relatively well, could navigate many issues, and knew who to call when I was stuck.
And soon, it wasn’t just the other new employees asking me questions, fellow nurses starting asking me what I would do or what I thought about a certain situation. The first time it happened, I had one of those, “did he just ask ME what I thought!? What parallel universe is this!? I’m the new one who doesn’t know what she’s doing!” moments. I collected myself and provided the answer I thought was best, and he agreed.
Stephanie B, RN said that this kicks in, “when you can confidently teach others.” Going back to this group who started after me, I had one new nurse ask me some questions about a Cardizem drip. I answered her questions and then dove a little deeper into the why. I was a little on autopilot and didn’t really think about it until after. As I was walking away from the conversation I thought, “waaaaaiiitt a minute… did I just teach another nurse something!?”
“Time. As it went on and my gut continues to be right about patients, I trust it more and more. I value being able to ask more experienced nurses their opinion. But I’ve loved the strengthening feeling of “I got this!” With each shift and with each health issue I’ve caught that could’ve been missed (or had already been by others). I’m not perfect, but I do my best to also learn from my mistakes, which I also feel makes me a stronger nurse.”
And I think that is a wonderful note to end on.
Thank you to all of the experienced nurses who responded on FB, offering their advice and encouragement to all of the newbies out there.
Did we leave anything out? What’s been your experience with learning how to trust your nursing judgement? Are you currently on orientation – what are you struggling with?
Resources to help you to gain confidence and trust your nursing judgement:
The best explanations of the mechanism of action behind medications I’ve personally ever seen – this can help really solidify the why behind the medications you give frequently
Monthly subscription to a ton of nursing resources, which includes the MedMaster course + test-taking, EKG’s (incredible explanations of this as well!), NCLEX® questions, med-surg, fundamentals, OB, cardiac, and more.
Need more in-depth cardiac info? Check out the Cardiac Nurse Crash Course brought to you by FreshRN® where we discuss essential topics like hest tube and arterial line care, cardiac nursing report for the ED/ICU/floor, CABG patient care, in-depth discussion on atrial fibrillation, diagnostics like stress tests and caths, and much more!
Graduation is upon us and there will be many new grad nurses among hospital units very soon if they have not started already. Starting a job in nursing can be very overwhelming. I would argue that learning the ropes of the healthcare culture is quite possibly one of the most difficult jobs. In addition, the new grad nurse must learn how to manage a sick human being, physiologically and emotionally. Therefore, learning to be part of the crew from the beginning can certainly help with the transition. The following are ways to be everyone’s favorite new grad nurse on the unit.
Help with admissions
Admissions can really put a hiccup in anyone’s day. However, they go so much faster with teamwork. Working on a cardiac surgery ICU, my unit had admissions down to a science. One person would chart, one person would connect the patient to the monitor, one person would write down time of arrival, vitals, intake and output on the white board, and the primary nurse would do a quick assessment of the patient, check the IV pumps and lines, then we would do a group report. Having a team of nurses help you admit your patient, even if for only 5-10 minutes, changes everything.
Also, for the benefit of the new grad, helping with admissions is a great learning opportunity. There is less pressure when you are not the primary nurse of the incoming patient. Also, helping with admits can help you learn to prioritize tasks and time management.
Keep your rooms cleaned and stocked
There is nothing more aggravating than starting your day having to clean and restock your patient’s rooms. I have worked on units where nurses had to do this and units where techs did it. Whoever is responsible, make sure it is done and help each other out. Although it seems like a small task, it can be the last thing you feel like doing at the end of the shift, but can make an exponential difference in the day of the oncoming nurse. It’s all about the little things.
Check the dates on dressings and IV tubing
Another task that should always be completed before leaving, is changing expired dressings or IV tubing. As a neurotic ICU nurse, I have difficulty focusing on other things when they are not done. Never, leave this task for another shift unless you absolutely are so busy you could not complete it. Also, not to mention, changing dressings and tubing are done to prevent infection, therefore, it’s more about the patient than anything.
Realize there is never down time
Recognize there is rarely down time. If you are caught up on all of your work and having a chill day, walk around the unit and see if anyone else needs help. Inevitably, there will be a nurse who needs help. Instead of just asking, “Do you need help,” offer specific help. Specific help would include: turning, bathing, cleaning up poop, drawing labs, emptying catheter bags, dressing changes, taking out the trash, or trach care. Sometimes nurses do not know what they need, they just know they are drowning. Realizing what needs to be done and just doing it, can change a shift from terrible to tolerable.
Bring coffee or coffee creamer
Coffee is liquid gold in the healthcare community. As a new grad, maybe you’ve never been a coffee drinker, but soon you will likely start to drink it. Nurses love coffee. It’s not necessarily about the taste, or even the caffeine buzz, it’s about the culture. Coffee brings us together. There is just something about someone saying, “I made a fresh pot of coffee if anyone wants some,” or offering to bring some to a nurse who is too busy to make some.
My cousin started a job in an ICU a couple years ago. She was not a new nurse, but was new to the ICU. She instantly recognized the “coffee culture” and started making homemade coffee creamer. The nurses on her unit went crazy over it because creamer is something we’re always wanting. Most of the time, we just take milk out of the patient refrigerator and use it. Of note, she took a large glass jar, mixed half almond milk with half almond cream, and added whatever flavors she wanted like cocoa powder, vanilla, almond, or caramel. This could be done with regular dairy milk as well, but it was the thought that counted.
Most importantly
Any nurse recognizes how difficult it is to start from the beginning, but despite these other suggestions, your teammates will recognize hard work the most. Work hard to understand why you are doing what you are doing. For instance, why is norepinephrine the first line vasopressor in sepsis? Why are you giving mannitol for brain swelling? Why are you starting a statin on every cardiac patient? If you care enough to work hard, you can’t go wrong, the rest of these things are just a bonus.
Welcome to your new career!
About the Author:
Danielle LeVeck is a critical care nurse, doctoral student, nurse advocate, blogger, and social media influencer. Danielle institutes a comical, but straightforward approach in her writing to discuss issues in nursing. She strives to achieve her overarching goal of empowering and inspiring nurses from different backgrounds and encouraging all healthcare providers to work together. Find her blog at Nurse Abnormalities or follow her on Instagram.
