FNP in a psychiatric office?

Jules A, MSN · Aug 7, 2015

In my state, there are FNPs working in outpatient psychiatry. It's not in violation of any regulations. What I submit, from experience, is that they can do less. They never do psych evals. They do med checks, and depending on the insurance, they may not be reimbursed at the same rates a PMHNP would be.
However, you'd be great to have around because we could throw the folks that have a thyroid disorder, dyslipidemia, hyperglycemia, obesity, epilepsy, migraines, etc. in your direction. Many of those are caused by our psychotropics. The latter two are frequent in our population.

Its a shame your board of nursing endorses FNPs doing psychiatric med checks on patients they aren't qualified to diagnose. How do they justify making med adjustments?

If you are running an all purpose clinic this would make sense but not if it is a psych clinic. You are fortunate your practice pays you so well if they have FNPs working psych as well as primary care.

traumanightsRN, NP · Aug 7, 2015

This is a wonderful segue into why NPs should have education that covers many fields and maybe a few clinical hours in each setting to see what truly interests them and then go on to residencies to choose a specialty. I know I have lots of interests. I worked in Surgery Trauma ICU for years and am interested in acute care, but I like primary care too which is why I chose FNP. But I also have an interest in dermatology and psych. Would have been nice while in school to get all this education and then choose a specialty afterwards. Just my opinion tho.

Whispera, MSN, RN · Aug 7, 2015

In my last job I was a psych consultant for a free clinic run by FNPs. The NPs were awesome for medical issues, but happy I was there for the psych things. All of them said they just didn't learn psych things in their education and didn't want to risk the patients' health and lives by doing something for which they were not prepared.

We all have our niches. Sometimes we can go a bit past the niches' borders, but no one can do everything. It's good to recognize our skills as well as what we are missing.

Jules, the FNPs that did physicals, where I worked before the clinic job, did them in a psych inpatient setting, not in the outpatient office. It was too complicated to get family practice docs to come there for physicals. The psychiatrists preferred to concentrate on the mental illnesses rather than any other medical issues.

PG2018 · Aug 7, 2015

Its a shame your board of nursing endorses FNPs doing psychiatric med checks on patients they aren't qualified to diagnose. How do they justify making med adjustments?
If you are running an all purpose clinic this would make sense but not if it is a psych clinic. You are fortunate your practice pays you so well if they have FNPs working psych as well as primary care.

No, my practice has no FNPs. There are around 9-10 PMHNPs spread around the state and 2.5 psychiatrists. I'm the only guy in my region so just me and 12-15 therapists. I don't know which are ours or which re contract. The local community mental health, same city but no competition, has some FNPs. The VA hospital has PAs in not only inpatient psych but outpatient clinic. There's such a shortage I suppose they have to hire someone with a DEA number.

Regarding the state, board, I've shared before that their polices are nebulous. In the saying of a former neighbor, they don't know if they're scratching their watch or winding their butt.

PG2018 · Aug 7, 2015

This is a wonderful segue into why NPs should have education that covers many fields and maybe a few clinical hours in each setting to see what truly interests them and then go on to residencies to choose a specialty. I know I have lots of interests. I worked in Surgery Trauma ICU for years and am interested in acute care, but I like primary care too which is why I chose FNP. But I also have an interest in dermatology and psych. Would have been nice while in school to get all this education and then choose a specialty afterwards. Just my opinion tho.

I somewhat concur. I believe ALL NPs should be prepared and licensed to provide primary, generalist care with added training in our specialty. It took three years of full study to become a PMHNP. A year of that was hog wash; write the paper and move on. I couldn't care less that my master's is in nursing - I went to grad school to study the science and art of making sick people better. I think that second year could've been more generalist, primary care oriented. It's so stupid for any political body to suggest that we're trained in only one area as in nothing we do in psych affects the rest of the body and nothing in the rest of the body affects their psyche. Likewise the acute care people need an idea of what it takes to diagnose and treat the random problem like corns or something. So what about the FNPs? Do the same, a year of generalist training we should all be getting followed by a subsequent year in generalist training.

