Critical care RN to PMHNP, am I crazy? Looking for advice

[ScottMedicRN]

All of my experience is as a paramedic, ICU RN, Transport RN at a large university with very sick patients, and soon to be Flight RN. I'm used to directing care by myself, knowing medication doses, intubating, managing vents, etc. My background looks good for ACNP. Yet, I just don't know if I want to do this stuff anymore. My passion is gone it seems and I no longer enjoy the hassle of sick patients. I'm still considering it, but what used to be glamorous to me feels like meaninglessly keeping dead people alive (no offense intended, just want to illustrate how I feel lately).

I might want something completely different. After dealing with psych issues of my own, I feel like I might have more of a passion helping people in this area than I do in critical care, which feels pointless at most times. I have no psych nursing experience though. The big downside I see if I don't like being a PMHNP I don't really have much if any room to change, and I would have lost my critical care skills.

I really would like to do outpatient. Some of the more severe inpatient cases probably wouldn't be something I would enjoy. It seems that med management is the primary role of PMHNP, but I really am curious how hard it would be to be trained and perform some CBT as well. After seeing how CBT changed my life from severe OCD, it's part of what is driving my passion towards mental health.

Should I try to shadow a PMHNP? Would I even be considered due to my lack of psych experience? Any advice would be appreciated.

[umbdude, MSN, APRN]

22 hours ago, ScottMedicRN said:

Should I try to shadow a PMHNP? Would I even be considered due to my lack of psych experience? Any advice would be appreciated.

It's always good to shadow if you can, and your lack of psych RN experience won't hurt you. However, it's good to have some experience working with psych patients to make sure you like this population. A lot of psych NPs are jaded, so it's important to know that you have a genuine interest.

22 hours ago, ScottMedicRN said:

It seems that med management is the primary role of PMHNP, but I really am curious how hard it would be to be trained and perform some CBT as well.

First off, you technically can perform CBT as a PMHNP and bill for it (even as a new grad). You can get certified later on to get more in-depth training. I would recommend getting your clinical placement with a preceptor who performs therapy to get more training. IMO, CBT is not too difficult because the process is logical and easy to grasp (unlike EMDR), and you can literally follow a manual. Having psych RN's therapeutic communication style and personal therapy experience will help a lot as well.

Many community health centers want PMHNPs to prescribe meds because they already have therapists in-house. So your best bet is to join a private practice group or any outpatient facility that allows you to book therapy appointments. You might not be able to make as much money though.

[ToFNPandBeyond]

15 hours ago, umbdude said:

First off, you technically can perform CBT as a PMHNP and bill for it (even as a new grad). You can get certified later on to get more in-depth training. I would recommend getting your clinical placement with a preceptor who performs therapy to get more training. IMO, CBT is not too difficult because the process is logical and easy to grasp (unlike EMDR), and you can literally follow a manual. Having psych RN's therapeutic communication style and personal therapy experience will help a lot as well.

I disagree with this recommendation. Umbdude, I see your credentials state BSN,RN, so I will assume you are not privy to the education APRNs receive. NPs, and even Psych NPs do not have enough education and training in psychotherapy to thoroughly perform this level of skilled care. I don't care how "logical" something appears. You can be doing more harm than good performing a skillset you are not fully trained to do. Leave it to licensed therapist to perform this skill.

If you are going to do psych NP work, be comfortable with the fact that most of what you will be doing is med management. And believe me when I say, that alone is enough!

[umbdude, MSN, APRN]

8 hours ago, ToFNPandBeyond said:

I disagree with this recommendation. Umbdude, I see your credentials state BSN,RN, so I will assume you are not privy to the education APRNs receive.

I'm in the last year of a PMHNP program and have worked in mental health for 4+ years. My clinical placements include inpatient psych and running a CBT group. I know quite a few Psych NPs who focus primarily on providing therapy (not only CBT but a variety of approaches). One of my classmates is in a private practice that combines med management & therapy.

