We’re all in this together : The ER/Floor Nurse relationship uncovered.

  1. Nicole says:

    Did you get your numbers flipped? I agree we are all a team and I have seen both sides and see that both are busy however our ER nurses take only 4 patients and usually have a float and our floor nurses usually have 6 patients!

    • krw07c says:

      The day I was inspired to write this blog, my friends had 7 dang pts! It was unusually busy, filling up after the holiday. they try to keep it a 4/1. It gets that busy though! and the staffing wasnt there!

    • Michelle says:

      As an ER nurse, thank you! I have worked the floor, so I know both sides also. I’ll stay in my ER : ) I can have up to 8 pts myself (with more waiting for an empty bed) and only occasionally do we have a float. And that’s not 8 pts for the day, its 8 pts at a time that rotate several times on my shift, so 20-30 pts a day, all to triage, treat, and discharge, if I wanted a more relaxed job I’d go back to the floor, lol! It’s hectic and crazy but I love it!

    • Kayla says:

      I think you are underestimating how many patients we nurses care for at one time in our er we can have up to 9 pts each

      • A says:

        I think you are missing the point, she is sticking up for the ER (which I am, so, no comments) and everything she says is helpful – the numbers are going to be different among different facilities.

    • PinkV says:

      I’m an ER nurse, we get 6 patients my dear! Some of whom are critically ill.

    • Karen says:

      In our hospital, floor nurses have four in the day and six at night for the most part (depending on the floor). In the ER, you can have many many more than that depending on the area you are working and how busy the day is! Also, good point that Michelle made about that’s not eight throughout the day but rather eight at a time constantly rotating.

    • Tasha says:

      Trauma nurse ratio at my facility is typically 3:1, ambulatory can be as high as 4:1, treat and street 6:1, and triage nurse can be as high as 30:1. The emergency dept is a revolving door. We are expected to flip these rooms multiple times a day. And I don’t wanna ruffle feathers, but you will typically keep your 6-7 patients in the floor for MULTIPLE DAYS at a time. So, please try to begin to explain how this even compares to what we do in the ER.

    • Tammy says:

      ER nurse ratios are us vs them period. There are no ratios. People in the halls, chairs and waiting room are our responsibility. Always. No one closes our doors and says ok that’s enough. They just keep coming.

      • ERFemale says:

        Exactly! If the floor runs out of room, those patients stay in our Department bc there’s no where for them to go. There is a limit to how many patients a floor nurse can get. In the ER, there is no limit. My pet peeve question is the one about the bowel movement. Dude, ask him yourself when he gets up there. His last BM is generally not relevant to my job, which is to help stabilize him and then move him on. We have EMRs now, look up his labs yourself. I have 6 rooms assigned to me, which are always full and depending on where in the ED I am, I will have 2-4 more patients in the hall. We don’t have floats. We barely have lunches or restroom breaks. Stop complaining and do your job, lol

        • Angella A says:

          Also there is no Cna in my Ed so guess who cleans up, waitress and keep it moving ?

    • Mkeck says:

      Hi, I work at a Critical Asses hospital we have 2 RNs and an EMT Working, the EMT is a huge help in starting lines and a lot of other procedures. But I get the pt. ratio and it’s about the same here. We do t divide up the area we All pitch in and work as a team, some nights I have 8 Pts the other nurse 1 or 2 just depends on pt. types. But we All know what’s going on in the whole dept. LOVE ED Nuring !!!

    • Lee says:

      Lucky you! I’m an ER nurse and we have 2 nurses to 9 patients and no float. 9 usually unstable, acute, new patients. 9 beds which are constantly turning over – I couldn’t tell you how many patients I actually see in any one shift. Our wards have a 4:1 ratio which is stuck to 90% of the time. And they are the ones who often get a float (usually an AIN which we can’t have in ED). I think the author of this awesome post was trying to point out that we are all busy, we are all under pressure and that we should be supporting each other instead of competing about who has it harder. Each area and department of a hospital has a different type of pressure and requirements and we all play important but different parts. I couldn’t do a ward nurses job as good as they could and vice versa – that’s why is a team effort to achieve the best result at the end for this patient that we could. Let’s stop the competitive mindset and appreciate, respect and support each other.

      • Mel says:

        Well said. Finally someone who gets what she was saying! I’ve worked ER, OR, the floor, L&D,, newborn nursery. As well as admin. Every position is just as important as the other for different reasons. Let’s show compassion for each other, please! If you can’t do that and recognize we are each unique and important in the processes of taking care of patients then I invite you to find another occupation because I’m not sure how much compassion you have towards your patients. Compassion is part of nursing; a very important part!

