What is it like being an A&E Nurse?
Whenever people ask what I do, I tell them I am a nurse. Usually, they ask what kind of nurse, which is when I tell them I work in accident and emergency (or the emergency department). At this point, they usually seem slightly more interested and declare that it must be incredibly interesting working in that field, and they would bet I have seen some really interesting/gruesome/cool/disgusting things.
Most people think for me to work in A&E must mean I am an adrenaline junkie, love helping people at their sickest, and spend half my days jumping up and down on people’s chests, but the reality of my working life is quite different.
I qualified as a nurse 11 years ago and had my first job working in a Gastroenterology ward. There I stayed for 18 months, working with an incredible team (one of the best I’ve ever worked with) and I learnt the fundamentals of nursing. However, I started to dread going to work, knowing the routine of your day shift before even stepping foot onto the ward. The washes, the medication rounds, the IV antibiotics prep, the endless note writing, social services referrals, paperwork, paperwork and more paperwork. Often having 10 patients to take care of, you were lucky if you got your breaks, if patients got their meds on time, and then staying late to finish your notes after a 12 hour shift. So, one day, I decided to pick up an additional shift in the A&E department to see what it would be like, and I admit I loved it immediately. There is no routine, you work hard, often don’t get your breaks, but part of me enjoyed the chaos of it all.
I have worked in A&E ever since that day. Although when my son was young, I did a few different jobs which fit round childcare such as, working as a civilian nurse with the army in their medical centres, and a particularly lovely job working as a school nurse in a boarding school. However, I always end up finding myself back in A&E.
Unfortunately, due to childcare issues with the long unsociable hours of hospital nursing and my husband’s job, I am now limited to working as an agency nurse, which means I am not permanently employed anywhere. This has some amazing benefits, as I can pick and choose where I work and when, I get paid better than I did whilst in the NHS permanently and if my husband goes away, I know I will be able to be home for our son. However, there are some drawbacks too such as, no NHS pension, no regular hours, having to travel much further for shifts and try to find cheap accommodation or sleep in my car in-between nights, not feeling part of a team, having to organise own training and it being a lot more difficult to remain compliant, etc. Some agency nurses even comment that they are greeted with hostility by NHS nurses on arrival to a new department, however this is not something I have experienced.
One of the best experiences I have had, is having the opportunity to work on Cruise Ships for the past 12 months. My husband is currently working in a more 8-17:30 job, and with use of before/after school clubs, and some amazing family for school holidays, I have been able to do something completely different. The medical centre on a cruise ship, is like a mini A&E department. It is amazing the emergencies we are able to deal with, along with running GP like clinics for both crew and guests. I loved working in the primary care setting with the army, so being on the ships is like the best of both worlds, along with the amazing opportunity to travel and the fantastic people I have met.
But when this is over, I will absolutely be returning to A&E. One of the reasons I enjoy working in the Emergency Department, is that you literally never know what kind of day you are going to have. Usually, my night shifts start with a groan when you see the ambulances queueing outside, but it is not until you have had handover that you know which area of A&E you will be working in for that shift. Most departments are made up of:
Triage – deciding how sick someone is and where they should go
Minors – the not very sick
Majors – the middle sick
Resus – the very sick
Paediatrics – small and sick
Ward – A small ward used as a holding area for people awaiting review by a doctor after treatment to see if they can go home or if they will require a formal admission to hospital.
Working in a department made up of lots of smaller areas helps to keep things a bit more interesting. As an agency/locum nurse, 9 times out of 10 I will be in majors. The number of trolleys/patients you will be responsible for varies greatly depending on which hospital you are working in and their staffing levels for the day. Usually, you can expect around 6 patients of your own, however it can be more and if really lucky, it could be less.
Most patients come via ambulance to the Majors area, although a few do walk in and get picked up by the Triage nurse who is responsible for assessing all the waiting room patients to ensure no one is sitting there waiting whilst very unwell, sepsis or having a heart attack for example. Once you have received your ambulance handover, the patient needs a triage completing (a few lines on symptoms, how long they’ve felt unwell, relevant past medical history etc). They have their blood pressure, oxygen levels, respiration rate, pulse and temperature taken at this point also. Then, an electrocardiogram is taken for us to have a look at the heart, any unusual rhythms etc, and we take the appropriate blood tests, testing for whatever we think is appropriate based on their triage. At that point, hopefully the patient is stable and can wait for the doctor to see them in the queue, however if they are in pain, showing signs of sepsis or anything else concerning, I will ask a doctor to review the patient and prescribe the necessary pain relief/antibiotics etc.