Sure, PMHNP training doesn't go in-depth into psychotherapy. That doesn't change the fact that PMHNP can technically bill for therapy. Among various therapeutic models, CBT is one of the therapies that, IMO, is easier to pick up on. I do encourage getting more training and there are plenty of training out there for CBT.

Personally I have no interest in providing psychotherapy, but in responding to OP's question about whether it's possible to conduct therapy (CBT in particular) as a PMHNP, my response is yes.

[Nurse Magnolia, BSN, RN]

I don't understand how someone can become a psych NP without psych experience? As a psych nurse, I couldn't go for an acute care NP without acute care experience, nor should I be able to. Our patients are just as important and deserve NP's that have experience working with the most critically mentally ill. Those patients show up to outpatient clinics once released from the inpatient units. I worked community mental health for years prior to nursing school and lack of providers is a major issue - but having ill equipt providers is another issue.

I'd say get a job as a psych nurse first, make sure you really do feel a passion for helping this type of patient. THEN go on for your NP. Psych nursing units are usually pretty accepting of specialty changers and they also usually need staff, so you may not have a difficult transition.

I commend your desire - I just don't think anyone should be able to go for an NP in a specialty in which they have zero experience.

[myoglobin, ASN, BSN, MSN]

While I agree that psych experience is optimal it isn't essential (at least not to get a job and perform at something that approaches competency). My wife is a PMHNP who graduated in 2016 after working in the ICU for about ten years. No pure psych experience other than the suicide attempts, ETOH withdrawal's, cocaine overdoses, and neuro-traumatic brain injuries commonly seen in her unit. However, she was still hired by FasPsych in her last year at $85.00 per hour working from home (a job she still holds today). My experience is similar to hers (i did take care of involuntary hold patients for about three years when we had an overflow unit, before our hospital's psych unit was formed when few others were willing to do this). While, I have not been able to obtain such a lucrative position fresh out of school (work at home $85.00 hour) I have had several offers in the 170K range in places like Washington State, Colorado, and New York state, and Arizona. Thus, I argue that while psych experience is optimal and certainly helpful is isn't essential. Furthermore, in clinical I witnessed a plethora of board certified psychiatrists with decades of experience who handed out benzo's virtually like candy, and amphetamines to professionals (like other MDs) who claimed ADHD since child- hood and practiced extreme poly-pharmacy. Thus, I conclude that the average person of reasonable intelligence who uses common sense and applies themselves (and refuses to do the 15 minute medical management appointment in favor of at least 20 and preferably 30 minute appointments where you actually have time to assess and listen to your clients) will often perform in a manner that is superior in terms of patient outcomes. I personally tried to get experience in psych over the last four years (the time it took me to complete my Masters degree part time), but no unit would hire me prn (since my experience was in ICU, they would have hired me full time, but that wasn't a viable option throughout most of school).

Thus, I conclude "get the experience if you can", but don't sweat it too much if you cannot. Model your practice to the best of your ability on clinicians like Dr. David Puder who hosts an excellent free podcast https://psychiatrypodcast.com/psychiatry-psychotherapy-podcast and use resources such as those offered by The Psychophamacology Institute https://psychopharmacologyinstitute.com/ and The Carlat Report https://www.thecarlatreport.com/. Also read Kaplan and Sadock's Synopsis of Psychiatry at least twice, and Stahls Prescriber's guide several times along with Wheeler's Psychotherapy for the Advanced Practice Nurse before ever starting your program (also consider subscribing to Lecturio.com and viewing the free material at The Khan Academy on a plethora of related fields for at least six months or better yet a year before starting your program as it provides a basic overview of a medical school curriculum). If you apply yourself to doing this for about a year before starting school you will find that you have a reasonably solid foundation upon which to build without regard to your specific experience. Furthermore, there is a case to be made for the stronger "medical" background (relative to psych) that can emanate from experience in things like being a paramedic, medical surgical, or ICU nurse. That is because so many medical conditions from heart disease, to COPD, and neuro-endocrine disorders can have such profound implications for mental health.

