More than 130 million people visit the ER annually in the United States, many of whom are admitted to the hospital or critical care.
Emergency room (ER) nurses work in a fast-paced environment where their nursing skills are tested daily. They can specialize in cardiac care, pediatrics, trauma, or geriatric medicine. Caring for a variety of patients requires strong critical thinking and quick problem-solving skills.
We spoke with Whitney Riley, an ER nurse from Trihealth in Cincinnati, Ohio. Riley works in the emergency department and recently passed her certified emergency nurse exam.
Riley discusses the ER nursing profession, why it was the right career for her, what it takes to be a good ER nurse, and common misconceptions about the ER.
Q&A With ER NURSE
Whitney Riley has been a registered nurse for two and a half years. She graduated nursing school in December 2020, during the COVID-19 pandemic. She started her career on a neuro step-down unit where she cared for many patients with neurological deficits. She is now in the emergency department at a comprehensive stroke center. Riley has been in the emergency department for over a year and recently passed her certified emergency nurse exam.
How did you first realize ER nursing was the career for you?
The first time I realized that emergency medicine was the career for me was my first code blue. I was fresh out of orientation in the ER, and I had recently taken the advanced cardiovascular life support (ACLS) certification exam.
While caring for a very sick patient, I noticed his heart rhythm had changed from sinus tachycardia to v-tach. The patient was unresponsive but still had a pulse and was breathing.
The family was at the bedside at this time. The family looked at me with fear in their eyes to help their loved one. I called the physician, but within minutes of the physician’s arrival, the patient lost a pulse. We performed high-quality CPR and followed ACLS for shocks and medication.
We were able to revive the patient, and he was transferred to a higher level of care. Saving this patient’s life in the presence of family solidified my love for emergency medicine.
Describe a patient experience that has stayed with you over the course of your career.
One patient experience that has stayed with me over the course of my career occurred when I was still working as a baby nurse on the neuro step-down unit.
In early 2021, I had a COVID-19-positive patient that required a central line. The patient was terrified of the procedure and extremely claustrophobic. It took two attempts by the general surgeon to insert the line.
The first attempt was made through the patient’s neck. This required the sterile drape to cover the patient’s face. In order to keep the patient calm, I stayed under the drape with him and provided comfort. We talked the whole time. I had a mask on that only revealed my eyes.
Fast forward a year later, after I started in the ER, this same patient just happened to come to the ER and was placed in one of my assigned rooms.
At first, I wondered if he remembered me. Roughly an hour later, I had to give a report to the oncoming nurse, and before I left, he said, “I remember your eyes. You stayed with me last year when I had COVID. Thank you! I was so scared.”
I bet there are some rather odd moments in the ER. Do you have a “now I’ve seen everything” moment?
The ER is definitely full of interesting moments! I believe my most interesting, though scary, moment happened roughly two months after my orientation.
I arrived for my shift at 7 am and received a report from the night shift. My patient had a shoulder dislocation that they put back in place using conscious sedation. The patient was slowly coming out of the sedation when I arrived.
Roughly 45 minutes later, the patient had fully recovered from the sedation and was ready for discharge. When the patient stood to get dressed, there was a handgun sitting on the bed. The patient and I made eye contact, then she said, “I thought they would have taken that from me.” She was very nonchalant.
After that moment, I thought, “Well, now I’ve seen it all.”
What do you think it takes to be a good ER nurse?
I think one attribute that contributes to a good ER nurse is the ability to stay calm. Our patients and their loved ones are scared, filled with fear of the unknown.
As an ER nurse, it is okay and even natural to be freaked out, but it’s important to keep in mind that our patients are the most scared. They are relying on us for reassurance that we are doing everything we can for them.
If you could go back and talk to the version of you just starting nursing school, what would you tell yourself?
If I could go back to Whitney in 2018 just starting nursing school, I would tell her that all her hard work is going to pay off. That nursing isn’t exactly how she pictures it to be, but it is very rewarding. I would tell her to keep her head up—even when she feels like she isn’t doing enough for her patients—because she is.
What does Hollywood get right and wrong about life in the ER? What misconception would you most want to clear up?
When I think of a Hollywood version of the ER, I feel that it shows constant patients with trauma who need large amounts of blood transfusions, limbs that have been cut off, knives penetrating chests, etc. Yes, we do see serious trauma and critical patients in the ER. However, it is not every day.
Patients that present to the ER vary in age, gender, comorbidities, and complaints. A large number of patients that we see in the emergency room are not suffering from something that is life-threatening.
One misconception that I would like to clear up is that nurses do not work for physicians. Nurses and physicians work together as an interdisciplinary team and collaborate on what is best for the patient.