During a patient’s time in A&E they should have their clinical observations taken, blood pressure etc, at frequent intervals, ideally hourly or more often if quite unwell. Often, patients will require repeat electrocardiograms (ECG’s), further blood tests, intravenous antibiotics/fluids/analgesia. During their time with us it is likely they may require assistance to go to the bathroom. If you have six patients, all requiring this level of care, things can get busy. During your shift, you will also have to escort any patients requiring further imaging to the CT scanner, take patients to the ward to hand them over to ward staff, and somehow continue to attempt to perform hourly clinical observations and their paperwork. Nurses are expected to complete detailed paperwork on each patient, including even having to list ever item of property they have brought in with them – not to mention make cups of tea and provide food to their patients. Each patient requires a skin assessment, and then regularly positioning on the tiny and uncomfortable trolleys if they are unable to move themselves adequately enough. Some patients can not eat and drink without help. Other patients may be intoxicated, so you can add cleaning up vomit and reinserting pulled out cannulas to your list of jobs.
Now, six patients can be just about manageable if you have a HCA to help you. A HCA is a Health Care Assistant and honestly these guys and gals are an absolute godsend. An A&E HCA is often very well trained, able to help with wound care, applying a plaster to any broken limbs, take bloods from patients, perform ECG’s, observations etc. They will sometimes do the escorts to CT that are so time consuming, help with the personal care of patients and keep everything stocked up for the department – there is nothing more annoying than finding your blood trolleys empty and having to run around and search for supplies when you’re in a rush, and generally just work as a team with the nurse to get the job done. If you have one very sick patient, who requires a time-consuming treatment, endless conversations with doctors, an hour in the clinical room drawing up treatments, your other five patients can become neglected as it’s just impossible to do all these things yourself. A HCA is able to help the nurse with the vast majority of their workload and there should be more of them in every department.
Yes, occasionally you will get something unusual through the door, something that stops you in your tracks. Most nurses are pretty gross, and if we see anything on the outside of the body that should be inside, we tend to think that’s pretty cool. I will also admit I like my patients to be pretty sick, to get that adrenaline rush of looking at someone and knowing if you don’t do something quickly for this person they may well die in the department. Resus is my favourite department to work in as the sickest tend to go in there, and sometimes you are able to provide some really fantastic 1-to-1 care. Triage is my least favourite, as I find not rolling my eyes or raising my eyebrow quite difficult when a patient complains of a three month history of back pain which they haven’t spoken to their GP about, haven’t taken any pain relief for, and absolutely didn’t consider any other option except to attend A&E at 9pm.
Working anywhere in the NHS right now is pretty awful. The hospitals are full, and I mean absolutely full. I usually work nightshifts, and overnight you know that none of your patients are going to get a hospital bed in a ward unless someone dies first to free up a bed. The ambulances are queueing outside, often for hours, unable to off-load their patients as we have no space. Our A&E corridors are full with patients along with our bed spaces. We try and keep a cubical or two free in Majors, so we have somewhere to take the hundreds of people patiently waiting in the waiting room to see a doctor. However, often someone becomes unexpectedly unwell and we end up having to use those spaces too.
A&E’s all over the country are popping up with these ‘fit to sit’ areas, which basically mean ‘somewhere to chuck people because everywhere is full’. Often a small little area, crammed with chairs and drip stands on wheels where we can hang drips and medications and hope we might be able to send them home, or move them onto a trolley at 4am when finally, A&E starts to quieten down a tiny bit. Staff are going without breaks, getting shouted at by frustrated patients who have been waiting for 6 hours. We have to deal with the knowledge that sometimes we miss things, because were just trying to do too much at once. You look at the old man with dementia on trolley 5 and you’re so grateful he’s finally gone to sleep at 2am, after spending such a long time with him trying to stop him pulling out his cannula or removing his cardiac monitor. Only to discover later he has a dangerously low blood pressure and have to rush him to resus because you have not been able to monitor him properly as your six patients, have turned into ten and there’s no HCA. Unfortunately, mistakes happen and its not like when I was a kid working a paper-round at 13 years old, where someone might get a copy of The Times instead of The Sun they wanted. In these areas, too many patients, not enough staff means that people are suffering.
What I love about working in A&E are the teams we work with. When things are crap, they are crap for us all, and it’s not unusual to be mixing some antibiotics and to feel an arm go round your shoulder and give you a squeeze by another staff member you barely even know. To be powerwalking past someone and to receive a sympathetic smile. I’ve even known paramedics to bring in bags of sweets and chocolates for A&E staff to get them through the shift. And although it can be crazy busy, more often than not it is, we do have fun too. I think it is a particular type of person that ends up working in A&E and we’re all a bit bonkers together.
I can’t imagine working anywhere else within the hospital environment, and honestly, I would recommend A&E for all nurses, HCA’s and doctors who like their shifts to fly by, like to be busy, enjoy the pressure and really want to make a difference. There is no routine (which I love) you never know what is going to end up on your trolley, and sometimes it can be a blast. I’ve been kissed by patients, spat at by patients, sworn at and thanked. I’ve laughed, I’ve cried (more than once) but I am proud of what I do.
How many weirdos does it take to screw in a light bulb?
One.. But it takes the entire emergency department to get it out.
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