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**This is a guest post, written by Lynn Sayre Visser, MSN, RN, CEN, CPEN, CLNC, PHN who is a registered nurse with over twenty-five years of diverse experience including pre-hospital care, emergency department, intensive care unit, post-anesthesia care unit, and organ procurement. Ms. Visser is the author of Rapid Access Guide for Triage and Emergency Nurses: Chief Complaints with High-Risk Presentations and Fast Facts for the Triage Nurse: An Orientation and Care Guide in a Nutshell, which was awarded third place in the 2015 American Journal of Nursing Book of the Year Awards in the Critical Care-Emergency category. The Fast Facts book is in its second edition which offers continuing education contact hours! This book is available in the United Kingdom under the title Essentials for the Triage Nurse. Thank you Lynn for offering your expertise to newbies!
Meet the Author:
Lynn Sayre Visser, MSN, RN, CEN, CPEN, CLNC, PHN is a registered nurse with over twenty-five years of diverse experience including pre-hospital care, emergency department, intensive care unit, post-anesthesia care unit, and organ procurement. Ms. Visser is the co-author of the 2015 American Journal of Nursing Award Winning Book titled Fast Facts for the Triage Nurse which is currently in its second edition and Rapid Access Guide for Triage and Emergency Nurses: Chief Complaints With High Risk Presentations. Her contributions to emergency nursing have been recognized by her peers with a nomination for the prestigious Emergency Nurses Association Distinguished Certified Emergency Nurse Award. She believes education and mentoring are at the heart of unraveling the exceptional nurse within us and empowers nurses of all experience levels to chase their dreams and reach for their potential. You can connect with Lynn at [email protected] (she would love to hear from you!).
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
- Comfortable, waterproof shoes – yes, blood, vomit, etc. may end up on them
- Compression stockings – more than likely, you will be on the move all shift long
- Trauma shears for cutting off clothes, bandages, etc.
- Hemostats for tough IV hubs and ports
- Roll of IV tape
- Name badge
- Index card – to write down things you will look up when you get home
- Your “Book of Brains”
Tips About Attire
Remember, first impressions are lasting impressions for both your patients and their family members as well as your co-workers. Wear nicely fitting scrubs, compression hose, clean shoes, and if you have long hair, pull your hair back.
A tip about your legs…if you don’t want jagged blue lines (also known as varicose veins) running down your leg, wearing compression hose is highly suggested. If you are in your twenties when you start your career this will be hard for you to understand the importance of this suggestion…but trust me on this…if you choose to wear compression hose, you’ll thank me for this advice twenty years from now (accepting your gratitude now).
A tip about shoes… Most ED nurses complain of foot pain at some point as the walking (almost running) in the ED is endless. Consider having two different pairs of quality shoes and rotate them either half way through your shift or every other shift. Rotating shoes gives any painful areas a break the following day and will hopefully help your foot health.
Understanding the Triage Zone
What the heck is triage? The word triage comes from the French verb “trier” which means “to sort”. The role of the triage nurse or triage nurses (more than one often in larger facilities) is to determine:
- Sick versus not sick
- How long the patient can wait for medical care
- What area of the department is most appropriate for the patient (trauma room, emergency department bed, FastTrack etc…)
Triage is often referred to as the area out near the waiting room. What is important to understand is that triage can happen anywhere at any time, even in the ambulance bay. Triage is a process, not a place. Larger facilities often have an internal triage area as well, that ambulance crews and their patients may pass through to obtain an initial evaluation that determines the best destination within the emergency department.
Most facilities use a 5-level acuity scale system. What do these levels mean?
- Level 1 = Resuscitation
- Level 2 = Emergent
- Level 3 = Urgent
- Level 4 =Semi-urgent
- Level 5 = Non-urgent
To truly understand triage, you need a comprehensive training that encompasses classroom didactic as well as time with a preceptor at triage.
One question to ask during orientation is what type of triage system is used at your facility. The most commonly used triage leveling systems include:
- Emergency Severity Index (ESI)
- Canadian Triage Acuity Scale (CTAS)
Knowing what triage system is used will allow you time to begin to research and understand the system even before you formally begin to use it.
ESI is one triage system frequently used. If this is what you will use, take the time to order a free book and DVD from the Agency for Healthcare Quality and Research titled Emergency Severity Index, Version 4.
