March 22, 2006, 4:09 pm

What I Think It Takes To Be An ER Nurse

“Mary Louise Shines”?

Yeah, and I’m Catherine Zeta Jones.

This is no real nurse. I haven’t seen her in a single recruitment ad in all the hours I’ve spent searching the internet.

Interestingly enough, she comes from New York, just like Beulah France, RN, our favorite nurse consultant when it comes to harsh toilet tissue.

So we can avert the nursing shortage and gain valuable staffing by just using Pepsodent?

“You’ll wonder where the yellow went, when you brush your teeth with Pepsodent!” I did not make that up. It’s the old ad jingle.

Never mind what year.


But wait!

Now she is recruiting for…clear skin?

She would never have recruited me.

She looks like a Stepford Nurse.

She speaks in thought bubbles.

And her cap is really yukky.

Hey, I have priorities, ya know.


Ever thought about being an ER nurse?

Ever wonder if you “have what it takes”?

I didn’t think I did until one slow day in ICU I floated down to a tiny, three-bed ER and fell in love with a whole new world.So here is my own, personal subjective take on what it takes to be an ER nurse:

  • A Strong Personality
    • Timid, fragile….no place for that in the ER. Things will get tense and tempers will fly.
    • Do you cry if someone says “Boo!” in the wrong way? If you are a “Sensitive Sam”, you will have a hard time. I know. I was a “Sensitive Sam”. Then I got older. Now I can say “Boo”! right back and then some.
    • Alternatively, if you are the type to hold a grudge, the ER is not for you.
    • That doesn’t mean you have to be a loud, boisterous person. Two of the best nurses I ever worked with were extremely quiet. They didn’t say much, but they were the epitome of efficiency and their patients were in superb hands.
  • An Assertive Personality
    • All nurses are patient advocates, but in the ER you do not often have the luxury of time.
      • Occasionally you will find that decisions are being reached (as in admit vs. return home) that you, as the nurse, can influence.
      • If you feel a decision is being reached that is not in your patient’s best interest (weak while ambulating and lives alone, for example), you must speak up. Can you do that?
    • The easiest doctors you will ever deal with will be the ER docs. There is a sense of teamwork and communication between the docs and nurses that is really unique to the ER.
      • You will be dealing with specialists from every department: surgeons, eye specialists, hospitalists, cardiologists, neuro docs, etc.
      • They don’t always know the policies of the ER.
        • sometimes they will make it quite clear that they could not care less about the policies of the department.
        • It will, occasionally, be up to you to assert that you cannot carry out a specific order because or ask them if an order can be done after admission to free up an ER bed. Are you willing to do that?
  • Energetic
    • If your idea of aerobic exercise is to click the remote twice in a row, you need not apply to the ER.
      • You will move. There will be shifts when you never stop moving. You need to be willing to walk in that door with roller skates on and well oiled to boot.
      • You have to be willing to put in the energy that the job requires. Can you do that?
  • Stamina
    • Energy is a willingness to work. Stamina is the ability to work.
    • You will never know what you will be dealing with on any given shift
    • You have to be able to go the distance – finish the shift giving 100%.
      • Often without breaks, sometimes without dinner.
      • Maybe even after your scheduled shift is over. Can you handle it physically?
  • The Ability to Prioritize
    • You have four patients, two cardiacs, one going to the cath lab, one GI Bleeder (stated at triage) and a patient with an ingrown toenail. Who ya gonna call?
      • Sorry, the Ghostbusters are busy – you make the decisions.
        • What orders go first on which patients?
        • You can always ask your co-workers for help, but you need to know what you want them to do! Can you make decisions on the fly?
        • Can you handle more than one crises at a time? Are you willing to take the chance that you will have to? Does the idea exhilarate you or make you nauseated?
  • The Ability to be Flexible
    • When your co-workers get overloaded (see above), are you able to see beyond your assignment and help prioritize their care?
    • When your rooms are empty, are you willing to discharge, start IVs, medicate your colleague’s patients? Are you willing to ask them if they would like your help?
    • Someone calls in sick. Are you willing to pitch in and help cover for them?
    • Your co-worker is having a bad day….sorta bitchy. Are you willing to cut them some slack?
    • The doc wants to add some tests to the patient, increasing your already heavy workload. Can you take it in stride?
  • Attitude
    • You must have a positive attitude.
      • No one wants to be around constant bitching or fault-finding.
      • That can drag down the morale in an ER faster than an unsuccessful code
      • Can you put on a positive front even when you are not feeling it?
    • Then, again, there is a time and a place for ventilating. The nurse’s station or the patient’s room is not it. Can you wait to complain until it’s appropriate?
    • Your patients already feel bad. They are sick, they are angry, they are tired, they are impatient. Can you smile and be upbeat when everyone around you is not?
    • Can you see your patient as an individual and empathize, not just see them as the “abdominal pain in the back room”?

