Experience for PMHNP

[RN356]

Hello All,

I am very interested in pursuing a PMHNP and am currently looking to enroll in programs. I enjoy working with psych patients and I see how bad the need is for more mental health professionals, especially in my area. However, my current experience as an RN has only been in ER and ICU, with no "specific" psych RN experience. I obviously work with psych patients every day in both of these specialties, and volunteer to work in the "psych pod" whenever possible when I work ER. I am wondering how important it is for me to work as a specifically psych RN before NP school?

I have been looking at opportunities at different psych facilities in my area, but flexible jobs are few right now and they pay literally 15 dollars less an hour than what I make now in critical care where I can completely dictate my own schedule. I'm not in it for the money, but at the same time I gotta pay my mortgage and that's a huge pay drop! I also want to keep my job flexibility during school/clinicals. Do you think my experience plus the experience I will gain from NP school will be sufficient to make me an effective practitioner? I would appreciate thoughts :)

[bryanleo9]

"and there are plenty of pmhnp openings."

Let's consider why this may be. It's a prime indicator of nurse burn out and an insanely high turn over rate. Those of us working side by side with the pmhnp or as them see it. A major hospital in the area has been continuously running an ad for pmhnp job paying 145,000 and yet they can't keep it filled. Staff come and go.

The nursing home down the road has plenty of RN openings as well in a primarily LVN dominated field. Every week the paper has an ad in the paper for them looking for RN's. I decided to check them out to see if I could get a little part time work. OMG I took a tour and saw exactly why they were hiring all the time. Terrible work conditions. With pmhnp's, the liability is intense. The job satisfaction is not there a lot of the time. The turnover rate and burn out is out of control. But it seems to be the one advanced practice nurse field that so many are now flocking to. Just do your homework and realize why their are so many vacancies.

[bryanleo9]

Yes, I gave people their pills for their heart disease, kidney disease, and lung disease, etc., on the psych units on which I worked, monitored their VS as ordered, and watched for anything I might notice that might represent a deterioration of their medical condition. As I said, that didn't help me develop any particular insight into any of those illnesses or how they are diagnosed and treated. I've also worked in settings in which I am the psych person covering the ED of a general hospital, and on the psychiatric consultation-liaison team that provides psychiatric services in general medical-surgical settings. I'm doing the latter now, so I spend all day every day dealing with people with psychiatric problems in addition to whatever med-surg problem has them in the hospital on a medical or surgical floor (or ICU; we spend a lot of time in the ICU). I can tell you confidently that the medical and nursing staff are in no way "treating" anyone's psychiatric illness. They're giving them their (psychotropic) pills, and consulting the psychiatric service as soon as anyone raises their voice or says something unusual (in fact, you wouldn't believe the ridiculous consult requests we get). In my experience in ED(s), the ED people are triaging psych people and attempting to get them out of the ED as quickly as possible so they don't have to deal with them any more than necessary. And don't get me started on the utilization of "therapeutic communication" in non-psych settings ... I've not encountered, at any point in my career, anything close to the rosy scenario you're painting of how well non-psychiatric staff (physicians as well as nurses) are "treating" psychiatric illnesses and clients in other settings.

As you point out, people don't know what they don't know. But, as you also point out, the larger nursing community has decided it doesn't care and this doesn't matter. The current goal appears to be to crank out as many minimally prepared clinicians as possible, and hope for the best. We'll see how that works out over time.

Indeed. Working the ER and asking patients pre printed psych screening questions does not make someone experienced with psych patients. Real mental health assessments are much more than that and come from years and years of direct patient care with this population group. Real world long term case studies that you have personally seen and have been part of are where the learning comes from. ER is about getting them out as soon as you can and let the responsibility fall on the outpatient clinic.

