FNP in a psychiatric office?

Jules A, MSN · Aug 11, 2015

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."

Don't ya love when it goes south with the PCP and now its time to "consult a specialist"? I see it all the time and what sticks out to me in addition to the less than subtle hint of malpractice in continuing to prescribe that much seroquel to a 6yo with no clue that it is notorious for significant weight gain and metabolic effects is that unless this kid is a neuropsych patient WTH are they getting that much of an antipsychotic for? Aggression, trauma history, ineffective parenting? Without ever laying eyes on this child I would be my license they have neither true Bipolar or Schizophnrenia so again whats the indication for a dose of that magnitude? Last I checked it wasn't FDA approved for behavioral disturbances in children in fact, from: http://www.fda.gov/downloads/Drugs/DrugSafety/ucm089126.pdf

"It is not known if SEROQUEL is safe and effective in children under 10 years of age."

While I'm not against trialing off label use if other avenues have been exhausted I'm normally reluctant to take that plunge with children unless as previously mentioned there is a neuropsych component. I would certainly not endorse a GP to attempt it especially when there are so many other medications that have FDA approval to trial first. It used to make me sad but after seeing it so often over the years now it just disgusts me.

Joebird21 · Aug 11, 2015

So if an FNP does one those one year "residency/fellowships" in psych will that be viewed as an OK replacement to the pmhnp cert.?

Will most state BON be OK with a residency trained FNP working in an PMHNP role?

harmonizer · Aug 11, 2015

So if an FNP does one those one year "residency/fellowships" in psych will that be viewed as an OK replacement to the pmhnp cert.?
Will most state BON be OK with a residency trained FNP working in an PMHNP role?

Joebird21, it does not make any difference. The states (OR, WA,MD AZ, IA and etc) that needs certification to practice in certain specialty will continue to require it. It may just give you peace of mind in the other states in term of practicing within the scope b/c of some verified training.

Why do we need to make things more complicated? There are post-master/post-DNP PMHNP out there that people can enroll so that credentials will be accepted in every states. Creating residency for an existing established specialty unnecessarily complicates the issues. I do not understand the point of this. I think the profession would benefit more in term of post-grad training to further specializing skills of PMHNP eg. psychotherapy, substance abuse, DBT rather than this residency idea.

Joebird21 · Aug 11, 2015

Yeah that's what I was confused about. Why do they even have psych residencies that are open for FNP's to apply to. I'd rather just do an additional cert.

JustKeepDriving · Aug 11, 2015

There is an FNP that was recently hired onto one of the inpatient psych units where I work (never worked psych before, I think she came from a primary care clinic). She was originally hired to help the residents manage acute and chronic medical problem on the tiny memory care unit (which would have been awesome). I work this unit a lot and the last time I was there, we had a patient on aspiration precautions that had developed a new onset cough and was agitated and confused. I did my assessment and asked her to come check him out. Her answer, "Not my patient" (Okay, this in and of itself is a huge pet peeve of mine - I'm new to this facility and never worked in a place before where my providers would have said this). Turns out she is carrying a psych caseload and spent most of the day on the computer and calling residents trying to figure out how to titrate risperidone for a patient with kidney/liver dysfunction. She was hired because a lot of the residents and psychiatrists are uncomfortable dealing with the medical problems - this is a geriatric population and a lot of the medical issues can mimic psychiatric problems or exacerbate psychiatric problems so you have to be able to manage them. However, she is currently not doing what she was hired on to do. I don't understand why she is carrying a psych caseload and managing psych meds instead of managing the medical problems like the facility promised.

If someone wants to work psych why wouldn't they specialize as a PMHNP or get the additional certification? As a Psych nurse working on a unit already crowded with "learners" it just adds more stress to the job. So right now instead of having an awesome FNP helping the Psych residents with the medical issues - we have Psych Residents that although decent in psych, are uncomfortable with the medical issues trying their best to manage them and an FNP that has no experience in psych - trying to manage Psych patients. I don't get it.

Having an FNP in a Psych facility to help with the Medical issues and physical assessments is great - my old facility worked like that. Having an FNP in a Psych facility trying to manage complex psych patients and psychopharmacology? As a generic psychiatric nurse floor staff seeing this happening on one of the units I work on... JMHO its all bad.

PG2018 · Aug 11, 2015

Joebird21, it does not make any difference. The states (OR, WA,MD AZ, IA and etc) that needs certification to practice in certain specialty will continue to require it. It may just give you peace of mind in the other states in term of practicing within the scope b/c of some verified training.
Why do we need to make things more complicated? There are post-master/post-DNP PMHNP out there that people can enroll so that credentials will be accepted in every states. Creating residency for an existing established specialty unnecessarily complicates the issues. I do not understand the point of this. I think the profession would benefit more in term of post-grad training to further specializing skills of PMHNP eg. psychotherapy, substance abuse, DBT rather than this residency idea.