For more info on being the best new grad nurse you can check out:
Need more in-depth cardiac info? Check out the Cardiac Nurse Crash Course brought to you by FreshRN® where we discuss essential topics like hest tube and arterial line care, cardiac nursing report for the ED/ICU/floor, CABG patient care, in-depth discussion on atrial fibrillation, diagnostics like stress tests and caths, and much more!
Please see my disclaimers page for more information.
Student Loan Forgiveness and Management for Nurses
Most nurses can rely on two things once they earn their degree:
1) they’ve found a lucrative and rewarding profession and
2) they’ll have years of student loan payments to endure.
Because of the growing expense of attending college and earning a nursing degree, that second part of the equation can be a real downer. Fortunately, an array of student loan forgiveness options exist and even some specifically for nurses.
Student Loan Forgiveness Options for Nurses
With average student loan debt hovering at around $35,000 for the class of 2015, current and future nursing graduates would be wise to explore loan forgiveness options sooner rather than later.
Here are some of the most popular student loan forgiveness options for nurses and what it takes to qualify:
Federal Perkins Loan Cancellation and Discharge
Since Federal Perkins Loans were created to assist students with serious financial need, they offer one of the best loan forgiveness options. If you work full-time as a nurse, you could get 100 percent of your Perkins loans discharged after five years.
Qualifying for this program is fairly easy. First off, you must have Federal Perkins Loans and be in good standing. Second, you must apply through your school that disbursed the Perkins Loans or through your loan servicer.
NURSE Corps Loan Repayment Program
The NURSE Corps Loan Repayment program was created to incentivize nurses to work in critical shortage areas. To qualify, most nurses need to commit to a two-year work agreement in a critical shortage area as defined by their state or municipality.
Nurses who work at least 32 hours per week in their new role can get 60 percent of their existing loans forgiven. By adding a third year to their commitment, they can qualify to have another 25 percent of their loans forgiven.
Applicants are only accepted once per year and nurses must have earned their degree at a school with proper and government-recognized accreditation.
Public Service Loan Forgiveness Program
The Public Service Loan Forgiveness Program, commonly referred to as PSLF, was created to reward college graduates who commit their lives and careers to public service. Through this program, college graduates can have 100 percent of their student loans forgiven after working in a qualified public service position for 10 years.
After 10 years of working at least 32 hours per week in a qualified position, loans under the Direct Loan Program can be wiped off the map. This program is an especially smart option for nurses who may lean towards work in public service anyway.
The best part is, unlike forgiven loans under some income-driven plans, loans forgiven through PSLF will not count as taxable income, and therefore, won’t result in a hefty tax bill.
In addition to loan forgiveness programs offered on a federal level, 33 states also offer local loan forgiveness programs that can help nurses.
For example, the Wyoming State Loan Repayment Program offers up to $20,000 in loan forgiveness after two years of employment in a critical shortage area. Also on the list is the Colorado Health Service Corps program, which doles out up to $50,000 in loan forgiveness for nurses who work full-time at a qualifying organization for at least three years.
Different states offer their own versions of loan forgiveness for nurses, with unique requirements and payouts depending on the type of the program and the criteria that must be met.
Managing your Student Loans – With or Without Forgiveness
Even if you decide not to work in public service, which often means a lower salary and less-than-desirable locale, there are options for reducing your student loan burden.
If you have good credit, a solid employment history, and are willing to forgo federal protections such as PSLF and income-driven repayment options, refinancing might be the way to go. Private lenders like Earnest and CommonBond might be able to give you a much lower interest rate, saving you thousands of dollars over the life of your loan.
Whether you’re a nurse who is tired of struggling with student loan debt or a future graduate who is already stressed over your future payments, it’s smart to research different repayment options to see if one might be right for your situation.
With some research and planning, you could escape a lifetime of student loan debt and instead focus on growing your career as a highly valued medical professional.
About the Author:
Andrew Josuweit is the CEO of Student Loan Hero, a company that combines easy-to-use tools with financial education to help the millions of Americans living with student loan debt manage their student loans smarter. Student Loan Hero is helping 150,000+ borrowers manage and eliminate over $3 billion dollars in student loan debt.
**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 andFast 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!
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
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.
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.
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).
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.
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…
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 Nurseprovides 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 Presentationsfocuses 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:
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.
Meet the author
Lynn 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 Nursewhich 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.
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.
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!
Melissa 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
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.
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.
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!
Melissa will also be our featured guest nurse in Season 2 of the FreshRN Podcasts.
Melissa 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
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.
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.
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!
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.
Melissa 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
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.
At some point and time even the most seasoned nurse was a new nurse. They too were bright eyed, anxious, excited, and scared to death they were going to mess it all up. I recently asked on Facebook for one piece of advice for new nurses. The response was so great that it just had to be turned into a blog post. So without further adieu..
Advice for a New Nurse
What is one piece of advice you would give to a new nurse?
Learn how to think critically. WHY is my patient in the hospital with a COPD exacerbation? What does that mean for their oxygen therapy? Why am I giving them these meds. What are some problems I should watch for?
I feel like being able to connect concepts, understand why, asking lots of questions will make it all come together for a new nurse! Don’t just look at your day as a bunch of tasks! ~Rachel
I love the advice to not ever be afraid to ask questions!
Ask the question, don’t be to intimidated to say that you don’t know something, and call out every “seasoned” nurse that tries to make you feel bad for not knowing something, most often they will shut up and never try to bully you again if you call them on it. ~Nikki
It’s okay to cry. Some days you will feel completely incompetent. Don’t be afraid to ask questions. Always listen to your patients. Always show compassion. Always know your resources. Listen and help your aides, but don’t be afraid to delegate. You will make mistakes and that’s okay, as long as you learn from them. ~Amanda
Remember that nursing school gives you the basics. The first couple of years you are going to feel like you know very little. As a nurse you are a life long student. Don’t quit asking questions or participating in new experiences. Everybody starts like this. ~Valerie
It’s OK to question something that comes from the mouth of a seasoned nurse….the answer “because that’s how we do it here” should not be a satisfactory answer, there should be a why and a how and a proper backup to the answer.
It’s ok to ask for a policy and procedure handout, it’s not that your questioning their ability, it’s that you want to be rest assured your doing it as it’s expected.