[elkpark]

I'm not sure what your concept of "treating" a patients illness means for an RN because it seem to imply something far beyond the scope of practice on their own unit and something approaching negligence and gross incompetence when in a different setting. I'm truly sorry that patients like yours don't receive quality nursing care on the psych unit simply because it doesn't match your perceived job description. I personally believe that a psych patient deserves quality care of the whole person regardless of what unit they find themselves on. That would mean more than pushing pills and blindly following orders. I don't think the fact that one is a psych nurse obviates them from being a basic nurse and caring for the whole person in an effective and competent way. It truly fascinates me that you're willing to denigrate the level of care provided by RNs while simultaneously insisting that this lackluster experience is somehow essential. From what I can surmise based on your descriptions of nursing care, it would be advantageous for someone to have minimal, if any, experience in this atmosphere of ridiculously subdividing the individual pt and passing the buck because "it's not my job."

I never said people don't know what they don't know although some individuals might not. I said that would be a danger. But I don't think the average nurse has that poor of metacognition. You continue to contend, without anything but personal anecdotes, a very grim view of both nursing in general and particularly advanced practice nursing. But then again, if you think doling out pills and blindly following orders is not only what passes for an experienced nurse but also what others should be forced to go through before they have the privilege to become an APN then I could see how you would arrive at that conclusion.

The truth is that APNs, psych and otherwise, are and have been providing quality care for decades. Anecdotes such as yours or the medical community who have an agenda that APNs are grossly incompetent and woefully ineffective because they didn't get there the "right" way. However, if that were true, wouldn't there be some indication after decades of NPs in every healthcare setting of this kind of negligence and incompetence. I guess we will have to agree to disagree but it sounds to me like you have this preconception of the "correct" way to move through a nurse career (which is not based on my evidence) and that shades your experience with those you've encountered. I'm sure the PMHNP students/practitioner you've encountered couldn't meet your expectations when you admittedly decided they weren't qualified before giving them a chance. An therein lies the world of difference between evidence and anecdote.

Well, you're right about one thing, you didn't say "people don't know what they don't know," that was someone else on the thread. I apologize.

[Jules A, MSN]

The truth is that APNs, psych and otherwise, are and have been providing quality care for decades.

The real truth is those APNs had stringent experience and admission requirements prior to getting accepted into a program there is likely to be a much different outcome going forward.

The other truth is the OP posted it as a question but as is so often the case later remarks indicated they only wanted support of their plan.

I can tell you confidently that the medical and nursing staff are in no way "treating" anyone's psychiatric illness. They're giving them their (psychotropic) pills, and consulting the psychiatric service as soon as anyone raises their voice or says something unusual (in fact, you wouldn't believe the ridiculous consult requests we get). In my experience in ED(s), the ED people are triaging psych people and attempting to get them out of the ED as quickly as possible so they don't have to deal with them any more than necessary. And don't get me started on the utilization of "therapeutic communication" in non-psych settings ... I've not encountered, at any point in my career, anything close to the rosy scenario you're painting of how well non-psychiatric staff (physicians as well as nurses) are "treating" psychiatric illnesses and clients in other settings.

My experience is similar and I can not count the number of times a patient was admitted from the ER or transferred from medicine without being medically stable because they either couldn't deal with their behaviors or blindly only saw the psych diagnosis by history.

The current goal appears to be to crank out as many minimally prepared clinicians as possible, and hope for the best. We'll see how that works out over time.

I agree and find it unfortunate. Working on the acute unit I see the bad diagnosing and prescribing of community psychiatric nurse practitioners. Bad prescribing isn't isolated to NPs but in the past few years things have gone down hill, anecdotally of course. My Chair, who was historically supportive of NPs, has filed complaints to the board over the past three years which is something I had not seen before. It is embarrassing.

[future_psych]

Hey there,

I'll be graduating from a direct-entry PMHNP program next May and have been working inpatient psych for the last 2 years (as a tech as well as RN). I also recently began precepting and can tell you without a doubt that my inpatient experience has given me a huge leg up. While you may see psych patients anywhere, there is absolutely zero comparison to working on a locked unit. The acuity of illness on a psych unit gives you a pathology perspective unmatched anywhere else. Disease presentation is the most extreme here and this allows you to fully grasp and appreciate subtle signs of psychiatric illness. For instance, can you easily identify vocal tendencies in schizophrenia? Sure you can go listen to a youtube video but I promise it is just not the same as hearing someone with echolalia for 8-12 hours (it gets stuck in your head)! I liken this concept to a baseball player's practice swing with added weights. After seeing the most severe variations of mental illness, nuances are more easily recognized in the outpatient setting.

