As a nurse staying up to date on your continuing education is important. But there are often so many options that it can be hard to decide what is the best course of action. This post discusses continuing education for nurses so you can make the best decision for you.
What is Continuing Education?
Continuing Education is exactly how it sounds. It is basically education provided for adults after they have left the formal education system, consisting typically of short or part-time courses.
Most states require nurses to complete some form of continuing education every two to three years as a condition of licensure. Even if your state board does not require any education for continuing competence for renewal, you may still be required by your employer or nursing association for job-specific certifications. So all in all, continuing education for nurses is something you should count on being required.
Online Continuing Education for Nurses
One of my favorite ways to get my CE hours is online. These units allow me to take the hours when they best suit my schedule. I simply follow along with the courses, pass the quiz and evaluation and then print off my certificate. Nothing is easier for getting my CE hours.
Nursing CE is one of the best ways I have found to earn my CE hours. They make getting my hours done a breeze. I am able to filter the continuing education hours by state and my specialty so I can make sure I am taking the exact courses I need to maintain my license. They even have courses geared to individual states. Let’s say I was in Florida, I could take the Florida Laws and Rules course.
Free Continuing Education for Nurses
Nursing CE even has free continuing education courses available. With their free online CNE courses, you can easily and affordably earn credits from anywhere. Simply click on one of the free nursing CE courses, login and you’re on your way to earning your free credits. Once you’ve evaluated the course, print out your certificate and you have your credit hours. It is so simple!
Save on Continuing Education for Nurses
Do you need to get some continuing education hours completed? Nursing CE has a great deal going on right now just for FreshRN readers. Sign up for CE courses and use code FreshRN to save 20% off your total.
More Resources for Continuing Education for Nurses:
I’m a tall woman. At almost 6 feet tall, I often find it challenging to find scrub tops that fit correctly. And I know I am not alone in this. So I decided to put together a list of the best tall scrubs for women. I’ve already shared my Nurse Gear post but I wanted to focus on just tall scrubs for women in this post.
Hands down, my favorite scrub tops is Figs. Their One-Pocket Scrub top is stylish, fitted, and I don’t have to wear a shirt under it. It moves with me while still covering everything that needs to be covered. I also feel like I look pretty fly in them, NBD. However, they’re not cheap. I do believe are worth the investment. I highly recommend getting on their email list because they frequently email out discount codes. They also have a student program, where you get 20% off. These are lean and longer than others.
Comfy scrubs that actually fit well? Yes, please. Tried out Jockey Scrubs and I am impressed! I’m kind of big on having scrubs that fit me well because I think that looks professional. Too tight and it’s inappropriate, too loose and it’s sloppy. These Jockey Scrubs hit that balance perfectly. I didn’t even need an undershirt because the top was long, yet form-fitting enough for me. Score. This might be the longest and slimmest scrub top listed, although Figs is close.
Cherokee Infinity is my third choice for scrubs for tall women. They fit well and move with me. I do like to add an undershirt but that is not because I need it. I find they get really hot when you run around. I had a few shifts where we had codes and I was sweating and running around and noticed at the end of the day that my skin was irritated. I feel like I look great in them, but I realized I am not a huge dry fit fan for 12-hours. The undershirt helps to avoid any skin irritation.
I’ve worn Grey’s quite a bit in the past and they’re in my regular rotation. They’re by far the softest and snuggliest. However, if you sweat in them they get a bit heavy. I’ve had to get a size larger than usual in the tops just so they fit my longer torso, and because of that, they’re not as form fitting. They’re available at a ton of places, even the tall pants. The Grey’s do have a slightly higher price-point. I have a long torso, therefore the tops are a little short on me and I need to wear a tank top underneath. They can be kind of heavy.
Happy Nurses week to all my favorite nurses. After the success of last years giveaway, we are back with Nurses Week 2018 Freebies and Giveaway. Be sure to check out all the great freebies you can score and enter to win one of these amazing giveaways.
If you need Ideas for Nurses Week it is not too late to do something special for those nurses in your life.
Now on to this years goodies:
Nurses Week 2018 Freebies and Giveaway!
This list will be updated with more freebies and discounts as we get closer to the start of nurses week.
Disney loves their nurses. They are offering discounts to nurses at the Swan and Dolphins resorts. Be sure to also mention you are a nurse and use promo code DREAMS!
Save 25% on all orders through May 30th. Use promo code 25NURSESWEEK.
Nurses can take 35% off their purchases with license verification.
Puckett’s Restaurant & Grocery
If you’re a nurse and live in the Chattanooga area, Puckett’s will be honoring nurses with Nurse Breakfasts, starting on May 7th, for a discounted price.
25% off all of the CE hours on NursingCE.com – Normally, users would get 40+ CE hours with a one-time payment of just $39 but with this sale they can get all of these CE hours for less than $30. Enter coupon code NURSES at checkout to get 25% off. Sale ends this Saturday, May 12 at 11:59PM PST.
This year the title of the free webinar from the ANA is 2018 National Nurses Week Webinar: Emerging Technology and Its Impact on Nursing Practice. All nurses who pre-register and attend will receive one continuing education credit.
DrFirst is giving away 1 pair of Dansko or Merrell shoes each week in May.
Johnson & Johnson
CE webinar: The recorded presentation “Substance Abuse and Women” will provide information about the unique substance abuse risk factors for women. Host Susanne J. Pavlovich-Danis, MSN, RN, ARNP-C, CDE, CRRN, will discuss reproductive concerns and other issues.
CE course:“Knocking Out Pain Safely with PCA” focuses on patient-controlled analgesia risks and how nurses can ensure patients are protected from medication errors and will receive adequate pain control.
NurseWatches.com is a designer and retailer of fashionable and functional watches and accessories for nurses. They strive to provide customers with the latest styles and products at competitive prices. And get free shipping during nurses week with promo code NW18FREESHIP.
Two winners will receive their choice of watch from NurseWatches.com
Every so often a new product comes along that I get super excited about. Steth IO is one such product. Steth IO is dedicated to building technology to improve patient experience and outcomes. Our smartphone stethoscope uses the ubiquity of mobile phones with the power of machine learning to make the heart and lung exams more objective. Unlike traditional stethoscopes or expensive alternatives like echocardiograms, our product allows physicians to hear, visualize, and analyze heart and lung sounds for improved diagnoses.
Two nurses will win a Steth IO. *Must have an iPhone to use.
The Nurse’s Guide to Blogging was engineered for any nurse who is interested in blogging. It addresses many of the issues unique to the nursing profession including patient privacy, upholding the integrity of the profession, and understanding your unique value. If you’re a nurse and want to blog, this book is for you
Being a travel nurse is not easy. It is not for everyone. You move around a lot, have a harder time forming real relationships, and you may not always know what you are walking into. Recruiters can be helpful but how do you really know if they are just trying to make commission or if they are really trying to place you in the perfect spot? Wanderly helps take all the guesswork out of being a travel nurse. Wanderly sets themselves apart by allowing you to:
Search and compare fully detailed pay packages from leading agencies
Chat anonymously with recruiters and keep their information hidden until they’re ready to accept a job
Fill out a one-time application and use it for all jobs
Now let’s look at a day in the life of a travel nurse and see how Wanderly can help make it smoother.
Wake up: wait…where am I?
It’s your first day in a new assignment…new city, new climate, new time zone.
It’s important to give yourself a few days to settle into your new, temporary home. Who knows what hiccups you may experience (car trouble, for example). You should have some familiarity on how to get to your new job location and know the traffic patterns. Also, getting used to any time changes can be challenging so having some extra days to get acclimated will make a difference.
Get ready for work
Make sure you have your orientation paperwork ready for you first day. Make extra copies of licenses, certification, even TB and vaccine records. You never know when things will get lost in the shuffle. Get your uniform ready the day before, ensuring to consider any scrub color requirements. This will make day 1 at the hospital much less hectic and anxiety-ridden.
How do I find my way around?
Your Wanderly recruiter will have provided you with directions, a map of the hospital campus, and where you should be on your first day of orientation. Once again, it doesn’t hurt to go on a scavenger hunt the day before you start to learn your way to and from work…and also to know where orientation will begin. Sometimes, hospital orientation is not even on the hospital campus. It could be somewhere else! You don’t want to realize this 5 minutes before you show up. It will also be helpful to be provided with directions on how to get to your unit. If you can, take a moment during hospital orientation to navigate around the hospital and learn where your unit is located.
As a traveler, this is the truth. That’s why it is so important to have experience under your belt before you decide to travel. You need to be efficient and knowledgeable as a travel nurse because your orientation will be short. You need to have exposure to the disease processes that you will be caring for in your unit. Your Wanderly Recruiter will make sure you are the right fit for the job, not just throw you into one to fill a quota. Plus they are able to answer specific questions about your assignment so you don’t feel like you are walking into any major surprises.
During your brief unit orientation, you need to have lots of practice with the equipment including IV pumps, the electronic medical record, and documentation. You should learn how to look up policies and procedures. Learn how to look up providers and know how to get in touch with them for both routine and urgent needs. You know how to take care of patients but you need to know what the unit norms are in order to manage your day. Write down any questions that you think of along the way- even after your orientation. It’s important that you have any questions/concerns addressed as early as possible.
Meeting my new coworkers
More than likely, your nurse colleagues are going to be so happy to have you with them. Most travel nurses are going to work in units where the patient census is high and staffing is short. Meaning, you are going where you are really needed!
Be friendly. Introduce yourself- even to the physicians and providers. Let them know you are a traveler. Talk to fellow travel nurses- they may know the ropes a little more than you do. Ask your coworkers about popular places to eat, sightsee, visit. Most people are enthusiastic about telling people about their town. If you do come across a few negative nurses, do not take it personally. It’s important to still try and be positive. There will be some coworkers who will just be difficult. It may be helpful to just let them be. You will learn who your reliable team members are. Surround yourself with them as much as possible. Also, remember that your assignment is only temporary. If you run into any major problems, you can know that Wanderly is there to help you on assignment.
Trust your instincts
If you travel long enough, it is inevitable that you will come across a travel assignment where you find you are not treated fairly. You may be consistently assigned a patient ratio that is more than what other nurses have to take. You may be consistently given the sickest, highest acuity patients on the unit. You may find that the practices and culture in the hospital are unsafe. You will know, in your gut, when things are wrong. If you are concerned about your patient assignments and the safety of your patients, you need to speak up. Follow proper chain of command; go to your charge nurse or the nurse manager. If you feel uncomfortable with this, talk to your Wanderly nurse recruiter. Their job is to support you and they are there to have those crucial conversations if need be. This is your nursing license that you need to protect and it is ultimately up to you to speak up if you have concerns.