Additionally, the AWHONN has created the Maternal Fetal Triage Index (MFTI) that covers triage of the pregnant woman during all gestational ages. This algorithm was modeled after ESI. Understanding the MFTI guidelines will give you a greater understanding of concerning signs and symptoms in the pregnant patient. Online training to further understand the MFTI is available at AWHONN for a small fee.
Deciphering the Medical Provider in the Triage Zone
In some EDs, you may find the utilization of a medical provider working in triage. What does this mean? In essence, this physician, nurse practitioner, or physician’s assistant aids in the flow of the ED by performing a quick assessment and initiating patient orders while the patient often waits in the ED lobby. In some cases, the physician can discharge the patient straight from triage, saving the patient a lengthy wait time while simultaneously reducing ED congestion.
Recognizing Potential Legal Issues
The ED is a high liability area so documentation is key as well as understanding the Emergency Medical Treatment and Active Labor Act (EMTALA). Every dedicated ED that receives Medicare funding is held to EMTALA standards. An EMTALA violation results in a $50,000 fine.
EMTALA states the following:
- Every patient that presents to the ED receive a Medical Screening Exam (MSE) to rule out an Emergency Medical Condition (EMC); this includes a woman in active labor.
- Necessary and stabilizing medical treatment is provided.
- Transfer to a facility with a higher level of care if deemed necessary.
- Care is provided regardless of the ability to pay.
To avoid an EMTALA violation, never…
- Send an ambulance that arrives into the ambulance bay (or anywhere on hospital property) off hospital property without an MSE performed by a person qualified to do so (this person would typically be a physician, or depending on facility rules sometimes a physician assistant or nurse practitioner).
- Fail to respond to a patient who requires assistance and is located within 250 yards of the building.
- Delay treatment while inquiring about insurance coverage or payment.
Centers for Medicare and Medicaid Services. (2017). Emergency Medical Treatment and Active Labor Act. Retrieved March 16, 2017.
These concepts are not easy even for some experienced ED nurses. Do your best to be proactive in understanding EMTALA and MSE and inquire further about this content during your orientation. You do not want to be the cause of the $50,000 fine.
Surviving the ED Transition
Accept it now. Likely your entire first year in the ED will be flooded with an explosion of emotions. Some days you may pat yourself on the back feeling rewarded by the knowledge you gained during your sleepless nights of nursing school. Other days (or nights) you may be completely humbled by all that you don’t know.
The more you see in the ED, the more you will realize how little you do know. What is critical is that you know when to ask for help from a colleague, when to consult with your charge nurse, or when to ask for a teaching moment with a physician. The scariest nurses in the ED are the ones who think they know it all. None of us do.
Recognizing Danger, Danger: Red Flag Signs and Symptoms
One of the many fun parts of working in the ED is putting the pieces of the clinical assessment and patient, family, or bystander story together and attempting to find the specific diagnosis while in the ED. Sometimes you may not know how to put all the pieces together, but what you can know even as a newer nurse, are red flag findings that could potentially make the patient a high acuity level (typically a level 1 or level 2).
In the books Rapid Access Guide for Triage and Emergency Nurses: Chief Complaints with High Risk Presentations and Fast Facts for the Triage Nurse: An Orientation and Care Guide, red flag findings are listed by body system. You may find similar lists in other books, but I’m not sure where else to send you. When you do find these lists, write them down, add them to your “Book of Brains”, or memorize them. You always need to correlate the clinical findings with the story, but more often than not, the red flag findings should alert you to notify the physician in a timely manner.
Receiving Nurse-to-Nurse Report
Whether receiving a report from an ambulance crew, another nurse, or performing the initial triage as the patient walks into the department, think of yourself as a detective. Your job is to connect the dots between the story told and the clinical signs and symptoms. Listen to every detail provided. Sometimes the details that seem meaningless end up being the subtle clues needed to get the right diagnosis. Use your senses…your hearing, sight, sound, smell, and touch.
Nurse-to nurse bedside report is the standard of care. Watch as many different nurses as possible take report and examine what they use for a report sheet and how they organize their “to do” lists. Then develop a customized report sheet to see the most important information with a quick glance.
