Psychiatric NP without Psych RN experience

[crs1978]

I know this topic has been covered before, however, I believe my situation is a bit unique and I wanted some feedback from PMHNPs if possible. Just to give a brief rundown of my background and situation. I have over 15 years experience working in mental health, as a case manager, therapist, completing crisis evaluations, and other types of mental health assessments full-time. I have a MA in counseling psychology and have obtained licensure as a therapist in two states. I decided a few years ago to change course in my career and become a psych NP, completing prerequisites and an accelerated BSN program in about 2 years, and getting an ED position as an RN last July. I'm already starting to apply to psych NP programs and am hopeful I will get accepted and start this Fall.

My dilemma is this: I have recently been offered a job outside of nursing doing mental health evaluations, making nearly 2x as much as my RN position. It's a job I can take at any time if I want, so there is no rush to make a decision. If I get accepted into a PMHNP program, I technically no longer need the RN experience since getting accepted into grad school has been my main goal. My other option is sticking with my ED position and floating over to the behavioral health units at my hospital for some shifts. This would give me useful psych RN experience, obviously. In my heart, I definitely would love to be able to quit my RN position and take the mental health job since it is something I am much better at, comes more naturally to me at this point, and pays a lot more. My question is, does working as a psych RN really matter? I have far more knowledge about psychopathology than most psych RNs or even PMHNPs and have extensive experience working with psych patients, so I'm not sure what I could possibly gain. Not trying to sound arrogant. I do recognize that there are aspects of how a psychiatric unit is run that I do not know, but I figure I can catch-on to those things during a preceptorship. Any feedback would be appreciated.

[Oldmahubbard]

You should run, not walk, to the nearest and best PMHNP program you can get into. And I am pretty sure you will get in.

You have great experience, and you will find yourself relying on it, over and over.

And yes, your situation is unique.

Welcome and good luck, but you don't really need it.

[Jules A, MSN]

I have far more knowledge about psychopathology than most psych RNs or even PMHNPs and have extensive experience working with psych patients, so I'm not sure what I could possibly gain. Not trying to sound arrogant. I do recognize that there are aspects of how a psychiatric unit is run that I do not know, but I figure I can catch-on to those things during a preceptorship. Any feedback would be appreciated.

You had me on board until I got here. This absolutely sounds arrogant.

[Oldmahubbard]

You had me on board until I got here. This absolutely sounds arrogant.

It could be true that he has more knowledge of psychopathology than some of the NPs of my acquaintance. Sad, huh?

Yeah, a little grandiose. Even with 15 years of experience.

Every population one works with will have a different diagnostic profile. So, when I worked at a Community Mental Health Center, where they accepted Medicare and Medicaid, I mostly saw lower income adults and chronically mentally ill people.

Then in the Corrections setting, it was the SPMI population and malingerers. This was inpatient, where I spent 12 years. I went to court on a regular basis to force inmates to take medication. I used a lot of clozaril.

In a private practice, where only private insurance was accepted, I saw many higher functioning adults.

Now I am in LTC, and it is mostly elderly adults with many medical co-morbidities.

Every population has taught me something different, but the most valuable experience was definitely the inpatient.

I would say, without extensive inpatient experience, it is possible to be a little overconfident in one's abilities.

And the prescribing part is a lot heavier than the talking part.

The drugs needed to treat SPMI almost invariably have heavy side effects, and I have had 2 patients die directly from these effects.

So, just a word of caution.

[Oldmahubbard]

Also, in thinking about my inpatient experience, over the years I had many patients admitted to me who had been treated in the community.

It was abundantly clear that many of those patients did not have the mental health condition for which they had previously received treatment.

I can be sure of this because in that setting, we often evaluated patients for up to a year. Our supervisors were sticklers, and we could not discharge anyone back to prison until every last possible clinical stone had been unturned.

Pia, but very educational.

Hundreds of people over the years, with no trace of the alleged "bipolar" or "schizoaffective" diagnosis received in the community.

The disability check sure was nice, though.

[crs1978]

Yeah, sorry, I think I used a poor choice of words there and can see why that comes across as a bit full of myself, at the very least. I think it would have been more accurate to say that my knowledge and experience in assessment and diagnosis of mental health disorders is well beyond a psych RN (hopefully that is plain obvious), and probably on par with an average PMHNP. I can probably go on a limb and suggest that perhaps my assessment and diagnoses skills are beyond some PMHNPs, particularly those that new or with little experience, or those who don't really apply themselves to really learning the DSM. I think that is what I really meant, just tried to condense in a poorly worded sentence. I did not mean, however, that I possess all the knowledge and skills of a psych NP, particularly with medication management and tasks involved with patient care in an inpatient setting. I obviously am familiar with most of the psychotropic medications and what they are used for, but an experienced psych RN could probably school me in this area.

[crs1978]

Just to address your last observation. There is no real accountability in providing a diagnosis in the world of psychiatry or mental health. That is why a mental health professional, whether a prescriber or therapist, can easily slap a bipolar disorder diagnosis on every-other-patient without any real consequences if they happen to be completely wrong. This is different than a diagnosis seen in the purely medical world. If a physician diagnoses a patient with iron deficiency anemia to account for decreased H&H, but the patient really suffers from an internal hemorrhage, it will eventually be accurately diagnosed and that provider may have to answer for his/her diagnoses and treatment.

