What Are the Steps to Becoming an ER Nurse?

What Are the Steps to Becoming an ER Nurse?

The key to finding work as an ER nurse is to be proactive before and during nursing school. Keep reading for pro tips on how to position yourself during school and after graduation.

Job Prospects

The availability of ER nursing jobs—especially for new graduates—depends on the needs and financial status of the institutions and geographic area in question. As reimbursement becomes more and more dependent on patient reviews, hospitals strive to update the accommodations and technological capabilities to satisfy their patient populations. The expense of these updates can limit the hospital’s ability to hire or even cause a hiring freeze.

Most managers would prefer to hire a nurse experienced in the ER because it is very time-consuming and expensive to train a new nurse. Furthermore, it delays the increase in staff numbers that the nurse is hired to relieve.  Many hospitals have created fellowship programs, which include a stepwise process of training for new grads to fully integrate them into the world of ER nursing. These are valuable programs for nurses who seek a comprehensive understanding of emergency nursing and an ongoing support system.  

They are, however, pricey to the hospital, and lengthy: nurse fellows receive full salary and benefits, and these programs last between six months and two years. For new nurses, these fellowship programs can be very competitive.

Building Bridges

As with any professional field, building bridges is a key to success. For ER nursing hopefuls, forming relationships within the ER can be a very strong indicator for acceptance into the fellowship program. This can be done by finding work at the ER as ancillary staff or volunteering.  

Working as a nursing assistant before and during nursing school is a great way to expose an individual to the life of a nurse, and either reinforce or redirect their goals. If a position working directly in the ER isn’t available, then employment in other parts of the hospital can still build those relationships and improve your chances of getting a job in the ER.

Although acute care is a part of every nursing school curriculum, emergency room nursing is not.  Nursing students interested in the emergency room can find out if their school has a relationship with a site that might allow them to shadow in the ER. They can also request through their nursing school administration to do requisite clinical work there.  

A capstone in the ER is a highly effective way to set oneself up for employment there. It introduces the nursing student to nurses and management, which gives the student an opportunity to demonstrate work ethic and nursing acumen.

Skill Building

If opportunities for work, volunteering, or clinical shadowing are not available, developing relevant skills for the ER is another way to make oneself more marketable for work there. Many emergency medical technicians (EMT) go on to become nurses and already have highly sought-after skills when they graduate.  Similarly, medical assistants, phlebotomists, radiology technicians, and scrub technologists all have skills and experience that are valuable to the ER.

Because nursing schools follow a general curriculum, there is no formal way to get into the ER as a nurse. The individual who hopes to be an ER nurse must take it upon themselves to be proactive in learning about the ER, building relevant relationships, and developing the skills necessary to be successful.  Being proactive during training is a skill-building opportunity in itself, as the best ER nurses are highly motivated, humble enough to remain teachable, and bold enough to advocate for a seemingly unlimited range of patient populations.

Taking Food and Drink Away From Docs and Nurses Is Just Cruel

Taking Food and Drink Away From Docs and Nurses Is Just Cruel

By Edwin Leap, MD–

It’s hard to explain what we do. And so maybe, it’s hard for others to sympathize with our situations. I mean, physicians, mid-levels, and nurses in emergency departments are tied to computers in often cramped work-spaces, even as they are required to be at the bedside almost constantly for the latest emergency or (in other cases) the latest bit of pseudo-emergency drama.

If you haven’t worked there, or haven’t for a long time, it could be that this lack of understanding is what leads hospital administrations to do one of the stupidest things imaginable. What is that thing? Banning food and drink from our work-spaces.

Now, this isn’t the case in my current job. But it is the case in all too many facilities. I talk to people. I hear things. And it’s usually justified with some unholy combination of infection control, Joint Commission and public health clap-trap, coalesced and refined, then circulated as a cruel policy.

When it’s enacted, clinical staff have their water bottles taken away. Nobody is allowed to eat where they work. Dedicated, compassionate staff members grow tired and dehydrated and hungry. (Maybe it’s a good thing. They often don’t have time to urinate anyway, and water just makes that happen more often.)

Mind you, the water bottles are sometimes kept in a nearby room, or on a nearby shelf. It’s an act of kindness, I guess. And the food? Well, all you have to do is take your break and go to the cafeteria or to the break room, right?