Make this experience an adventure
One of the reasons to chose travel nursing is you have an opportunity to get out and see the country! Wanderly shows you pay packages and benefits from leading agencies, so you can compare and choose what works best for you. Wherever your assignments take you, get out and explore the area you are living in. Learn the history, the culture, and the people who live in the area. Make the most of your days off! Talk to your colleagues about interesting places to go and things to do. This is also a great way to build a connection with your colleagues.
If the opportunity presents itself, travel with a friend. It can ease some of the anxiety and stress of traveling to a new place when you are not alone. Also, keep an open mind to learn about new practices or protocols while you are at work. You never know what ground-breaking research may be underway at your facility. Keep your eyes open and don’t be afraid to step out of your comfort zone.
Finishing your assignment
It seems as if you just started yesterday and before you know it, your assignment contract is coming to an end. If you are being offered an extension of your contract, your nurse recruiter or the nurse manager will let you know. After this, it is up to you to decide. If you decide to move on, it is important to leave on a good note. Thank your team members who helped you to feel welcome and appreciated, especially the nurse manager. You never know who you may work with in the future.
Leaving a lasting and good impression will keep opportunities open. Make sure you give yourself ample time in between assignments. Also, check with your recruiter to verify who is responsible for taking care of housing needs (ie, cancelling cable, power, etc). Make sure you are not leaving your housing a mess. Don’t be mean: leave it clean! Wanderly will even help you find furnished housing for your stay!
Start your first assignment
If you’d like to embark on your first travel assignment, check out Wanderly. Compare pay packages and benefits from agencies anonymously, fill out one application and skills checklist and then apply to as many jobs as you’d like. It’s a lot more efficient than filling out one for each and reaching out to different agencies individually. Wanderly is proud to offer affordable health, vision and dental insurance that travels with you from one assignment to the next regardless of switching agencies!
Being an ICU nurse sounds like a pretty cool job, doesn’t it? Really, any job with the word “intense” in the title sounds… well, intensely awesome. I’m here to dispel any doubt and inform you that yes, ICU nursing is pretty legit.
While it sounds cool, many are not aware of what ICU nurses actually do during a typical 12-hour shift.
From 2012-2016 I worked in a neurocritical care unit, and floated to the intensive care unit (ICU), cardiac intensive care, and step-down/intermediate care unit. I obtained my national critical care certification, and loved working there. Let’s go over how a typical shift in the critical care environment typically flows.
What do ICU Nurses Do?
Before you can take care of your patients, you have to learn about them, meet them and their families, and review their chart. Nurses share this information in a fast-paced discussion called “nursing report”. Let’s dive in!
Starting your shift – report
Report in the ICU takes 30 minutes, however you’re discussing only 2 patients during that time rather than 5-7 like you would in the med surg environment. (Interested in what a med surg nurse does? Check out my previous post on med surg nurses.)
Generally speaking, the information discussed report in an ICU consists of the following:
Name / attending and consulting physicians / Code status / allergies
Precautions like fall, seizure, infection prevention, bleeding, etc.
Chief complain / why they’re in the hospital
Past medical history and current status
For example, “the patient has a history of PAD, CAD, HTN, OSA, DM, hyperlipidemia, GERD, gout. They were admitting on 12/2 after being found down at home unresponsive. They were intubated in the field, started on Levophed, and a head CT showed a large ICH.”
Important events that have happened during the admission with corresponding diagnostics
For example, if they had a decreasing level of consciousness and the CT showed the left paraychamal ischemic stroke has increased in size from 5 cm to 7 cm, or a change in lung sounds and increase in WBC was noted so a chest xray was completed and showed pneumonia in the left lower lobe.
Assessment findings by body system
Neuro: LOC, cranial nerves, if they follow commands, movement and strength of extremities, sedation/pain medications that may impact assessment
Cardiovascular: cardiac rhythm and any changes, blood pressure and/or heart rate limits, drips/PRN meds needed, intravenous access
Pulmonary: breath sounds, O2 sats/respiratory rate, oxygen requirements, ventilator settings/ETT size and location if the patient is intubated, secretion from the oral cavity and via ETT suction catheter noting the color/thickness/frequency of suctioning
Gastrointestinal: how the patient is getting nutrition (oral vs. enteral vs. parenteral), size and location of any feeding tubes and corresponding flushes, type and rate of any tube feedings, or oral diet orders
Integumentary: any skin issues, wounds, or incisions
Genitourinary: how the patient voids, if an internal or external urinary catheter is being used, last bowel movement or if a rectal pouch or tube is required, if output it inadequate, adequate, or excessive
Activity order: strict bed rest vs. up to the chair vs. ambulation, and if therapy (physical/occupational/speech) is ordered
Pertinent and abnormal labs like the latest CMP/BMP, CBC, blood gases and trends
Questions to ask the medical or any other member of the health care team
Any psychosocial / family and support system concerns that may not be reflected in the chart
Important medication considerations
Weaning off vasoactive drips, transitioning to oral medications, electrolyte replacements, blood product administration, PRN meds needed and so forth
Pain management and goals
What are our goals this shift?
For example, getting an MRI, weaning off of a drip, transferring out of the ICU, family care conference, sedation holiday and hopefully an extubation
Another thing I do during this time is verify orders and corresponding alarms. I love my colleagues, but I trust no one when it comes to this! If the previous nurse said the goal is to keep the systolic blood pressure less than 160, but I look in the chart and it says less than 140 – we need to make sure we’re on the same page. Then, I check to make sure the bedside monitor has its alarms set to match the orders. That way, if I’m in my other patient’s room for an hour doing an extensive dressing change, bath, assessment, meds, and tubing changes, I will know if my other patient’s blood pressure is too high or too low because I’ve set my alarms appropriately.
During report, I’m checking to make sure my drips have enough volume in them for a few hours and aren’t going to run dry mid-med pass. I also check when tubing needs to be changed, and if my patients need to be changed.
Once I obtain report on all of my patients, I take a second to analyze which patient is the most unstable this moment. Does someone need a drip titrated? Are vitals within parameters? Is there a time-sensitive medication? Is their arterial line leveled and zeroed appropriately so I know their blood pressure on the bedside monitor is accurate? Does someone need an intervention right now?
ICU patients are not always going to be stable and things change so incredibly quickly; sometimes, it’s moment-to-moment… literally second-to-second. And occasionally, you are receiving report in the midst of a soon-to-be code, or urgent situation. Yes, shift change codes happen. You truly have to be ready to pivot any second.
Now, let’s say my patients are both relatively stable. Once I get report, I sit at a computer to fill in any questions left from report, collect my thoughts, and get my to-do list finalized.
This list includes:
A full assessment at least every 4 hours
A more focused assessment more frequently may be required. For example, most neuro patients require a full neuro assessment every 2, if not more frequently or a patient who just received a femoral-popileal graft may require more frequent peripheral vascular checks
My documentation requirements
Telemetry strip, education, care plan
Are all meds appropriate?
For example, if a patient is on a drip to RAISE their blood pressure, I need to see if they have any scheduled home medications intended to lower blood pressure,hold those, and clarify with the physician if they should be discontinued
If oral meds are due, can they be given orally?
Are the medications safe and necessary given the latest labs and diagnostics?
What are the trends?
Is the patient on a drip?
Frequency of blood sugar checks, sliding scale insulin, and/or scheduled
Any time-sensitive tasks
Usually, by this time it’s approximately 0800. I am permitted to administered my 0900 medications at 0800 so I’ll grab all meds and supplies for my first patient. I then grab all of my gear(stethoscope, alcohol swabs, saline flushes, brains, Sharpie, pens) and head into my first patient’s room
PS – if you want to see all of my recommended nurse gear from scrubs, to bags, to socks, to water bottles, check out what nurses need.
Assessing my patients
After I get everything I need, I head into my first patient’s room. I say hello to the patient and anyone else in the room and then complete a detailed nursing assessment. I’m looking over every inch of skin, at every piece of equipment (ventilator, enteral feeding pump, IV pumps, arterial line, central venous pressure monitoring, bedside monitor) as well as every tube coming out of the patient (endotracheal, urinary catheter, extraventricular drain, pacing wires, chest tubes, rectal tube, JP drain, arterial line, central venous catheters, IV catheters).
I complete the assessment, check out the equipment, lines, drains, airway, and monitoring, and then give meds. Many ICU patients receive meds through a feeding tube, so it can take some additional time to crush these, mix them appropriately, and flush them down, in additional to any IV push or an IV piggyback medications. Of course, throughout this process I’m watching their vitals and drips closely, to see if they are tolerating their medications.
Throughout this time, I’m talking to the patient and whomever is with them about what I’m doing, why I’m doing it, and what else to expect for the day. Providing any amount of predictiability for intensive care patients and loved ones is very valuable because they have lost all control over everything with their loved ones hospitalized, being taken care of by strangers.
Once I see this patient, I head in to see my other patient and follow the same process. In the med surg world of nursing, I would spend approximately 10 minutes with each patient between the assessment, conversation, medications, education, and documentation. In the ICU, you’re looking at more like 30-45 minutes each.
Constant monitoring and evaluation
ICU patients can change in a matter of moments, therefore it is the ICU nurse’s responsibility to keep a vigilant eye on them. One must know their vital sign and assessment trends to know when they’ve deviated.
Like I said before, instead of assessing a patient once per shift, an ICU nurse must complete a head to toe assessment on the patient typically at least every 4 hours. If changes occur, another one must be completed. If a procedure was performed or the patient went for surgery and came back, then assessments occur more frequently.
The ICU nurse must know their patient backwards and forwards. I’m talking vitals, labs, assessments, meds, history, lines, airway, equipment… everything. It’s crucial to know these things because when things go downhill, you don’t have time to put the clinical picture together in that moment.
You’re constantly asking yourself questions about the patient, whether the goal is to get them more stabilized and figure out what’s going on, or to progress them out of the ICU.
You will find yourself asking…
Can we wean this drip?
Is this patient suffering from ICU delirium, or is this a neuro change?
Should we switch this drip to a different one?
Do we need another CT scan, set of labs, MRI?
Is this medication even working?
Is this patient working harder to breathe?
Should we get another ABG?
Where’s respiratory? [spoiler alert: if you’re an ICU nurse, you’re going to become BFF’s with respiratory therapy]
What are our goals here? Is what we are doing in line with the patient’s advance directives?
Who is the next of kin?
Do we need an arterial line?
Do we need to get a central line?
Do we need to start dialysis?
Can you call respiratory again? I know they were just here 3 minutes ago… but, I need them again 🙂
Physicians round once per day and many times the ICU physicians are housed within the unit for constantly changing needs. However, it is still up to the bedside nurse who is constantly monitoring the patient to update the physician as needs change.
It’s no surprise that codes happen more frequently in the ICU. ICU nurses quickly become acclimated to those adrenaline-filled scenarios. ICU nurses know when a patient starts to not look so hot that things are about to go down. You become familiar with a code cart, the various roles within the code (chest compressions, meds, considerations, ACLS algorithms, and the person running the code). ICU nurses also know that some people will help with the code, while others have to continue to care for the rest of the unit who is not actively dying.