    • Dawn says:

      I work Med-surg and I wish I only had 4-6 pts. I usually have 8 or 9 most days.

  2. Dixon says:

    Great story and you are so right, when you put a face to the name and get to know people, you are less apt to be rude or nasty (either department). We can’t shut our doors in the ED so yes, sometimes we have to “flex” up and take care of 5,6,7 or more patients at a time- what is the alternative? I love my floor peeps, they don’t want anything to do with ED nursing which is fine, it takes all to make the hospital work and run smoothly.

  3. Christine says:

    Oh my god girl! This is so dead on right! Kudos to you for opening up your experiences and your heart to understand both sides. I’ve saying this for years I wish all floor nurses were required to spend a shiftvirvtwo helping out in the ER. Then they would all understand. Again thanks for your insights , you rock!!!!
    Christine ?

    • betty says:

      And vice versa all er nurses should spend a shift or two on the floor… tired of all the ER nurses thinking they have it harder, it’s nursing it’s all busy, it’s busy in different ways…. stop acting like you have it way harder than “floor nurseS”

      • Ihbarn10y says:

        Been both and I felt bad for so many of the responses I had to the ER nurses the first shift I worked in an ED. You have no idea what it’s like to have 40 patients in the waiting room waiting on a bed, to have a patient coding that ties up 3 of your 5 nurses and your only ED doc (and we don’t call code blues in the ed so we have no extra help), and to hear there are 3 ambulances inbound. Unless you have experienced both ED nursing and inpatient nursing neither can judge the other. I’ve experienced both and firmly believe med surg nurses need a big dose of suck it up.

        • Rose says:

          I was just thinking tonight as my patient was taking a turn for the worst (quite unexpectedly) that no wonder I feel stretched. On the ward I would have at called a code and had 3-5 nurses, 2-3 dr, wardsmen, ecg tecs, blood collectors… But no, just me and the occasional passerby and one (very helpful-quite the team player) dr. I could have just done with a scribe. That would have been spectacular.

      • Citygirl says:

        I don’t know where you work, but I can tell you that at our university, we can get 5-6 patients Plus have an ICU patient also. Please go work in an ED before you make comments of something you never have done. When your on the floor and your rooms are filled, you don’t need to worry where the next patient will go. In the ER, rooms are filled, hallways are not, place stretcher in the spot or wheelchair and take another hit. Our doors are open 24/7.

  4. Kim says:

    Amazing!! Thank you!! I’m a PEDS ED nurse and you hit the nail on the head with this!

  5. Spook_RN says:

    I used to work the floor before I became an ER nurse.
    That’s the thing a lot of people forget – we can’t close our doors, no matter how busy we get 🙂 If you’re a 30 bed unit, when you get 30 patients; you’re done! If I have 4 rooms assigned and 4 patients, I get a 5th and a 6th in the hallway while my charge nurse is trying to figure out where to put the 80 year old grandpa who came by ambulance with a pulseox in the toilet.

    No we don’t always do a full assessment. When someone comes in with head trauma, I’m not checking bowel sounds. I know having an IV in the antecube is a pain in the butt – but did you see the patients veins 3 bags of fluid ago? And sometimes, certain tests require IVs in the a/c. Y’all do things by a certain way on the floor – ’tis the same down here too 🙂

    I had an ICU nurse grouse at me for not starting 3 different antibiotics and some other meds. I was like “Well, at least he had a pulse now…” :-p

    That being said, as I used to work the floor (nights too!), sometimes when taking verbal orders (at old hospital. Not at new one); I’d make sure I atleast had something ordered for pain, sleep, nausea and fever. That way some poor nurse doesn’t wake the doc at 2 am for some Tylenol or Zolpidem. Not all my ER colleagues do that (“not my job”, I was told once.)

    You know who loses out when we aren’t team players? The one with the most to lose and with the least control over the situation – the patient.

    • Brittney says:

      Love it! So do I…left with 4 holds today & my alcoholic had CIWA scale ordered & medicated properly, and my other 3 all had something ordered for sleep 🙂 !!! Score. Use to be a floor nurse, but love the ER!

  6. Teresa says:

    I’ve been a RN for 35 years, 14 was in ER. No matter where we work, I notice a common theme. Effort needs to be given towards solving the problem instead of blaming each other. Some problems are not to be solved, but managed. We cannot control people, what they think, or what they do, but we can put effort into ourselves, our mindset, and our skills. We don’t know how much we would have gotten done given the same circumstance. You never know the circumstance without “walking the line” yourself. Good post.