When working with a someone you’ve never oriented with ask them “what do you expect of me today?” I’ve worked with XYZ and I’ve done this and that, but I’d like to know what your expectations are of me today?” ~Amanda
Above all else, stick with it!
The first year is the hardest. Sleep well, take care of yourself, talk to your manager about your stresses or other nurses. They can help you put your mind at ease. Ask to be next to a seasoned nurse who likes to help. One day it all just clicks! ~Chrissy
Prioritize your care and stick to it. You will have many people demanding your time, energy, attention–but only you know what is the highest priority in your patient assignment. If you’re being pulled in a million directions, take a minute to re-prioritize your care. Let people know that you are aware of their needs and have made a plan for meeting them. ~Kip
Don’t give up! You will have days when you leave in tears, but never ever give up! ~Jen
And we all need practical advice from time to time!
Find humor in every work day, or you will be ever searching for the wine…… ~Debi
Among all the politics, targets, impossible expectations from management, remember what matters…patients. ~Sally
Always chart in real time whenever you can! ~Erin
Wear compression socks. ~Kim
Invest in a great pair of shoes ~Jessica
Work with others, not against them!
A good CNA is worth more than their weight in gold. Remember that. Show them that you respect and appreciate what they bring to the table. The CNAs I worked with as a new nurse were some of my greatest teachers. ~Nikki
Be good to your staff…. Everyone, housekeepers, kitchen and especially your CNAs!!! ~Karen
Don’t ever forget how you felt being the new nurse.
Don’t forget this feeling. Nurses tend to develop a superiority complex over the years. Never forget where you started and how it felt. ~Tiana
And finally:
Go pee!!! Seriously, make it a habit, part of your time management. Take the time to go to the bathroom, hydrate and take a lunch. You can’t take care of your patients if you don’t also take care of yourself. If anything a bathroom break can be a couple minute re-prioritization break! ~Courtney
Be humble and teachable and never forget the power of compassion and a gentle touch. ~Kelly
What is one piece of advice that you would offer to a new nurse?
This week I am featuring an interview with my sister in-law, Elizabeth Fields. She recently went to Bora, Ethiopia with the medical mission group Health Gives Hope. Last week, I interviewed their founders, one of whom is actually a Nurse Practitioner! Click here to check out the previous post.
To give you a little background about Bruce and Elizabeth Fields, they are quite the athletes and world travelers. Bruce played professional basketball in Europe for 9 years and now works at State Farm in the Chicagoland area. Elizabeth played volleyball at Parkland College (where I played basketball for a short time!) in Champaign, IL and then completed her BSN at Indiana Wesleyan University while continuing to play volleyball. She has worked at Northwestern Memorial Hospital for the last ten years as a registered nurse, working the last two years as a Nurse Practitioner. She obtained her FNP from Walden University.
These two crazy kids. They met in Austria some odd years ago and have traveled to the following countries either together or separately: Turkey, Switzerland, Austria, Thailand, Ethiopia, France, Italy, Belgium, Norway, Spain, England, Philippines, South Korea, China, Russia, Ukraine, Poland, Germany, Mexico, Japan, Denmark, Canary Islands, Romania, and Canada. Oh, and Bruce has lived in a handful of them as well! Clearly they know a bit about traveling! Me, I’m more of anxious traveler (think Monica Gellar going to London).
I decided to interview them to give people a look into the practical side of what going on a medical mission looks like. As you read, Bruce is not medical. However, what he lacks in nurse-ness, he makes up with hard work and height. (He’s 6’5″.)
Please note, answers given below are from Elizabeth, unless otherwise indicated.
Why did you decide to go on a mission?
I went to Bora, Ethiopia because they don’t have access to health care, and this was something I could not only make a difference doing, but I knew it would grow my knowledge and stretch me professionally. I also went on a mission trip to live out something I was taught and believe in deeply: you should use any talent you are given to bless others. Nursing is a talent that was given to me and I am passionate about sharing it.
What was the travel there like?
This is from the HGH website: The team flies from the US to Addis Ababa, and then drives south through the lower rift valley into the Guge Mountains of southern Ethiopia. The team will then hike 6 miles, ascending nearly 2,000 feet, from where the road ends in Chencha to the village of Bora.
Travel in Africa is entertaining and challenging. We were on planes, boats, buses, and on foot – our baggage traveled up the mountain by donkeys and our road was often congested with cattle, camels, and people.
Tell me what was going through your mind the first time you saw their set up for medical care?
The clinic set-up is smart, efficient, and well planned – their resources are growing – but the first thing you think is – “WOW – they have access to SO LITTLE compared to what we are used to; how am I going to make it work?”. But then, you make it work, and realize how MUCH we have in the States and how profound your assessment skills are!
What are some of the biggest differences between the care you provided there versus in the USA?
We had no access to running water, internet, or specialty consults. We had no diagnostic testing. I had to be excellent in my history and physical taking, and in my assessments so that I could determine differentials and treat appropriately. The creativity needed to get medications into infants, translate reasons, times, importance and information to patients was profound. The translators were amazing, but I have to hand it to the nurses – they had so many amazing ideas to help make these challenges ones we could overcome.
What were your meals like?
AWESOME and different! It was a mix of American food and authentic Ethiopian foods. The people there are extremely hospitable and loved cooking for us. We got to observe and help them cook in a “cooking hut”, and experienced what is like to cook without any modern conveniences. Some of the meals they made for us I have tried to recreate here, and have been moderately successful in accuracy.
What were the sleeping conditions?
We slept in mud huts, on straw, in our own sleeping bags. At first I struggled with the conditions – it is exactly like you would see it in the National Geographic! But looking back, I wouldn’t have wanted to sleep anywhere else; I lived and experience it in the most authentic way possible.
Tell me the bathroom situation, STAT.
Bathroom? You mean tell you what it was like to squat on a gorgeous mountain side and hope no animals or humans saw my southern regions? Two words: wet. wipes.
Tell me about some practical cultural differences.
One of the things that hit us hardest was the reverence and respect for elders that everyone had. Here in the states the elderly population is often viewed as a burden, while in Ethiopia they are cherished and consulted for their wisdom. Another shocking difference was how hard the women worked. The Ethiopian people often refer to women as “provider”. You will see in our pictures that women do the heavy lifting there.
Elizabeth, walk me through one day as an NP there.