[TiffyRN, BSN, PhD]

I know this thread is a few weeks old but I was having some similar questions. My DH is about 1/4 through PMHNP school, he also came from a non-psych background. Whereas he knew most PMHNPs mostly do med management, he had visions of possibly doing some psychotherapy. First semester they only had general family practice practicums and he just started his first psych practicum. He follows a very busy PMHNP who rounds in various LTCs seeing at least 20 patients a day.

His concern is, is it reasonable to expect to find employment that is not so fast-paced? He is older and kind of just wanted something to gear it down a bit from hospital work and would be perfectly happy to work part-time but has concerns he would be able to work part-time, or at least go part-time after a year or so. He's open to multiple environments, is not turned off by the LTC-type patients, just wouldn't want to see so many. Would be open to office work, would love to do therapy appointments even if that meant decreased income. Would be open to tele-medicine (is that reasonable for a new grad?). We are in one of the most restrictive practice states so he would have to have an association with an MD, don't know if that makes a difference.

[myoglobin, ASN, BSN, MSN]

Tele is hard to find without several years experience. However, many states including New York, Maine, Wash. and Colorado have 30 min. medical management appointments. You have to get out of the South by and large. Also, there are positions where you would visit LTC facilities available.

[umbdude, MSN, APRN]

11 hours ago, TiffyRN said:

His concern is, is it reasonable to expect to find employment that is not so fast-paced?

Private practice is usually slower (e.g., 30 min follow up and 1-hr initial eval).

11 hours ago, TiffyRN said:

We are in one of the most restrictive practice states so he would have to have an association with an MD, don't know if that makes a difference.

It depends and every place is different. He will have to ask about these factors during his interviews in order to find the right fit.

[myoglobin, ASN, BSN, MSN]

On 2/14/2020 at 4:31 PM, umbdude said:

Private practice is usually slower (e.g., 30 min follow up and 1-hr initial eval).

It depends and every place is different. He will have to ask about these factors during his interviews in order to find the right fit.

In restrictive practice states I would suggest contacting MD's  directly rather than applying to posted jobs if you want to find "a deal" where they act as your "covering physician". I would be surprised based upon my experience if you could not find someone willing to do this for around 10%.  That's still a fair deal. Then the challenge is  getting credentialed, billing insurance, software, finding clients and office space (unless you want to practice remote from home). Being "cash only" will save on the insurance part. Still should be relatively easy to make at least 150K "on your own terms" in almost all areas of the country even in "low paying" areas like Florida.  

[umbdude, MSN, APRN]

9 hours ago, myoglobin said:

In restrictive practice states I would suggest contacting MD's  directly rather than applying to posted jobs if you want to find "a deal" where they act as your "covering physician". I would be surprised based upon my experience if you could not find someone willing to do this for around 10%.  That's still a fair deal. Then the challenge is  getting credentialed, billing insurance, software, finding clients and office space (unless you want to practice remote from home). Being "cash only" will save on the insurance part. Still should be relatively easy to make at least 150K "on your own terms" in almost all areas of the country even in "low paying" areas like Florida.  

Yes that's one way to do it. How long will it take to build up a panel that is enough to make $150k?

[myoglobin, ASN, BSN, MSN]

3 hours ago, umbdude said:

Yes that's one way to do it. How long will it take to build up a panel that is enough to make $150k?

It will depend upon your initial resources. If you are working with a "big" company such as the one that I do (it costs more 30% plus $600 per month in fees) then about three months (to earn a monthly income equivalent to 150K per year).  If you work for a "smaller" company (or isolated MD) who might only be taking 10%-20% with little if any other fees then it will depend upon the resources you can invest. You will start with a Psychology Today advertisement and add other (probably primarily online) media as you can afford to do so.  It might take at least six months to a year. One option might be to work say "two" days per week someplace and spend another two or three building "your" practice.