When the report is given consider what you need to do for the patient and why you’re doing what. Ask the nurse going off shift for clarification or an explanation if you don’t understand “the why”. Refraining from asking a question because you feel it’s a silly question or something you should know will only serve as a disservice to the patient. Inquire, inquire, inquire. I cannot emphasize this enough.
Refraining from Judgment and Avoiding Compassion Fatigue and Burnout
If you are not cautious, judging patients within the ED can easily become part of you. The volume of repeat patients coupled with crisis after crisis results in staff coping via humor and often later coping via burnout. Judgment suits no purpose. Don’t let yourself become jaded. This statement is easier said than done if you are not astutely aware of this potential. To help avoid compassion fatigue and burnout, instill these tips in everyday clinical practice…
- See every patient as a person; a mother, father, sister, brother, uncle, aunt, grandparent etc…
- Remember that most of the time, a patient presenting is experiencing their own emergency. The situation may not be an emergency in your eyes, but it is in theirs.
- Refrain from adding your own commentary or thoughts about the patient in report as this wastes time and serves no purpose. What nurse wants to start their shift poisoned by your negative?
- Don’t work too much overtime. Overtime increases the opportunity for burnout. No paycheck is worth lowering your standard of care because you are tired and irritable.
Take time for self-care on a regular basis…
- Exercise regularly
- Create regular sleep habits
- Learn something new (i.e. meditation, painting, dancing)
- Get out into nature
- Use your vacation time
Remember: Caring for and taking the time to rejuvenate yourself is essential in this line of work.
Assessing Your Patients
Every patient needs an assessment, but how much of an assessment do they require? Focused assessments are the name of the game in the ED. Learning to what degree of assessment an ED patient requires takes time. Use your critical thinking skills. Maybe a person is complaining of pain and swelling of both feet (no injury is reported). Will you only assess the feet? No, of course not! You certainly need to evaluate heart and lung function as well.
Be patient with yourself and be open to feedback from others. Lots of critical thinking is involved in the ED in weeding out the important parts of the patient story and determining what body systems really need a thorough exam. For resuscitation and emergent patients, a quick full-body assessment should be completed as often the diagnosis is unknown and documentation of the patient baseline on arrival to the ED becomes vital to trend changes during the hospital admission.
You will see tremendous variation in the extent of physical assessments completed in the ED. Giving you a black and white system to follow is impossible. Remember: You are the patient advocate. Use your critical thinking and assess accordingly.
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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 on 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 time frames. When these time frame 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 time frames 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 a 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!)
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Discharging Patients: The Down and Dirty
The time of discharge can be a time of high liability exposure to both you as an individual and the facility, thus creating an adequate visual image of the patient condition at discharge through your documentation is essential. This time frame is when you should review the chart one last time to be sure you have documented the care delivered. One approach to documenting the discharge note is to go back to the chief complaint that was elicited when the patient arrived (also consider other complaints noted during the visit) and establish a clear picture of the patient presentation following treatment. At a minimum, you should document:
- Level of consciousness
- A full set of vital signs
- Skin signs
- Readdress the chief complaint (or complaints), and the condition of the patient at discharge
The patient will benefit from leaving the facility with written discharge instructions that include:
- Information about their diagnosis
- Recommended post-care instructions
- Follow-up information with appropriate telephone numbers and contacts
- Any supplies required for the patient at home (i.e. urine strainer, crutches etc…)
If a patient has received sedation or any medications that impair judgment, documenting that you informed the patient not to drive or operate any heavy machinery is critical. Inquire with the medical provider as to when the patient can re-engage in such activities. If the patient is leaving the ED before that time frame, 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…
Fast Facts for the ER Nurse, Third Edition: Emergency Department Orientation in a NutshellFast Facts for the Triage Nurse, Second Edition: An Orientation and Care GuideFast Facts for the Radiology Nurse: An Orientation and Nursing Care Guide in a Nutshell: An Orientation and Nursing Care Guide in a Nutshell (Volume 1)Sheehy’s Emergency Nursing: Principles and Practice, 6th EditionSheehy’s Manual of Emergency Care, 7e by ENA (2012-03-15)A Daybook for Beginning Nurses
In the interest of full disclosure, I co-authored Rapid Access Guide for Triage and Emergency Nurses and Fast Facts for the Triage Nurse. I do not have any financial interest in these books or any of the other products recommended. Fast Facts for the Triage Nurse is a triage specific book that gives you an understanding of the front-end inner workings of the ED along with content that correlates with each body system. Even if you aren’t working in triage yet, understanding what is going on at triage and in the waiting room is important even as a newer ED nurse. The Emergency Nurses Association recommends a minimum of one year of experience before working in the triage area (though some facilities will send you to triage sooner and others will wait until you have two years of experience). However, understand that you really begin triaging on day one as ambulance patients are placed into a room. Lots of content is covered that will also help you in caring for your everyday ED patients.