It is correct to say that inpatient psych experience isn't NEEDED, but it definitely helps you be more prepared when you see patients as the provider.

[Oldmahubbard]

I did not have inpatient psych experience, but I did have 4 years of Community Mental health Clinic experience with the SPMI population that prepared me quite well. And yes the pay was really awful. It was a large sacrifice. I was fortunate enough to pick up some hours at an Assisted Living facility where most of the pts were chronically mentally ill.

I must add that I did a very large amount of independent self preparation while in school. Most semesters, I only took one class.

When I graduated and started my job in the inpatient unit, there was a small learning curve. But I was on a first name basis with serious mental illness.

[Malenurse12345]

I completely skipped working as an RN and recently finished my DNP-PMHNP program. Many of the "old guard" nurses tried to deter me from doing this, but I am so glad I did it anyway. With so many discouraging words, I started my first day of clinicals feeling dumb, like I was going to fail, and that I had no business being there. I discussed my concerns with my preceptor and she could not relate since she was a psych RN for 10+ years before becoming a PMHNP for another 15.

At the end of my first semester, this preceptor wrote that I had overcome any shortcomings that I may or may not of had related to lack of experience. Looking back, there is absolutely no reason whatsoever that you need previous experience to go into psych. You may be more familiar with diagnostic criteria, related medication/labs. But at the same time you may have some incorrect notions or negative biases. I had no problem learning this information, its in a book, make flashcards etc. You can even use psychometric screening tools (PHQ-9, GAD-7 etc) until you develop your own routine/questions.

There are not a lot of variety of diagnosis in general outpatient psych. Mostly MDD and GAD, then bipolar and schizophrenia, SUD can co-occur a lot depending on the setting, tons of patients have co-occurring insomnia, and dementia is pretty prevalent on gero populations, which you can always refer to neuro or neuropsych for consult/confirmation. Oh yeah, lots and lots of ADHD in peds.

[clunkygirl]

Please do not let your lack of experience with an all-psychiatric population prevent you from studying to be a PMHNP.

While I was in my FNP program this was a hot topic and quite frankly, as an RN with 20 years experience in cardiology and psych, I felt my experience was often times a hindrance. I say this because my role was almost entirely different as an RN and I heard a lot of RN-speak in the program. I regret to say that a lot of RNs have a martyrdom view of their career, they believe they should do everything at the cost of their own happiness (you shouldn't expect a break from working, kill your back moving patients alone, getting UTIs as a badge of dedication, etc.). While a lot of experience as a nurse is nice as it makes for familiarity with terms and such, you honestly can learn that without all the exposure. As far as I know, there is not a study that indicates otherwise.

I do encourage you to try and find something, even if it is just one day a week, working exclusively with psychiatric patients as I feel it adds some additional depth to be immersed in a whole day with several inpatients (you also get more familiar with medications).

In the outpatient setting things are different yet, seeing patients who function at a higher level that may never be in a crisis unit is another matter altogether. However, it is not mandatory.

Lastly, I worked with an FNP in an outpatient psychiatric private practice who was never employed as an RN, she completed a program at Vanderbilt that went from 2 years prerequisites to FNP. She started out in family, did that for about a year, then went into psych as a provider. She was an excellent NP and taught me tons.

Best of luck

[Oldmahubbard]

There is RN speak around psych and some of it is inaccurate. Yes. And yes my role as an RN was a little different, but I went home every night and did extensive case studies on my own.

[FullGlass, BSN, MSN, NP]

The quality of psych RN experiences varies widely. There is a small acute in-patient locked ward facility in my home town that is terrible. The "psych" RNs literally spend their whole shift locked in a room and are hardly ever seen. All floor work is done by peer counselors. Personally, I don't think that provides much true psych experience. Yes, there are wonderful psych RNs, but there are plenty of crappy ones, too.