  7. Wendy Harmon says:

    @ Nicole, I’ve been an ER nurse my whole career. I almost NEVER “only have” 4 patients. If we are on lunch coverage (we self cover by taking on extra patients so we MIGHT get a break in 12hrs). Rarely a float. I have to cover another nurses’ patients when he/she is in a Trauma for a couple of hours. Or when they are giving tPA. Or when they’re taking their STEMI up to the cath lab. I’ve had up to 8 patients, 3 of them intubated and unstable ICU admits. I do my best not to make the floor nurses’ lives hell, but when there’s 30 in the waiting room and 5 squads waiting for beds and my charge nurse says I have a ready bed for my patients, up they go. I try not to piss you off, but…….like she said. Don’t hate the player, hate the game. It’s healthcare today.

  8. John says:

    Thank you for this! I am a former ER nurse at said facility and now in a different department at the same facility. The ER truly has no control over the influx of patients – we nonetheless have to care for them. I always did my best to give as good a report and getting the most important orders done – as I could when the patient is admitted. That said I know that not everyone has the same work ethic both in the ED and on the floors. I have never worked on the floor I have been an ER (and flight nurse /paramedic) nurse since day one but I respect all nurses. However I would like all nurses to think outside the box and to understand the other side. The ER IS CHAOS, the floor as well but a lot more controlled. When the floor is full they don’t receive any more patients yet the word FULL doesn’t exist in the ED. I have had the privilege of having 2 ICU admissions (holds in the ED) to care for while taking care of 4 ED patients – not an easy task and certainly full of STRESS. Meanwhile they keep coming in and literally piling up in the waiting room. That said I would do my best to make it easier for the floor by starting the orders….i.e. Hanging the ordered IV fluids (on a IV PUMP), starting the needed drips, medicating the patient for the pain prior to sending them up, preparing the patient with knowledge that the nurse up stairs wants to take the best care of you but a lot has to happen first before they can get the medications/treatment you need…..etc etc. I have taken patients up myself and offered bedside reports while helping the tech and nurse move the patient or in a few cases clean the patient up because they soiled themselves on the way. Ultimately this job is thankless and we don’t need to work against each other but rather with each other! Even now as a nurse clinician where ever I am at – I am always willing to lend a hand when needed. Though now my hands seem more restricted by the current job description that I know work under at the hospital wh e it comes to hands on care but I will still do what I can to help.

  9. Brisget says:

    Very well said and very true! Another kicker is when you have an ICU admits in the ED and you have 3 other pts to care for! One time I had 3 ICU pts at once! And the floor will get frustrated, but wait, I am running around caring for these 3 ICU pts and when they come to your floor, the nurse pt ratio is 1:1!!

  10. Regina says:

    I’m an ER nurse who has worked in 4 different ERs. Great article! The nurse to patient ratios aren’t the same at every hospital, but the message is. I always try to”manage up” the care my patients will receive on the floor and if I have time I always try to start floor orders or admission databases, but, the reality is, I cannot sacrifice stat orders and stabilizing urgent care for another patient, so I am often not able to start their stuff. What I CAN do, is start managing up the floor as soon as there is any indication the patient might be admitted. It is my hope that this small piece of teamwork makes for a better admission of the patient, for everyone involved.

  11. Sheila says:

    Id love to hear more about the position you took in the ED to help manage admissions!! Could you provide more details? I think that would be a HUGE help in the ED I work in 🙂

    Amazing article, thank you for sharing!

  12. Gladys R. Pelosi retried MLTladysrpelosi@yahoo.com says:

    Now if all nursing staff through out all hospital could apply the some out look to the 3 to 11 stiff and the 11 p.m. to 7 am in the lab. I have worked all three stiffs however there are not same number. Three maybe if you luck there might be a photo with us. However the midnight staff there are only two. The hospital think that only need two because doctor don’t do much lab orders at night. Ya right. If they know there is a tech in the house of any kind they will order testing.