I agree with you. If NPs were educated as PAs (generalist model) I would see the point of a residency, and in that instance it's a great idea. PAs have a lot of them. However, with nursing, ANCC, et al with their specific requirements the residency model doesn't make sense. If one completes this, say a Peds NP, is s/he then eligible to take the ANCC PMHNP exam?

FWIW, nursing has too many convoluted points of entry.

1. LPN

2. Diploma RN

3. ADN RN

4. BSN RN

5. MSN RN

6. Direct Entry MSN/RN-APRN

7. MSN-APRN

8. DNP-APRN

9. Residency? What the hay?

Guess how many ways there are to become a physician? Dentist? Podiatrist? Pharmacist? Even veterinarian?

sailornurse · Aug 11, 2015

The local university offers a 15 or 18 month program to get the PMHNP. One of the faculty holds both PMHNP & FNP which indicates there are differences & No you can not assume if you are FNP that you have the knowledge base for psych NP. She was one of my students as as PsychNP for the advance assessment course. As someone mentioned, nurse practice act may be silent on some issues ( does not say you can do something but it does not say you can not) . In our local NP group we have discussed Acute Care Gero NPs doing paps. Are they "trained" ? meaning was it part of the basic education? BON had an algorithm to help people understand but unfortunately unless some one is reported to the BON they might continue working out of scope until they are caught of bad outcome occurs.

Jules A, MSN · Aug 11, 2015

BON had an algorithm to help people understand but unfortunately unless some one is reported to the BON they might continue working out of scope until they are caught of bad outcome occurs.

The million dollar question is do we start reporting them? I have not ever done it but it is tempting especially when I see some of the medication regimens that are horribly inappropriate.

In addition to the BON I would imagine medicare or medicaid might not think it is cool being billed by a practitioner who is actually practicing outside of their scope?

Your thoughts?

sailornurse · Aug 12, 2015

The million dollar question is do we start reporting them? I have not ever done it but it is tempting especially when I see some of the medication regimens that are horribly inappropriate.
Your thoughts?

It would be good to talk to each NP individually then chain of command. It might be forced to go to BON for final decision but we have to advocate for patients. It's possible to get caught in the crossfire if their is bad outcome and investigation or lawsuit results. It comes down to being a profession that is responsible for monitoring our selves and yes report. And no before anyone says it, this is not a TURF issue, it's a scope of practice issue & again patient advocate for best care possible following current clinical practice.

PG2018 · Aug 12, 2015

My state has an algorithm to aid in decision making as well. Like most publications they produce, it is exceedingly vauge.

Take suturing as an example. In my advanced health assessment practium course there was a "skills day" that included everything from doing pelvics on anatomical models to suturing. So one day, we had university-sponsored suture training. It lasted maybe two hours and was actually pretty good albeit cheesy. So according to the vague algorithm I have been formally trained. I have sutured as a RN (not out of our scope in my state), but at that time I'd never really been trained to just witness to a thousand different throws. It's a skill considered to be in the scope of NPs. However, it has nothing to do with psychiatry, but is it in my scope? I couldn't care less really. It's an example. I'm pretty sure the board would crap a brick if I started taking walk-ins that needed sutures in my psych clinic. They'd find it out of my scope no doubt. However, based on their algorithm it technically is in my scope, and I've met all the required criteria to do it. I've had precepted training in lido, lido-epi, bupivocaine, LET, etc, and have observed their use in scores of people. But those agents are not psychotropics, and I've certainly never given lido injections. So anyway I'm losing my train of thought here and am just rambling during a cancellation. I continue to be perplexed as to how and why the state nurse board regulates APRNs. I think it's tomfoolery to have LPNs and RNs judging APRNs. The state medical board regulates RTs and OTs here. Do you think the RTs are on a board judging physician action? Heck no.

Dogen · Aug 13, 2015

In Oregon the OSBN executive council includes one APRN, and because she's an FNP they bring in a consulting NP if there's a practice question or investigation of any other specialty.

The full board still votes on investigations, though, and it includes two staff RNs, a CNA, an LPN, a nurse administrator, and two members of the public. So, assuming we had extremely clear scopes, which we don't, only 1 out of 9 board members would have any idea.

That's why the APRN board member is on my Christmas card list.

Chocolate_RN85 · Aug 15, 2015

Love this topic! I always asked if as a FNP I can work in a psych office , I just did not want to focus my specialty only on psych , just in case I get bored I want to try something else!