Those who come up with these rules don’t understand that a scheduled break is a great idea … that never happens. It’s an emergency department. It isn’t (technically) a production line; however, we try to impose time restrictions and through-put metrics. It isn’t “raw material in/product out.”

It’s “sick, suffering, dying, crazy human being in” and if all goes well, “somewhat better (at least no worse) human being evaluated, stabilized, saved, calmed, admitted, transferred, and sometimes pronounced dead” out of the other end of the line.

Those Herculean efforts can take anywhere from, oh, 20 minutes to 12 hours. During which time, it’s pretty hard to leave the critical patient in the understaffed department, with the “five minute to doctor” guarantee and the limitless capacity for new tragedy rolling through the door.

That setting makes it remarkably hard for breaks or even meals to happen at all.

As such, it’s nothing short of cruel and unusual for anyone to say to the staff of a modern emergency department, “you can’t have food or drink” — especially when it’s typically uttered by people who have food and drink in their offices and at their desks. People who have lunch meetings with nice meals or who have time to walk to the cafeteria or drive off-campus. And who feel so very good about protecting the staff from their deadly water bottles.

The argument, of course, is that the clinical staff work in a “patient care area.” Even when they aren’t at the bedside but are, for instance, behind a glass wall at a desk. If this is the case, then one could argue that the entire hospital (including administrative suites) is a “patient care area.”

They are afraid we’ll catch something. That it’s unsafe for us to eat or drink where we work. Of course, this is while we positively roll around in MRSA and breathe in the fine particulate sputum of septic pneumonia patients. This is while staff clean up infectious diarrhea and wear the same scrubs all day.

This is after we intubate poor immigrants who may well have tuberculosis and start central lines on HIV patients. This is after we wrestle with meth-addicts who have hepatitis C. And this concern for our “safety” occurs in places where physical security, actual security against potential violent attack, is a geriatric joke which is often tabled until the next budget cycle.

And as for our patients? Our food and drink are no danger to them. They and their families fill the exam rooms with the aroma of fried chicken, fries, and burgers, eaten at the bedside (often by the patient with abdominal pain). Their infants drag pacifiers across floors that would make an infectious disease specialist wake from bacterial nightmares in a sweat-soaked panic. In short, our food or drink are no threat to them and no threat to us.

But the absence of food and drink? That’s a problem. Because the ED is an endless maelstrom of uncontrollable events and tragedies, of things beyond our control for which we are responsible. It is a place of physical, emotional, and spiritual exhaustion where we rise to the challenge and manage (against the odds) to do so much remarkable good by virtue of our knowledge, our training, our courage, and our compassion.

In the midst of all that, a bottle of water, a cup of coffee, a glass of Diet Coke, a Styrofoam cup of iced tea is an oasis in the desert. And that sandwich, slice of pizza, cupcake, or salad is the fuel that helps make it happen.

More than that, food and drink are among the few pleasures we have time for each shift. They serve as bridges to the end of the day, small reminders of normalcy in a place where so little is normal.

Doubtless, one day someone will take away our music so that it doesn’t hurt our ears, or offend our patients. We’ll fight that battle when it comes.

But until then, depriving staff of food and drink proximate to where they work is of no health value and strikes me as just one more way of exerting control over the people actually engaged in the hard, grinding work of saving lives.

And worse, it’s just mean.

Originally published in MedPage Today

Mass Shootings: How Docs and Nurses Heal

Mass Shootings: How Docs and Nurses Heal

Some healthcare professionals see blood, mangled bodies, and death every day, yet certain days are worse than others. As when, for instance, a dozen police officers are gunned down or 20 kids are killed in their elementary school in a mass shooting. Because public mass shootings happen nearly every 6 weeks in America, these tragedies are having a more frequent impact on the healthcare workforce.

Research data are sparse. One study surveyed 24 surgical residents working at Orlando Regional Medical Center in Florida in 2016. On June 12 that year, a gunman shot 49 people to death and wounded 53 others at the mass shooting at the Pulse nightclub. Three months later, rates of post-traumatic stress disorder (PTSD) and major depression were two and four times greater among the 10 residents on call that night versus the 14 off-duty residents. Though the differences didn’t reach statistical significance, assessments were revealing. A survey of the same residents 7 months after the mass shooting found that PTSD persisted in those affected in the on-call group but completely resolved in the off-call residents.