These happen unexpectedly, so ICU nurses must always try to stay caught up on their tasks because you never know when you, or your coworker, will be dealing with a coding patient for 2 hours. And, should the patient pass, once they have been taken to the funeral home or downstairs to the morgue, you’ll be open for the next admission… which, consequently, could be another code from a nursing floor or the emergency department.
That brings me to my next point: ICU nurses have to be ready to receive any patients who may code out in nursing units or stepdowns. (A patient who codes on a regular med surg floor has to be emergently transferred to an ICU bed once they are ready to move.) Because of this, a bed in the ICU must be ready for this… and it’s typically called “the code bed” because it’s reserved for that unexpected patient.
As you can imagine, documentation for an ICU nurse is incredibly detailed. In addition to all that the med surg nurse must document, you’ve got to document even more in the ICU. Some patients get vitals every 15 minutes (or even more frequently), you’ve got more detailed assessments which occur more often. Some patients change frequently, and these changes must be reflected within the documentation. Also, patients typically have many invasive lines and it is paramount to prevent infection. Therefore, you’ve got to meticulously document what you’ve done to clean and prevent infection, as well as that you’ve reviewed its necessity.
After working on both med surg and the ICU side, I can confidently say that the amount of time it took for me to document on one of my ICU patients is equivalent to 2.5-3 med surg patients.
Furthering the care plan – working towards transfer
While the med surg nurse’s goal is discharge, the ICU nurse’s goal is transferring the patient out of ICU. We’ve got to note the medical diagnoses, consider our nursing diagnoses (yes, you actually use these whether you realize it or not!), and progress them to a point in which they don’t need constant monitoring.
Do we need to increase their cardiac output? Do we need to transition them from drips to oral medications? Do they need some fluids, or do they need a beta blocker to increase the efficiency of their cardiac contractions? Is there an electrolyte imbalance that needs correction? Will that help with our cardiac output? [Spoiler alert: yes.] Do we need to increase gas exchange? Does that mean we’ve got to do some pulmonary toileting and increase activity to attempt to wean the oxygen down?
There is a lot to consider, all at once, in a very fast-paced, constantly-changing environment. Being a new grad nurse in an ICU can kind of feel like…
But it’s okay, it gets better! (Overwhelmed? Check out tips for aNew Grad Nurse, it might help.)
It’s also important to get them out of the ICU as fast as possible because of something called ICU Delirium. Basically, when a patient is critically ill, in a different environment, receiving many different treatments, medications, and interventions, hearing many different alarms, buzzes, and sounds while being cared for by strangers, it is terrifying and people become delirious. People who seem totally fine neurologically can suffer from this, and it may impact individuals years later and result in long-term cognitive impairment and PTSD. This is another reason why it is crucial to transfer patients out of the ICU as soon as it is medically appropriate.
Physicians and their support staff round on their patients once a day, but it’s a little different in the ICU. Because things change so quickly, ICU nurses are chatting with the providers more frequently than on the floor. In addition to rounds, you’re updating the physician whenever the patient declines or new needs arise.
In the ICU environment, it’s a bit more realistic to be present for when physicians and their APP round because you’re balancing 1-2 patients rather than 4 or more. It’s also really helpful to do this because you hear what the physician is telling the family, so you can reinforce this information throughout the shift.
Like med surg units, this rounding is done during day shift, which means routine order changes, transfers, and scheduled post-op patients arrive during day shift. New orders will typically only come through on night shift when acute changes occur.
Interdisciplinary rounds occur daily as well in many facilities. The attending physician, the nursing staff, therapy services (PT/OT/ST), chaplain, dietician, pharmacy, case management, social work, and nursing leadership typically go through each patient and their needs.
While discharges are a big focus for med surg nurses, admissions are more of a focal point for the ICU nurse. An ICU admission is typically an unstable patient who needs the typical tasks completed like (good IV access, admission documentation, med administration), a very solid baseline assessment, labs/diagnostics, and so forth. But they also need to be stabilized FIRST! Stabilization is the key!
In the med surg world, a patient coming to that unit must be stable enough for the nurse to patient ratio, only having 1 assessment per shift, and vitals that are [typically] only done every 4 hours. This is not the case in the ICU. Your next admission could be an actively coding patient, one who was just coded, or someone on the brink of a instability. The patient could have very little going on, or they could be hooked up to 8 IV pumps, a ventilator, CRRT (continuous renal replacement therapy) machine, an arterial line, and more. For the level of unpredictability you may have in med surg nursing, it’s significantly increased in the ICU.
In addition to transfers when patients are ready, there’s another piece to the puzzle. Sometimes, the ICU is full and there is no room to admit another patient. However, you get a call that there is a patient who needs to come who is incredibly unstable and must be in the ICU.
What do you do?
Well, what happens is one patient must be transferred to another ICU with open beds, or the nursing staff (or medical staff if it’s a closed unit) must analyze which patient is most appropriate to transfer out to either stepdown or the floor to make room for this new patient. You may be in the situation in which you have to urgently give report to another unit to get one patient out, only to get a much sicker patient back.
Dealing with death
Patient die in all areas of the hospital, but it’s a bit different for ICU nurses. It’s more frequent than many other units (with the exception of possibly oncology and hospice, respectively), and can be pretty… well, ugly and traumatic. Patients die after long and brutal codes, after sudden injuries, at any age, both expectedly and completely out of the blue.
In nursing school, we learned a lot about advanced directives. I remember thinking to myself that the likelihood I’d ever need to pull one out for a patient to actually follow it was slim to nothing. When I started working in neurocritical care, I realized how often this is actually done. You may find yourself, as an ICU nurse, pulling up a patient’s advanced directive to have a difficult conversation.
Dealing with trauma and death on a routine basis does take an emotional toll on an individual. Therefore, if you’re considering ICU nursing, I highly recommend getting set up with a counselor to emotionally process work in a healthy way. I know many ICU nurses, myself included, who see a professional to work through all of the tragedy with someone objective and also to develop healthy coping and processing techniques.
After 12 hours of assessing, monitoring, pivoting, stabilizing, tweaking, educating, and documenting, it’s time to give report to the next shift. Sometimes, you feel like you’ve run 20 miles all around the unit, and you get to report and feel like it looks like you’ve done nothing all shift. It can be a little defeating. But, what’s important is that the tasks that needed to get done for the patient are completed. Documentation is important, but it’s not more important than providing the in-the-moment, time sensitive care to the patient. So, if someone tries to make you feel bad for not getting that admit navigator done when you’ve been running around drawing labs, hanging fluids, starting IVs, and getting CT scans, don’t trip. Rest in the reassurance that you’ve done the tasks that needed to be done for the patient in that moment and you are only 1 person who cannot do 50 tasks at once.
Another thing that I felt was unique to my experience in ICU versus med surg nursing was the shear amount of adrenaline and how it took time for me to calm down after a shift. Med surg was challenging and exhausting, but when you’re regularly dealing with urgent or emergent situations, it’s hard to just turn that off after you clock out.
Like a workout, it’s helpful to have a post-work cool down routine.
Nurses typically get off work at 7:30 pm at the earliest and may have to be up again at 5:00 am for the next shift. The sooner you can relax and calm down post-shift, the better you will sleep, and the more mentally prepared you will be for your next shift.
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.
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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!
NRSNG Academy is primarily an NCLEX resource, but there is a ton of information applicable for the new ICU nurse. The EKG, Lab Course and MedMaster Course are particularly applicable to this group. They go in depth on mechanism of action, nursing considerations, contraindications, and more within MedMaster. The EKG Course dives deep into each rhythm, nursing considerations, pathophysiologically and electrically what’s occurring, and more. The Lab Coursedoes a deep dive into specifically what each lab is measuring, why it’s important, and more. You can even get a 7 day trial of NRSNG Academy for only $1. It includes all these courses and more.
Maybe you’re trying to figure out if you want to go to nursing school… maybe you’re in school and not sure of where you want to work… or maybe you’re an experienced nurse looking to change things up. Many have heard of med surg nursing, but are not sure what med surg nurses actually do during a typical shift.
Well, you’ve come to the right place! Let’s walk through a typical shift on my [cardiac] med-surg unit.
What Do Med Surg Nurses Do?
Starting your shift – report
Like many other areas of nursing, the med surg nurse will begin his or her shift in report. The off-going nurses share information with the oncoming nurses about their patients. The number of patients a med surg nurse nurse will care for during the shift will vary depending up the state and facility in which you work.
A good nurse to patient ratio on a med surg unit, in my personal experience at the bedside, is 4 patients to 1 nurse. With 4 patients, I can keep information about them straight easily, have enough time to see each one and not feel rushed through interactions to get my other patient’s medications and tasks addressed. I’ve seen ratios as high as 1 nurse to 7, 8, and 9 patients on med surg units, however. Therefore, if you’re looking to become a med surg nurse, make sure you ask about the nurse to patient ratios in the interview because they can vary widely.
Report typically lasts about 30 minutes, so around 5 minutes per patient plus some time to have a short huddle of the entire shift of nursing staff members, and some time to find each nurse to obtain report from.
Here is a video example of me giving report on a fictional med surg patient:
Generally speaking, the information discussed report on a med surg unit consists of the following:
Chief complain / why they’re in the hospital and important things that have happened during the admission
Pertinent history (it’ll take time to figure out what pertinent and not, don’t get hung up on this one. You’ll also figure out, with time, shorthand/abbreviations for history)
Abnormal assessment findings from body systems (do not waste time going through normal information)
If they’re on oxygen and how much via which delivery method and if that’s changed recently (nasal cannula, face mask, non-rebreather, etc.)
Any tubes (feeding tubes, foley catheter, rectal tube, etc.)
Intravenous access (IV, central line, port, etc.)
IV fluids / drips / anything continuously infusing
Activity level / how they go to the bathroom
Pertinent / abnormal labs
Questions to ask MD / questions for any other member of the health care team
Any psychosocial / family + support system concerns
Important meds (you can look up this stuff in the chart, but they may mention some meds)
Any tests, procedures, transfers, etc. that need to occur during this shift
General discharge plan / what are our goals this shift? (get out of bed 3 times, eat, pass swallow evaluation, transfer out of ICU, etc.)
As the oncoming nurse, you will be RECEIVING all of this information and need to be aware of it throughout your shift. At the end of the day, you will provide it to the night shift.
It’s a lot of information in a short amount of time. A good report sheet is really helpful as well because you will not memorize all of this information! Here’s a great resource of 33 free PDF’s ofnursing brain sheets. (Yes, the one I use is in there!)