And now the controversial statement:

I do not believe that a nurse should begin their ER career as a new graduate. It is imperative that she/he gain the skills of prioritizing and assessment/evaluation on at least a monitored unit.

The “feeling in your gut that something isn’t right” comes from your experience outside the ER. You need to have enough experience to have developed that sixth sense.

You should be comfortable with drips,coding and defibrillating (basically, Critical Care) well before coming to the ER. The other stuff is just clinical and can be picked up quickly.

You have to be able to carry your own weight.

There are always exceptions, I have worked with nurses who are barely out of school who were made to work ER. But they are few and far between.

If you were meant for the ER you will love every minute. If you were not meant for it, you will know almost immediately.

I think it may be in our genes…….


  • Mama Mia

    March 23, 2006 at 5:33 am

    Yes. Exactly.

  • Jodi

    March 23, 2006 at 7:32 am

    Great advice and I totally agree with you about the new grad thing. I can only think of one classmate who MIGHT do well starting in an ER and that’s because she used to be an EMT.
    It’s kind of the same principle I have for pediatrics. They overtrain us in RN school for Med/surg…I’m gonna get comfy in my skin there before branching out into the Pedes World.

  • Susan

    March 23, 2006 at 8:28 am

    I LOVE this entry! You hit many nails right on the head. I’m linking to this post, baby.

  • Angela

    March 23, 2006 at 9:34 am

    I totally agree. The floor is the best place to learn organizational and assessment skills. I even think one should have floor experience prior to working ICU. When unit nurses would get floated to the floor a lot of them had a hard time keeping up! Even though ICU pts are more acute,in my unit we only had 2 pts a piece which is much different than taking at least 6 floor pts.

  • Jenn

    March 23, 2006 at 2:04 pm

    I agree with you on the new grad thing. I started in open heart step down and I’m not sure even that was a good idea, though I did well. I still don’t think I have what it takes to work in an ER.

  • Anonymous

    March 23, 2006 at 2:09 pm

    Wow – I’m not meant for the ER, then!
    But that’s OK, because my heart lies with the Path Lab – and I knew that it was where I was meant to be for the rest of my life from the first day (I know because I wrote and told my sister so, and she’s still got the letter!).

    Isn’t it strange when you DO know the job you’re made for? And how if people give you funny looks when you say so, you know that they’re sort of marking time (doesn’t mean they’re not doing a good job, though, of course).

  • Flea

    March 23, 2006 at 3:39 pm

    Mary Louise is from Scarsdale for chrissake!

    For those of you across the ponds or even the other side of the Hudson, that’s an upscale bedroom community for New Yorkers looking for them wide open spaces.

    Definitely not nurse-tough.


  • marcus

    March 23, 2006 at 4:39 pm

    A very thoughtful post that is all the more meaningful for your experience.

  • Karen

    March 23, 2006 at 8:59 pm

    Thank you for an informative post!

  • TC

    March 24, 2006 at 10:01 am

    Ah, Kim, you make me long for my ER days(er, nights). And I agree, my floor experience served me well before going to the ER-coding people, learning to read rhythm strips. I could not for the life of me, start an IV when I first hit the ER–that lasted about 2 shifts. Now I’m proud to say I can get a vein on a IV drug abuser with sickle cell.

  • unsinkablemb

    March 24, 2006 at 10:12 am

    When I was in nursing school, my top choices were the ER and OR. (I used to volunteer at a Level I Trauma Center’s ED and loved it). I often wonder what things would have been like if I would have chosen the ER path… Well, for now, I’ll just have to live vicariously through you! 🙂

  • Sean

    March 24, 2006 at 10:18 pm

    I went into nursing wanting to be in the ER, and now, as I am nearing graduation, I still want to be there. However, I am with you on the waiting before going to the ER. I plan to spend time on units for a few years before taking that leap.