[Jules A, MSN]

Just to address your last observation. There is no real accountability in providing a diagnosis in the world of psychiatry or mental health. That is why a mental health professional, whether a prescriber or therapist, can easily slap a bipolar disorder diagnosis on every-other-patient without any real consequences if they happen to be completely wrong. This is different than a diagnosis seen in the purely medical world. If a physician diagnoses a patient with iron deficiency anemia to account for decreased H&H, but the patient really suffers from an internal hemorrhage, it will eventually be accurately diagnosed and that provider may have to answer for his/her diagnoses and treatment.

Right there with ya. The rampant bipolar diagnosis and subsequent polypharmacy I see on a daily basis could only be considered malpractice. I know this isn't fail safe but one of the reasons why I think it is so important to have mental health experience prior to attending one of our brief, superficial programs and deciding it is a good idea to prescribe lithium to a disruptive 10 year old with trauma history, not bipolar. Unfortunately as you pointed out there are no checks or balances in psych and even when a patient is harmed very often no one seems to care.

[Oldmahubbard]

No accountability and a whole bunch of dabblers, people practicing outside their scope, and people who make judgments when they have zero understanding of the pt's culture.

The result is a plethora of African American males falsely diagnosed with schizophrenia.Among other things.

An FNP of my acquaintance thinks he is very knowledgeable about psychiatry, because he worked inpatient psych for a year.

Indeed, that type of experience is invaluable, if the nurse involved puts forth substantial personal effort to grasp the clinical intricacies involved, correlating didactic material with what is observed in the milieu. Personal effort on your own time.

Just being physically present on a psych ward, handing out pills and giving the occasional injection is not going to result in a vast knowledge of psychiatry.

But this FNP thinks he has it, and I shudder to see the dumb errors he makes. Really dumb.

Another RN from the inpatient unit wanted to follow in my footsteps, and I encouraged her when she told me she was starting Psych NP school. I gave her some of my books.

But I warned her about the need to personally grasp the information, and that is wouldn't happen by osmosis. That she should, in effect, take notes during the work day, and go home each night and study.

I told her "no one is going to teach you to be a Psych NP. No program can. You are going to have to actively pursue it yourself, or you won't be prepared".

A year later, she complained to me that the program wasn't teaching her anything. Later I heard she switched to a non-clinical Master's.

[Dempster]

Last time I checked, something like 80% of general practitioners treat mental illness. Mental health care, access, Insurance to go to the nicer place in the state (sometime's there are 3 in my state), post-psych ward follow-up in the US, and community outreach for the 1 out of 4 (at least) that will be diagnosed with a mental illness in their life-time, and the pyscho-social help for family and friends. Not to mention the public health, outreach, and education for our communities, counties, states, and country. It's easier to go to prison for years, than get long-term care like they had at places like Dorthea Dix in NC that was shut down.

Some of us are getting the message through! In NC, you can hand your variety of drugs over and tell him that you need shelter, food, or just help getting off drugs. Most likely an opiate now-a-days. My last office manager actually sat me down and discussed how to increase my monthly patients. Monthly- pain pills, diet pills, anxiolytics.... People get hooked, bc the brain is lazy. It would rather make you feel pain that should no longer be there, than actually release dopamine the old way it used to do. This, itself, is a mental illness bc it changes your brain chemistry and pathways in the brain.

The rest are in prison, or self medicating on the street. They'd rather sleep outside than risk strangers and scabies in a shelter.

Try to commit someone- but, do it on a Friday if possible so they stay more than 1-2 days after downing a bottle of Xanax.

There are not enough psych professionals. It can be hard. Behaviors that are directed by a sick brain start looking oppositional, defiant, and devious. You start to get pissed when they act out or try to guilt you.

It's hard. It's rewarding for so many afflicted, there friends, and families. They will quit meds despite having a medical background, very knowledgeable, and very intelligent. Mental illness could give a F@k about your fancy education or lack of, or how smart or gifted you are (higher suicide rate with higher education and IQ, generally).

We need you in psych. Prepare though. Study in depth about personality disorders, mental illness, and addiction. Don't listen to your new coworkers about the patients. It's a high burnout area. Look at treatment holistically. Know that you may be the first person to treat them like they are human and not dangerous a weirdo. Remind them and ask them about their strengths, not just the crappiness of disease. This may sound strange, but, ask what about their condition is a strength, helps them see the world like no other, and makes them a good type of interesting- many with hallucinations will mourn the sounds and visuals that were special to them. Not all hallucinations are dangerous, but most people don't hallucinate and therefore understand why some of them would feel like a huge loss, like losing a hand or foot.

Know your meds and side-effects, good mouth checking, and know all the hiding places. You don't have to get an education in psych to make a bigger difference. Read and study new literature/ studies. Set an example for your coworkers and back it up with research and known outcomes.

I'm a little passionate about mental health care! Do it! If you want to be a psych nurse, find a mentor if you can. All of this will help you as you get your advanced degree, even when you find out that some things you learned in the unit are wrong and have to be changed!

I wish you the best and pray more people follow this path helping pts and family, decreasing crime, educating and breaking through the stigma. That is better, but not good enough. You will be treating the most difficult diseases plaguing your pts. Treating the pt's brain, the most important and least understood organ. You are a super-hero!