If you could wave a magic wand and change something about the ER nursing profession, what would it be?
If I could wave a magic wand and change something about the profession of nursing, it would be to address the lack of support for new nurses.
An example taken from my own experience: I was still in orientation when I made a mistake with the Pyxis while taking out a narcotic. I miscounted, which we all know throws off the count and creates a flag indicating that there is a discrepancy.
The charge nurse had to fix the count and type in a reason as to why the count was off. The charge nurse typed, “New nurse doesn’t know how to count.” The charge nurse and my preceptor laughed, but I felt so discouraged.
Two and a half years later, I seek out our new nurses to offer help and encouragement. We need to change how we train and treat our new nurses. They are our future.
What Does an ER Nurse Do?
The day starts with a report from the nurse who is leaving. Instead of patient assignments, ER nurses are given room assignments and take care of patients admitted to those rooms during their shifts. Within the first 30 minutes, an ER nurse has received a report and completed a quick assessment of the patients and the rooms to determine what needs to be restocked.
On a unit, a nurse might have one admission and discharge during the shift. In the emergency room, you can have multiple admissions and discharges. This means documentation must be completed in a timely fashion because you can’t always record patient information after they’ve been discharged.
ER nurses must be adept at moving from one emergency to the next. Patients come in via ambulance or car with possible deep vein thrombosis, broken bones, cardiac events, fevers, and shortness of breath. They must have lab work drawn and imaging tests ordered. The ER nurse must keep the information separate and appropriately organize care for each patient.
In between the rush to complete testing and get the results to the ER physician, patients require education and a calming voice to help them through the healthcare system and testing, which is entirely unfamiliar.
Sometimes, the shift is so busy that it’s challenging to stop for 10 minutes to grab some food. Admitting and discharging several patients from each room during one shift is not unusual. This includes giving discharge instructions and connecting some patients with community resources.
There is no such thing as an ordinary day in the life of an ER nurse. While nursing school gives students the basic information they need to practice, it cannot prepare a nurse to work in the ER.
Clinicals are tightly controlled environments with organized notebooks or notecards and time to think and plan. In the ER, anything goes. After years of ER nursing, most nurses can still be surprised by the variety of diagnoses and challenges that come through the door.
“Patients that present to the ER vary in age, gender, comorbidities, and complaints. A large number of patients that we see in the emergency room are not suffering from something that is life-threatening.”
— Whitney Riley, RN
ER nurses work in a variety of settings. Their responsibilities vary slightly depending on the workplace environment.
ER nursing jobs are rewarding but also physically and mentally challenging. To accomplish their tasks, ER nurses must have these key skills to fulfill their responsibilities, some of which you can only learn on the job:
- Critical thinking
- Composure under stress
- Time management
- Communication skills
- Triage and patient assessment
- Administer treatments (medication, pain control, fluids)
- Assess and initiate treatment for trauma and allergic reactions
- Coordinate and document discharge planning
- Administer life-support treatments such as during a code
- Clean wounds
- Draw blood
- Assist with insurance paperwork
How to Become an ER Nurse
You must first obtain your registered nurse (RN) license in the state in which you work before practicing as an ER nurse. Nearly all hospitals require RNs to have advanced cardiac life support (ACLS) certification for employment. This ensures a level of care in the ER that cannot be consistently found in other outpatient venues.
You can get an RN license after graduating from a two-year associate in nursing (ADN) or four-year bachelor of science in nursing (BSN) program. Most hospitals are moving toward employing BSN-prepared nurses and may require nurses with an ADN degree to complete a BSN within 3-5 years.
Nursing graduates must pass the NCLEX-RN. All states require that you pass this exam to obtain your state license to practice. The exam uses computerized adaptive testing technology to reliably measure nursing competence.
Most ER departments prefer nurses with ER experience. While many nursing students get some ER experience during clinical hours, you can gain the most experience by working in an emergency department. Most hospitals have training programs for new ER nurses, and some have residency programs.
Certification in ER nursing is optional, but it raises your employment and salary potential. Certification also builds consumer confidence and contributes to better patient outcomes. You must have a current, unrestricted nursing license and two years of clinical experience to sit for the exam.
How Much Do ER Nurses Make?
ER nursing salaries vary depending on your location, education level, certifications, and experience. Salary data can also vary across companies that gather information.
ER nursing is challenging and fast-paced. But it’s also rewarding and a unique way of using your nursing skills to save lives and impact families. Each day in the life of an ER nurse is different. ER nurses learn something new about themselves, their patients, or medical procedures every day. Only you can decide if ER nursing is the right career path for you.