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Psychcns 11,816 Views

Joined Feb 10, '06. Psychcns is a Psych APRN. She has '30' year(s) of experience and specializes in 'Psychiatric Nursing'. Posts: 849 (42% Liked) Likes: 780

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  • Sep 2

    After thirty years psychiatric nursing experience in various roles, locum tenens is perfect for me. When I want to work, I sign up with a few agencies, tell them my availability and hope something will come through. This time I can only work in 2 month blocks- a normal assignment is three months so I was not sure anyone would take me for only two months. Luckily my recruiter found me a spot.

    "The position is in corrections." She said. My husband was immediately worried about my safety. I had my interview and I found out the facility was a forensic hospital, not a correctional setting and that I would have inpatient responsibilities. I have many years of inpatient experience working as a staff nurse and a manager. This will be my first inpatient experience as a provider.

    After a week of orientation mostly about HIPAA, and using the computer system, I start on the units. I have two inpatient units and one 4 hour block of outpatients. I am on transition units where patients are preparing for discharge to the community. They work at least 15 hours per week at on campus jobs, go to groups, and have privileges to go outside, some alone.. For admission to the facility patients are committed by a judge as mentally ill and dangerous. Many of these patients have caused harm to other people, usually when they were not taking medications or were abusing substances. The average length of stay is seven years and the patients home community has input into advancing privileges and determining discharge.

    My role is to do a psychiatric interview and review psychiatric medications at least every three months on my assigned units. On the inpatient units, this is called "rounds". Patients are invited in one at a time by appointment. Several staff are in the room to observe or participate in my interview. I have never interviewed patients like this before. One of the social workers told me she likes to come in the room to make sure the patients are giving me the correct information and this can be helpful. A pharmacist is there also, to take notes and sometimes participates. I try to talk to her before or after my time with the patient so I am not distracted by medication information during my interview. Since I am doing the assessment and making the medication decisions, I have to make sure I am comfortable. I also put in my own orders which is a change for them. Because of the cumbersome computer system, previous locums had operated using mostly verbal orders which were inputted by either the nurse or the pharmacist.

    There is a shortage of psychiatric providers at this facility. Systems like the pharmacist taking notes, which are minutes of the interview, and verbal orders are a way to provide some continuity and compensate for the shortage. I am the sixth psychiatric provider in two years. They are recruiting and in the meantime I learn a lot.

    The main things I learn about are high dose neuroleptics, polypharmacy, and clozapine. Traditional psychopharmacology tells us to streamline medications. With these patients, it is not entirely clear if patients could do as well on lower doses or if they need the high dose for stability. There also seem to be a lot of negative symptoms of schizophrenia, ie poor motivation, blunted affect, which one of the psychologist says is not treatable with medication. My research tells me medication is worth a try but I am not there long enough to introduce this. I wonder if some patients are overmedicated but I am reluctant to adjust doses very much because of being new, unless, of course it was clearly indicated. And I become proficient in laboratory guidelines for long term medication monitoring.

    Every patient has a primary MD who has been treating them for years and each patient gets a comprehensive physical every year. These MD's are readily available for consultation. The pharmacists are also available for consultation and also seem to like attending my rounds. There are also other professionals including psychologists, social workers, nurses, and security counselors. I found out later that there are some psychology fellowship classes I could have attended if I had known about them.

    I am scheduled to return to this facility in a few months. Locums gives me the opportunity to learn. When I return, I look forward to getting a better understanding of high dose neuropletics and polypharmacy and I may try to medicate negative symptoms . Or since I now know the system, I may be assigned to an acute admission unit where I will learn about rapid titrations of psychiatric medications and ordering seclusions and restraints. If I come back to this unit, I will better be able to treat the patients since I have interviewed everyone at least once and have the trust of some of the staff.

    Forensic psychiatry is not a popular area of psychiatry. Many of these patients are severely and persistently mentally ill and have crossed the line into criminal activity. They are well care for at this facility as the long term psychiatric patients which they are. Many of them will never be able to live in the community. In the old state hospitals and if they hadn't committed a crime, many of these patients would have stayed for years living in a community within the hospital. Some may have been discharged to group homes with case management. Some of my forensic patients may also be discharged. Evaluating stability, degree of outpatient containment and likelihood of relapse is very challenging and the focus of much of their treatment.

  • Aug 27

    Those of you who disparage the DNP should really try to get your input into the "powers" that make the decisions about curriculum. In between the negativity and sarcasm you have some good ideas about updating the np or DNP curriculum. Why not try to influence the direction of your profession. And if you don't like nursing, change your profession!

  • Aug 24

    After thirty years psychiatric nursing experience in various roles, locum tenens is perfect for me. When I want to work, I sign up with a few agencies, tell them my availability and hope something will come through. This time I can only work in 2 month blocks- a normal assignment is three months so I was not sure anyone would take me for only two months. Luckily my recruiter found me a spot.