  13. Ari says:

    I get that the ER is a crazy busy place to work. I’m a floor nurse at a Level I Trauma Center and I did an ER clinical rotation day in the ER at the hospital I am currently a floor nurse. My experience has often been the total opposite of what you’re describing. Yes, there are times floor nurses get a little snippy at ER nurses. But a lot of times, ER nurses are not only snippy with us, but downright condescending. Yes, I work at the bedside and I don’t deal with critical care, but I’m not a moron. The quick reports aren’t totally bothersome, but at the same time, make a little effort to make it at least halfway decent. In our ER, a nurse giving report to the floor isn’t going to be taking care of an ICU level patient at the same time. Not that credit should be taken from the ER nurses for doing the amazing work they do, but I don’t think it’s necessary to chastise floor nurses and implore us to be more understanding, when many times I’ve been chastised and berated by ER nurses for needing to call back for report because I’m in the middle of a sterile dressing change or doing a discharge.

    • Kelsey Rowell says:

      I hear you girl. There are definitely people that need to just learn to be more considerate, kinder, and more understanding no matter where they work….I’ve worked at 3 hospitals and this was the culture at all three. If was an incident reporting fest, having people thrown under the bus in the ER for such petty things. We all need to support each other on both ends….

  14. William Kumprey says:

    Great post! As an ED doc, past director at multiple facilities, regional director, manager and hands-on worker @ many EDs in many states… having direct interaction with many hospital CEOs and CNOs in several states… with a lot of interaction and past training on the floor and in the ICU… including working at facilities in the bottom 5% of the country and working at, administrating and being the quality director for another where we were in the top 1% for all 12 years I was there… I must say this is excellent stuff! The best performing hospitals with the best scores have some cross training and nurses that float to the ED and house sups that spend a lot of time in and communicating with the ED… and benefit from this relationship and mad respect, not hate, between the ED and floor nurses. The two require different things, often different personalities, pressures, expectations, annoyances, etc. The hate is unacceptable. I have worked in an ICU where literally at one point the ICU was super slow and they were all sitting in the break room with coffee and Krispy Kremes, talking about their weekends… And the ED charge nurse called to get a patient up. The ICU nurse hung up on her 3 times in 10 minutes saying “we are too busy, I’ll call you back.” After hanging up they would all laugh, and a couple would say “f@&$ them nurses!” Insane! I walked down to the ED and all hell had broken loose, a couple codes, a STEMI, a full ED and waiting room. This crap can’t happen, but it does. The ICU nurses handle very complicated patients, drips, pressors, crazy Swans, etc. They can have a critically ill patient their whole shift. They may have 2, or 3. Floor nurses have a ratio, but can go over that, and different wings can open up, and responsibilities change. Being more anal/ controlling, etc with their patients, really desiring stability and control, they have different goals and attitudes. Yet, the ED never does close. Their is no Mac patient number. Hell, I’d someone dies in the parking lot, that patient is yours. If a family member faints, that patient is yours. If a coworker gets attached or poked, they are yours. If two gunshots get dropped off at the door, and 2 EMS rigs show up without a call, and you have no rooms open, they are yours. If their are people yelling in the waiting room, or stacked in the hallways and pissing in the floor, they are yours. The abrasive belligerent family members are yours too to deal with. It’s chaotic. And in this environment you need to stay calm, focused, and to the best of your ability, remain in control. Your goal may not always be to figure out everything, but to prioritize, evaluate, stabilize, and minimize unnecessary deaths while planning to pass the button to your teammate at the end of your sprint. You want that teammate to be ready, at the line, ready to take it from their, with the same goal in mind. You are a team. You don’t want to be belittled, ridiculed, told about what you didn’t do, or should have done, or asked about what you did and why you did it. You want them to take the damn button and run their arse off. Why? So you can grab the next button from EMS, or the triage nurse. Because you never stop sprinting. And after all my years, I have never heard an ED nurse bit$& about a floor nurse except to say how rude or mean they were. They just want help, respect, camaraderie. It’s sad when they get the opposite. ED nurses are amazing. They see 0-10patients at a time and rarely even complain. They kick @$$. Good floor nurses and ICU nurses are also amazing. The ones that get the ER, the craziest place in the hospital, the first impression for most patients, making an indelible mark on not just Press Ganey scores but HCHAPS as well, the place that often accounts for up to 90% of hospital admissions, the place that never closes (even when on diversion), is never truly safe from violent unscreened patients, and at the highest risk of law suits, caregiver stress and burnout, and unrealistic patient expectations… Those floor and ICU nurses are just as amazing, and a joy to pass the patients on to. We trust them. We know they will get the job done. We know they trust we did what we could, but have to get back to the ED battle. They have out back, and we have theirs. Teamwork and mutual respect and admiration is vital for system success, and articles such as this can only help. God bless y’all, stay safe, and spread love, not hate.
    WK MD (extemporaneous text, please excuse grammatical errors,etc. )

  15. Jane Reilly says:

    Very true. People just need to get on with it and stop knit picking. We are definitely the least popular area in the hospital. People get so self obsessed and forget that the reason we are there is for the patient. If everyone could just remember that before they bark down the phone about bringing the patient up at handover then we would all get along a lot better. I have to say that I think the general attitude is changing and the nurses are very understanding. The odd nurse you get giving out just has issues and is taking it out on us. Not sure where you all work but where I work there is usually 1 nurse to 15 patients. We would love a 1:8 ratio!