I had two interpreters assigned to me. Each patient would come in my exam room, tell me their complaints/history, and symptoms. I would do an examination, diagnose their problem, and prescribe medications (pending availability). When I had a patient that “stumped” me, I called upon the other practitioners and nurses for their expertise. Because we had no diagnostic testing available (labs, X-ray machines) collaborating was our lifeline; we all needed each other to make each day in clinic work and it was an incredible experience!
Bruce, walk me through one of your days there.
Every morning we wake up and walk from our hut down the mountain to a place we called “the cliff”. It was an incredible time to enjoy a beautiful view and reflect on our days there. We then returned to our compound to have breakfast that was made for us by the locals. It consisted of grains, potatoes, sauces, and amazing Ethiopian coffee (FYI, Ethiopia is the birthplace of coffee). We hiked up the mountain a mile to the clinic every morning, with the village children holding our hands the entire way — this experience melted my heart.
My time in the clinic consisted of building shelves, setting up a privacy tent for the bathroom over a hole dug by a previous team, working in the pharmacy dispensing the medication prescribed by the practitioners, and helping teach patients how and when to use them. I often made lunches for the entire team with another group member and did what was necessary to ensure a good flow at the clinic. I was concerned that because I’m not medical I wouldn’t be very useful, but when I got there I found the opposite to be true. We each had a role and without each other it would’ve been impossible for the clinic to be successful.
How much did it cost?
About $2500 a person, and this included flight, ground transportation, lodgings, food/water, two days of sight-seeing. It was the cheapest 2 weeks abroad!
How do you feel this impacted your marriage? Do you recommend married couples going together?
YES! GO TOGETHER! My husband isn’t medical, but the need is so great and watching him use his gifts in service by building shelves, working in the pharmacy, making team lunches, setting up privacy tents, and playing with the kids was – well, SWOON. I can’t exactly bring him to work with me to see patients here in the States; watching each other in our own elements was amazing. It gave us greater respect for one another, and made me want to encourage him more in what he excels in.
I know these experiences are hard to predict how they will affect you. What did you anticipate versus what did you experience?
I didn’t expect to want to stay there longer – but I was so sad to leave. There are days at work when I find myself in the grind of the day, burnt out and discouraged; to feel so needed and impactful in Bora, Ethiopia was priceless, and it took me off guard. I didn’t know I would fall in love with medicine again – I didn’t know that I needed to be there for my own benefit, just as they needed me there.
What did you learn that has changed your practice as an NP in the US?
Because I had to rely so heavily on my assessment skills and collaboration with the team when I was faced with a questionable diagnosis, I have worked much harder to perfect those areas since I’ve been back. Those areas include knowledge and differentiation of various heart and lung sounds, alternative treatments, and preventative medicine. My desire to be a better provider has substantially increased since going to Ethiopia.
Would you do it again?
We would go back tomorrow. Without blinking. It was professionally and personally something that humbled us, empowered us, and revitalized my passion for medicine and nursing.
Last month, my nurse practitioner sister in-law went on a medical mission to Ethiopia with her husband. She had an unbelievable time! I have been asked about medical missions before so I thought I would do an interview with the founders of the organization and my sister in-law.
This post is my interview with the founders, Amber and Jerry Kaufman.
All answers below are from Amber, unless otherwise noted.
(Also, please note Jerry’s solid beard.)
Amber and Jerry!
Amber, I know you are a nurse practitioner. Where did you get your nursing degree and your NP? Do you still work in the USA as an NP, if so, where?
I got my nursing degree from Purdue University. I initially became a Pediatric NP from the University of Central Florida. I later got a Post-Master’s Certificate for adult NP from University of Massachusetts – Boston. I currently work as an NP with One Medical Group.
Jerry, what is your professional background?
I am a Ph.D. student at the University of Chicago. My areas of interest are health, globalization, race and ethnicity, and organizations.
Why did you both start going on medical missions?
Amber: When I was in high school I heard a woman speak about doing medical mission work in Papua New Guinea – from then on, I knew that I wanted to do it. As soon as I had my first clinic day in India, my first medical trip, I knew I was hooked. Little did I know that I would be where I am today in 8 years!
Jerry: I’ve been involved with international nonprofits for over a decade, so I’ve been interested in international work for a long time. I got into medical mission because, well, my wife!
Where was both of your first medical missions?
Amber: My first medical mission trip was to India.
Jerry: My first medical trip was to Ethiopia.
Why that particular region of Africa?
Honestly, it just fell into place. We were set to go to another country with a medical team and the trip fell through due to political unrest. The other co-founder, Dan, happen to know someone from college that was teaching in Ethiopia. We asked if we could bring a medical team in 5 weeks to Ethiopia and she said yes. She introduced us to Israel, who is now the Health Gives Hope Program Director in Ethiopia (4 of his siblings also work with us). Israel was our leader for the trip. Amber knew right away that Ethiopia was were we were suppose to work. And here we are 7 years later with a health center and teams going twice a year. Amazing!
What are some practical differences in the way you provide medical care in Ethiopia versus the US?
You have to make due with less. We have solar powered lights but that’s it for modern conveniences. No running water and limited supply of medications. We don’t have access to labs and diagnostic testing. In emergencies or for critically ill patients, we will transport them to the nearest hospital. But for the most part you use the patient history and exam to make your diagnosis and treatment plan. It is a challenge, but rewarding.
What do the villagers do day-to-day for medical cares/concerns when you do not have a group there?
We have a nurse that travels from a nearby town, Chencha, and works at the health center we run in Bora (Hidota Health Center). She works 3 days/week to provide care. If she is not there, the people either have to walk 6 miles to Chencha or they don’t go, which is usually the case.
Hidota Health Center
Every nurse also has a patient experience that they can look back upon and say “I am a better nurse because of this person” or “I am a better nurse because of this particular patient experience”. What specific patient experience from Ethiopia has made you a better nurse?