As part of an ongoing effort by MedPage Today to explore job stress and burnout among healthcare professionals, reporter Shannon Firth talked at length with physicians and nurses who shared personal experiences with mass shootings and how they affected their lives and careers.

Three Encounters With Mass Shootings

“After I Saw What I Saw, I Really Thought to Myself, ‘I Hope I’m Not Broken:'” Richard Kamin, MD (Sandy Hook school shooting, 2012)

“The Worst Night of My Professional Career:” Brian Williams, MD (Dallas police sniper attack, 2016)

“I Still Get That Pit Feeling in My Chest of, I Can’t Believe This is Happening:” Megan Duke, RN, CEN (San Bernardino terrorist attack, 2015)

MedPage Today intern Amanda D’Ambrosio assisted with reporting for these stories.

Originally published by MedPage Today.

Workplace Violence Prevention Bill for Health Providers Passes in House

Workplace Violence Prevention Bill for Health Providers Passes in House

On November 21, the US House of Representatives passed the Workplace Violence (WPV) Prevention for Health Care and Social Services Act of 2019 (the bill now moves to the Senate). Strongly supported by the Emergency Nurses Association, the bill now moves to the Senate for consideration.

In the U.S., the prevalence of workplace violence (WPV) in the healthcare industry is four times higher than in other private industries. According to surveys by the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA), some 70 percent of emergency department (ED) nurses have been hit or kicked while at work. Because of ease of public access, crowding, long wait times, presence of weapons, and other factors, the emergency department is a highly vulnerable area, especially where triage occurs.

ED Health Providers Literally on the “Front Lines” for WPV

The shocking statistics on WPV in emergency departments are behind ACEP and ENA’s campaign, “No Silence on ED Violence.” This joint effort aims to educate, empower and protect doctors and nurses working in emergency departments. By raising awareness of the serious WPV dangers emergency health providers face every day, and promoting action among stakeholders and policymakers, the campaign seeks to ensure a violence-free workplace for emergency nurses and physicians.

Acts of workplace violence (WPV) can cause physical and/or psychological harm to emergency nurses. WPV can lead to job dissatisfaction, emotional exhaustion, burnout, secondary trauma stress, PTSD, absenteeism, and intentions to leave the job or nursing profession, all of which have potential impacts on patient care.

Workplace Violence Affects Majority of ED Doctors and Nurses
Workplace Violence in the ED: serious incidents of WPV are 4 times more common for healthcare workers than for any other workers in the US.
Click Infographic to View Full Image

ACEP President William Jaquis, MD, FACEP, said, “If you asked the majority of our nurses and our physicians, they have all been impacted directly by violence—as have I. It goes everywhere from verbal violence, which happens frequently, to physical violence. Ultimately, we hope that in sharing our stories we will gain insight and share resources on how to prevent future harm to our medical teams and our patients.”

The “No Silence on ED Violence” website includes a variety of workplace violence resources for emergency healthcare providers, including guidelines for safety in and around the Emergency Department, and lists of warning signs indicative of potential violent events.

Inspired by the Raise Your Hand movement—which first encouraged emergency nurses in 2018 to share their workplace violence experiences — ACEP and ENA have collaborated on this effort to minimize the frequency of attacks, protect emergency department professionals and build a new level of awareness about this crisis.

Some Tips on Staying Safe

To increase program effectiveness, it is recommended that a workplace violence prevention program include education and training; formal incident reporting procedures; and administrative, environmental and consumer risk assessment, physical design, and security components to address all types of WPV.

13-Point Approach to Dealing with a Potentially Violent Individual
  • Trust your feelings if you feel uncomfortable around a patient.
  • Be vigilant.
  • Don’t isolate yourself.
  • Have security around.
  • Call security when you first become aware of a threat.
  • Maintain safe distance.
  • Keep an open path for potential exit.
  • Present a calm, caring attitude.
  • Don’t match the threats.
  • Don’t give orders.
  • Acknowledge the person’s feelings.
  • Avoid any behavior that may be interpreted as aggressive.
  • Limit eye contact.

