A conversation with emergency nurses

Jeff Solheim, Alison Burton Shepherd, and Patricia Howard | 12/11/2018

Three leaders in the specialty share their perspectives.

A conversation with emergency nurses

Matthew Howard, director of educational resources at Sigma Theta Tau International Honor Society of Nursing (Sigma), interviews three emergency nurses about their work. 

Setting the stage
Emergency nursing is a unique specialty area that encompasses roles in a variety of settings, including emergency departments, urgent care, medical missions, or pre-hospital settings such as ambulances, helicopters, or cruise ships. The defining characteristic of this specialty is the care of individuals across the lifespan with perceived or actual health concerns that are undiagnosed. Episodic and multifaceted, the role involves rapid decision-making, triage, stabilization, interventions, prevention, and education.

When thinking about working in emergency nursing, several images come to mind: fast-paced, unpredictable, adrenaline rush. No two shifts for an emergency nurse are ever the same. This is all familiar to Jeff Solheim, MSN, RN, CEN, CFRN, TCRN, FAEN, FAAN; Alison Burton Shepherd, PGCAP, FHEA-R, Nutr, MSc, BSc (Hons), RN, TCH, Queens Nurse; and Patricia Howard, PhD, RN, CEN, CPEN, TCRN, NE-BC, FAEN, FAAN. Interviewer Matthew Howard, DNP, RN, CEN, CPEN, CPN, is also an emergency nurse.

Matthew Howard:
Tell us something in general about emergency nursing. How do you define it?

Patricia HowardPatricia Howard: 
Emergency nursing is the specialty that cares for all ages and all acuities. We possess significant clinical knowledge and are technically very skilled. It is our honor to intervene and make a difference in some of the most challenging times in our patients’ and families’ lives. We care deeply about our patients, families, and each other.

Alison Burton Shepherd: 
Alison Burton ShepherdI work in urgent care—a place people come to when they do not have access to their family doctor’s office. We see patients who present with illnesses such as sore throat, respiratory tract infections, and urinary tract infections. We also see people who don’t think they are very unwell and have sat in front of me, as the nurse on duty, suffering serious heart problems, including myocardial infarction or heart failure. More recently we have seen and treated people with sepsis originating from pneumonia and skin infection. We deal with surgical emergency, including appendicitis, peritonitis, and obstruction. Gynecology emergency, including miscarriage. Addison's disease, people in crisis, mental health problems ... the list is endless. We have to be always on the alert as we do not know who will walk through the door next.

Jeff Solheim: 
Jeff SolheimAbout a decade ago, emergency nursing was still not recognized by the American Nurses Association as a specialty area of nursing. When we applied to become a specialty area, we were challenged to define what made emergency nursing unique. After much thought and debate, it was determined that one of the main defining qualities that made emergency nursing unique in the field of nursing was the fact that we are one of those unique clinical areas where we care for patients without a diagnosis. Our patients present with symptoms but often lack a diagnosis. This makes our focus different from other areas of nursing. My job as an emergency nurse is to not only care for your acute needs but to also figure out what is wrong with you so that we can either direct you to the proper care or provide you with the proper treatment. I enjoy being a sleuth. I love the challenge that comes with every patient I care for, determining if that patient is indeed ill and, if so, what is causing their illness.

M. Howard:
Matt Howard
What steps, if any, would a nurse take to move into emergency nursing? Experience? Advanced education?

I would advise to work in Medicine, Surgery, and of course ED. Learn to prescribe. Put yourself in an advanced nurse practitioner programme.