On the 2nd trip to Ethiopia, we had our clinic set up in a local church and we were seeing patients there (the Hidota Health Center was still a few years away!). A father came frantically to the clinic and asked if I would come see his wife who had just given birth during the night. He just kept saying she was sick. I packed my backpack full of medical supplies – trying to think of every possible scenario I might encounter. We hiked down the mountain about a mile to their hut. A woman was lying there and clearly not doing well. After a quick assessment and history, I determined that she was severely dehydrated (she hadn’t had any water in about 36 hours – and delivered a baby in that time!) and she had a possible early infection. I gave her IV fluids and IV antibiotics. We stayed with her much of the afternoon until she turned the corner and started feeling better. I assessed the baby who was happy and healthy! By the time we left, the mom was able to sit up and drink water on her own. The family then told me that they decided to name their baby “Amber.” It was an incredible moment. I was so thankful we were there – otherwise, I am not sure that mom would have made it.
In nursing, we learn tricks of the trade in our day to day practice. I have a feeling that tricks of the trade in providing nursing care are a bit different in Ethiopia are different than in the US! What are some tricks of the trade or pro tips for nurses providing care with HCH in Africa?
Your face and tone says a thousand words! Since you are using 1 or 2 translators (sometimes you need translation from the local dialect to the national language to English), the people are really looking at your expressions. It really does make a huge difference. Also flexibility is a must – in all things, all the time.
Tell me some common rookie mistakes that nurses make during their first medical mission?
Honestly, there aren’t too many. It’s not a mistake but it’s common for nurses to feel bad about the times where we can’t provide the care that is needed (for example, medications or treatments that we don’t have). It can take time to realize that this is just part of working in a rural setting.
Providing patient care!
Tell me your biggest reality shock as a nurse when you first started serving missions?
I don’t know if I would call it a shock…but maybe an area of growth.. For me, learning to slow down and have patience. Things just don’t happen as quickly as I am used to or that I want them to. I have finally arrived at patience, for the most part.
Do nurses need to have a certain amount of experience to serve?
No – new nurses and seasoned nurses are welcome. As long as they are willing to serve, they can join!
My sister in-law (Elizabeth Fields) is second on the left. She’s an NP and the other three are nurses with about 1 year of experience!
Can nursing students serve?
Absolutely. I have also had NP students and I was able to serve as their preceptor for clinical hours.
What is the average cost?
The cost is $1500 for your land package (everything except souvenirs and vaccines) plus airfare. Airfare tends to run between $1300-1600 depending on your departure city.
When many people hear medical mission, they may connect it with a faith-based organization. Do you need to be of a certain faith to serve with your group? Our organization usually calls our trips “medical service trips.” No, you don’t need to be a certain faith.
I noted that you are based out of Chicago. Do people interested in serving need to be from that area? No – we have travelers from all over the country join us!
If I decide I want to serve or learn more, what are my next steps?
Email Amber at [email protected] The next trip is November 9-20, 2016 (then in April, 2017).
Next week, I’ll post an interview with my sister in-law (Elizabeth Kleber, MSN NP about her trip!
For those of you that may be interested in learning more, check out their website! Please note that while these trips are extremely rewarding, the travel can be very challenging physically. Upon arrival to Addis Abada, Ethiopia, you take a 10-12 hour bus ride, followed by another half day drive, then hike for half a day at an altitude of 10,000 feet above sea level up mountains. If you have specific questions/concerns about the travel and if it would be a good fit for you, shoot Amber an email! You’ll hear more about my sister in-law’s experience, both with the travel and her entire time, next week!
Have you ever been on a medical mission? If so, please comment below with where you went and which organization you worked with!
Please note that this post is sponsored by Capella University. All opinions are my own. Please check out this video about my 2016 partnerships and why I’ve decided to work with these amazing organizations.
When I graduated from nursing school I was given a packet of information about the various professional nursing organizations. I was so overwhelmed at that time that I just put them aside and forgot about them. It took some time for me to begin exploring what they really meant, and looking back, I am sad I missed out on that time to be a part of these organizations from the get-go. It really took some time for me to comprehend exactly how big our profession really is. There really are two parts of nursing: the nurse providing the direct patient care, and then the nurses working behind the scenes to support those providing direct patient care. Upon graduating, I had no idea how big (and essential) this side of nursing really is. I think on some level I knew that had to exist in some capacity, but I didn’t realize exactly how essential this piece of nursing is to the entire profession.
Who they are
These organizations are comprised of nurses. When you work for a hospital that is run by business people, it is great to be part of an organization that is run by nurses! While there are groups of various specialties (and practically every single specialty you could imagine!) there is also the American Nurses Association, which is for any registered nurse in the United States. There are also nursing organization for each state as well.
What they do
These organizations provide a host of resources and support to their members. What I find particularly valuable are the publications that most provide. I am a member of the American Nurses Association (ANA), the North Carolina Nurses Association (NCNA), the American Association of Critical Care Nurses (AACN), and the American Association of Neuroscience Nurses (AANN). Every month I receive journals from these organizations that are talking about the latest research, evidence-based practice, and issues that affect that particular patient population or region.
By staying up to date with these you are being constantly informed about the latest information and best practice for your patients. It is quite empowering. This information and access to their databases allows you to know what is most current, what other hospitals and health systems across the country are doing so that you may implement the latest and greatest with your patients at your hospital. Knowing the latest research allows you to engage in educated and thought-provoking conversations with your team members and those that are in decision-making positions at your facility. This is how change happens!
These organizations are also closely affiliated with specialty certification organizations. In most cases the professional association establishes the standards upon which the certification is based. Many specialties offer a certification. For example, the AACN Certification Corporation offers several certifications for critical care nurses. I took that CCRN certification exam in Sept. 2015 and am now a certified critical care nurse!
Why you should join
Professional organizations provide an outlet for your professional development outside of the walls of your facility. These groups will help complete the picture of our profession for you. While the face-to-face interaction with the patient is an essential aspect of our profession, the behind the scenes work is just as vital, and this is where it occurs. They provide many educational and networking opportunities, from online CEUs to national conferences. Many organizations work with schools and provide various scholarships for degrees as well.
How much does it cost?
It really depends on which organization, so I won’t outline it here. However, many hospitals and employers will reimburse for the membership fees. They do this because it furthers your professional development and enhances your career. Most will reimburse after you pay for your membership upfront but some will submit payment for you. It is definitely worth checking out if your employer offers this benefit!
How you can get involved
This is a link to all of the professional nursing organization in the United States. I encourage you not only to join the professional organization for your patient population, but also the American Nurses Association and your respective state organization. Becoming a member of these organizations will enable you to complete the picture of nursing for your specific population and the entire nation as well.