    Anyway, great post!

  • Beastarzmom

    March 27, 2006 at 2:17 pm

    And I find that those suited to ICUs are those who don’t mind, dare I say it, even LIKE playing with toys and tubes. You will troubleshoot more equipment and manage more tubes than people have places for. Since I moved over to IT some 15 years ago, I found the most successful of the nurses transitioning to this field were either ER or ICU nurses. Yep – toys, machines, making things work.
    Funny how that works…

  • rnxmas

    April 3, 2006 at 9:05 pm

    I did an externship on med/surg while finishing my last year of nursing school. I went directly into ER after graduation and haven’t looked back since. I can’t really say that working on the floor helped me prioritize once I got into the ER. I find it to be a different beast entirely.

  • jeepgirl

    April 9, 2006 at 4:17 am

    AMEN Kim!

    I went into a Level 1 ER right out of nursing school, was put on night shift… and thus the story begins. 4 years later I love the job, love the people, occasionally love the patients (just don’t LOVE the patients!!). Its just not for some folks. Love your posts….

  • orthorn

    December 28, 2006 at 5:17 pm

    This post makes me miss the ER,too. I went in as a new grad but had woirked floors for two years as an aide. Once I hit that ER I had found my home and my true love–trauma! I just don’t have the physical stamina for it anymore.(But I miss it everyday.)

  • Airway Control

    December 28, 2006 at 11:37 pm

    Straight out of school into a level 1 Trauma ER. Yeah, it takes a certain personality, but if you’ve got that personality, you can do this job as a GN or 20-year RN; sure the shit-your-pants curve and learning curve are steep, but if the personality fits … . I’ve got about 1 1/4 years under my belt in the ER, and I am nowhere near reaching the knowledge base of real ER vets, but I know when I’m seeing something that ain’t quite right, and it usually leads me to a doc andd an artificial airway for my patient.

  • justcallmejo

    December 30, 2006 at 11:47 am

    Great advice, Kim. I admire ER nurses, and I have never met one that I didn’t think was whipsmart and sharp.

    As a one-year-out grad, I think you’re right on target by saying that it is NOT a place for a new grad. We come out of school from our BSN programs, and we aren’t bullet-proof. I think it’s important to recognize that nursing is a profession and ED nursing, like ICU nursing and some others, are specialties you can do after the groundwork of good med-surg has been laid.

    A lot of new grads don’t want to hear that, and bristled at this while in school (particularly those of us in accelerated programs). But medicine has that structure…there are excellent general prac’s, and excellent oncologists…and they don’t know the same things. But they all had to learn general practice. Why should nursing be different from this?

  • Amie

    December 30, 2006 at 6:12 pm

    I am with you on the new grad thing… I believe that every new grad needs a good year on a step down or med surg floor for experience before entering the ED/ICU. My hospital offers the “internship program” for new grads and then dumps them into the ED, ICU, or possibly PACU.
    No business.

  • Lisa

    January 1, 2007 at 5:31 am

    I came into a Level 1 trauma center as a new grad 4 years ago. I learned more the first week then I learned in all of my ADN program. I don’t agree that everyone needs med/surg experience. There are some of us with life experience who were built for ER. I couldn’t work anywhere else. The nurses who aren’t made for ER weed themselves out within a week.

  • TeriYoung

    January 7, 2007 at 2:41 am

    Thanks. I needed to hear that. I just started in a busy ER after 16 years of nursing. 2 in peds, 6 in oncology, 5 in Home health care and 3 in med surg. And still my Butt is Way KICKED. I am enjoying the challenge but stll….ohmygod…I am into my 4th week of orientation…I told them I didnt need to have
    the six week ER course, as I felt I had lots of experience but, jeeze, it’s so different from any kind of nursing I have done before. This is a level 1 trauma center but I am not expected to do trauma pts until I’ve had 1 year of ED experience. Also, the nurses where I work all help eachother out lots…Hey…You know we need an ER nurse chat room…for just us…so we can inspire and encourage eachother….how about it?


About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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