So a recent student came to me for advice. “I got the summer internship in the ER. Now what do I do?”
We talked. She will be at a big ER, and I’d written a letter of recommendation for her that emphasized her ability to keep track of details and to be accountable for followup. She was worried about how she would respond to all the emergencies. She is a bit of a perfectionist…
“First off, they will never put you in the emergency side, trying to figure out what’s wrong with a critically ill person, until you prove yourself on the basics. The ER has had many other nursing students and they know how to bring you along and develop you.” this, I knew, was a deep fear: will I be able to deal with all the blood, gore and trauma? Many newbies wonder this. What they don’t know is that there are systems in place so as not to expose them to anything they can’t handle. trust me.
Repeat this mantra over and over: The rules of good basic nursing care don’t change just because you are in an ER (or ICU) as opposed to a med-surg ward.
If you are overawed, thinking you now possess magical powers, be advised: the only way to achieve magical results in patient care is through hard work by a team of dedicated nurses.
The semi-acute side of ER care
She was relieved at this. I told her that she needed to be very careful about the role she was in, and that not every single minute would be worthy of a TV show about saving lives. “There is always a section in any ER where the patients are nursing home residents sent there for further evaluation, such as for urosepsis or pneumonia, and I am sure they will assign you there first. You will be doing such things as delivering personal hygiene care prior to straight catheterization to obtain a culture and sensitivity. You will start off by using the exact same basic skills you would use in clinical. ”
The three things to do
Does this sound familiar to you? Here is the rest of the advice I gave her.
Road Map also known as “Nurse’s Brain”
1) continue to use a Road Map. (see other entries on the blog). at first, you will say “no way, the whole deal is that the patients come in from scratch and we don’t have time to prepare a road map, it can’t possibly be useful” – whenever I hear somebody in an acute situation say that, my ears perk up. My reply is, keeping track of details despite chaos and a fast pace, is exactly why a road map is even more important. frankly, a person who doesn’t write stuff down is setting themselves up for failure. Your clipboard/nurse’s brain doesn’t have to have the same list of items on it that might be used in an inpatient setting, but you will still be assessing, implementing, planning and evaluating. The road map for ER can be a simple plain piece of paper on which you write down the name and what you are told, for every patient to whom you deliver care.
Get in the habit of carrying a clipboard and writing down every thing you are assigned to do, especially if it involves followup later in the shift. you will be constantly writing little memos to your self. think of the similarities between ER nursing and being a server at a restaurant with up to ten tables of four persons each. If you were taking the order for dinner and cocktails at a table for ten, you would write it down! do the same here.
TIP: here is an example. for a patient requiring a workup for fever, they get a) blood drawn, b)urine and sputum samples sent, and c) an x-ray. Maybe they get d) an IV and e) one dose of an antibiotic followed by f) rechecking their vitals. So – the clerk and the RN deal with these orders, but somebody has to see that they are actually carried out. Learn the system, and use your road map to help keep track of whether the x-ray was actually done, whether the samples were actually collected, whether the results arrived back and somebody was told that the data is ready.. If all you do is to prevent your patients from becoming lost in the system, you will be making a contribution. If there are hanging around the ER very long they may also need help with food or going to the bathroom. those things, you can do.
Delegation and Communication
2) think about, and review, the rules on effective communication and delegation of nursing tasks. ( betcha didn’t know that there are rules for this!). You will be practicing within a scope of practice, and you will only be doing those things an RN delegates to you, for which you get checked off. (for example, don’t do any appendectomies all by yourself…) Review the blog entry titled ” the unwritten rules for a nursing student’s job dedscription” – these are taken from the Marine Corps rules for sentries, and they describe basic lines of accountability. You need to become a good follower in the intern role, it will later that you become a good leader.
On the NCSBN website, there is a 40-page document on delegation of nursing tasks to unlicensed assistive personnel, titled Working With Others…… Download it, print and study it. It’s about effective communication in the clinical setting. Nobody will ask you to recite the ECG criteria that indicate possible procainamide toxicity; but everyone will want to know whether you are smart enough to know when to seek guidance or to report something weird that just happened. In the most recent ACLS manuals from the Heart Association, there is also a section on how to make sure that orders are clear during a high-pressure team response to an emergency. This is also good reading. T.O.R.B. on steroids.
3) think about Maya Angelou, who wrote; “I did then what I knew how to do. Now that I know better, I do better.” Makes notes on your road map about the new things you see. At the end of each day, take the road map home and analyze it as to what to study that evening. This is an essential professional habit, some people call it “praxis” – making a structured plan for your self-directed learning then using it the next day. For example, one day you look at the road map and you realize, you were in the urgent care clinic doing vital signs and prep work for a bunch of kids with otitis media (happens all the time). how did you do and what do you need to learn? you might come up with, gee, they were all two years old, maybe I should review growth and development of 2-year-olds so as not to tweak their stranger anxiety; what is the usual medicine the NP orders; what is the dose of ampicillin for a kid that weighs forty pounds; what are the usual vitals signs, etc. If you can’t come up with these sorts of things, ask the nurses around you for advice as to what you might study. Next time you are on the walk-in pedi clinic side, you will be better prepared. praxis.
Use all resources!
If you can, bring your textbook to work. refer to it for quick look-ups when you need to. this is professional behavior, not a sign of weakness!
Or maybe you spend the day in the casting room. or an eye injury comes in and they use the Morgan Lens. or maybe nasal packing or any number of odd things. ask you self how often any given incident occurs and what you will need to know next time. then go home and crack the books.
More study out of work will always be rewarded. Sure, it is summer and you can take time to enjoy your self. but attending to these two things will pay off in a big way.
be sure to share this widely with every summer nursing intern you know; why not subscribe?
PS – if you are too young to recall the TV show ER – go get the DVDs. It was on for 15 years. In my opinion, they had a good handle on what was important.
and yes, read my book…..