New grad of PMHNP. Is this a typical first job experience?

Oldmahubbard · Jan 25, 2018

Are you concerned specifically about diagnosing on your own, or prescribing, or something else?

It doesn't surprise me too much that a new grad would be expected to function, right out of the gate.

Jules A, MSN · Jan 25, 2018

I started on an inpatient unit as the only attending and this was how it was also. I got keys, a prescription pad and 2 hour introduction to the EMAR. Fortunately I had a strong inpatient psych RN background so it was a comfortable environment except the pucker factor every time I ordered a new med or had to decide what to do with wonky labs.

If you are having trouble with the charting or orders the nurses and help desk are invaluable. If however you don't know what you are doing with regard to managing an inpatient milieu you need to get out. That is not the environment for an inexperienced NP in my opinion. Do you have psych and more particularly geri psych experience? I have worked with many gracious psychiatrists but none has had time to take someone from zero to sixty for free all while managing their own patients.

Oldmahubbard · Jan 25, 2018

I started on an inpatient unit as the only attending and this was how it was also. I got keys, a prescription pad and 2 hour introduction to the EMAR. Fortunately I had a strong inpatient psych RN background so it was a comfortable environment except the pucker factor every time I ordered a new med or had to decide what to do with wonky labs.
If you are having trouble with the charting or orders the nurses and help desk are invaluable. If however you don't know what you are doing with regard to managing an inpatient milieu you need to get out. That is not the environment for an inexperienced NP in my opinion. Do you have psych and more particularly geri psych experience? I have worked with many gracious psychiatrists but none has had time to take someone from zero to sixty for free all while managing their own patients.

Yes, I had enough RN experience that I was fairly good to go from the first day. I was fortunate in that the pace of the work at the forensic was not too hectic, and I could look things up as needed.

Geriatric Psych is quite problematic on many levels. The most common diagnosis there is probably "dementia with behavioral disturbance", or something along those lines. The patients have been admitted because they were doing poorly at home or in the SNF. You will be expected to prescribe off-label, FDA black box warning with antipsychotics for dementia patients, etc,etc. The patients will have multiple medical comorbidities.

This is possibly too large of a can of worms for a new grad without real support.

Jules A, MSN · Jan 25, 2018

Geriatric Psych is quite problematic on many levels. The most common diagnosis there is probably "dementia with behavioral disturbance", or something along those lines. The patients have been admitted because they were doing poorly at home or in the SNF. You will be expected to prescribe off-label, FDA black box warning with antipsychotics for dementia patients, etc,etc. The patients will have multiple medical comorbidities.

Agree 100%. This is a challenging population. The drug:drug interactions alone are enough to make my head spin. In my opinion this specialty requires significant training and experience to manage safely and effectively. Hopefully OP is aware there are no medications with FDA approval for behavioral indications in dementia.

Oldmahubbard · Jan 25, 2018

This population, and the dementia diagnosis itself wasn't even covered in my graduate program.

I encounter it daily in my role as a consultant at various SNF's in the area. The situation has typically been grossly mangled by various PCP's, and the patient has ended up on as many as 6 different psychotropic drugs, all usually at very small doses. Because everyone is afraid to prescribe and they don't know what to do. So they add a pinch of this and that.

Step one, reduce polypharmacy, rule out medical causes to the best of your ability, contact family and SNF staff for a good history, and establish reasonable goals for treatment. Consider risks and benefits. Verbal aggression doesn't warrant antipsychotic use in most cases.

That being said, I have treated a number of patients with dementia who remain ambulatory and are persistently aggressive, repeatedly assaulting other residents. Family members are begging me to" do something", and in cases like that, I do.

In my experience, treatment for aggression is fairly effective. Again, it is off-label. Black box warning. Everyone has to be on the same page. Health care proxies have to be notified. Potential side effects need to be communicated and documented.

Some of the pts at a Geri Psych unit will have a history of mental illness, often since they were young adults. Again, the history is essential. Good luck actually getting any previous records, though.

You will need to find out what the person has previously responded to, and consider their current medical problems in prescribing. Risks/benefits.

That is it in a nutshell.

katprit80 · Jan 25, 2018

Hi. I do have RN psych experience but with pediatrics. Yikes!

Oldmahubbard · Jan 25, 2018

Well, I am a stranger and this is the internet, but you are probably in over your head.