Once I obtain report on all of my patients, I need to collect my thoughts for a few minutes. Provided everyone is stable and no one needs anything urgently, I’ll find a computer and start looking up additional information in the chart. I look up any questions from report about missing information (for example a lab value, if a certain test has come back yet, if a scan scheduled later, if physical therapy is ordered).
I also spend this time organizing my to-do list for the day.
This list includes:
My documentation requirements
Assessment, telemetry strip, education, care plan, IV and pain assessments
Medication due times
At this time I also am ensuring all medications are appropriate to give and if any need to be held
How often they’re ordered and their trends
Their ordered parameters for vitals (keep their systolic less than 160 and use PRN meds to keep it below that)
Blood sugar checks
How often, if there is sliding scale or scheduled insulin, how they’re been running
Follow-up labs based off a drip, continuous infusions, and weaning parameters – below are some examples
PTT or Anti-Xa for a heparin drip
Cardizem or Amiodarone drips, noting their heart rate, blood pressure, and cardiac rhythm
Enteral feedings, noting the ordered goal rate, residuals, bolus vs. intermittent feedings
TPN, noting its necessity, access point, and blood sugar monitoring
Questions for the rounding provider(s) – below are some examples
The patient is eating and drinking well, would you like to discontinue their IV fluids?
The patient has 20 mEq potassium PO BID scheduled, but her K+ on her BMP this morning was 5.5, would you like to discontinue it?
The patient has not had had cardiac events in 5 days, may we discontinue the order for cardiac monitoring?
The patient does not seem to be tolerating their diet and I’m concerned about aspiration. Can we order a speech evaluation?
The patient has refused their Nicoderm patch for the last 5 days, can we discontinue the order?
The patient’s IV antibiotics have been completed and appears to have decent options for peripheral IV access. Would you like to remove the central line?
This takes around 10-15 minutes to get everything together. I make sure my brains are well organized with information and to-do checklist for each patient, I have what I need in my pockets (alcohol swabs, saline flushes, Sharpie, pen, brains, unit phone), and a full bottle of water, and get ready to begin my day!
(If you want to see all of my recommended nurse gear from scrubs, to bags, to socks, to water bottles, check out mynurse gear master post.)
Seeing my patients
After I’m all geared up, I decide which patient I will see first. What influences this decision depends on if anyone has a time-sensitive medication (like insulin) or needs to get off the unit ASAP (for something like dialysis or some other off-unit procedure). If someone is leaving the unit, I’ve got to visit them first.
Basically, I need to see every single patient and complete a nursing assessment on them. This consists of a basic assessment of each body system, focusing on areas of concern if needed. This only takes a minute or two, depending on what’s going on with the patient. I’ll start with asking basic orientation questions, listen to heart/lung/bowel sounds, look at skin, feel pulses, look incisions/wounds, ask about pain, elimination, ambulation, and a few more things.
After I’ve completed my assessment, I then administer their scheduled medications and see if any as needed (or PRN) medications are needed. These meds can be things like pain meds, nausea meds, stool softeners, and more.
I then see if the patient needs anything specific from me, and discuss the plan of care / plan for the day with them and their loved one(s) briefly.
“So, I’d like to go over the plan for the day with you. Currently, the plan for today will be to not eat or drink anything until the cardiologist comes by and takes a look at you. He or she will determine if we need to go for that ultrasound called a transesophageal echocardiogram later today to get a better look at your heart. Your labs should be back for them to look at, and they will look at that ECG that was just taken as well as the heart monitor that was on overnight. I will give you your normal medications with sips of water this morning, but that’s about all you can have to drink until we hear more. I know that was a lot of information. What questions do you have for me?”
Assessment, medications, education, repeat
I basically do this routine with my entire patient load. If I find something alarming or concerning in my assessment, labs, monitoring, or in talking to the patient, I alert the physician or the advanced practice provider (abbreviated as an APP, meaning a nurse practitioner or physician assistant).
Pro-tip: don’t call nurse practitioners or physician assistants midlevels or physician extenders. Some don’t care, but many really don’t like that. Here’s an articlewith a little more information about why.
As the nurse at the bedside, I’m the one who’s responsible for monitoring the patient all day. While the provider (physician, physician assistant, nurse practitioner) rounds once a day for a few minutes, I’m there the rest of the time. They are relying on me and my clinical judgement to communicate any concerns promptly.
As you can imagine, I have to be somewhat speedy when seeing all of my patients to make sure everything is completed on time (4 people have 9:00 am medications due and I am one person who is responsible for administering them all before 10:00 am). Not only do I have to assess, give meds, and education, I have to document it all.
I have a love-hate relationship with documentation. I loathe documenting because it takes up so much time and is frustrating. However, when I’m trying to figure out what’s going on with a patient, I rely on documentation to do so. If the previous nurse didn’t chart the meds, blood pressures, or assessment findings, I can’t compare it with what I’ve done or my current issues and concerns.
Sadly, documentation is a necessary evil.
Furthering the care plan – working towards discharge
In addition to rocking out awesome assessments and safely administering medications, med surg nurses are also focused on furthering the patient’s care plan and getting them safely discharged.
During my time in intensive care, discharge was not a big part of report or my hour-to-hour tasks. While we took note of potential discharge needs, it was not a focal point because their needs were still pretty up in the air due to current circumstances. Med surg nursing is different – we are pretty focused on discharge about when and how we are going to do so safely.
Discharge can be smooth as silk or pretty tricky. Some patients have great support systems, some don’t, some have significant financial concerns, transportation issues, health literacy issues, and more. There can be quite a few things to get into place when trying to get a patient home. Med surg nurses work closely with case management and social work to help facilitate discharge to help address concerns or get patients to another facility if needed.
Med surg nurses are also working even closer with physical, occupational, and speech therapy because their assessments recommendations are required for insurance purposes to get things covered (like nursing home stays, rehab, home health, medical requirement) by insurance.
Rounding – the entire team
The typical routine during day shift is that the attending and consulting physicians and their support staff round on their patients.
What are rounds? When a physician and/or advanced practice provider sees, assess, write orders, and document a progress note on their patients
This means that most patients are being seen by their provider during day shift. This is typically when most orders changes occur. Patients may be discharged, medication changes, activity order changes, procedures, new dressing changes, removing tubes or lines, and so forth.
This is an important time because you know the providers will be rounding, so you can address non-urgent needs at this time, provided they touch base with. Because you have 4+ patients, it’s not a guarantee that you’ll be in the patient’s room when the providers round. You know you’re working with an awesome and efficient provider when they take the time to call/find you during rounds to update you and see if you have any needs.
If you work in a teaching hospital, you may also work with residents. They may “pre-round” early in the morning to see their patients and get themselves ready for rounds with their attending (the physician they report to during their training). They may come by and ask you questions and touch base at this time, and then again later with the rest of the team.
Any other consulted member of the health care team may also round. This means physical therapy, occupational therapy, speech therapy, case management, pharmacy, social work, dietitians, chaplains, and so forth.
You may have to participate in interdisciplinary rounds as well. This is when the entire health care team gets together and rounds on the patients in the unit. From the med surg perspective, rounds are typically more discharge-focused than in the critical care setting. This means that you have to manage your time appropriately to be available for these rounds also.
As you can imagine, it’s a lot to coordinate for one patient – let alone 5 or more. I have to carry a phone with me throughout the shift so people can speak to me as needed without searching the entire unit for me. I feel like it rings every 5 minutes. If I have 5 patients and they all have a medical team, PT, OT, and case management, that’s at minimal 20 calls right there.
But let’s be realistic – it ends up being much more than that!
Admissions, transfers, discharges, oh my!
Another important aspect of the med surg level of care is discharge planning.
Things med surg nurses do in regards to discharges:
Work closely with case management (CM), social work (SW), therapy services, etc., to ensure the patient is safe to go home
Provide detailed discharge instructions and teaching
Ensure patient can obtain discharge prescriptions
Facilitate transportation (typically with CM/SW)
Facilitate obtaining getting any financial assistance (typically with CM/SW)
Ensure all needed discharge orders are placed
Ensuring all core measures / required documentation / required education has occurred
Facilitate transfers to other facilities like nursing homes, skilled nursing facilities, rehab (again, typically with CM/SW)
Teach the patient about wound care, taking meds, eating, bathing/showering, follow-up appointments and lab draws, contact information
Oh, and documenting ALL OF THAT.
Once you get a patient out the door, typically there’s another one waiting to come to your unit. There is quite a bit of turnover on a med surg unit. As patients are discharged, others fill their place. While I may start a shift with 4-5 patients, I may discharge 2 and get different 2 back.
Admissions have their own set of documentation requirements, assessments, medications, and orders. Transfers (typically a patient who was in intensive care who no longer needs close monitoring is “downgraded” to a med surg unit) also occur, but typically have less paperwork because it’s all been taken care of in critical care or another unit.
It is a safe assumption that if the unit you’re working on a unit with a 4:1 or 5:1 nurse to patient ratio, that you will most likely always have 4-5 patients. Nursing units have to adjust their staff based on the amount of patients on the unit. So, you won’t have days where you only have 1-2 patients because if that were the case, they would either send a nurse home and give the other nurses the additional patients, or send that nurse to another unit who needs another nurse.
I wish we always had the same number of nurses every shift so nurses weren’t always constantly busy, thus enabling us to do things like check our email, complete education and trainings, and simply be more present… however, that’s not the case.
Towards the end of the shift (a mere 11 hours later…) you start to consider concerns for night shift (or the next shift) and make sure all routine needs for the physician have been addressed.
Pro-tip: it is not cool to call a physician or APP at midnight for a non-urgent need that could have been addressed during the day with the attending physician. They will almost always tell you to wait until the next day when the patient’s normal physician is on because it is much more appropriately addressed by them. Nursing school teaches you to notify and clarify about many things with the physician, but doesn’t necessarily go over when. I dive deep into this topic in my book.
The end of the shift includes ensuring all tasks and required documentation were completed. This includes care plan documentation, education, and incident reports if they were necessary. Nurses must document how they educated their patients and how they furthered (or attempted to further) the patient’s plan of care safely towards discharge.
You also begin getting ready for report. Now that your shift is coming to a close you will provide a short, yet detailed, report to the oncoming nurses caring for your patients. Nursing care is a continuous process. Some days you’ll have a crazy shift and won’t have finished that admission navigator, discontinued that non-essential order, remembered to ask that one question, or perfectly tucked and fluffed all of your patients. Some days, you’ll be thankful to have everyone’s meds passed and bare minimum documentation completed… while other days, you’ll be early or on time with everything and have all of your patients ready to go for the next shift.
Each shift if different, patients are dynamic, and things in an instant. Ah, the nurse life.
Alright guys, my work here [for the last 12 hours] is done…
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!
ADN vs. BSN – a nurse’s thoughts on the New York bill requiring a BSN in 10
In December 2017,New York State signed a bill that requires all newly licensed nurses with their Associates Degree in Nursing (ADN) to obtain their Bachelors of Science in Nursing (BSN) within 10 years of their initial licensure. (Here is a link to an article explaining this in more detail.)