  16. Linda says:

    every nurse that works in the ER should work as a floor nurse first, and every floor nurse should do a shadow day or two in the ER , both are busy and equally hard but very different, as like the story states floor nurses please do not get mad when you ask questions about things that the ER nurse couldn’t wouldn’t answer.. In the ER, the nurse focuses on the complaint. ex: chest pain is an EKG, VS, CXR, telemetry monitor, and MONA (morphine, oxygen, nitro, aspirin) get them stable and get them to the floor where they can be watched better, because the nurses in the ER don’t know what is going to come in the door, if the patient complains of belly pain, it is meds, ultrasound, xrays, everyone gets blood work and an IV, Where I work the nurses work as a team 2 nurses and a paramedic because if a trauma comes in it will take at least one person from each team for as long as it takes (30 minutes to hours) there are ambulances driving up and people walking in all at the same time, and you never know what is next, On the floor, the nurse is busy discharges, admissions, call lights, families, etc but you usually know your patient’s Dx, history, allergies, medications etc. and that does make things a little easier.
    so unless you have walked in the shoes of the other department, you shouldn’t complain, and if there are issues, bring them up to management and maybe you can get things changed, we are all there for the patients.

    • Aroundtheblock says:

      I agree linda, everyone should walk a mile in the others shoes. All nursing is hard work. Hosever, I will say ,as an ED Nurse over 10yrs i believe i can step on a general medical or cardiac floor and cover a shift just fine but a floor nurse can not just walk in and pick up an ed shift. It is a different mindset as well as skillset that takes time to master. Every patient who shows up is unstable. They do not come to us with much, if any, report. They are a mystery you must figure out quickly.and as quickly as you do they can change. Stop-quickly reprioritize. While their condition and treatment is changing-and you better get to it fast before they crap out- you’ve received 2 more mysteries oh.. stop-hurry, reprioritze again. Do this over and over and over again for 12 hours straight on 6-7 patients at a time…then come back and do it all again tomorrow. It is mentally and physically exhausting. Shadowing an ed nurse for a few shifts lets you see busy but it cant make you feel this pressure . …Now add mgr asking why is this pt still here and you will know why it really doesn’t matter that that you want to do a dressing change and discharge before you take report on this pt and let me move them out…. that dressing its not a priority- the diaphoretic 40yo who just came in clutching their chest IS.

  17. Jesse King says:

    I’m a pt that has been on that ride at shift change and seen the struggle 1st hand.
    I owe my life to all of you nurses, from the ED to ICU, through Chemo and radiation.
    I love all of you.
    I wish i could post the picture of my latest tatoo.
    It’s in honor of all of you nurses.
    It’s the medical caduceus with a stone inscription that says “thank you for saving my life”
    None of you get the thanks and praise you deserve, just know that i have a permanent “thank you” to all of you amazing people.

  18. Amt says:

    Short reports don’t bother me at all but what does is when the er nurse can not figure out what the priorities are. Yes the pt might have came in with a sore foot but when the BP is 250s/130s and rising after TX don’t just glide over that part and send them to a med surg floor be a pt advocate and get them to ccu.
    And know what radiology results mean….don’t send me a pt with a ruptured bowel and please for the love of God either do the home med rec correctly or don’t do it at all!!@
    As far as shift change admission they don’t bother me in the least. I have to assess the iv BM skin etc when I do my admission so save us both the time and skip it!!

  19. ER Nurse says:

    Great article! I am an ER nurse and yes it does get crazy but the one thing I see again and again is ER nurses trying to move pts out at bad times when they don’t need to. Yes if every bed is full, the McDonald’s line is at the triage window, and multiple rigs are in bound there is no choice. However, if the floor needs 30 minutes and I can, I don’t mind waiting. I think if some nurses stopped practicing pt avoidance as a rule, more ER nurses would stop practicing moving pts no matter what as a rule.