    "The position is in corrections." She said. My husband was immediately worried about my safety. I had my interview and I found out the facility was a forensic hospital, not a correctional setting and that I would have inpatient responsibilities. I have many years of inpatient experience working as a staff nurse and a manager. This will be my first inpatient experience as a provider.

    After a week of orientation mostly about HIPAA, and using the computer system, I start on the units. I have two inpatient units and one 4 hour block of outpatients. I am on transition units where patients are preparing for discharge to the community. They work at least 15 hours per week at on campus jobs, go to groups, and have privileges to go outside, some alone.. For admission to the facility patients are committed by a judge as mentally ill and dangerous. Many of these patients have caused harm to other people, usually when they were not taking medications or were abusing substances. The average length of stay is seven years and the patients home community has input into advancing privileges and determining discharge.

    My role is to do a psychiatric interview and review psychiatric medications at least every three months on my assigned units. On the inpatient units, this is called "rounds". Patients are invited in one at a time by appointment. Several staff are in the room to observe or participate in my interview. I have never interviewed patients like this before. One of the social workers told me she likes to come in the room to make sure the patients are giving me the correct information and this can be helpful. A pharmacist is there also, to take notes and sometimes participates. I try to talk to her before or after my time with the patient so I am not distracted by medication information during my interview. Since I am doing the assessment and making the medication decisions, I have to make sure I am comfortable. I also put in my own orders which is a change for them. Because of the cumbersome computer system, previous locums had operated using mostly verbal orders which were inputted by either the nurse or the pharmacist.

    There is a shortage of psychiatric providers at this facility. Systems like the pharmacist taking notes, which are minutes of the interview, and verbal orders are a way to provide some continuity and compensate for the shortage. I am the sixth psychiatric provider in two years. They are recruiting and in the meantime I learn a lot.

    The main things I learn about are high dose neuroleptics, polypharmacy, and clozapine. Traditional psychopharmacology tells us to streamline medications. With these patients, it is not entirely clear if patients could do as well on lower doses or if they need the high dose for stability. There also seem to be a lot of negative symptoms of schizophrenia, ie poor motivation, blunted affect, which one of the psychologist says is not treatable with medication. My research tells me medication is worth a try but I am not there long enough to introduce this. I wonder if some patients are overmedicated but I am reluctant to adjust doses very much because of being new, unless, of course it was clearly indicated. And I become proficient in laboratory guidelines for long term medication monitoring.

    Every patient has a primary MD who has been treating them for years and each patient gets a comprehensive physical every year. These MD's are readily available for consultation. The pharmacists are also available for consultation and also seem to like attending my rounds. There are also other professionals including psychologists, social workers, nurses, and security counselors. I found out later that there are some psychology fellowship classes I could have attended if I had known about them.

    I am scheduled to return to this facility in a few months. Locums gives me the opportunity to learn. When I return, I look forward to getting a better understanding of high dose neuropletics and polypharmacy and I may try to medicate negative symptoms . Or since I now know the system, I may be assigned to an acute admission unit where I will learn about rapid titrations of psychiatric medications and ordering seclusions and restraints. If I come back to this unit, I will better be able to treat the patients since I have interviewed everyone at least once and have the trust of some of the staff.

    Forensic psychiatry is not a popular area of psychiatry. Many of these patients are severely and persistently mentally ill and have crossed the line into criminal activity. They are well care for at this facility as the long term psychiatric patients which they are. Many of them will never be able to live in the community. In the old state hospitals and if they hadn't committed a crime, many of these patients would have stayed for years living in a community within the hospital. Some may have been discharged to group homes with case management. Some of my forensic patients may also be discharged. Evaluating stability, degree of outpatient containment and likelihood of relapse is very challenging and the focus of much of their treatment.

  • Aug 18

    Those of you who disparage the DNP should really try to get your input into the "powers" that make the decisions about curriculum. In between the negativity and sarcasm you have some good ideas about updating the np or DNP curriculum. Why not try to influence the direction of your profession. And if you don't like nursing, change your profession!

  • Aug 18

    DNP negativity is similariar to the BSN negativity as noted above. I think the DNP will in time become the standard. Hopefully we will be grandfathered. The DNP could be the vehicle to upgrade and standardize curriculums. Most APRNs should be paid closer to our physician colleagues when we do the same job.

  • Aug 13

    I have a Filipino sister in law and she works more than my brother. I worked with Filipino nurses. Stay in Med school. Do not have a child now. Get some couples counseling or individual counseling. Best wishes

  • Aug 7

    The nursing "fluff" courses could probably be condensed to one course and meet accreditation requirements. The big take away from research and evidence based practice is how to evaluate research and how to apply to individual situations. More science is always good. Genetics is huge and likely will have big impact on patient care.