Most posters on this thread assume PMHNPs only work in-patient. That is simply not true. At least in my state, there is a far, far greater demand for outpatient psych. There are many high-qualify outpatient facilities that are physically beautiful and are sincerely dedicated to serving patients of all incomes. They will transfer patients to in-patient as required. In other words, these are very nice working environments.

And to all the naysayers, I am a primary care NP. And I am applying for PMHNP post-master's certificate programs now. Currently, I treat A LOT of basic psych issues such as depression and anxiety. In my area, we literally do not have a single psych prescriber in over 7,000 square miles! We desperately need PMHNPs. We have some excellent talk therapists on our staff and we do have a psychiatrist that is available via telemedicine. I am the only provider that has actively collaborated with them to develop treatment plans for complex patients.

Being a good mental health provider is not just about knowing the meds. That is important, of course. An important attribute that no one on this forum addresses is people skills. A PMHNP must have excellent interpersonal skills when working with people who have mental health issues, and the ability to collaborate with therapists and social workers, as well as primary care.

My goal is outpatient only. I am very interested in the issue of comorbid mental and physical disease and I deal with this a lot in my current position. Personally, I would say my experience is far more valuable to a future outpatient PMHNP than psych RN experience (which may be of dubious quality) in a locked ward.

[Oldmahubbard]

My Psych NP experience consisted of a year as a Clinical Coordinator at an assisted living program, a population of 80-90% severe and persistently mentally ill, and the remainder mostly intellectually/developmentally disabled. I made it my business to know the residents backwards and forwards. My role was to identify and address clinical needs. What an opportunity. I was new to the game and soon learned the meaning of the term "word salad". Among a variety of things. I also learned the population was poorly served by local mental health clinics. The position was eye opening to say the least. Unfortunately I was replaced by an LPN. I was devastated because I was learning so much.

Then onto 4 years at one of the aforementioned mental health clinics. As an RN, I diagnosed, and I started verbal therapy while we waited for a provider appointment. The clinic had great trouble keeping any psychiatrist. It was 4 very intense years, I saw 15 patients a day and handled most of the medication problems that occured. Towards the end I was practically running the place after the clinical director left.

I made it my business to get the experience. I did extensive self preparation.

I graduated, got a psych NP job in a forensic setting and stepped right into it with no problem. There was still plenty to learn, but I had no problem knowing who was mentally ill, and who was just looking for a break from prison. 13 years later, I left for a much better paying job.

From my experience in the corrections setting, I would caution any would be Psych provider that many psychiatric conditions can be very difficult to diagnose in an office setting. Mostly because you only have the pt's perspective. People are very prone to omission, they are prone to exaggeration, and quite a few are looking to get drugs or disability.

A quick example. Bipolar pts rarely perceive themselves as having mood swings. In their minds, they are only responding normally to their situation. Other people tell them they have mood swings.

Metabolic syndrome is a real concern with antipsychotics. I have had 2 deaths directly from their effects.

I think it's great you are going on to get your Psych certificate. Just be cautious with the rx pad. Many of your patients are not telling you the full story. And many are really in need of therapy.

[FullGlass, BSN, MSN, NP]

57 minutes ago, Oldmahubbard said:

I think it's great you are going on to get your Psych certificate. Just be cautious with the rx pad. Many of your patients are not telling you the full story. And many are really in need of therapy.

Thank you for your encouragement and words of wisdom. To reassure you, I have a lot of personal experience with the mentally ill, as several of my family members suffer from mental illness. This has instilled a healthy skepticism in me with regard to self-reports. At the same time, I can develop a good rapport with such patients. I also emphasize the need for talk therapy. In fact, for certain patients, I tell them I will not continue to prescribe meds unless they are in talk therapy! I also recognize my limitations and refer complex conditions such as poorly managed bipolar, treatment-resistant depression, and schizophrenia to our telemed psychiatrist for medication management.