To show you exactly what you get and what access you have with a membership, I logged on to the American Nurse’s Association website with my member login so you can really see what is there. There is such a huge amount of information about so many things and I just want to show you how it is all set up. I also will quickly show you the homepage of the American Association of Critical Care Nurse’s homepage so you can see how much information each group provides. Spoiler alert – it’s a lot.
What I also really appreciate is when schools work with these professional organizations to provide more ways to further your career as a nurse. For example, Capella University and the ANA Leadership Institute are now offering a “Nurse Leader Scholarship” for nurses who want to advance their career and move into expanded clinical and leadership roles. The scholarships, ranging from $4,500-$7,500, are available for Capella University’s Master of Science in Nursing (MSN) program and Doctor of Nursing (DNP) program. Applicants for the scholarship are required to be ANA members as of May 1, 2016, new to Capella and must apply and start by September 12th.
I encourage you, professional to professional, to check out your specialty’s professional organization as well as the American Nurses Association and your respective state organization. Read journals, write to your member of congress, participate in research studies, get more education. You don’t have to be a nurse with a certain number of years experience to be a member and dive deeper into your professional development. You just have to be a nurse!
Please note that this post is sponsored by Capella University. All opinions are my own.
This is some quick info on a few very common meds you run into in the neuro intensive care unit. However, please always follow your hospital’s policies and procedures. This is for informational purposes only and focuses on nursing considerations.. not going in depth on the drug.
Propofol or Diprivan
We love this med with all of our neuro hearts. It is given IV as sedation for patients with increased ICP or for patients with seizures. A continuous propofol infusion is one of the options for someone who is having continuous seizures (status epileptics). It is NOT a pain medication. To get this med, they must be intubated or are the process of being intubated
Why we love it: it works quickly and wears off quickly, allowing us to get a quick neuro assessment. You can detect changes quickly, which is essential.
Interesting fact: they were attempting to use it for executions, but the manufacturer refused to supply it for that need
Nursing considerations:
You must frequently change the tubing (usually every 12 hours)
You must pause it to complete a neuro assessment (usually only a few minutes needed to get the assessment)
Work with your dietician to ensure your enteral feeding formula is appropriate. If you are weaning it or increasing it significantly, they may need to change it. Lots of calories!
Weight based, make sure an accurate weight is in the chart
Watch for hypotension and oversedation
If a patient is getting this for status, make sure you know if they want you to pause it for assessments (most likely not) – make sure there’s an order
Always flush the line – never pause and leave for a while.. it will clot your line!
Titrate to clinical response – don’t just coast. Back off if you need to, increase if you need to.
Mannitol
Mannitol is an osmotic diuretic given to decrease ICP. It doesn’t cross BBB. You increase the plasma osmolality to pull fluid off the brain and out of the body. It increases intravascular volume (pulls fluid into the vessels) and therefore cardiac output.
Interesting fact: it’s actually a sugar alcohol also used in the food industry. It’s a naturally occurring substance found in marine algae and mushrooms.
Nursing considerations:
Make sure your serial labs are ordered: q6hr BMPs most likely
Holding parameters! Make sure you have an order or know when the MD wants to be notified
Serum sodium: typically around greater than 160 (normal = 135-145)
You want to drive the sodium up to remove fluid, but not TOO much
Serum osmolality: typically greater than 320 (normal = 275-295)
Can cause renal failure because of intra-renal vasoconstriction and intravascular volume depletion
Increases CO so watch patients with CHF
Administer through a filter set or draw up with filter needle
If the vial is crystalized, send back to pharmacy to re-warm
Hypertonic Saline (3%)
Used to treat hyponatremia and cerebral edema.
Interesting fact: hyponatremia is the most common electrolyte imbalance
Basically it is salt water. Some docs will use this, some will use mannitol for increased cerebral edema. Evidence is not super awesome about if one is much better than the other.
Nursing considerations
Probably will need a line
Use judgment.. mild hyponatremia with only one dose.. talk with doc
Watch for a rapid increase in sodium. Shouldn’t rise more than 8-12 mmol/L. in 24 hours. Otherwise central pontine myelinolysis can occur.
Severe damage of the myelin sheaths of the nerve cells in the brainstem. A BIG deal. They can become paralyzed and die. Extent of damage depends on how many axons get damaged.
Need more in-depth neuro info? Check out the Neuro Nurse Crash Course brought to you by FreshRN® where we discuss essential topics like essential neuroanatomy and disease processes, primary and secondary injury, neuro nursing report, meds, time management, mastering the neuro assessment, and more!
Craft beer this week: Coffee is for Closers, an iced coffee stout by Fullsteam Brewery in Durham, NC.
The ICU is dynamic and things change constantly and quickly. Patient conditions and staffing change significantly in an instant. No two shifts will be the same. However, it is important to know what your routine would be if you are adequately staffed, have an appropriate assignment, and nothing happens that changes your plan (which happens q3years, I know!)
Remember, these are suggestions. Time management is not the same for everyone. Adapt as you see fit. As long as tasks are complete and needs are met, you’re good to go. This is a starting off point.
Assumptions: this is day shift, you have two patients, and a CNA is working with you
Report
Maximize this time
Look at orders (what needs to be done immediately, sooner, later)
Look at meds (make sure none are overdue, look at what is due 0900 and before and if you need to get it from pharmacy/is it very time sensitive)
While they’re talking, look at all of your lines
What needs to be changed, when?
How much is left of your fluids/drips? Do you need to get new ones sooner rather than later?
Mentally plan your day
When will you change your lines, do you have any procedures/scans/tests?
Learn to give and receive report efficiently
30 min is MAX for report
Speak concisely when giving report, don’t ask questions until the end when receiving report
It’s not a time to catch up with buds – it is precious time
When you’re done – LEAVE! Don’t linger!
Consolidate Constantly
Complete meds, a turn, assessment, and chart all at once
Spending slightly more time in a room and completing more tasks at once is much faster than one task at a time with each patient. You’ll be constantly chasing your tail. It’s better to complete tasks slightly early or slightly late than everything is late.
If an MD is rounding and completing an assessment, complete one then as well and save yourself another trip
Be proactive with educating patients/families while in the room to cut down on questions/call bells just to answer questions
Stay ahead
Move quickly at the beginning to get everything done. Beginning of shifts are busiest between meds and getting that first assessment charted
Even if you are ahead or don’t have anything pressing going on, move fast to get these things done. You never know what’s about to happen.