When this news hit, the nursing community had a pretty polarizing response across social media. While some were excited for the education advancement, others were pretty upset. As an experienced nurse, I’d like to explain a little of the background and offer my thoughts.
Why (some) people are happy about it
Many feel that requiring the BSN degree continues to legitimize and increase the professionalism of nursing.
When you look at the health care team, nurses have the lowest educational requirement for an entry-level position next to respiratory therapy.
See below for the entry-level requirements for the other health care team members:
Physician – medical degree
Advanced practice provider (NP/PA) – graduate degree
Pharmacist – doctorate degree
Physical therapist – doctorate degree
Occupational therapist – master’s degree
Speech therapist – master’s degree
Chaplain – bachelor’s degree for entry-level, but to work in a hospital most have a Master’s of Divinity with additional certifications in crisis support
Social work – bachelor’s, many with master’s
Case management – bachelor’s (in some instances, an ADN-prepared RN)
Many feel that if the nurse is the leader of the health care team, that there should be only one option for entry-level practice. And given the complexity of nursing care today, many also feel the minimum requirement should be a bachelor’s degree.
Without getting into the research of why a BSN should be required, the legislation in New York noted several reasons. Supporting literature noted that because of increasing complexity of the American healthcare system, and rapidly expanding technology, the educational preparation of the RN must be expanded. – Jennifer Mensik, PhD RN FAAN
There is also research to suggest that hospitals with more BSN-prepared nurses have better outcomes as well.
Why (some) people are really not happy about it
Many individuals feel that the ADN who is fresh out of school is not more clinically-prepared than the BSN-prepared nurse. Many health care facilities also do not pay nurses more for having a BSN. Rather, they offer a clinical ladder option which enables the nurse to be paid more for achieving certain professional development goals, and this typically includes a BSN.
Therefore, the argument is: why should anyone spend more money and more time to get a degree in which it doesn’t appear to put them ahead of the curve clinically, nor does it offer more money?
Many bedside nurses also work elbow-to-elbow with incredibly intelligent and amazing nurses who have their ADN. It can also feel pretty insulting to someone who has been an awesome nurse for the last 20 years with an ADN only to be told they have to go back to school on their own dime… when a fresh newbie nurse with a BSN who doesn’t know the basics yet is just fine.
And finally, the main difference between the ADN degree and the BSN degree has to do with the additional credit hours. These additional courses tend to be more research-based or increased requirements in pre-requisite (IE not nursing) courses. Again, why pay thousands of dollars for a research course, community health course, and some pre-req’s that have nothing to do with nursing?
Oh, and did I mention the whole nursing shortage thing? We’re already struggling for nurses, and now we’re going to up the requirement to become one? Humm…
Also, the inflation of higher education, and how it is substantially higher than the increase in personal incomes and the general inflation rate. It is becoming more and more expensive to have a bachelor’s degree, and for many – they simply cannot afford to to take on additional debt… especially when it will not necessarily increase their pay.
How I feel about it
First, I want to give you some background on myself… I’m a BSN-prepared nurses working on my MSN, who has worked at the bedside in both critical care and floor nursing with ADN, BSN, and even MSN-prepared nurses at the bedside. I never started with an ADN.
When I think about this ideally
I think it makes sense for the minimum requirement of a bedside nurse to at least be a bachelor’s degree. With the amount of information I need to know to be successful at the bedside, as well as the fact that technology and research will continue to advance as patients become more complex… a 4-semester / 70 credit hour degree isn’t going to cut it. Especially when I think 10 years down the line.
When I think forward, to 2030… 2040… 2050, do I believe should we make some progress towards more education for entry-level for into our continually evolving profession?
I also can’t deny the research that has come out over the years, nor the efforts of organizations to have this come to fruition.
I think it makes sense… ideally.
When I think about this practically
Now, when I sit down and think about the fact that we’re in the midst of a nursing shortage… that college is becoming more and more expensiveeach year, while income and inflation don’t hold a candle do it… and that we don’t have enough nurses as it is today… how can we start get picky now?
I think about the nurse with 3 kids, a mortgage, a car payment, and student loans from the associate’s degree… the nurse who works overtime, is the head of committees, the best damn nurse on the unit, who has saved countless lives, and works himself to the bone just to make ends meet. Should he have to take on more debt, and spend less time with his kids, all to just have 3 different letters behind his name and not make a dime more?
That doesn’t seem fair to me.
While I think we need to progress in our educational requirements, I don’t know how we can do so while we’re barely holding our heads above water. I feel like some facilities are struggling so much for nurses that by upping the entry-level requirement to BSN, we’re handing them a 20 lb weight. And they’re just going to start sinking.
But… I don’t think that’s where all progress should go. I think we need to step back a bit as well.
What I think the BSN should look like
If an individual knows they want to become a nurse, I believe the core curriculum should change.
As I mentioned before, a typical ADN program is approximately 4 full-time semesters or 70 credit hours. A typical BSN program is approximately around 120 credit hours. The difference in the courses is usually a few nursing courses (like a research course and maybe community health) but also more requirements for pre-requisites.
Now, that seems just silly to me. More pre-req’s? Some of my pre-req’s were… well, completely unnecessary to my career as a nurse. I took a music theory course, film appreciation, and some computer courses.
I personally don’t believe that the first two years of a BSN should look like another major. While the core prerequisites (microbiology, anatomy and physiology, chemistry, nutrition, sociology, psychology, developmental psychology, and so forth) should remain, I think there should be different courses required for the nurse seeking a BSN.
I also believe the BSN courses should be less NCLEX-focused and more centered on practical-preparedness.
I would love to see courses like:
Health care policy and law – because it is constantly changing
Evidence-based practice – one course on what it is, another on how to evaluate and implement it
An entire course on lab values
An entire course on just anatomy and electrophysiology of the heart and cardiac medications
An entire course on the respiratory system
Time management / delegation / prioritization
Theoretically, if a nursing school had 6 full-time semesters to prepare a someone to become a registered nurse (and let’s just say 2 semesters of those science-pre-req’s) they wouldn’t be so pressed for time to ensure the graduate passes the NCLEX and would be able to spend more time preparing the student for actual practice.
I feel that nursing education has strayed from truly preparing students for practice and focused more on NCLEX pass rates. I get it – the school must be able to demonstrate that graduates of their school can pass boards… and while that is an admirable focus, it’s not all there is.
Hospitals now have residency programs to facilitate the transition to practice for a graduate nurse because the learning curve is so steep… but why is that the case? Why is the nurse who has graduated from an accredited nursing school, with thousands and thousands of dollars in debt, not practically prepared? I believe in residency programs, but I also believe in more of a partnership between nursing schools and health care facilities to make this transition smoother.
I believe the that requiring a BSN as an entry-level degree for the profession of nursing is a good thing, provided that there are improvements to the existing BSN educational requirements that would enable the graduate to not only pass the NCLEX but also feel confident providing patient care after graduation.
Better for our patients and our profession?
In my opinion – absolutely.
What are your thoughts about this new legislation?
Most posts about social media for nurses focus on don’ts and the fear factor…
OMG YOU’LL GET FIRED! DON’T’ DO IT!
But, let’s be real. Most nurses use social media. Most people use social media. Heck, try to walk down a hospital hallway and NOT see someone in scrubs on some form of social.
Instead of telling you all of the scary you’ll-get-fired-scenarios, I want to chat about ways to use social media to enhance your professional experience.
Tips to Maximize Social Media for Nurses
But first, like everything in nursing… we’ve gotta look at the policy FIRST!
Look at your facility’s social media policy
Would you ever administer intrathecal vancomycin, administer tPA in a central venous catheter, or insert an internal urinary drainage device without looking at a policy? I hope not! Using social media is the same, especially if you’re using it while at work.
Social media is a POWERFUL tool. It can help bring new research to light faster, disseminate information, inspire, encourage, educate… but, like most things, there is the potential for harm as well. HIPAA violations is a major potential for harm, as well as lateral violence.
Hopefully your facility has a social media policy. If they don’t, propose one!
If they do, make sure you look at it closely. You don’t want to do anything that may violate this. All social media policies are not created equal. I’ve seen various policies with big differences and it’s important to be aware of these things. For example, some may say you can’t post while at work while others don’t outline that. Some may say you cannot post on social where you are employed. Many say you cannot take and post photographs, violate HIPAA, or communicate with patients/loved ones via social media.
Basically, if you have concerns about getting fired, it is essential that you are well aware of the specifics of this policy.
Essentially, the message from the professional nursing organizations isn’t don’t use social media. Their message is use social media responsibly.
Follow interesting medical and nursing accounts
I believe a lot of people think social media is just for entertainment, but there is a ton of professional value that can be extracted. Have you ever checked out Figure 1 on Instagram?
It’s incredible. They upload various medical conditions and cases. You can download their free app and discuss it with other healthcare professionals all around the world within the app, and follow them on social media as well. I love that when I’m scrolling through my IG feed that some cool and interesting medical case comes up. I’ve actually learned a few things that I’ve used in practice when discussing the clinical picture with the physician.
There’s no need to wait until the next major nursing conference to see what major medical facilities are up to. Go follow Cleveland Clinic, Mayo, John Hopkins, or whomever you think is awesome. It’s great when Cleveland Clinic tweets out some nursing research they just published, or a news article from John Hopkins about a new procedure… but what’s even better is when this is weaved into your existing social media that you’re already looking at.
I’m also really interested in neurosciences, so I follow various neuroscience accounts on Instagram and Twitter. I love seeing a random head CT in my Twitter feed! I also follow quite a few emergency department/critical care physicians and EMT’s who regularly post really short videos of ultrasounds with interesting findings, ECG’s, telemetry monitors, CT’s, MRI’s, and more. Seriously. Amazing.
Go check them out! I promise you will learn something new!
Pro-tip! if I’m not sure who to follow, I go to someone who I like and enjoy and see who they are following. Unless they’re following over 2K people, I tend to go look closely at who they’ve chosen to get updates from because clearly I trust their judgement.
At the end of this blog post, I have a long list of people I recommend following! Or you can just check me out on social and see who I’m following. That’s basically how I came up with that list. Follow me on:
One of the best ways to find interesting things that are specific to you is by checking out a hashtag on that particular social media channel. For example, if I wanted to see some examples of ECG’s with ST elevation, I could hop on Twitter and search #STelevation. Go and do it right now. Seriously.
You can do that on Instagram as well. Facebook isn’t so awesome for hashtags, but you get the picture. Hashtags are essentially a way to group things. So, think about something you’d like to see and search the hashtag (nurses, nursing, nursing school, nurse authors, neuro ICU, neurocritical care, etc.)