Further, if you do become a victim of workplace violence, report it! Underreporting is a documented barrier to effective identification and mitigation of workplace violence. Although many nurses do report WPV incidents using both informal (e.g., telling a supervisor or colleague) and formal channels, the latter is only likely when an injury is sustained. Organizational commitment including workplace policies such as zero tolerance and the role of nursing leadership for establishing a just culture that discourages bullying and retaliation—is essential to mitigating all types and forms of WPV in emergency nursing and other healthcare environments.

Passed in the House, Now Advocate for the Bill With Your Senator

Among other features, the “Advocacy” page on StopEDViolence.org focuses on S. 851, the Workplace Violence Prevention for Health Care and Social Service Workers Act. Resources include an easy form for writing your Senator to support the act. In its current form, S.851 will require health care and social service employers to develop and implement comprehensive workplace violence prevention plans. These plans must include procedures to identify and respond to the common risks that make health care settings so vulnerable to WPV incidents. In addition, the bill is designed to help ensure that employees are appropriately trained in mitigating dangerous situations. For examples of action taken in State legislatures, see this PDF.

Working as a Certified Pediatric Emergency Nurse

Working as a Certified Pediatric Emergency Nurse

The nursing field is filled with various specialties. And that’s a good thing, as while working in emergency would be too stressful for one nurse, it is the perfect fit for another.

Cara J. Szeglin, BSN, RN, CPEN, a Clinical Ladder III Staff Nurse at NewYork-Presbyterian Morgan Stanley Children’s Hospital, is one of these nurses who thrives working with emergency patients. She took time from her schedule to answer our questions about what it’s like to work as a Certified Pediatric Emergency Nurse (CPEN).

How long have you been a CPEN? What drew you to get that certification?

Cara with BCEN Board of Directors Chairperson-Elect Kyle Madigan, MSN, RN, CEN, CFRN, CTRN, CCRN, CMTE right after she received BCEN’s 2019 Distinguished CPEN Award
(Photo courtesy of Brian McCarthy)

I became CPEN-certified in November 2014. By this point, I had been an emergency nurse for about seven years. The first year was with only adult patients, the next two years with adult and pediatric patients, and the last four years were solely pediatric emergency patients. 

When I applied to sit for the CPEN, I had reached a point in my career where I felt like my education and pediatric emergency experience were enough for me to be ready. The Board of Certification for Emergency Nursing (BCEN) recommends nurses have two years of practice in their specialty. Passing BCEN’s Certified Pediatric Emergency Nurse (CPEN) examination proved to myself, my place of employment, and to my patients that I was indeed an expert in my field.     

Why do you enjoy working as a CPEN?

I absolutely love working in pediatric emergency care as a CPEN. I still cannot believe I get to do my job because it is just so much fun. The pediatric patients are great, the parents and guardians are grateful, and my co-workers are amazing. 

Some of the greatest moments I have as a Certified Pediatric Emergency Nurse are when a patient comes in sick or injured, and their guardians and the patient can be confused, worried, upset, and experiencing a host of other emotions, and as a CPEN, I’m able to anticipate what the plan of care should be and I know how to tell them what’s happening and what to expect in a way they will understand. You know by their questions if they understand or if they need you try to explain it another way. I always tell them it is all right to ask questions — as many as they like — and as a CPEN, I feel confident I know the answers or know how to get them and explain them.

The biggest thing about being a CPEN is that you have gained their trust because you are an expert professional who is going to give their loved one the very best care.

What are some of the biggest challenges to being a CPEN?

I have known some extraordinary pediatric emergency nurses who just needed a motivating nudge to get their nerve up to take the exam and get board certified. When I first started nursing and heard about the CPEN, I thought “Those are the elite people. I want to be them one day.” And then when I passed the exam, I said “What took me so long?”

What are some of the greatest rewards?

As a CPEN, I’m part of the care plan for my patients. Before I became a CPEN, fully understanding the rationale of why providers were requesting what they were ordering and engaging with the whole team had really been a challenge for me. Earning the CPEN has helped me find my voice and offer suggestions instead of just accepting all orders as they are. I love being able to constructively question the providers and asking for rationales.