When the chaos ensues…
Immediately think: “who needs me most right now?”
Stop and breathe. Ask a coworker for help prioritizing if you don’t know.
Everyone may try to make you think that what they are worried about/asking about is a priority, but only YOU know the needs of both of your patients. Be unapologetic about this, even if someone is mad. You can’t make everyone happy when patients are unstable/have immediate needs.
Delegate to your coworkers the task-oriented things, not the things that require you to provide information about your patient that would take too long to explain
Charting
If you are pressed for time, chart the ABNORMAL things only and go back and fill in the “chart this same basic thing on everyone” stuff later. So if their assessment was normal except for their lungs and their peripheral pulses, just chart those things in real time and then go back later. It is really, really easy to forget this stuff.
If you don’t have time to chart anything at all, at least chart “reassessment” or at least one thing at that time so you have a time stamp.
Learn shortcuts. The faster you can chart, the more efficient you will be. The less time spent charting, the better. This doesn’t mean chart LESS, this means chart more EFFICIENTLY. Focus on less clicks, learn the shortcuts, read the updates or tips and tricks sent out by IT via email.
If deemed appropriate, copy and paste your assessment and change what needs to be changed (saves a LOT of time)
Sample morning of time management
Before report: print telemetry strips
0645-0700: Report on patient #1, quick intro, and “I’ll be back shortly after I get report on my other patient.. do you need anything before I come back?” Check to see if you need to bring any replacement drips/fluid when you return.
0700-0715: Report on Patient #2
0715-0730: With patient #2, introduce, educate, assess, chart (only a few things.. stuff you would easily forget), give any meds (typically minimal at this time), level your lines check your alarm settings, see if you need to replace any fluids/drips. Before leaving the room, check to see your 0800/0900 meds for patient #1 and get those on your way back to #1’s room. Be quick and efficient.
0730-0800: Back to patient #1 and educate, assess, chart, turn, level lines, check alarms. Once 0800 hits, scan and administer all 0800 and 0900 meds and replace fluids/drips. Before leaving the room, check #2’s chart to see what you need to bring in to that room for 0800/0900.
0800-0830: Back to #2 and medicate, turn, finish charting
0830-0845: At nursing station, interpret/chart tele strips and double check orders/chart to make sure you haven’t forgotten anything
If nothing happens, which is rare, you’ll be done with everything at 0900. It is essential to be as caught up as possible constantly because you never know who is going to be unstable and what’s coming through the door.
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.
Disclaimer: this is a short and sweet explanation of a nursing assessment of an unconscious neuro patient.
References are included at the end with supplemental information.
Always refer to your hospital’s policies and procedures to guide your practice.
This post contains affiliate links.
I was a neuro ICU nurse for four years and worked with some amazing neuro ICU nurses, neurologists, neurosurgeons, and physician assistants. Below are some of the tips I’ve learned along the way!
Education for the family is critical
Before you even touch the patient, let’s chat education.
Let the family know about painful stimuli before you perform it. It can be pretty shocking for someone to see this, so please warn people beforehand.
Another thing that’s really important is to educate them about the importance of the frequent neurological assessments. Family members frequently want their unconscious loved one to do as much as possible (squeeze their hand, raise a finger, wiggle toes, etc.). This is a normal desire. They want them to do well. However, it’s critical that the family allows their loved one to rest between assessments. I’ve just finished bathing, turning, and assessing a patient who needs to rest until I come back in 2 hours to assess them all over again… and before I walk out of the room I start to hear someone scream, “COME ON SWEETIE, SHOW ME HOW YOU CNA SQUEEZE MY HAND!” Please let them know how essential it is for the patient to save their minimal energy for your assessments.
Encourage and educate them about the importance of maximizing rest between assessments because these assessments. This is essential because when changes in brain occur, they are evident in the assessments, not vital signs.
There are lots of beeps and buzzes in the neuro ICU. Educate them about monitors, equipment, and when to worry. Some don’t realize that most of the equipment is connected to a monitor at the nurse’s station and will put on their call light with every beep (which would mean A LOT of call lights!). Some will freak out with each beep, and some will even try to get the beeping to stop by themselves and press buttons they shouldn’t press. Proactively educate.
Unconscious neuro patient assessment tips
Here are some essential neuro ICU assessment tips!
Pause sedation! You must pause sedation for each assessment unless an order tells you not to, otherwise you cannot accurately assess their neurological status
Do your assessment the same way every single time – like your golf swing or how you would shoot a basketball… there should be a very specific routine you go through
Look at CTs and MRIs and compare them to diagnosis
Change in level of consciousness is usually the earliest reliable indication of a change in intercranial pressure (ICP)
Vital signs / pupillary changes are LATE. If you’re just watching vitals and checking pupils, you’re missing something and your intervention will be too late.
Do your first neuro assessment with the off-going nurse to compare
Temperature can profoundly affect your assessment and increase ICP
For each degree increase, the normal metabolic demand is increased by 10%. They increase cerebral edema and infarction!
Temp changes does not typically signify a change in the neuro injury, but requires prompt intervention
Keeping the head of bed at 30 degrees is ideal, unless contraindicated. This keeps head midline, promotes venous return, which decreases ICP. However, make sure this isn’t contraindicated in your patient before implementing
Avoid shivering and agitation, as this also increases ICP. Notify the MD if you’re noting either of these, as they’ll likely order something to decrease it.
Don’t try to interpret your assessment in your documentation, just write what you see (so don’t write “seizure”, write what you’ve observed specifically, like “rhythmic twitching”)
Know your acceptable forms of pain:
Trap pinch
Supraorbital pressure
Sternal pressure – not rub
Nail bed – can elicit a spinal reflex and be reproduced in a brain dead patient.. I only do this if I’m not getting a response
How to go through your neuro ICU patient assessment
Alright, now that you’ve gone through some basic tips, let’s go through a systematic way to approach assessing an unconscious neuro patient.
Look at vent – are they breathing over the vent before you stimulate them? What’s their respiratory pattern?
Look at them before you touch them – are they making any movements? (Remember, your sedation is paused at this point.) Is this movement purposeful? Are they going for the ventilator, scratching themselves, picking at bed linen, and so forth? Does their face look symmetrical? Note their hemodynamics before you start getting them all riled up.