Share with colleagues
When you find something cool, share it! You can share things privately or publicly. Some of my neuro buds will find a great neuro article and tag me when they tweet it out. Or, you can share it on your Facebook timeline and tag people, or directly on another’s timeline, both ensure they see it. It’s a great way to quickly share information where people are already looking.
Some of you may even have a unit Facebook Page to share it to – bonus points! If it’s not a policy violation, I recommend creating one. On Facebook, you have the option of creating secret groups. You can create a secret group and invite the employees one by one. You can post education updates, when you are in need of staff, when a due date is coming up, cool events in town, interesting articles related to your patient population, staff life updates (having a baby, birthday, moving, promotions). It’s just important that someone is monitoring the page diligently. You don’t want people posting anything inappropriate, a HIPAA violation (“Is Mr. Jenkins in bed 4 still there!? UGH!”) or anything that may be lateral violence. You also want someone in charge of revoking access if someone leaves the unit and adding newbies.
Everyone is watching
And make sure to keep in mind, everyone is watching. How many of you seen someone post something reckless on social, but didn’t say anything?
Most of the time, people don’t say “Heyyyy Kati… that wasn’t cool” – their opinion of you just changes. Your credibility just changes. You reputation just changes. You don’t feel it, but it happens.
And even if you have great privacy settings, someone could screenshot and share what you’ve said (seriously… seen this happen). Even if you don’t mention someone’s name specifically, but describe a scenario in a detailed manner, you may be engaging in lateral violence or a HIPAA violation.
Pro-tip: have the mentality that anyone could see what you’re posting… from your nurse colleague, to your manager, to your chief nursing officer, to the physicians, to your patient, to your patient’s mother, to the CEO of your hospital… literally everyone… and consider if you would be okay with them seeing that, and using that as a filter, then you should be safe (provided you’re not violating policy.)
Yes, it’s your social media outlet and you technically can do what you want from it. What you choose to post however, impacts your reputation and what people think about you. And if you publicly identify as a nurse, what you say reflects on our profession… and what the public thinks about our profession.
Have no shame in your unfollow game
One of the great things about social media is that it is customized to you and what you want to see. You follow who you want to follow. It is your timeline, no one else’s. Therefore, I am very unapologetic about unfollowing. If someone posts something really mean, inappropriate, gross, or whatever… CLICK unfollow. I don’t need to see that on my precious timeline.
Facebook tip: for those of you tired of seeing the very polarizing or rude posts of various friends, but don’t want to unfriend them and deal with that… simply “unfollow” them. They will not get a notification, you just won’t see their posts in your timeline anymore. Winner winner, man now I want chicken for dinner…
Personal story: a friend would post really polarizing biased political posts multiple times a day. I was considering unfriending because it was just too much. It was pretty disrespectful and clear this person wasn’t taking time to chat with people of the opposing viewpoint, trying to look at unbiased sources as best they could, or just have a consideration for those that didn’t agree. Once, this person posted a picture that said something along the lines of, “If you don’t like what I post, then don’t read it.” I thought to myself… “Alright, I won’t.”
I’m not trying to consume negativity, even if it’s just through scrolling down my Facebook timeline. Continually seeing and consuming negativity, even if it’s somewhat passive, does take a toll.
An easy way to decrease negativity or bad influences is to unfollow them on social media. Remove it from your space. It does not get to be there. It’s like when you’re trying to eat healthy and removing the junk food from the house. Out of sight, out of mind.
I decided to remove bad influences, people that made me cringe, people who were frequently complaining/venting from my timelines. I started to be very intentional with who I follow on Twitter, FB, IG, Pinterest, and Tumblr. It’s been wonderful. I want people who will challenge me, enlighten me, encourage me, educated me, humble me. This is my social media, my timeline. I’m not going to keep negativity on there because I am worried about what someone would think if I were no longer following them.
More social media tips and blogging advice
Over the past few months, Brittney Wilson BSN RN (The Nerdy Nurse) and I have been writing a blogging and social media guide book for nurses. At over 200 pages, it’s full of practical help, our experiences, recommendations, and major mistakes to avoid.
We truly want nurse bloggers to have a successful experience and also empower them to know their worth. In addition to the book we’ve written, we are also developing an in person 5-hour seminar during the 2017 NNBA Conference in St. Petersburg, Florida.
We’re elated to work with the NNBA (National Nurses in Business Association) because they offer a huge network of support… support I could have used when I was going through this whole mess. It would have been helpful to already be in a network of people to bounce ideas or situations off of that just didn’t seem right, but I couldn’t really specify why.
The NNBA consists of over several thousand nurses, leaders, and mentors. Growing a successful business, balancing life, and making sure to consider our profession as a whole can be challenging. If you’re a nurse business owner, or considering starting a membership, an NNBA membership is truly an investment in your success.
In addition to being a member of the American Nurses Association and the American Association of Critical Care Nurses, I’m also a member of the National Nurses in Business Association, and I highly recommend becoming a member. Join me.
Registration for our 5-hour seminar is officially open. Take this opportunity in professional development, earn some continuing ed, and come hang out with us!
Pro-tip: use the trip as a tax write off!
What: Nurse Blogging 101: Growing a Profitable Business and Community at the 2017 NNBA Conference Where: Sirata Beach Resort in St. Petersburg, Florida When: September 8-10, 2017 (our seminar is on the 8th!) Why: Grow your brand, positively impact the nursing profession, and make money doing what you love How:Register Now!
Pre-conference seats are limited and filling up fast!
This post has been sponsored by Aurora University.
Please see my disclaimers page for more information on our partnership.
Instant messages, email, video conferences – these and other forms of technology now allow patients to access their health care providers via a new field known as telehealth, created by the demand for greater access and convenience in health care, according to Hospitals & Health Networks.
What is Telenursing?
Nurses are now able to interact with patients remotely, thanks to advances in technology, thus the terms “telenursing” or “telehealth nursing.” According to the American Telemedicine Association (ATA), this is defined as “the use of telehealth/telemedicine technology to deliver nursing care and conduct nursing practice.”
Telenursing is not a specialty area of nursing. In nearly all practice settings, a nurse is able to provide some care at a distance. Due to the rapid rise and demand of telenursing, experienced nurses as well as new graduates may expect growing career opportunities in this field.
Growth and Benefits
Some form of telemedicine is now in use at more than half of all hospitals in the United States, according to the ATA. A survey demonstrates the development or implementation of a telemedicine program among 90% of health care executives.
Other signs reveal the growth of telenursing and telemedicine. State lawmakers now support legislation for telemedicine-related reimbursements; both private and public insurers are accepting these changes. The ATA reports that more than 200 academic medical centers across the United States offer video-based consults across the globe.
Telemedicine offers primary benefits, including the following:
– Cost Savings. According to the American Hospital Association, a cardiac telemonitoring program resulted in eleven percent cost savings, with a return on investment of $3.30 in cost savings for every dollar used for program implementation. Global professional services company, Towers Watson, states that U.S. employers could save an estimated six billion dollars by offering telemedicine.
– Flexibility. Americans residing in rural areas comprise about twenty percent of our population without ready access to primary or specialty care. Greater than forty percent of hospitals surveyed have opted to invest in telemedicine tools for the purpose of filling the gaps to these remote communities. Software Advice, a company that compares electronic health records, conducted a survey of patients. They found that twenty-one percent of their consumers most value telemedicine for its ability to deliver care without long travels.
– Quality Care. The aforementioned cardiac telemonitoring program saw a drop in patient readmissions by forty-four percent over a thirty-day period, and thirty-eight percent over ninety days, when compared to patients not enrolled in the program. A patient-care study of eight thousand outcomes showed no difference in the virtual appointment vs. an in-office visit. In a Humana Cares remote health management and monitoring program for congestive heart failure patients, at least ninety percent of patients report feeling more connected to their nurse, found ease of use with the virtual care suite and were willing to recommend the program to friends.
For those patients who have not experienced a telemedicine visit, seventy-five percent showed an interest in using one rather than an in-person office visit, says the Software Advice survey. Sixty-seven percent of those patients who have used telemedicine state that it “somewhat” or “significantly increases” their satisfaction in the care received.
Careers in Telenursing
“Telehealth nursing is practiced in the home, health care clinic, doctor’s office, prisons, hospitals, telehealth nursing call centers and mobile units,” the ATA says. “Telephone triage, remote monitoring and home care are the fastest growing applications.”
The popularity of telehealth has created new telenursing areas of practice:
Telehealth is transforming health care, even in the ICU. “Although the role of the bedside care-giver can never be replaced or diminished, it can certainly be augmented, enhanced, and facilitated,” according to Critical Care Nurse. “The key to the long-term success is the continued consistent collaboration between the bedside team and the tele-ICU nurses, which can transform how critical care nursing is practiced.”
The creation of the teleICU has improved outcomes for critical patients by shortening hospital and ICU stays, reducing ICU mortality, increasing compliance rates with evidenced-based best practices, decreasing patient care costs and improving cardiopulmonary arrest patient outcomes. By simply clicking a mouse, a nurse can access medical records, laboratory results and diagnostic images, as well as standard monitoring including hemodynamic values and electrocardiography.
A teleICU nurse will shoulder important responsibilities, such as regular rounds via camera and assessing all patients, which may include equipment checks for safety, assessing the patient’s physical well-being and appearance, verbally verifying infusions and speaking with the staff, patient, and patient’s family. The teleICU nurse is a vital resource for the bedside nurse, able to quickly retrieve data and information, and compiling detailed, complete admission notes should the patient arrive in the unit.
“As the US healthcare environment continues to evolve due to changes in reimbursement, legal issues, and shrinking healthcare resources, the expanding role of telehealth nurses will continue to evolve,” says the ATA. “Leadership and collaboration among international nurses is needed to outline the uses of ehealth/telehealth technologies to provide nursing care in an interdisciplinary manner to patients, regardless of staffing, time, or geographic boundaries.”
Those pursuing telenursing opportunities should have a strong educational background. More hospitals across the country already require nurses to hold a BSN degree, indicating educational standards are on the rise. Aurora University’s online RN to BSN programs prepare graduates with the knowledge and skills required to pursue advanced career opportunities. The program boasts an online learning environment, which allows students a convenient and flexible schedule to complete their degree while maintaining a work/life balance.
Interested in Telenursing? Aurora University provides a strong foundation in this specialty. Aurora’s RN to BSN degree Completion Program prepares students for management-level positions and other nursing specialties. The program offers a convenient and flexible online learning environment, accommodating the personal and work schedules of students. For more information on telenursing, check out Transforming Health Care: The Emergence of Telenursing .
Nurses end up feeling short changed, as another year goes by when their hours of overtime, staying late, and switching their schedule last minute is merely recognized with a cookie platter delivered to the unit on their day off, and a water bottle with a logo that rubbed off in about a week.