I had 5 years of outpatient psych clinic experience, some of which was quite intense.

chiromed0 · Jan 25, 2018

I am not PMHNP but to just comment on general as a newby (kind of). My first NP job, I was there 1 hour, handed a laptop (no training on EMR), and told "go see patients, you know what you're doing". Okay, so I did know but in the beginning nobody knows if they "really" know what they are doing. Odds are you are fine, know enough, and you are just wanting reassurance. Unfortunately, I don't think there is much of that in "provider land" in most jobs. So, yes, it probably is typical, not unique to PMHNP, and as my wife said, "When you make six figures or more they expect you to walk in and do the job otherwise they would have hired someone else". She's got a point. It's not the best way to "on board" someone but feel some confidence that you DO know enough to do the job, maybe not as well as a seasoned provider but you do belong, you are capable, and you will survive. Just know you are not alone in this adventure, still reach out to find a confidant (even someone not a provider but can guide you to right people/process...you'd be surprised who can help you), and take it day by day for your first year. Good luck.

Oldmahubbard · Jan 25, 2018

I am not PMHNP but to just comment on general as a newby (kind of). My first NP job, I was there 1 hour, handed a laptop (no training on EMR), and told "go see patients, you know what you're doing". Okay, so I did know but in the beginning nobody knows if they "really" know what they are doing. Odds are you are fine, know enough, and you are just wanting reassurance. Unfortunately, I don't think there is much of that in "provider land" in most jobs. So, yes, it probably is typical, not unique to PMHNP, and as my wife said, "When you make six figures or more they expect you to walk in and do the job otherwise they would have hired someone else". She's got a point. It's not the best way to "on board" someone but feel some confidence that you DO know enough to do the job, maybe not as well as a seasoned provider but you do belong, you are capable, and you will survive. Just know you are not alone in this adventure, still reach out to find a confidant (even someone not a provider but can guide you to right people/process...you'd be surprised who can help you), and take it day by day for your first year. Good luck.

Definitely a lot of truth here.

I would also recommend the Integrated Textbook of Geriatric Mental Health, and similar titles, available cheaply used. It's a couple of years old, but still relevant. It didn't provide instant answers, but did make me feel more confident when I first started working with the population.

Regarding NP scope of practice, it's astounding to me how many people seem to think that Psych NP's, in particular, only have the easy patients, or that they are just refilling scripts for the physician, and that it doesn't really require that much independent knowledge or judgment.

Or that we only use simple pre-scripted protocols. Or that we only can practice if a physician is present in the building.

Of course, none of this is true.

Good luck to the OP.

Jules A, MSN · Jan 26, 2018

as my wife said, "When you make six figures or more they expect you to walk in and do the job otherwise they would have hired someone else".

Excellent choice in women. She is spot on here and while I felt it was a bit of sink or swim I understand and appreciate the rationale.

It's not the best way to "on board" someone but feel some confidence that you DO know enough to do the job, maybe not as well as a seasoned provider but you do belong, you are capable, and you will survive.

I disagree that we can confidently say they "DO know enough to do this job". I don't think we have enough information about the OPs skill set or their clinical experiences to make that call. What I do know is they only have peds psych RN experience which is almost all behavioral. I suspect even a garden variety inpatient adult unit would be a major challenge unless they spent a large portion of their clinicals there which would be rare as most psych clinicals are OP. In my experience inpatient geripsych is no place for a new NP without significant experience with this population, a solid medical background and a supportive psychiatrist on the unit.

redbullz9 · Jan 26, 2018

This is a classic example of the **** mentality in America. You have a theoretical background and apparently no actual experience as an NP yet you're expected to 'figure it out'. Of course to really know how to practice medicine, which is what you are doing, you'd need actual training like a residency or an apprenticeship of some sort with a more experienced NP or MD. Most MD's would be completely clueless in your situation. You are basically a first year resident-intern, green behind the years, but without the benefit of the formalized training program that exists for MDs- the residency.

Your best bet is finding another job where the supervising MD or NP can take you under their wing and provide you with some informal training for the first year or so. Or finding a residency /fellowship for NP's...which are hard to come by. Your last option is just taking patients and seeing what happens....could be fine because everybody is too busy to notice if you screw up, could be bad if you really screw up and somebody gets hurt or sues.

Hopefully it all works out. Great thing about psych is providers (even inexperienced ones) are so in demand that chances are you'll find another job even if this one does not work out. If that happens, make sure to emphasize that you are looking for a situation where you will receive some mentorship from a more experienced practitioner , during your next interview, even if it means you negotiate yourself into a lower salary until you learn the ropes.

Your current employer has basically screwed you by failing to appoint someone else to oversee you as a brand new grad, after your regular supervisor got sick. Speaks more to their organization and willingness to invest in their employees than to your abilities as a new NP.

Basically, it's not your fault-the system is ^^^^-ed up. Sorry you're having to deal with this non-sense and good luck.