Dogen · Aug 7, 2015

Somewhat off topic, but I went through this last year, and I wish I'd had more generalist training. I got the "3 Ps," a single course each in physical assessment, general pharm, and pathophys. I can confidently do a drawer pull test or check for the psoas sign, but can't treat a cruciate ligament tear or appendicitis. I didn't decide to become an NP to do ortho, but it would be nice to be able to do more primary physical healthcare, especially things that overlap frequently with psych.

Since I'm not an expert, I'll defer to the practicing NPs for the solid advice to the OP, but it seems like there are two scenarios:

1. You're being asked to prescribe psych meds

2. You're being asked to do physical health in a psych setting

Scenario 1 sounds dicey. It's drilled into us that we need both the education and expertise before prescribing, which is why I don't (won't) prescribe abx even though under my license in OR I absolutely could. Scenario 2 seems legit in general, since the inverse happens frequently here (a psych NP practicing in a physical health clinic). People with mental illness very generally have more physical health issues, so it would be synergistic to provide interdisciplinary care in one place. My concern, as a newbie, is that I want to work somewhere I have access to talented, experienced providers within my specialty so I'm not going it alone. So, being the sole psych provider anywhere is not going to be my first step... and presumably the same rationale might apply to other NP specialties.

sailornurse · Aug 10, 2015

I recently was hired at inpatient psych facility to do H&P's for new admits, covering only Axis III diagnosis. Psych issues are addressed by the PMHNP or the staff psychiatrists/therapists. It is my understanding that in my state I can not replace a PMHNP in any setting.

Jules A, MSN · Aug 10, 2015

I recently was hired at inpatient psych facility to do H&P's for new admits, covering only Axis III diagnosis. Psych issues are addressed by the PMHNP or the staff psychiatrists/therapists. It is my understanding that in my state I can not replace a PMHNP in any setting.

I bet they will love having you! This is a great, well rounded team.

elkpark · Aug 10, 2015

I recently was hired at inpatient psych facility to do H&P's for new admits, covering only Axis III diagnosis. Psych issues are addressed by the PMHNP or the staff psychiatrists/therapists. It is my understanding that in my state I can not replace a PMHNP in any setting.

I've worked on units that used this model, and it worked really well.

sailornurse · Aug 10, 2015

Hi JulesA,

The medical director is Adult NP. He is my direct boss, there are 2 other FNP's that cover on the weekends & yes it does make for great team. I am learning tons!!!! I feel as if I'm "peeking over the fence" at psych meds/dx when doing the H&Ps.

Jules A, MSN · Aug 11, 2015

We have PAs at two hospitals where I work and hospitalists at the other for medical management. I'd love to have a good NP.

PG2018 · Aug 11, 2015

Hi JulesA,
The medical director is Adult NP. He is my direct boss, there are 2 other FNP's that cover on the weekends & yes it does make for great team. I am learning tons!!!! I feel as if I'm "peeking over the fence" at psych meds/dx when doing the H&Ps.

You make me think of a story I heard today. I have a newly inherited patient taking 150mg quetiapine tid, and over the past year she's gained approximately 40 pounds and today weighed 114 pounds at age six. Her pediatrician recently "had her tested" for diabetes and hypothyroidism. She's euthyroid, but apparently the glucose and A1c were lost as the mother said the pediatrician couldn't find the results. The patient's mother told me that she asked if medication could be causing her weight gain and insatiable appetite. The pediatrician reportedly replied "No, I don't think anything she's taking is associated with gaining weight." This goes to show that psychopharmacology is a niche field, and most docs don't have a complete handle on it. And that's ok. That's why people like me are here.

The PCPs in this area still love to sling quetiapine and alprazolam. They are the total go to psych meds. And there's almost always a better choice. I'm kind of anti-alprazolam. You can just about bet if you show up to my office taking it, say qid, you're going to leave with one less dose.

Then again, I took over a psychiatrist's practice that used Abilify as a first line everything; sleep, depression, mood, psychosis, anxiety, poor appetite. He even prescribed it totally prn to people - like (I'm not making this up) "take 0.25 - 2 tablets PRN for moodiness."