This year instead of wishing you a happy Nurses Week and calling it good, I decided to try and put together a fun giveaway. It is pretty simple. There are different prizes given away each day. Some will have multiple winners, some will just have one. Use this simple form to enter:
Developed by a nurse anesthetist, Soothing Scents makes 100% natural and earth-friendly essential oil inhalers to combat PONV and ease patient anxiety – without pills, unwanted side effects, or the need for a doctor’s order. Our flagship product, QueaseEASE, is used in over 1,000 hospitals and clinics across the country, and is a go-to essential for medical professionals who are looking for natural but effective ways to help their patients.
Each giveaway kit contains:
1 x QueaseEASE inhaler for general nausea and travel-related queasiness
1 x Expecting designed specifically for morning sickness
1 x Focus for mental clarity and stamina
1 x Still for relaxing the body and mind
10 sample-size Quick Tabs that can be given to patients and last for up to 72 hours.
Don’t forget to enter and share the giveaway with other nurses.
This post has been sponsored by Alvernia University.
Please see my disclaimers page for more information.
Traditional healthcare settings, including hospitals, operate under a hierarchy of nursing to define the structures of order and organization. Nurses are ranked according to levels of license and education, and by years of experience. This can be kind of confusing to the new nurse walking into the hospital (“Uhhhh he just told me he was the DON and I don’t really know what that means…) , so I’ve outlined a typical hierarchy of nursing below.
Understanding the Hierarchy of Nursing
Chief Nursing Officer (CNO) The CNO, also known as the CNE or the chief nursing executive, is found at the top of the hierarchy pyramid, and reports directly to the chief executive officer (CEO) or the hospital or agency. The CNO functions in both administrative and supervisory roles and is responsible for the delivery of all nursing services across the hospital or healthcare unit. A CNO or CNE will generally have a minimum of a master’s degree and previous experience in nursing leadership positions.
Director of Nursing (DON) The director of nursing acts as an administrator, providing leadership for the department and/or service line, which ultimately directs patient care. They can be a director of the entire hospital, service line, or single department, depending on the size of the facility. As an administrator, duties may include budgeting, record keeping, decisions on how different educational requirements are met, dealing with regularly issues, working with physician groups and other departments nursing works with, and so forth. Related positions at this level may include director of nursing services or director of patient care services. A DON will generally have a minimum of a master’s degree.
Nurse Supervisor or Nurse Manager Nurse supervisors and nurse managers function as a part of a leadership team, taking responsibility for various units. A nurse manager may be the manager for one nursing unit, or a group of them. They are the step between administration and the bedside staff, and communicate changes back and forth. They typically are holding or coordinating staff meetings to update the employees they are responsible for, as well as attending facility leadership meetings to touch base with who they report to. Generally, they arrange for nursing care to be provided to patients (however that may look at the facility), in addition to many (and I mean many) other tasks including hiring, scheduling, and budgetary needs of the unit, . The nurse supervisor or nurse manager will typically be required to have a bachelor’s degree, and a master’s degree is recommended. The nurse manager typically is not providing direct patient care, but rather coordinating things for the nurses who are.
Advanced Practice Registered Nurse (APRN) An APRN offers treatment services and patient care, typically in direct collaboration with a physician. However, in accordance with the laws of each state, they actually may practice independently with complete authority, and without a physician’s collaborative agreement. (Pretty awesome, right?) They may diagnose and treat patients, and in some environments, be the primary healthcare provider to their patients. There are four different types of APRN’s, including: Nurse Practitioners (explained below), as well as Certified Nurse Midwives (CNM), Certified Registered Nurse Anesthetists (CRNA), and Clinical Nurse Specialists (CNS). An APRN must currently hold a master’s degree and their specialty training in one of the four aforementioned areas, but many APRNs are seeking terminal degrees (DNP, PhD).
Nurse Practitioner (Certified Registered Nurse Practitioner, CRNP) A CRNP, or more frequently abbreviated as a NP, is a type of advanced practice registered nurse. A nurse practitioner may work with patients of all ages and their families, providing useful and important information to help in decision making regarding lifestyle and healthcare. The nurse practitioner practices in accordance with the Nurse Practice Act, as prescribed by the state in which they work. The majority of nurse practitioners chose an area of specialty in which to be nationally certified. The areas of specialty recognized by the American Nurses Credentialing Center are: Acute Care, Adult Gerontology, Emergency, Family, Neonatal, Pediatric, Psychiatric, and Women’s Health.
Staff Nurse or Bedside Nurse (RN) A staff or bedside nurse is typically a registered nurse providing direct patient care, by directly assessing, monitoring and observing patients as the first point of contact. They coordinate care for the patient within the entire health care team. Today, to practice as a registered nurse one must pass the NCLEX-RN after graduating from a diploma or associate’s degree program. However, many hospitals and other employers, however, now require a bachelor’s degree to comply with the IOM’s recommendation for the nursing workforce to be 80% bachelor’s prepared by the year 2020.
Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) An LPN/LVN will often provide basic medical care and assistance, however depending on the facility and state, the LPN/LVN may provide care in a very similar scope to the RN with the exception of a few tasks (like hanging blood, for example). These tasks may include dressing changes, catheter insertions, administering oral medications, obtaining vital signs and so forth. Most LPN/LVN-prepared nurses work in the long term care setting, but can work in many different areas. To be an LPN/LVN, one typically completes 1-2 years of training and takes the NCLEX-PN exam.
Other Nursing Positions and Career Growth
The nursing hierarchy includes many roles and titles not listed here. Johnson & Johnson’s website Discover Nursing lists 104 areas of specialty positions in nursing, describing some great employment opportunities.
Nursing career development potential is highlighted by the growth and size of the profession. Nursing employment is projected to grow 16 percent by 2024, which, according to the Bureau of Labor Statistics, is much faster than the average for all occupations.
“Nursing is the nation’s largest health care profession, with more than 3.1 million registered nurses nationwide,” says the American Association of Colleges of Nursing. “Nurses comprise the largest single component of hospital staff, are the primary providers of hospital patient care, and deliver most of the nation’s long-term care.”
Pursuing Nursing Opportunities
So many advanced career opportunities are available for nurses and can advance the quality of patient care. Alvernia’s online RN to BSN degree Completion Program prepares students for management-level positions and other nursing specialties. The program offers a convenient and flexible online learning environment, accommodating the personal and work schedules of students. Alvernia also offers a Post-Master’s online DNP Clinical Leadership Program. Check out Alvernia University for more information on nursing hierarchy.
Throughout my career as a nurse, I’ve cared for many individuals who are addicted to opioids. When you’re a nurse caring for patients, you can kind of forget that nurses are just as likely to fall into addiction as anyone else. While nurses are no more likely than the general population to struggle with addiction, nurses have a unique situation in that we have a high-stress job with very regular access to medication.
I’d like to provide an informational post for support, encouragement, and resources to any nurse out there who may be struggling with addiction.
I had the honor of interviewing Kathy Bettinardi-Angres, APN-BC MS RN CADC. She is a Board Certified Nurse Practitioner and Certified Alcohol and Drug Counselor. She is currently the Director of Multidisciplinary Assessments, a Family Therapist and the Psychiatric Mental Health Nurse Practitioner for Positive Sobriety Institute in Chicago, Illinois.
I’m a Nurse and I’m Addicted
How common is addiction in the nursing profession?
“Addiction in the healthcare professions is the same percentage as the general population, approximately 15%. Though this is an estimate calculated in the 1980’s and I believe with the opiate epidemic it would be closer to 20% or 2 out of 10 nurses.”
I did a little research and found similar numbers calculated in the 1990’s and again in the early 2000’s that substantiated Kathy’s estimate. If 20% of the 3 million nurses in the nurses in the US is roughly 600,000 nurses struggling with addiction.
Is there a typical road to addiction with nurses you see?
“There is typically a ‘magical connection’ feeling an individual has, plus access to powerful drugs, and/or a family history and stressors in their life. Another individual would not be able to predict accurately which nurse is most susceptible, however. Also, nurses attracted to the adrenaline of ICU’s and ER’s are at higher risk.”
What does treatment look like for a nurse?
“Treatment for a nurse is optimally in a program with other healthcare professionals. In the 1980’s and 1990’s, nurses and physicians were always treated together, along with pharmacists, and so forth. Lately, nurses have not been financially able to afford professional programs, which are longer in length of stay and usually residential. A typical treatment course for a nurse is 6-12 weeks, depending on the severity of the addiction and dual diagnoses, such as anxiety disorder, depression, and so forth. A lot of treatment programs say they treat nurses and are not familiar with the intricacies of reentry and monitoring.”
What is the most common barrier to treatment you see with nurses in particular?
“Money and lack of income while in treatment.”
If a nurse expresses to their employer that they are struggling with addiction, can they face legal issues?
“Yes to legal issues. Some organizations will press felony charges if the nurse diverts (see definition below). Regarding loss of licensure, if a nurse admits they have a substance use disorder, is adequately treated and monitored following treatment, the nursing boards are usually open to allowing them to keep their licenses.”
Definition of drug diverting/drug diversion: Drug diversion is a medical and legal concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use. The term comes from the “diverting” of the drugs from their original licit medical purpose.
Have you seen nurses successfully go through treatment and be able to work at the bedside again?
“Absolutely. If their drug of choice is a narcotic, and especially if they have diverted, they are asked to not work with narcotics for a period of at least a year.”
According to this article, published in American Nurse Today, the Official Journal of the American Nurses Association,
“Currently (2011) 37 states offer some form of a substance abuse treatment program to direct nurses to treatment, monitor their reentry to work, and continue their license according to the National Council of State Boards of Nursing. Alternative programs monitor and support the recovering nurse for safe practice. Strong recovery programs offer a comprehensive, bio-behavioral, individualized treatment plan. The phases include in-treatment or outpatient detoxification in a safe environment; education about the disease; group, individual, and family therapy; and most important a relapse prevention program. However, boards of nursing have a responsibility to safeguard the public, so they may suspend the nursing license of an identified impaired nurse if they suspect he or she may pose a danger to patients.”
Do you have any success stories you can share?
“Many many success stories. One that comes to mind is a nurse in school for her nurse practitioner degree, she wanted to be a nurse since pre-school. She diverted and came to treatment. She followed all recommendations and is now completing school and has several job offers.”
Kathy co-authored another amazing article which was originally published in the Journal of Nursing Regulation entitled, Nurses with Chemical Dependency: Promoting Successful Treatment and Reentry. The article states, “few reliable studies exist on nurses’ recovery success rates (abstinence after 2 years) after reentering the workplace. The California Nurse Diversion Program includes 1,000 nurses who successfully returned to work (Grauvogl, 2005). According to Diana Quinlan, MA CRNA, chairperson of the AANA peer assistance program, “programs that are put together well have an 80% recovery rate and some have a rate as high as 95%” (pg. 20, 2003)”.
