New grad of PMHNP. Is this a typical first job experience?

Jules A, MSN · Jan 26, 2018

You are basically a first year resident-intern, green behind the years, but without the benefit of the formalized training program that exists for MDs- the residency.

And this is where we need to take our schools to task. That someone is licensed to practice and is receiving a full salary while not actually ready for the role is a problem and it isn't the employers. They expect what they are paying for which is a capable employee.

Basically, it's not your fault-the system is ^^^^-ed up.

Unfortunately it has trickled down from undergraduate nursing where everyone needs a 6 month orientation. Now employers, probably due to the shortage over a decade ago, sucked it up rather than insisting schools provide a product that is capable of working with reasonable but minimal guidance upon being licensed. NPs need to take some responsibility in being realistic about the roles we are capable of filling regardless of what our schools or our licenses indicate because the real world isn't going to pay six figures and offer a free residency. Not being proficient or appropriately supported is dangerous for our patients and puts our licenses in jeopardy.

Its unfortunate once again to read that mental health is minimized into the demand is so great even inexperienced, aka not fully competent, providers are in high demand so no worries about a job. With all the no-psych-experience charlatans now joining this specialty in many locations that is no longer the case.

Oldmahubbard · Jan 26, 2018

This problem of extremely green NPs being unleashed on the public is directly related to economics. Medicare reimburses NPs at 85% of the MD rate. Are you making 85% of what an MD makes, or even close?

Someone is making a ton of profit from your labor.

MDs have required residencies, which are essentially hybrid education/training programs. They are extensive, they are paid at some level, and the residency supervisors are well paid. The program rules are well defined.

I am fairly sure that if the regular supervisor couldn't be there, a substitute would be found. In any case, the residents wouldn't just be unleashed on patients.

In the NP world, we have some type of loose collaborative and/or supervisory relationship. Depending on your state. My state did away with it for experienced NPs, but even when we had it, it amounted to about 4 hours a year of supervision.

4 hours a year! Thankfully, I didn't need it, at least not after the first year or two.

Even in a perfect world where the supervisor was available on site, they would be busy with their own work most of the day. The supervision would entail maybe a half hour at the end of the day, if that.

NPs have been a big windfall for health care organizations. We bring in 300k in billing, and are lucky to make 100k.

But are we competent to practice at that level?

Because we aren't just doing the easy cases anymore. That went out more than 20 years ago.

psychlady17 · Jan 26, 2018

Hey OP,

I just started my first PMHNP job in Sept 2017 in outpatient psychiatry. I had a similar situation where I had new patients my first day without any orientation whatsoever. I pretty much learned as I went through my day and eventually figured out my routine, preferences, etc. Even though I was mostly independent from the start, I still have an awesome group of psychiatrists that are super helpful when I need them. I think it's expected for us to be independent right out of the gate, which isn't always realistic.

I also did my last full year of clinical hours in an outpatient clinic since I knew that's where I wanted to work. Geriatric psych is a whole other can of worms, I can't imagine doing it. I wanted to get my regular psych NP skills improved before I take on constant comorbidities and polypharmacy.

Honestly, if you continue to struggle and get no assistance whatsoever, I'd encourage you to look into NP residency programs where you get way more support and additional education. If I were not confident in my job as a provider, I definitely would not risk my newly attained license on a job that's set you up for failure.

LadysSolo · Jan 27, 2018

I am an adult NP, and was functional from day 1 (but have improved over the years,) but psych meds are a whole other "can of worms." I would completely feel unprepared to decide on what psych meds to use, although I am completely on board with decreasing polypharmacy in other areas. I am not familiar with the clinical rotation for psych NP, but I had 23 years as a floor nurse before becoming an NP, so assessment and diagnosis was not unfamiliar. We arranged our own clinical sites for the program I was in, so I could focus where it would be the most helpful. Hopefully the OP can find someone to "bounce ideas off of," or the collaborating physician will get well quickly.

GradNP · Jun 1, 2018

I'm an FNP for 25 yrs, recently completed my PMHNP post masters with ANCC cert, working at PMHNP for the past few months. I feel your pain. Its challenging, exciting, remember you were cert to practice safely. Nothing can take the place of experience and although a residency would help, you won't feel prepared even after that. Remember this is the "practice" of medicine. Part of being a professional is knowing when you don't know and demanding from your employer that certain conditions need to be in place for you to be supported. If they are unwilling to set up those conditions, don't be afraid to look for another employer who will, and I guarantee you will find them. Thats what I did. I didnt take a residency but I made sure I had either a psychiatrist onsite or available by phone before I took the job and made sure it was in my contract as a 1099 employee. I am supported, the psychiatrists are available and willing to teach, the ancillary staff schedule me 2 alternating with 3 patients an hour, and management is supportive. I'm hoping to transition to the emergency critical decision unit for emergency room psych in the next year or two. Good luck and get what you need to feel supported and safe in your workplace.

Jerrysdogmommy · Aug 7, 2018

While I've been accepted to a psych NP program, I'm not certain if this is for me. What I see myself doing is helping people uncover what's "really" going on and helping the individual identify the issue while progressing towards a better outcome. I do have a lot of compassion for those addicted to drugs and alcohol and would help them through the detoxing while ensuring they are taking the right meds, etc. While I can see how Psych NP does help with medication management, seeing 4 patients an hour does not appeal to me. I even thought about teaching special education since I enjoy helping people find within themselves their own answers and assisting them towards betterment.

I've done a lot of research about the psych NP role yet, am very confused. I remember the physicians working at the inpatient psych ward I worked briefly 9 years ago and saw their brief interactions with patients and thought that could be okay but I'm just not sure. Would psych NP fit my above description? Thank you in advance for any wisdom offered.

InquisitiveAPN · Aug 7, 2018

I just started my first job as an NP on an inpatient geriatric psych unit. My collaborating physician unfortunately is on medical leave, and she is very ill! Other doctors come to see the patients in her place but they are frequently in and out quickly and otherwise unavailable.
Ive only been there a week and it's a disaster. I took one patient, and have no one to ask questions to as I haven't had any oreintation...and there is no one there. I feel like crying! I'm not taking any more patients until I get some sort of guidance. Am I being unreasonable? We had a new admission that I wasn't comfortable taking and I asked a doctor (that's there for 2 hours a day) if we could do it together and was blown off and he said he would just do it.
Im worried that I'm going to be perceived as wanting too much handholding, but I'm literally just on my own.
Has anyone been through this? Any advice?

I don't know if it's helpful or not, but when I started out I was given a handwritten memo by the director that said "there are only three things to know, and he listed those." There was that and a figurative key to the executive washroom, lol. Hang in there and get a good malpractice policy! In realist, you might want to job hunt. Just sayin'.2

RatchettRN · Sep 7, 2019

I am a relatively new Fnp and with both jobs I took, I made it very clear that I expected some support and backup. Yes, you are prepared for your field and with clinic hours, but it's not ok to guess at what your patients need. Your employer will not know or care what you need, so you need to be very clear. I work in Peds neuro now, very non-standard for an Fnp prepared nurse, (though I have years of Peds RN experience, not the same) but I have excellent support from my team. I also added slowly to my patient panel. Let the fear factor guide what you find acceptable in a job and don't be railroaded into going beyond your comfort level.