Although emergency nursing is a specialty area, we are a specialty of generalists. There are few other areas of nursing that require me to know as much as I do to work in the emergency department. I have to be prepared to deliver a baby, care for a patient in cardiac arrest, stabilize a trauma patient, calm a psychotic patient, and meet the intense social needs of a homeless or abused patient. I am not necessarily an expert in any of these areas (I have no problem assisting with a healthy delivery but have little knowledge in what to do if it were a breech delivery). But I know a lot of stuff about a whole lot of clinical areas as well as age groups I care for. The more skills that a nurse brings to the emergency department with them, the easier integration will be. Develop a strong clinical background in various areas prior to seeking a job in the emergency department. Today, there are programs that allow new graduate nurses to enter the emergency department directly, and these programs are excellent. They do, however, limit future career mobility. It is always preferable to develop skills in various clinical areas before specializing, especially to an area like the emergency department. Specialty areas will seek evidence of experience for transfer, and if you have spent a long time as a generalist, that lack of specialty background does not always translate to easy career mobility.

P. Howard:
Becoming an emergency nurse can be accomplished though several career paths. In my institution, we have an emergency nursing internship for new graduates. During this intensive, five- to six- month program, the intern completes the emergency nursing orientation online modules; the essentials of critical-care orientation modules; and the ACLS, PALS, TNCC, and ENPC. The intern also works 24 hours per week in the ED with a preceptor. The other pathway is to come to the ED with experience in another clinical area and complete an individualized orientation program.

M. Howard:
What characteristics do you see as invaluable in someone who is to be successful in emergency nursing?

What makes emergency nursing a unique animal is that people who work there need to be able to thrive in chaos at the same time as they need exceptional organizational skills. This is not a characteristic that many people have. I often ask people to describe their sock drawer to me. Are all your socks not only paired in the drawer but lined up perfectly and perhaps even color-coded? If this is you, I am not going to say that you will fail in the emergency department, but the chaotic nature of the emergency department may grate on your personality at times and require adjustments on your part. Is your sock drawer a jumble of socks that are not even paired up? Because the ED is chaotic, some degree of organization is required. Without a sense of organization, important tasks can be overlooked, and because we sometimes deal with life and death situations in the ED, overlooking tasks can have disastrous outcomes. Is your sock drawer between these two? Are your socks paired but perhaps a jumble in the drawer? This bridge between perfection and lack of organization may indicate that you will be well-suited to the chaotic environment of the ED while still being able to function safely.

P. Howard: 
Resilience is essential; teamwork, good communication skills, and the ability to collaborate with other members of the interprofessional healthcare team are also needed. Compassion is important for all nurses, but especially in the ED, where critical illness and injury occur frequently.

You need to be calm, be able to work under pressure, be methodical, and rule out serious illness through your history-taking and assessment. If you cannot rule it out, then refer on to an experienced clinician who can.

M. Howard:
What is unique about emergency nursing? Why would someone want to join this specialty?

It is fast-paced, challenging, exciting—a chance to mentor new staff and save lives. This is why I love to work in the area and will continue to do so.

P. Howard: 
The ED nurse has more autonomy that most areas of nursing. ED nurses care for all patients; in one shift we can be a critical-care nurse, a pediatric nurse, or a palliative care nurse. ED nurses may see the entire continuum of care and life in one shift. A baby may be delivered at triage, and, a few moments later, we may participate in a resuscitation where our most important role may be helping a family make difficult decisions. ED nursing is extremely rewarding. It is a privilege to be an emergency nurse and care for patients in their time of need.

The emergency department is fast-paced. The patients in the emergency department provide a variety. Many of our patients present without a diagnosis, so being inquisitive is a must. Do you like a rush of adrenaline? Do you like to solve puzzles? Do you like to drive to the same destination but use different routes for variety? Perhaps the ED is for you.

M. Howard:
What, if any, professional organizations specific to your clinical specialty do you see as critical to participate in as a member or leader?