Level of consciousness – this is super important, people!
Awake / alert: do I really need to explain 😉
Confused: disoriented, agitation, poor memory
Lethargic: awakens, but takes some effort and is kind of cloudy when they wake up
Obtunded: needs repeated stimulation but falls back asleep
Stuperous: minimal movements, pain or vigorous stimulation needed
Comatose: no response to anything at all, not even pain
Eyes, eyes baby
See if they’ll open them by themselves (“Sir, can you open your eyes for me?”)
If they will follow that command, see if you can get them to look in all four quadrants (look up here, down
here, over here, etc.)
Walk from one side of the bed to the other, see if they’ll follow you
If cannot open eyes, do so for them and note that
Close them frequently for them during the assessment
Check pupils for size, shape, level of reactivity (brisk, prompt, sluggish, nonreactive, hippus).
Check blink to threat reflex by pretending you’re going to poke them in the eye, but don’t!
If blink isn’t present, check corneal reflex by using cotton or saline
Oculocephalic reflex/Doll’s Eyes: briskly move head with eyes open. If eyes stay fixed, that indicates loss of brainstem.
I always do this one with the doc, I’m not so great at telling this unless it’s painfully obviously
Cough and gag reflex
Perform oral care, then touch back of throat with oral care kit and observe
Suction patient to elicit cough reflex, note facial response to further assess facial symmetry
Can they follow commands?
“Grip my hand, show me two fingers, give me a thumbs up, wiggle your toes”
Must be repeatable and consistent
Educate family about reflexive movement
Assess all 4 extremities for commands
If no commands.. must elicit pain
See beginning for acceptable forms
Use your pain stimuli on each arm
Progression from best to worst..
Follows commands (yay!)
Localized pain: attempts to stop painful stimulus
Withdraws from pain: pulls away from stimulus
Flexion: flexes arm, note how far (midabdomen, nips), legs will extend
Extension: you’ll know this when you see it! Some will extend and then flex, legs will extend
No movement/response to pain at all (most ominous)
Plantar stroke – we do not want to see their greater toe fan
Assess tone!
Lift hand and drop. Rapid drop = coma, slow drop = consciousness
Bend knees; put heels on bed and release
External rotation and drop = coma
Slow extension to bed = consciousness
Video demonstration of the above assessment
As part of a short series of videos, I performed a demo of an unconscious neuro patient on my husband. Here is the video!
More neuro resources
Need more in-depth neuro info? Check out the Neuro Nurse Crash Course brought to you by FreshRN® where we discuss essential topics like essential neuroanatomy and disease processes, primary and secondary injury, neuro nursing report, meds, time management, mastering the neuro assessment, and more!
Please enjoy this guest post, written by Tricia Hussung at Concordia University, St. Paul
A job interview can be one of the most intimidating hurdles involved with securing a new position as a nursing professional. However, being prepared can help calm your nerves and make you stand out as a strong candidate. Here are some frequently asked nursing interview questions and answersto help you feel relaxed and ready to make a great first impression.
What do you feel you contribute to your patients’ care?
Discuss your strategies for patient care and advocacy here. Because interaction with patients is a major part of any nursing career, employers are looking for individuals who have excellent bedside manner. As is the case with most interview questions, specific examples are always beneficial. Talk about how you listen to patients and provide comfort as part of their medical care.
What are your salary requirements?
Do research so that you are asking for a realistic amount and aren’t pricing yourself out of the market. It’s also a good idea to keep your experience level in mind. Try to find out beforehand what the pay grade is at the company and stress that it’s negotiable. If they want specifics, provide a ballpark figure.
What motivates you to be a nurse?
This question gives you the chance to prove that you’re passionate about what you do. Show that you’re motivated by ideals and a desire to help others, rather than things like money. Be specific and talk about past experiences that have motivated and inspired you.
Why are you leaving your current nursing job?
It’s important to be truthful but diplomatic when this question comes up. Don’t throw your previous employer under the bus because it makes you seem ungrateful. Some examples include wanting to move to another region, learn new skills or focus on a different clinical area. Talk about the new opportunities that this position will give you, rather than dwelling on negative aspects of your current job.
What do you find most challenging and rewarding about your work as a nurse?
It’s important to stay positive, even when you’re discussing the more challenging aspects of nursing. Talk about real experiences you’ve had in the past that have challenged you, but be sure to explain how you overcame or dealt a difficult situation. This question also gives you a chance to talk about your passion for nursing. Whether patient interaction, helping with the recovery process or some other aspect of nursing is what you find most rewarding, discuss your feelings and provide specific details of a rewarding situation you’ve encountered with a patient or family in the past.
Give an example of a major nursing care problem and how you addressed it.
Try to keep any anecdotes relevant to the workplace, rather than discussing personal details. Define the problem in a straightforward way, identify options and explain the solution you went with. Highlight any personal or professional skills that helped you handle the situation effectively.
Where do you see yourself as a nurse in five years?
You want your future employer to know that you are motivated and career-focused, so now is the time to explain why you are committed to nursing. Discuss new skills you want to acquire and any specific workplace goals you may have.
How has your nursing training and experience prepared you for this position?
When the interviewer asks this question, they’re looking to see whether you are qualified for the open position. Talk about any relevant experience you have, both during clinicals and in previous jobs. You can also discuss any relevant research projects you’ve worked on. If you don’t have much on-the-job experience that relates, it’s a good idea to mention coursework you’ve completed that prepares you for the role— just be sure to express your interest in expanding your experience to a new nursing area.
Nursing at CSP
No matter what kind of nursing jobs you’re interested in, earning a bachelor’s degree is a great way to stand out among other applicants. Concordia University, St. Paul offers an online degree designed for working RNs like you who are ready to advance their career and increase their earning potential. Build on your previous experience and become a leader in the field with our online RN to BS in Nursing program.
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Danielle LeVeck is a critical care nurse, doctoral student, nurse advocate, blogger, and social media influencer. Danielle institutes a comical, but straightforward approach in her writing to discuss issues in nursing. She strives to achieve her overarching goal of empowering and inspiring nurses from different backgrounds and encouraging all healthcare providers to work together. Find her blog at 
About the Author:
Lynn 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 
~Jessica