The Second Edition of Fast Facts for the Triage Nurse provides expanded content that includes new chapters on active shooter/active violence, emergency management when disaster strikes, pain management, triage competency, and endocrine emergencies. Additionally, continuing education contact hours are offered with the book so you can knock out learning and renewing your nursing license all at once!
Rapid Access Guide for Triage and Emergency Nurses: Chief Complaints with High Risk Presentations focuses on a wide array of patient chief complaints and helps you sort through essential first-line versus second-line questions, assessment, and interventions that help you determine the patient’s level of urgency. Considerations for pediatric and older adult populations are covered, along with pages of other quick reference information, and there are even blank pages to add your own nuggets of information. Both books cover “red flag findings” that you do not want to miss!
I am also recommending Fast Facts for the Radiology Nurse and A Daybook for Beginning Nurses each of which I have contributed to in a very small way. Nonetheless, I can recommend these books wholeheartedly. Fast Facts for the Radiology Nurse gives the ED nurse an understanding of the radiology department and the many mysterious procedures that take place in that department. A Daybook for Beginning Nurses is filled with 365 days of practical and inspirational quotes and provides empty page lines for quick journaling. I highly recommend you journal your first-year as a nurse (and then keep going).
The ER-specific books are full of a wealth of information too. Fast Facts for the ER Nurse covers information in a quick, easy to read format. The two of 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:
- Certified Emergency Nurse (CEN)
- Certified Flight Registered Nurse (CFRN)
- Certified Transport Registered Nurse (CTRN)
- Certified Pediatric Emergency Nurse (CPEN)
- Trauma Certified Registered Nurse (TCRN)
The Board of Certification for Emergency Nursing, known as BCEN, is the accrediting body for these certifications. Requirements to sit for the exams can be found at https://bcen.org
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:
- Active Shooter
- Legal Issues
- 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.
A few more resources
Kati here! I wanted to provide some additional helpful resources for the ED nurse.
Lynne Grubb says
Excellent, comprehensive, current and on target!!
Lynn Visser says
Your comment warmed my heart! Thank you for taking the time to express your thoughts.
Alexander Tataryn says
Great advice! Thanks for this hope to be an ER Nurse someday. 🙂
Lynn Visser says
Emergency nursing is an amazing experience. Chase your dream! Best of luck.
This was much needed and right on time!
Lynn Visser says
Wonderful Heather! That made my day!
Lynn Visser says
You made my day Heather and started my day with a smile! Thank you for that!
Article is right on! The most difficult aspect of ED nursing is learning to know who needs you first, who can wait and when to say NO! No that you can not accept the responsibility of one more patient. Remember it is your license!
Lynn Visser says
Such valuable advice Judy. Thank you for chiming in!
Lynn Visser says
Valuable advice Judy! Our nursing license is such a precious commodity, we much treat it as such.
RN Didi says
Very thorough article Lynn!
I’ve been an ER RN for three years now. Things do get better. There’s never a dull moment, which is great! At times, it drains your energy level. I know that I won’t be an ER Nurse my entirely nursing career. But I’d recommend ER to all nurses who are willing to learn lots about nursing and how to develop your skills in a fast paced environment!
Lynn Visser says
The ER is an amazing place to work full of adventure, endless learning, and lots of opportunity for continuous growth. I’m so glad to hear that you have settled into your role there and seem to be enjoying it. Absolutely wonderful!
I just got my first job out of nursing school on a level 1 ER. I’m excited because this is my dream and I went for it thinking I will not get it but I wanted to.say I at least try .
On the other part I’m petrified , I hope I have patient preceptor and lots of opportunities to learn I’m gonna take you recommendation on making a brain book. Thanks for.this article.
