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Chris Armstrong explains the key skills it takes to excel in A&E Nursing.
23rd April 2018
Written by Chris Armstrong
In a decade of working in Blackpool Victoria Accident & Emergency, I learnt far more than I could ever recount or remember. I grew as a nurse and as a person, worked with hundreds of amazing people, and gained enough life experience to fill a book.
I experienced things that will stay with me forever, in good ways and bad, and saw things some people simply would not believe.
It was that ten-year rollercoaster of learning that shaped me into the nurse I am today. I realise now, I learned all the fundamentals of being a good nurse in that busy sea side hospital. I could build on skills that ultimately led me to my current position as a Deputy Intensive Care Sister at Guy’s and St Thomas’ hospitals.
We all know the basic qualities a good nurse needs:
But let’s focus on what it takes to be a great A&E Nurse. It’s a high pressure and fast paced role that is sure to keep you on your feet; but is it right for you?
As an accident and emergency nurse you are often the first point of contact for patients seeking treatment. This means you should be ready to deal with whatever the world can throw at you. As the name suggests, “emergency” is the care you will be administering in A&E.
Many of the patients you see will be in a critical or anxious state. You will need to react quickly and decisively to a never-ending barrage of random injuries and illness.
I loved my time in A&E, and although I no longer work in the department, I carry the skills that made me a great Accident and Emergency Nurse wherever I go and call on them every day.
As an A&E nurse you will treat a huge number of patients over any given shift, and chances are one will be totally different from the last. The tide never stops, it just eases and builds.
You never know who or what is waiting behind the next curtain, and you need to be ready for every eventuality because believe me given enough time in accident and emergency, you will see EVERYTHING!
Flexibility is what allows a good A&E nurse to jump from patient to patient and maintain a good level of care. Trying to keep all the plates spinning can be daunting, but with a little time and some guidance you will get there.
If you are the kind of person that needs a set routine and familiarity, then A&E may not be the place for you.
On the other hand, if you thrive on constant change and rising to varied challenges, you’ll never be happier than in a busy A&E department.
Handling Difficult Patients
Every department receives their fair share of difficult patients, but the very nature of A&E means the most obnoxious, foul tempered and unreasonable patients are heading your way. You should be prepared for them.
You will encounter people getting the huff about having to wait, to drug induced hysteria and beyond. You are on the front line of dealing with these patients and many times it will come down to your ability to keep a cool head and defuse the situation before it puts more strain on the department.
Handling difficult patients is an invaluable skill to any nurse. It can be incredibly hard and testing at times. It is also a skill that is infuriatingly hard to teach or learn. The more outgoing and flexible of us seem to have a stronger natural aptitude but there is no single approach.
I once worked with a lovely little Scottish nurse who was all smiles and sweetness in the break-room but had a professional face of solid stone. She was by no means uncaring and was a fantastic nurse, but she just had this presence that could quell even the most badly behaved patients. To this day, I’m still not totally sure how she did it, but shifts were invariably calmer when she was on duty.
In my experience, difficult patients all require slightly different treatment. With some, you may need to use a firm hand and show them you are in charge. With others, a sickly-sweet approach can dump a bucket of water over the building tension. It takes some time and a lot of experience before you instinctively know which approach to use and even then, the occasional mistake is bound to happen.
Dealing with each difficult patient on a case by case basis is essential to the smooth running of any A&E department and ties back into our initial need for flexibility.
Every nurse needs to be sensitive to their patient's condition, but in A&E you will be tested in ways you couldn’t imagine:
• Keeping your composure dealing with traffic collision injuries or drunken brawl wounds,
• Are you phased when a DIY carpenter walks in carrying his hand in a Tupperware box,
• Could you keep a straight face dealing with the patient that has a Hello Kitty radio lodged where it was never meant to be (not a real example but close)?
It can be harder than you think, and you will certainly be tested.
Over the years, I’ve been faced with countless examples of the most delicate situations. I have always found it beneficial to try and look at the injury objectively and do my best to ignore the elephant in the room.
Sensitivity can be stretched far in A&E and a momentary lapse can cause a lot of red faces, not just for the patient who is likely already having the most embarrassing day of their life.