Being a CPEN has boosted my confidence — I am a valued member of the care team who needs to know what is going on and why and whose voice needs to be considered when the care plan is being discussed. This also means I’m better able to ensure that my patients and their families know what the plan is and understand why. 

If nurses reading this are interested in becoming CPENs, what would you say to them?

The CPEN is for nurses who want to demonstrate their expertise in treating infants and children in emergency settings. The exam covers the most common pediatric illnesses and clinical issues of all kinds, including trauma, respiratory and cardiac issues, plus less common things that you still need to know because you never know what might come through your doors. The BCEN website contains all the information you need to apply for the exam, how to schedule a test date (which you can do all over the country throughout the year), plus a lot of helpful resources. 

I studied for the CPEN exam just as hard or probably even harder than I had for the nursing boards. A key part was scheduling a test date along with a pediatric emergency nursing friend of mine — so there was no backing out. We studied together, supported each other, and passed on the same day together! Each of us study and learn in different ways.

What else is important for readers to know?

There are so many good things, rewarding things about being a nurse, especially pediatric emergency care. There are days when everything seemed to go so smoothly and you excelled at everything you did. And then there are the days when something came through the doors totally unexpected, and you only hope you can hold it together until the end of your long shift so you can cry about it on the way home. The same can be said for all specialties of nursing. But you pull it together and show up for work the next shift, with the same level of care, dedication, and enthusiasm because being a nurse is the best career

I love being a CPEN, and I hope that readers can feel my passion and get motivated to become certified themselves, and if they are already certified, I hope that this inspires them to seek out other nurses and start being a mentor for them!

What Happens During a Code in the ER?

What Happens During a Code in the ER?

When a patient is described as having “coded,” this generally refers to cardiac arrest. In such a case, urgent life-saving measures are indicated. This can happen within and outside of medical facilities. The benefit of the occurrence in a professional health care setting is that policies and guidelines are in place to address this life-threatening crisis. What follows is the perspective of responding to a code from an ER nurse.

Just as every patient is different, so is every code. The causes and outcomes of every code have to do with the characteristics of the patient in question: the history of present illness and, of course, their comorbidities. Timothy Wrede, RN, is a long-time emergency and critical care nurse in the suburbs of New York City, as well as a former EMT who has seen his fair share of codes. According to Wrede, nothing matters during a code so much as the team that responds to it. “It is imperative to ensure that a good team of doctors, nurses, and ancillary staff are working together efficiently in order to achieve resuscitation of spontaneous circulation (ROSC),” says Wrede. 

According to Wrede, a veteran of level-I trauma care, when it comes to staffing a code, less is more. Studies suggest that thirteen is the maximum number of personnel participating in an effective code. Included in this number are professionals that go beyond those immediately at the bedside, such as pharmacy, lab, and spiritual services. “There’s nothing worse than 25 people crammed into a patient room trying to coordinate resuscitation,” according to Wrede. For him, the minimum is five ‘in the box’, or in direct proximity to the patient, as well as one team member ‘outside of the box’. “One doctor, three nurses, and two aides are more than sufficient to obtain or sustain an airway while maintaining a clear line of vision of the patient, the patient’s monitor, and other team members,” he says. This consists of one nurse on either side of the patient responsible for gaining peripheral IV access, administering IV medication, and obtaining blood samples for lab work. The code recorder, usually an RN, documents everything that occurs, including every medication given, timing, team actions, compressions, defibrillation, and patient response. 

Wrede’s description of the ideal code team is very similar to the American Heart Association’s recommendation for high-quality CPR teams.  It includes a “triangle” of providers doing chest compressions, defibrillating, breathing for the patient, and providing medications, in addition to a code recorder and a physician outside of the triangle.  The physician acts as a team leader by making high-quality treatment decisions, providing feedback, and overseeing team actions.

For Wrede, the most important times for a code are before and after it.  Having a competent team with pre-assigned roles, as well as the opportunity to review and debrief afterward to improve the process continuously, and allow for best patient outcomes. Many hospitals address this by establishing a code team that arrives every time a code is called, with well-established roles, and protocols. Wrede’s experiences describe codes in the ED, although codes are generally run the same regardless of where they take place. The biggest difference is the patient context.

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