P. Howard: 
The Emergency Nurses Association is the professional nursing organization for emergency nurses.

The overarching professional organization that encompasses emergency nursing is the Emergency Nurses Association (ENA). Although there are subspecialties within the field of emergency nursing, all nurses working in this field should belong to the umbrella organization. But within the field of emergency nursing, there are subspecialties, many with their own professional nursing organizations. Many emergency nurses, for example, have training in forensic nursing and belong to the International Association of Forensic Nurses (IAFN). Some emergency nurses work as nurse practitioners within the emergency department and should belong to the American Academy of Emergency Nurse Practitioners (AAENP).  Emergency nurses who specialize in trauma may want to belong to the Society of Trauma Nurses (STN).

In the UK, we have emergency nurse forums but nothing specific. Becoming a member of Sigma and participating in online communities such as the Emergency Nursing Community on The Circle are great ways to connect with other emergency nurses who are part of Sigma. Each Community of Interest has a discussion forum where great conversations and information-sharing take place. I get a convenient Daily Digest email, so I’m always updated about the discussions happening among Sigma members from around the world.

M. Howard:
How has being in this area of nursing advanced, changed, or impacted your career journey?

The emergency department helped me develop the skills that were needed to branch out into all of the other interests in nursing that I have pursued. Some of the things that I have done in nursing over the years have included international humanitarian work, flight nursing, disaster response, cruise ship nursing, and camp nursing. Because the emergency department helped me develop skills in caring for different age groups and various specialties and taught me how to improvise on the fly, I was better prepared for unique opportunities as they arose.

I am now in charge of my department (three other nurses) on weekends assisting in mentoring, clinical decision-making as a team, and dealing with enquiries from staff and patients alike. I am about to embark on credentialing to become an ANP and would not be able to do this without working in this role.

P. Howard:
Emergency nursing has allowed me to do things I would never have predicted at the beginning of my career. If I can ever give back even half of what this profession has given me, I would be making an impact beyond my expectations. I have been blessed to not only care for patients, families, and staff but also educate, mentor, lead, and promote other nurses. The opportunity to help other nurses reach their goals is very rewarding.

M. Howard:
What else would you like someone to know about emergency nursing?

P. Howard:
Emergency nursing can appear overwhelming. At times, it can be. I always remember, no matter how many patients there are, it is important to be present for the patient in front of you; the same is true for staff. Be present in the moment while maintaining situational awareness because the environment is very dynamic.

It is very rewarding, and it is best, if you want to work in this area, to gain as much experience first as you can. Instinct with evidence-based decision-making is a key aspect of this role. Remember Benner and her work on clinical decision-making and intuition. RNL

Jeff Solheim, MSN, RN, CEN, CFRN, TCRN, FAEN, FAAN, is owner and president of Solheim Enterprises, the 2018 president of the Emergency Nurses Association, and emeritus executive director of Project Helping Hands. Alison Burton Shepherd, PGCAP, FHEA-R, Nutr, MSc, BSc (Hons), RN, TCH, Queens Nurse, is a specialist advisor (nursing) at Care Quality Commission. Patricia Howard, PhD, RN, CEN, CPEN, TCRN, NE-BC, FAEN, FAAN, is enterprise director of emergency services for UK HealthCare and the 2018 president-elect of the Emergency Nurses Association.

If you would like to learn more about how to get into emergency nursing, visit Sigma Career Mentoring and Coaching Program on The Circle and match with an emergency nurse mentor.

To join the Emergency Nursing Community of Interest, navigate to The Circle at thecircle.sigmanursing.org. You’ll be prompted to log in using the email address you have on file with Sigma and your seven-digit member ID number as the password.

Once you’re logged in, click on Groups and then All Groups from the main purple navigation bar. On the next page, use the All Group Types drop-down box to select Communities of Interest. This will pull up all 15 communities available to join. 

Find the Emergency Nursing Community and click the Join button to become a member of this group. Be sure to introduce yourself in the discussion forum and begin posting your own questions and conversations!

A Hugoton Foundation grant awarded to Sigma Theta Tau International Foundation for Nursing in honor of the Foundation’s president and Sigma member, Joan K. Stout, DM, RN, FAAN, DL (H), DST (HS), makes this mentoring/coaching program possible.

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