The break neck pace of a busy accident & emergency department can be a daunting psychical challenge, but do not overlook the emotional burdens that come with the position. We all bond and care for our patients and we grow attached to them no matter how little time we spend with them. The good patients, like the bad, are always moving through your hands, away to other departments or back home to their daily lives.
It can be hard dealing with 100 patients per shift if you give a little of yourself to each one. In a busy A&E, you may only spend a small amount of time with each patient. You must make the time count and do all you can for each one. The levels of exhaustion I have felt after a particularly busy 12-hour shift in A&E are only rivalled by those of giving birth to my two girls.
Every nurse should end their shift with the same levels of energy and attention they started with. But we are all human and this isn't always the case.
An A&E department can be a challenge from the first minute of a shift to the last. A good accident and emergency nurse should be able to manage their energy levels to deliver a consistent level of concentration and effectiveness for the duration of any shift.
It may seem obvious, but the real critical factor in longevity is of course diet. Nothing will keep you going better through a long shift than a healthy and balanced diet high in slow release energy foods.
Snacking can be helpful and provide some quick fixes when needed but is certainly not a substitute for hearty meals. Even with the body and dietary regime of an Olympic athlete, no one is immune to fatigue.
Just as important as managing our energy levels is recognising and acknowledging the times when our energy levels are low. At these times, it is vital to communicate to and alert your colleagues of the issue so that proper support can be provided.
You are human and sometimes you will need help. Accept that and move on.
Every department has its peaks and lulls, busy days and quiet days. A&E is no different. There will be plenty of “rushed off your feet every second of the shift” days, and you face more of these days than most other departments.
Equally as important as longevity is the ability to shut off after a long hard shift. The turnaround time before the next shift may be short. After you have factored in travelling, eating and all the other little jobs life throws your way, the time is soon gone.
A particularly hard or tragic shift can weigh heavily on your mind, keep you up at night and impact your day. You won’t be as fresh and ready as you should be if you’ve been up all night reflecting on the events of the day before.
Leaving your job at work is the only way you can have a life of your own. I can’t deny that I've sat up mulling over the events of the day or arrived home in floods of tears.
We’re all human, and if we weren’t affected by these things we most likely wouldn’t be very good nurses. Finding the balance is the tricky part.
Everyone deals with this in their own way. You should find what works for you. There are plenty of healthy ways to relax and find a sense of inner peace, but there are plenty of unhealthy ways too. Nurses are not insusceptible to self-destructive behaviour. Playing as hard as you work is not always the best answer.
At the hardest times, when I can’t contain the hurt, anger and pain I have witnessed, I try to think of the things I am most grateful for; my gorgeous little girls and all my family, safe and well.
It helps me realise just how lucky I am to be feeling this suffering from an outsider’s position.
I focus on the thought that what I feel is only a minor wound in comparison to what the people involved must be feeling.
I can’t tell you that this fixes the problem entirely, but it helps!
The difference between life and death in A&E can be seconds. One moment's hesitation in administering treatment or recognising symptoms can lead to fatal consequences. An experienced A&E nurse needs to not only act fast, but think even faster.
After a while, you should develop an intuitive ability to recognise symptoms, make quick and accurate judgements, and administer relevant care. An A&E nurse doesn't waste time searching a patient's notes for root causes, we deal with the immediate injury at hand quickly and effectively.
This may be an area you struggle with. I did at first.
It can be hard to jump straight into situations and act. It is a lot of responsibility and needs to be taken seriously.
This quality may not be inherent in you from the start, but it can be nurtured and developed. I haven’t always had the confidence I have today. For me, what helped the most was talking and sharing with my colleagues and completing additional learning through sources like e-learning.
E-learning is a very powerful tool for nurses. Not only is there an abundance of valuable information at your fingertips, but it can keep you updated on the latest training and equipment, open discussions and share opinion in a way a textbook cannot. It can also boost your self-confidence.
Like most education, e-learning only gives as much as the learner puts in. I would strongly urge any nurse to make the most of all the learning opportunities open to them.
Knowledge equals confidence, and confidence equals decisiveness.
