Caring isn't enough as a psych NP

[juschillin, MSN, RN, NP]

I'm back in my old role as a psych np, this time in community mental health. I put all I have into the job, trying to provide the best care I can. I have 20 min. for follow-ups and 45-60 mins for new clients. I have found it to be impossible to see these clients in that amount of time. They are a pretty sick bunch, with a lot of complex trauma and substance abuse. Because of turnover with NPs and therapists, they have had little consistency in care over the last couple of years, which of course has impacted them negatively. I work incredibly hard. But I feel that it's never enough for the bean counters, who constantly tell me "more more more". I cry often because of the work load and know something has to give.

In June, one of my coworkers was violently assaulted in the early evening hours while working late (he survived); someone tried to break into the office via a back door, believing no one was inside, most likely looking for drugs. It's common for staff to work late because we're short staffed and horribly over worked. I've been trying my best not to work such late hours, and finally had to put my foot down. They have done very little to improve safety since that incident, despite repeated requests to do so by myself and other staff (that location is one of 4 that I work in every week, so I'm there physically only once a week, thankfully). Just yesterday I had to call the police re: a client that I felt was too threatening.

It's the end of the day at the end of the work week, and I'm exhausted. But I wanted to write this for a few reasons. For one, those of us in mental health (all of healthcare, really) need to have safe work environments. OSHA has a guideline about this, particularly in the mental health setting. Google that website and read it. I think it's called "Universal Precautions for Violence", or something. LOTS of good info. Of course, my company has broken every rule in OSHA's book.

But I just needed to vent, I guess, too. I cannot seem to find a place to work that has a good balance, one where I feel truly supported as a healthcare worker. I also know that this theme, compassion fatigue and burn-out, is a main one on this site and other forums like it. Whoohooo! I'm not alone! That doesn't make me feel any better, though.

I don't want to quit this particular job, but I don't know how to make it work. I don't know how to survive in this field. Can anyone offer suggestions about how to hang in when you're not feeling supported by the administrators, aka, the bean counters? Does it ALWAYS have to be "us (nurses) vs. them (bean counters)"?

This was way long and I ought to edit it but I'm too tired to edit. Thanks for reading/listening. Have a great weekend.

jc

[Jules A, MSN]

It sounds like that is a horrible place to work. I can't speak for everything else but I wonder how much time you are spending attempting to do psycho-therapy? If much more than just a few comments per med check it is too much. We are hired to do medication management only and this is where I think NPs of all specialties have problems with time management. Good luck.

[slashdot]

Forgive me, I am not a PMHNP, just here learning about the role. But I am on my way to being licensed as a therapist and I have a few thousand hours of mental health behind me. I quit a job at a place similar to how you describe; we began taking on acute patients due to a state hospital closure. But we weren't a medical facility and often our 16 beds were overseen by TWO staff members. Some of our patients were unstable and not required to be on their medication. A staff member was sexually assaulted (can I call it minor? traumatic, but not as severe as it had been intended) and after that we got two pieces of paper with "tips" on safety that we had to sign. The staff was not beefed up. No actual training on safety or take downs occurred. I just want to say I empathize a lot with what you are dealing with, even in therapy or psychoeducation, the demands on time were far too high. In my experience it has not been as bad everywhere and it might be time to see if the grass is greener? Good luck to you.

[PG2018]

I agree with Jules. I work in a thriving but also outpatient clinic. All of my patients are certified SMI or SED. I barely take 20 minutes for an eval, often less. I'm not there to discuss their entire life.

Before I see them they've had a diagnostic evaluation by a therapist covering social and developmental history, psych hx, SA, fam hxas well as their own version of a HPI. They diagnose, and I review their stuff when the patient shows up as we talk about their CC and my HPI. I ask again about SA, fam, med hx and amend the diagnoses as needed, order whatever tests I want and prescribe. I can't fathom needing an hour to do this although I've worked with those that do.

I feel bad for them too, but I seem to do well with what I do. Additionally, I also can see thus help more. And incidentally make more revenue as well. I think NPs spend too much time chasing this holistic mess than a RN can a RN or LPN can do. I've been with a NP who wanted to know how many servings of vegetables someone at each day. There's just no time for that. You're not going to make them eat more celery or make their depression go away in a 60 minute gab session.

[juschillin, MSN, RN, NP]

Thank you for these thoughts. I think every community mental health and/or outpt clinic has different levels of acuity and there isn't one method that will work for them all. I have a lot of clients that need higher levels of care, such as ACTT or CST and it's not available. Lots of them don't have primary care and haven't seen a PCP in years.

I recall seeing a post on here not long ago and a NP had a form that each client filled out before being seen that had them list their meds, how much sleep they're getting, appetite, mood, all that stuff, and so when they were being seen they focused on that only, and it was much quicker. I'm going to try and do that this week coming up and see how it goes. I try not to get into side stuff with them and rarely do anything but a little bit of support counseling. We're very short on therapists and they're lucky if they see someone every 3 months.

I know there are NPs that are able to get 'em in and out quickly, I just haven't found that sweet spot.

[synaptic]

If it's that bad you can complain to osha. They have whistler blower laws. Also, we can't do everything. Just focus on medication management. That's all the psychiatric same pmhnp do in our psych center and outpatient places. Don't burn yourself out

[Whispera, MSN, RN]

I'm a psych CNS who prescribed at an outpatient clinic. I had to do an extremely detailed assessment on first contact with a patient, since I was often his or her first psych caregiver. Followup appointments were expected to be no more than 15 minutes long and I was expected to triple-book them. I was usually able to do initial assessments in an hour, but the followups were very difficult in that time frame.

I saw patients who were just released from prison. Some made my spidey-safety-sense very nervous. My office was wayyy down a hall where no one would hear me if there was a problem. I asked to have my office moved closer to the reception area (there were two vacant offices), and was denied. I resigned.

I empathize with you. It seems it's time for you to weigh the positives vs. the negatives with your job...

[PG2018]

This seems to me more a problem of system-abuse of the NP rather than provider mismanagement. There's a shortage of psych-trained prescribers. I really don't think it's outside the realm of possibilities to negotiate a correction for all of your concerns. If not, find other work, then quit. There's plenty of work to be had, and not a single one of us should take some crappy job where we're thrown in the back hallway and triple booked.

Do not be Milton on Office Space.

[Psychcns]

I had a locums job which gave me 90 min for an eval and 30 min for follow up. I incorporated therapy and did a great job choosing meds. I can manage with less time. If I am not satisfied with my assessment/plan due to feeling rushed I try to get the patient to come back more often. I had one pt figure out how to see me every week while I adjusted her meds. As noted above, Having a symptom check list pt fills out when they check in would save time. Outpatient can feel like an assembly line.