What advice can you give to nurses who think their friend or coworker may be struggling with addiction who want to support them?
“In a nutshell, say something because death from overdose is a real possibility. Talk to the nurse first, and tell him or her you will accompany them to administration to ask for help.”
If a nurse is looking for treatment options, what are things they need to consider when looking at different programs?
If you are a nurse struggling with addiction, I hope this post provided some practical information for next steps. If you know someone who is struggling, check out some of these resources, support them, and encourage treatment. If you have struggled with addiction yourself and would like to share your story, please contact me.
I really want to thank Kathy for taking the time to answer these questions! To learn more about her, check out her bio on the Positive Sobriety Institute. I also want to thank the team at the Positive Sobriety Institute in Chicago, Illinois who specialize in treating healthcare providers who struggle with addiction. Your time and expertise were greatly appreciated in compiling this post.
**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.
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)
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…
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
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
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.
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.
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.
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
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
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.
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:
Documentation for Legal Purposes
Understanding Chronic Pain
Mental Health Issues
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.
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.
NRSNG Academy – while it’s a great NCLEX review, it’s also amazing resource once you’re on the floor. It’s an excellent clinical education program for new nurses and a huge confidence builder. You can get a 7 day trial for just $1.
It’s that time of year again for nurses in administration…
Time to think up ideas for Nurses Week.
For those of you that let out a weary sigh, I feel you. I used to plan those activities and it was not an easy endeavor at all. It can become so burdensome that turns into just another thing to mark as “done” for the year.
Budgets are getting smaller. Nurses are working more, with less staff, and constantly going through change. They’re tired. Every year it seems the expectation for the celebration of nurses week increases as nurses become wearier, but the budget to devote to a great celebration decreases.
Nurses end up feeling short changed, as another year goes by when their hours of overtime, staying late, and switching their schedule last minute is merely recognized with a cookie platter delivered to the unit on their day off, and a water bottle with a logo that rubbed off in about a week.
Nurses are starting to plan their own celebration entirely, which misses the point. Call me crazy, but I believe the people who should be planning Nurses Week are those in administration whose entire hospital operation completely depends upon nursing care. You know, all those people who say they could never do what we do, it’s time for them to say thank you in a genuine and meaningful way.
I firmly believe that nurses should not plan their celebration. That’s like planning your own birthday party.
Nurses don’t want water bottles. They don’t want gear with the hospital logo plastered all over it. They don’t want cookies or cake. Patients and families bring in enough treats, so dropping off a plate of cookies isn’t really making anyone feel special. It’s just another thing to avoid as you attempt to be healthy. Nurses also enjoy volunteering in general, but when you turn Nurses Week into Mandatory Volunteer Week, it feels like all the overtime isn’t enough and now you have to volunteer on top of it.
Nurses are people too. And what do people get excited about?
People get excited about things that foster a sense of identity and pride, nostalgia, are cool, or provide value.
It’s an added bonus to the facility if your Nurse’s Week recognition and efforts also rejuvenate the staff. Instead of dropping off some flash drives with the hospital logo on them and a bucket of candy, what if you provided something that not made the staff feel recognized and appreciated, but did so in a way that reignited their passion for their job?
Ideas for Nurses Week Celebrations
Below is my sample list of cost-effective ideas for Nurses Week. In addition to these, I suggest getting a Happy Nurses Week banner or two printed and placed at the hospital’s main entrance as well as where the employees walk in. Cost-savings idea: don’t get the year put on it and re-use it annually.
Hire a few people to go from unit to unit to give 5 chair minute massages, with a nurse to relieve people as they took turns.
Get a few essential oil diffusers and diffuse lavender in nurses stations
Walk a Mile in My Danskos Tuesday
Schedule the CEO and entire board of VP’s to put on some scrubs for 6 hours and follow nurses
Involves those who should be most enthusiastic: non-nursing leaders
Leverage your media department to take photos and share on your organization’s internal website, external new sources, and social media
During this time, schedule Blessing of the Hands (where chaplaincy services makes rounds to units and offers to bless the hands of caregivers). This is profoundly meaningly for many and it would be incredibly impactful if this occurred in front of administration.
The Sacred Heart University College of Nursing’s annual Blessing of the Hands ceremony in the Chapel of the Holy Spirit. Photo by Tracy Deer-Mirek
Calling all therapy dogs!
Schedule all therapy doggies (and any other therapy animals) to make multiple rounds on all of the units
Bonus if you can get special Happy Nurses Week bandanas for the pups to wear
Double bonus if you can get some “I pet the therapy dog” stickers to be handed out
Triple bonus if you can just get the dogs to give the chair massages
Have every physician and their support staff hand write a thank you note to a nurse.
Cost-effective: you’re only out the $0.20 per thank you note
See which nurses have been picking up a lot of overtime, staying late, floating, or switching schedules and ask them to come to administration. Have a nursing administration sit them down and sincerely thank them for their efforts, and let them know it has not gone unnoticed. Provide a nursing book as a gift, and have that administrator hand-write a thank you inside the book. Something like:
“Sarah – I just want to thank you for all of the overtime you’ve picked up on the stroke unit. Nurses like you are why patients like coming to our hospital. We sincerely appreciate everything you do for the organization. Signed, the CNO”
Key point: it MUST be personalized, and not something mass-produced.
Have a special award or recognition for people who have been nurses for over 30 years
Make sure nursing administration participates!
Have a place set up in the cafeteria or some obvious place and display old school medical and nursing equipment
Take photos and share on your social media and internal/external sites
Nurses Week To-Do List
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A virtual conference
Consider sending your staff, or a portion, to a virtual nursing conference. It’s a fraction of the cost of physically sending someone and functions as a phenomenal and comprehensive Nurses Week gift. Each day provides a new topic, discussion, and CE’s. You can schedule a viewing on campus, or staff can access it at home on their own time.
A great virtual conference is The Art of Nursing Nurse’s Week Celebration created by Elizabeth Scala, MSN/MBA RN. You get 12 30-minute sessions from nursing leaders, a PDF booklet for participants, staff get CE’s (staff love CE’s!), and other bonus goodies.
Click here to check it out, and let Elizabeth’s Art of Nursing be your Nurses Week celebration.
If your hospital doesn’t do anything for Nurses Week
Don’t let it just pass by! Schedule a massage for yourself, take a PTO day, bring your favorite foods for lunch, get some new scrubs, get a good nurse book, go to a conference, or buy a pass for The Art of Nursing virtual conference yourself.
Take some time for yourself – you are valued, even if you’re not being recognized by your employer.
What are some of the best things that you’ve received during Nurses Week? What worked, what didn’t? Were you a part of one of the 49 organizations that used the virtual conference, the Art of Nursing – what’d you think?
A culture of negativity is not something very obvious and apparent. Nurse bullying can actually be quite subtle. A comment here, an eye roll there, gossip in the dictation room, or a passive aggressive sigh. It can be really hard to navigate this at any point in your career, but it is especially difficult for people who are new to the profession.
I think one of the most important ways to survive working in a negative unit culture and dealing with nurse bullying, and maybe even potentially shift the culture, is this:
Be outside of the negativity, not within it.
I’ve outlined some practical tips for those of you who find yourselves in the thick this situation:
When people around you start being negative, don’t participate
Simply be silent. It’s a little awkward at first, but people will soon learn that they can’t go to you to talk about people or complain. It’s kind of like getting used to the awkward silence that’s necessary when supporting your patients. I’ve done this. It takes time, but it works.
When people start talking negatively, provide a positive point for every negative one
So if they’re talking about how stupid an employee is, bring up times when they were smart or did something great. Counteract the negativity… soon, it won’t be fun bringing up the things they think are funny because you’re forcing them to think about the positive things.
Learn about some things the informal leaders enjoy that is NOT negative, and spark up conversations about it
Be engaged and interested when they start talking about that, and completely disengage when they start to be negative.
Be unapologetic about being positive
If you’re doing something the informal leaders think is lame, like pulling a policy they think you should know, or giving you heck for being involved in shared governance, just be you and do what you want. Talk about it with others positively in front of them; show that you’re not scared to go against the negative grain.
Be all business when it’s black and white clinical stuff
If they’re simply not doing their job, in an all-business way, call them out.
“Hey Mary, your alarms keep going off for no reason. Can you go adjust them so we don’t keep thinking it’s our patient?”
“Hey Joanna I love you but, I’ve answered about 19 of the last 20 of your call lights while you kick it here in the nurse’s station.”
“Hey Joe, I’m going to need you to quit calling out last minute! You really left is in a bind!”
**Everyone is sitting at the nurse’s station and Sarah’s patient is alarming again and she’s not getting up to address it, hoping someone else will** “Sarah, looks like your patient is going off again!”
But don’t stop there – the most important aspect of this is not shunning them after you say something like this. Call them out respectfully, but don’t treat them differently. “Hey Sarah, your patient’s alarm is going off again. What did you bring for lunch?”
Only bring a manager in when absolutely necessary
Part of professional accountability is holding each other accountable, not having to bring in a 3rd party who wasn’t there. It merely turns into “he said she said” and minimal progress is made. We are professional nurses; we should be able to speak to each other when someone isn’t pulling their weight. The manager should be brought in for serious things that can’t be mediated between one another. A lot of people just want the manager to step in and fix something, but the manager isn’t there to see the subtle behavior; you and your colleagues are. Some people also don’t want to “get involved” but they want to complain. If you’re frustrated enough to complain about it, be professional and speak to them about it.
Don’t always assume it’s laziness or malicious
Maybe someone seriously doesn’t know what they’re supposed to do and whenever they’ve asked for someone to explain it, they get brushed off. If someone keeps forgetting to chart something, or doesn’t adjust their alarms, take a second to show them how and answer any questions before assuming they’re being lazy.
Be quick to admit when you’re wrong
Set an example of it being okay to be wrong and to not be perfect. Many times, mean and negative coworkers set this unrealistic example of what they expect people to be like. Showing fault or flaw in themselves is unthinkable because they must maintain their tough exterior. Fear is one of the biggest motivators! Take ALL the power from that and make it okay to be wrong and to ask for help. Model that mentality. Be the change you want to see in others.
I hope these practical steps and talking points will help you the next time you find yourself in a negative situation. Remember, just because other people are negative does not mean you need to be. You can still be a positive, joyful person. Bullies and negative people do not get to dictate who you are. Be empowered to be you!
We can never change someone else’s behavior, but we can change how we perceive it. We can take away the power they think they have. So what if they think I’m lame because I go to committee meetings? I enjoy them. I enjoy my job. I enjoy my life. That’s what matters, not what some negative person thinks about me.
If someone is being negative or demeaning to you, do not give it any power or make you think less of yourself. Release the power that has on you. You are way too awesome to let a complacent and negative person take that away from you!
Need more nurse-motivation or tips on communicating with people who aren’t happy?
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
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?