This is an important skill of any nurse, but an A&E nurse must be a multitasking marvel. You may be responsible for ten or more patients at any given time, all with different conditions needing varied treatment. You need to look at the list and prioritise patients; suspected heart attack over bloody head wound, uncontrollable sickness over broken fingers. The choices are in your hands.
You need to give relevant treatment to all your patients as quickly and effectively as possible, whilst prioritising and distributing your time to try and give everyone the best care possible, ensuring that no one feels left out or abandoned.
At first, it's like patting your head and rubbing your belly with six arms at once, but you will get there.
The best advice I can give you is take everything step by step. It may be slow at first but soon you will get faster until you don’t even think anymore; you just do them.
It’s all about practise and experience. You will get plenty of that in A&E.
Team work is essential to the smooth running of any hospital department, but it is really tested under the pressures of A&E. Working with others can be a challenge at the best of times, but tempers can wear thin under the strain of a busy shift.
A&E has no space for drama or confrontation. There is enough of that to go around on every shift anyway.
• be a team player,
• support and provide clear communication between team members,
• encourage good working relationships.
In your first few months working in a busy A&E department it will feel like a war zone with constant activity, noise and confusion.
Screams of pain will rattle in your ears and bodily fluids will rain down upon you.
You may look around and think, “I can’t do this, I am totally lost”.
Don’t worry. The first few months are the same for us all.
Just do what I did and look to your senior colleagues around you. They will lead you through the craziness and confusion of those first few months.
Stick it out and you will soon find the confusion and fear are replaced by certainty and action. Then you will be at home in the hustle and bustle of A&E.
You won’t even remember how you felt in those first few weeks.
The First Steps
If you have the qualities listed above and a passion for care, then any A&E department would be happy to have you.
You may be wondering how you start the journey into nursing, accident & emergency, or elsewhere.
In my case my journey started in care in a sleepy little nursing home. I knew I wanted to work in care from an early age. I watched and worked with the nurses and knew I wanted to be one of them. I wanted my own pin.
When I started my training, a nursing degree wasn’t compulsory but today you need a university degree to be a nurse.
My training seemed slow at first, but it soon flew past in a blur of exams.
Nursing degrees tend to have a longer academic year than other courses, making it harder (but not impossible) to hold down a job at the same time.
Most universities offer a range of nursing degrees, and the entry requirements tend to vary slightly between the various degrees and universities.
Generally, you can either do a 3-year undergraduate course (BSc) or a two year post graduate diploma (PGDip). The base requirements for most these degrees are 2/3 A-levels or equivalent points, and GCSEs in English, maths and science.
Once you have a nursing degree, you are ready to take a job as a registered nurse in A&E.
Then the real journey begins.
Past the Front Line
The average salary for a band five A&E nurse is between £22,128 and £28,746 per year, with band seven nurses earning between £31,696 and £41,787 (figures taken from Royal College of Nursing NHS pay scales 2017-2018).
For many nurses the profession is a calling not a job. Duty of care can often come over financial gain for many nurses. It’s why we do what we do.
You also have the choice between being an adult or paediatric nurse. Both require different training and subsets of skills.
As a rule, the average banding of accident and emergency nurses is 5 and 6, with band 7 nurses filling sister roles in the department.
It is also not uncommon for speciality nurses to operate within accident and emergency departments, but as the name suggests, speciality training and qualifications are needed to fill these roles.
A&E is a great place to start a career as a nurse. It may not be for everyone but those that enjoy rising to a challenge and taking control of a situation will love it.
The incredibly broad spectrum of experience in the average accident and emergency department cannot be matched anywhere else.
The time I spent as an accident and emergency nurse shaped me in several ways. It helped make me the person I am today, and I wouldn’t change it for anything.
I have always been a nurse at heart, but I became a nurse in my head amongst the hustle and bustle of the Blackpool Victoria Accident and Emergency department.
During your time in A&E, I am sure you will feel and experience every emotion you could possibly imagine.
You will meet and treat people from every walk of life whilst they are at their most vulnerable and in need of help.
You will grow, learn, share, laugh and cry but remember, it's just another typical night in accident and emergency.
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