Lynn Visser says
Congratulations on your new job! The first year of nursing is a wild ride for most so be gentle on yourself. If you take the time to add to your Book of Brains every time you learn something new, you will quickly have a wonderful resource at your fingertips that is designed especially for your needs. Best of luck! Enjoy the adventures of emergency nursing. No day is a dull day!
Nadia Purcell says
WOW! just great information.
I am going to be starting this journey in a month or so and to be able to get all this thorough information in the one place is a blessing! I feel more prepared already..\
thank you for taking the time to write this up!
An Excited Newbie 🙂
Lynn Visser says
Dear Nadia aka Excited Newbie,
Thank you for taking the time to comment. Feedback from people like you makes writing feel so rewarding. I hope you find you can apply many of these tips on your new journey. The ED is so different from other units and it seems these days the exposure nursing students get to the ED is limited or non-existent. If I can help make the transition a tad easier, than mission accomplished! This post will be forever evolving so if you or anyone out there have additional content they would like to see added in the future (or tips of your own), please email me privately.
Be inquisitive, jump in, learn from mistakes, and be forgiving of yourself. Best of luck on your new adventure. Congratulations!
One of the topics you missed is new graduate nurse ER burnout rates. I worked in a short staffed ER with long shifts and many days in a row. This is usual for most ERs due to nursing shortages. I had wished myself that someone would have warned me about the high burn out rates for ER nurses. One topic that would have been helpful is knowing at the end of the day you did good for the patients that you could. This helped me a lot through my beginnings as a nurse and should be passed on to others.
Thank you for sharing your thoughts, Isabella. Awesome food for thought! I definitely believe we need to have some level of self-forgiveness in knowing that we did the best we could with the circumstances we had and with the staffing available. ER is one tough place to work but also full of many wonderful opportunities and rewards. Best of luck in your career.
Thank you for your inspiring and very relative post. I have recently started my career as a new graduate RN in the emergency department and I can strongly agree that the more I learn and see the more I feel I don’t know anything. It is amazing how being open to each new opportunity you face and approach will expand your depth of knowledge and experience so immensely. I have learned that not every day will be easy as I am still finding my way, but I see the challenges faced in the emergency department as new learning opportunities to further my practice. I often feel that as a new graduate, with very limited experience I am not good enough as emerge is a challenge and thus I tend to lack confidence. I am hoping however as I continue to learn and further my practice each day I will become more and more comfortable.
Thank you for your kind words and for touching my heart. If even just one person benefits from this blog post then I have made a difference. Your confidence will definitely develop in time. Be gentle on yourself. Read all you can. Go home and process what you saw, how you responded, and think about what you can do better the next time. The fast-paced environment of the ER often makes it difficult to think through all the pathophysiology but taking time to put it all together after the fact will certainly benefit you in the long run. Best of luck in your new dynamite career!
Fresh RN, I just recently stared working in the emergency department. Coming from a medical/surgical unit, the ER has opened my eyes to many different ideas and opportunities. I started a blog covering everything from nurse experiences to life experiences. I would love for everyone to check it out, subscribe, and give feedback! Thank you so much for your time
Kati Kleber, MSN RN CCRN-K says
Awesome! Myself and Brittney Wilson started a website to help out nurses starting blogs over at healthmediaacademy.com if you need any practical information about the technical side of blogging. Yay for nurse bloggers!
I’m so happy being one of the emergency nurses and working in the ER. The ER is an amazing place to work full of adventure, endless learning, and lots of opportunities for continuous growth.
Lynn Visser says
Yes it is! So glad you love your job!
Wendy Caldwell says
What a great idea to change your shoes mid shift! This article provides excellent clinical guidance! Thank you!
What a great idea to change your shoes mid shift! This article provides excellent clinical guidance! Thank you!
Lynn Visser says
So glad that you found value. Thanks for sharing!
Kim Glover says
My daughter wants to be an ER nurse. She is taking a nursing class in high school and they have to do a shoebox project that contains items that represent her chosen career and then. Has to present to the class what they represent. She doesn’t want to do the usual bandages, tape, etc. Any ideas would be greatly appreciated. Thanks in advance.
Kati Kleber, MSN RN CCRN-K says
Great idea…. maybe a watch, because often time is of the essence in emergency nursing… she could get some blood glucose monitoring supplies from CVS or something as a representation of the many labs/diagnostics, bandage scissors, a pair of disposable gloves – I’ll try to think of more!