Reflections of a Locum Tenens Psychiatric Nurse Practitioner
This is an essay of a psychiatric nurse practitioner working in a rural clinic as a locum tenens provider. Patients have few resources. The psych NP needs to make connections with patients and also find her own psychological supports so she can do this intensely personal work.
I drive on long, winding, country roads. The roads are paved here--always a shock when I come to the United States from my expatriate home in Costa Rica. I am in the first world now: it is early spring, still chilly from winter, no leaves on the trees. I am in my second locum tenens job ever--the lady on my GPS directs me so I don't get lost. I provide psychiatric care in a rural setting where patients have poor supports, poor health, and poor dentition. "Working here is like being in Appalachia." My colleague says. I am given a schedule of continuous appointments. The mental pain that people bring to me is draining. My role is to provide psychiatric diagnoses and to prescribe medication for their mental disorders.
I am trained as a therapist--psychopharmacology came later. As a therapist , I learned how to connect with people, how to provide a safe environment, and how to draw out a history. As a psychopharmacologist, this approach helps me to find symptoms that I can medicate. I try to listen, with all my senses. I am alert for counter transference, the feeling the encounter elicits in me. "Tell me your understanding of why you are here today. What's going on with you?" I say.
And their replies: "I don't like being around people." "I moved up here to be close to my kids and now they don't have time for me." " I suddenly found myself with a loaded gun in my mouth. I thought I was dreaming." "I was drinking and I ran my car off the road-I could have killed someone." "I can't sleep." " I get panic attacks when my uncle visits." "My boyfriend abused my daughter." "I sexually abused my daughter when she was 7."
Staying with myself I am grounded. I start with what I am told and look for ways I can be helpful. I ask questions. I provide emotional support. I end each session handwriting a few prescriptions while I mentally review the encounter to see if I missed anything. Sometimes patients need medications but can't afford them; in these cases, I may give samples or choose from the Walmart prescription discount list.
Time passes and the work gets easier. I am still swimming in mental anguish, a new patient every half hour, but I am getting used to it. Sometimes, I have a patient new to the facility and I can spend one and one/half hours doing a full diagnostic assessment. People wait months for these full assessments and look forward to finally having the possibility of some relief. I now have friends at work--clinicians I can talk to, a great support staff, and a helpful supervisor. My company finds me a house, a large homey condo with high ceilings so I can move from the hotel. I join a club so I can swim after work. Now, after hours of immersion in human misery, I swim refreshing laps. Driving home in my rented Nissan, I feel my tranquility and my humanness. I take care of myself. I no longer am drained. I can be there for my clients.
I meet a hospice nurse. We reflect on our jobs, how it can be difficult to find peer support. "We are in the deep waters." She says. I feel brave to dive into other peoples hell and help them bear their feelings. I talk to my husband in Costa Rica every day on the telephone. He can't listen to much about my work day. "It's hard enough for me to keep my own head above water." He says.
When I see a patient for a follow-up session, I often find that the meds I chose are working. People tell me: "I am sleeping through the night." "My anxiety is better." "My depression has gone. I feel like myself." "I feel better-no more mood swings." "I don't want to kill myself anymore." When people give me this feedback, I feel a sense of accomplishment. I tell myself I am a good clinician. I also know that patients can improve due to many factors including the placebo effect of medication, the relationship effect of the therapeutic encounter, or just the passage of time. What I love about my work is to know that I am a witness, or sometimes a guide, to an inner psychological place of mental and emotional healing. Sometimes I feel profoundly honored to participate.Last edit by Joe V on Jul 2, '12
Trained as an advanced practice psychiatric nurse. Thirty years experience in inpatient and outpatient settings. Six years psychopharmacology experience. Live in Costa Rica with my husband and my dogs where I swim every day in my lap pool under the tropical sun with the soft breezes coming up from the Pacific Ocean.
Joined: Feb '06; Posts: 883; Likes: 873
Specialty: 30 year(s) of experience in Psychiatric NursingJun 30, '12Beautiful.
Bless you for doing this life-saving work. I cannot imagine what it must be like to go through the hell of a depressive episode or the desperation of SI in a place where there is no hope of getting help. You provide a critical and most valuable service, and I salute you for doing so. :bowingpur
Living in a middle-class world where I can call my psychiatrist any time I'm in trouble and see him regularly for 'maintenance', I tend to take mental health care for granted.......thank you for reminding me of how very fortunate I am.Aug 13, '12I am just beginning my career in nursing. I fnished pre-reqs and am working as a CNA at a hospital. I am getting a good idea of what sort of things an RN does but want to better understand different jobs available for NPs so I can see if that might be a good/better option for me. This was really helpful. Sounds like you do wonderful work. For Psych NPs I understand alot of job openings tend to be in rural areas like the one described here. Is that accurate?Aug 13, '12Thank you for reading my article and giving me feedback.@knightr4. There are more psych np jobs in cities-permanent positions. A lot of locum tenens jobs are rural because more people want to live in or near cities.Psych is a wonderful specialty-less inpatient now because the meds are more effective.Aug 17, '12I'm on my way to a psych NP degree and can't wait to be in your shoes. It sounds very rewarding. Bless your heart.Apr 1, '13Thank you psychcns for posting such a poetic and heartfelt entry. I have been working in a very poor community as a psych np, and am looking at doing some travel np work. I wonder if you can share some sage words of wisdom for me and others like me. I am not even sure if I know the right questions to ask... perhaps you can help with that? And whom would you recommend I contact? I have come across a few but they all look about the same. All claim to be leaders in placing folks, competitive wages, etc... Any suggestions? Thanks so much in advance!Apr 2, '13Quote from Serendipity1966Hey. Thanks for reading my article. I found the response by accident. I was browsing psych.Thank you psychcns for posting such a poetic and heartfelt entry. I have been working in a very poor community as a psych np, and am looking at doing some travel np work. I wonder if you can share some sage words of wisdom for me and others like me. I am not even sure if I know the right questions to ask... perhaps you can help with that? And whom would you recommend I contact? I have come across a few but they all look about the same. All claim to be leaders in placing folks, competitive wages, etc... Any suggestions? Thanks so much in advance!
I work for Staff Care. I have come close to getting jobs with Barton and Advanced Practice. Staff care comes through with the jobs. I am trying to work 3 2 month assignments per year. Most assignments are 3 months. I just started with a forensic population.
I like locums because I am only doing psych and not getting involved with the politics--or not too much.. Please PM me with specific questions.
It is hard entering a new community and the first week or so I am shell shocked. And then I am just working. I try to be positive and try to have a good effect on the organization.
I would rather not be working but I like psych a lot..I am reading Daniel Carlats book on psychiatric interviewing and how at every encounter you try to relieve suffering. I am also pretty good at picking meds and that is gratifying.Feb 9, '15Thank you for sharing your story. I'm hoping to have a locums position soon, and it probably will be in "Appalachia", so I can empathize with you. Also, when I have a paycheck again I'm going to subscribe to the Carlat newsletter, and probably by his medication book. I think it's good for Steven Stahl to have some sort of competition.Feb 24, '15I enjoyed reading your article. I have been a psy case manager (RN) and the work is very challenging. I have been considering going back to school to earn my master's degree so that I could have a role similar to yours. How do you feel about the job outlook? It seems like a lot of psychiatrists in my area are already overburdened with patients/case loads so NP's would be a welcome addition. Would love your feedback.Feb 24, '15Love the article! I've been working as a PMHNP for several months now, and I can relate to so much of what you wrote. It is hard work but SO rewarding.
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