  • Aug 2

    The nursing "fluff" courses could probably be condensed to one course and meet accreditation requirements. The big take away from research and evidence based practice is how to evaluate research and how to apply to individual situations. More science is always good. Genetics is huge and likely will have big impact on patient care.

  • Aug 1

    To the APRN hecklers, critics and malcontents.Many of you say that your MSN nursing education has too much “fluff”, referring to classes like cultural competency, and management that have no relevance to your jobs. I have read very little about how you will address this with the people that accredit NP curriculums.

    I am not sure of the credentialing process at all but I did find the American Association of Colleges of Nursing on the web and this seems like a place to start. In 2013 they developed NP competencies in which we are all expected to be proficient.

    These competencies expect cultural competency, trauma informed care, as well as all the things you complain there is not enough of such as pathophysiology, pharmacology, physical assessment. I have been in nursing since the early 80’s and have been through a few transitions in health care and in my own nursing career. Now I just try to keep up. I have no venom to toss at nursing leaders. I am very grateful to the nursing profession for my livelihood. I work locum tenens as a psychiatric APRN. My advanced practice nursing skills allow me to find work in interesting settings on a limited basis. This semi nomadic lifestyle is mine by choice. Everyone wants to hire me permanently.

    The APRN role exists because of the dedication of nursing professionals with advanced degrees who have done the hard political work of fighting for the opportunity for all of us to practice to the full extent of our education. This means that our education prepares us to diagnose and treat illnesses in our respective specialties. We have a record of patient outcomes similar or better than MD’s. We are not MD’s and we are not junior MD’s, we are nurses. If we were MD’s we would be regulated by Boards of Medicine, physician extenders of some sort. As nurses, regulated by Boards of Nursing, we are eligible in many states for independent practice. There is an overlap between MD’s and NP’s and this is where a lot of NP’s and MD’s practice: Seeing patients one at a time in inpatient or outpatient settings. Since we are doing the same job as MD’s in many cases we do need to catch up on their rich science background and the intense mentoring they get in residency.

    Or we can wonder how much education do we or they really need to do this job? We probably do not need nursing theory at this stage of our development as a profession though I did like my theory classes. We probably do not need healthcare management classes though I learned in those classes also. In today’s day to day NP jobs we need to keep our diagnostic and prescribing skills sharp to give patients the best care that we can. We often have MD role models and some are surprised we are doing the same jobs as them and many are happy to consult on cases and make use of their intense education. To my colleagues who are angry with the nursing profession that benefits you, I would encourage you to review the history of nursing (we were housecleaners one hundred years ago), and as science developed nurses had to fight the AMA to be professionals as opposed to handmaidens or servants.

    At one time only an MD could take a blood pressure. Now we are fighting for the right to practice to the full extent of our education. We are nurses and we need to continue to define ourselves differently from physicians. That we are different from the medical profession has benefited us politically and gives us the responsibility to self-regulate our profession.The people with the energy and aptitude to criticize should learn to become political. Start by looking up the website I note above and figure out how to have input into curriculum development. You might have to join a committee. This is how hard work often starts. As in today’s general politics it is possible the nursing leadership is losing touch with its base.

    Those who see what needs to be done would benefit all of us by becoming active and help to maintain and improve standards and influence the direction of the nursing profession.Best wishes.

  • Jul 25

    For a PMHNP and a FNP you will have two certifications to keep up. For a psychology degree you will learn more about how to do therapy I would think. If you get your PMHNP you would be qualified to do therapy and you could pursue programs to learn to treat trauma etc. Psychotherapy is less valued in our culture than it should be. It is much more all-encompassing and interesting than meds but meds are where the jobs are for PMHNPs.

  • Jul 25

    I make $78 HR in New England. This is psych aprn. Locum tenens. No benefits. Try looking up on salary.com

  • Jul 23

    Start taking prerequisites to remember how to study and write papers.,

  • Jul 19

    I make $78 HR in New England. This is psych aprn. Locum tenens. No benefits. Try looking up on salary.com

  • Jul 17

    At the clinic after 4 years was making 100k per year. Her hourly rate didn't change because she was doing therapy. They were very glad to hire her and she wanted therapy experience. Private practice is a 60-40 split. (She gets 60 percent-the practice gets 40 percent). You are only paid when people show up so you have to have a good business head. ( I like hourly myself).

  • Jul 17

    A PMHNP friend, just out of school, worked 4 years in a community outpatient rural clinic with good MD supervision. She also negotiated for 4 hours of therapy per week. She just left that clinic to join a private practice where she will be doing meds and therapy with supervision for therapy by a psychologist. There are ways you can incorporate therapy but your market value is meds.


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