catch33er

Thanks for your input/opinions. I am finding, in several different types of patients, that at first I took on too much and overstepped my scope of practice. I am really backing off now, and being better able to tell patients they need to see someone else. I'll do more investigation for resources, but have been told, again and again, that there's nothing around for these people. It's really sad to see how much this is ignored. This is what I come to this forum for. I really appreciate the information.

The problem is that there is no psychiatrist (or psych NP) to treat them. Do I just send them out the door? Most of the time I am not starting new medications, but adjusting doses. I do not want to do psych, but it always seems to find me...

I am a family NP in a pretty large community health clinic (10 MD's, 2 NP's). We're in a pretty rural area, at least four hours away from the nearest major metro area. I see between 18 and 28 patients a day, and I would say that at least 25% of my patients a day are actually in for mental health concerns. We have one psychiatrist in the area, who doesn't take the Medicaid most of my patients have, doesn't take the disability insurance, and will not see anyone who is self pay unless they come up with the initial visit up front (at least $300). The mental health clinic we did have, staffed with at least one psychiatrist and numerous psychologists, apparently imploded a few years back because of poor management. I spend more time with these patients than I should (try 15 minutes for a suicidal teen:angryfire), end up prescribing meds that I'm not really comfortable with, and now the one psychiatrist's office is sending their patients to me for primary care. I have talked to the other providers in my office about how much they're doing, and it seems that they tell these patients "sorry, that's not my specialty." Meanwhile, these people are suicidal, depressed, bipolar, even schizophrenic and not getting any help at all. What is your experience? Do you find that it's better to try (I stick with depakote, lithium, tegretol, and very little in the atypical antipsychotics) than to leave it alone? Or am I exacerbating the problem by trying at all? I have a lot of mental health background just from experience with family and friends (how do I learn not to attract those people :trout:!?!), but I am definitely not trained for this. I'd love any input. I have actually thought of trying a distance psych NP program (I'm a pretty new grad, though, so probably wouldn't do that for at least two or three more years).

thank you so much for saying this! i had several years working in women's health care before going to school, and i am very comfortable in primary care working with family planning, gynecology, etc. this has given me a base to start with, and now i'm getting better at psych, hypertension, derm, and all of the other things i come face to face with every day. i have a new coworker who was an icu nurse for many years, and i do go to her, as well as to the physicians i work with, for assistance on the more complex patients. but she comes to me for help with several things as well. we all bring different strengths to this career, and we have to make room for all, as long as the quality of our care remains solid. that must remain the bottom line. i went into this to deliver the best care possible to my patients, in partnership with other health care providers! administrator note: edited out reference to de

I have always had one area of confusion about the "a fertilized egg IS life" way of thought. There are times when an egg is fertilized, but due to the timing of its fertilization (e.g., it's too low in the uterus), by the time it's ready for implantation a few days later, it's already "fallen" out of the uterus. Is that an abortion? Also, if you take any NSAID (ibuprofen, celebrex, naproxen, etc.), it can have the same effect as Plan B - decreasing the chances of implantation of a fertilized egg. Does that mean NSAID's need to be controlled/labels added? I am very happy Plan B will be available, but sad to know how many pharmacists will probably not stock it. For those in small towns, it may be just as difficult to get Plan B as to have access to a reliable birth control method.

Hey, TB - congratulations on coming so far! I graduated in 2004 from Vanderbilt's direct entry program, and did have to work as an RN (364 hours) before sitting for the certification exam. That is a state requirement in Oregon. The only place I seem to get questions about my doing a direct entry program come from other nurses, especially on this forum :chair:. Once I was able to get my certification and started looking for work, the distinction of having done a direct entry program seemed to disappear. I was considered a new NP, and compared with other new NP's, whether or not they had RN experience. I was offered jobs by both of my first interviews, and both organizations seemed to understand my capabilities as a new NP. I do not feel that to do primary care you need a lot of RN experience. I would not even dream of trying to be an NP in an ER, or an ICU. For those positions, I would much rather have years and years and years of RN experience. Many of my classmates were able to find jobs right after graduation, and in positions where there was an understanding that they would take some time to really get on their feet. I'm sure that having lots of RN experience would help with some of the initial jitters, and there would be a better grounding of understanding of the use of certain medications, but I feel that I am as capable of being a good NP without that experience. I am sure that there are great NP's who did not have a nursing background, and some lousy ones who did. I think it depends on the person, on motivation, and on having the right environment to nurture your growing skills. I am bothered and hurt by the backlash against direct entry NP's, but I try to ignore it as much as possible. Best of luck! :w00t:

I graduated from Vandy in 2004 as an FNP from their bridge program. My background had been in many different areas of women's health - infertility to family planning to gynecologic oncology, from front desk to rooming patients/assisting with procedures, etc. I have mixed feelings about the program, although I do feel I was fairly well prepared and am now working at a job with a loan repayment program. I live in Washington state, and not many people know about Vandy's program, but the name sure carries some respect! While I was in Nashville, I did hear many negative opinions about Vandy's program. There seems to be several problems, from resistance to the "direct entry" idea, to feelings that the program moved too quickly to possibly cover everything. Nashville has so many different NP programs, as well as PA programs, that opinions abound. I was shocked when I started the program at how little "real world" experience my classmates had. I am an older student, and there were students who were not even finished with college (Vandy accepts their own undergrads after three years in a special program), as well as several who were straight out of college with no background in human services. Also, the classes for the "direct entry" program are getting larger and larger every year, and it begins to have an almost "puppy mill" feel - they're accepting more and more people so they can say they're one of the largest programs. Not always the best thing. I graduated, and moved back to Oregon, where I was required to work as an RN for 364 hours before I could sit for the certification exam, so before working as an NP I did have experience as an RN. This did help, but I do not feel it was absolutely invaluable for me. The program is fast, and the work is hard, and just like everything, it is what you make out of it. And don't worry about the loans. It is expensive, but the potential is so good that it's totally worth it.

Whoo-hoo!!!!! I would love to see a program like this! Fantastic idea... I am very fortunate to have a first job where I have several family practice physicians and an NP who are extremely supportive of my learning curve, but it is so frustrating spending time looking up anatomy, etc. I am now to the point where I don't have to ask questions more than three times a day, but it's so hard waiting for other providers to help me when I need them. Full-time internship would have been so helpful, rather than making my first job out of school pay for my learning. I think this would also be a huge selling point for that type of program. I'm sure there'll be flack for the idea of taking the nursing out of things, but all the theory can get pretty bogged down. I didn't feel like I was really making any headway in my program until I started my clinicals!

If estrogen is the problem both with thrombosis and with most seizure controlling medications, her only option would be a POP - progesterone only pill, which has its own limitations, and must include counseling about same time daily dosing, etc. And the previous poster was right - it might be a "counseling" type question - why do you particularly want to use the pill, why not DMPA, an IUD, condoms.... And I know you can find the answer about Parkinson's - its diagnosis is confirmed with a trial of this medication..... Good luck.

I am a FNP who went the direct-to-NP route, but lived in a state where I had to work as an RN (364 hours) before I could be licensed as an NP. I gained a lot of good experience (in an urgent care) and ended up staying for six months. Many of my classmates did not do this, and are still practicing as very good NP's. The point that I want to make is my concern for the disdain that seems to come across in several posts and comments from students in direct-to-NP programs for the bedside RN role. The role of the NP would not even exist unless there had been excellent nurses who had pushed for more autonomy based on their experience as a bedside nurse. Even if we personally are not required to have RN experience, the jobs we do are because of the medical community's exposure to and subsequent trust of the nursing profession. If we do not show that same respect for our bedside RN counterparts, we are not showing ourselves in a very positive light.

I am so sorry that is happening for you. That exam is so painful I can't even imagine how you must feel. If you continue to have problems, check with the computing center where you took the test. They may have had a computer glitch... I'll be thinking about you!

I Just graduated in August 2004 from Vanderbilt's FNP program. They do have a CNM/FNP program and my classmates who graduated with CNM's are working all over the country. The CNM/FNP works by doing the CNM part first, which ends in December, and adding another semester or two to do all of the FNP preceptorships and coursework. Vanderbilt was not difficult to get in to as far as I could tell - it seems like they're accepting larger and larger classes each year. And people who already have their BSN's seemed to be in greater demand than the "bridge" folks. The CNM program is very good and very well respected... Also, I think a lot of MD's, etc. hear the word midwife and think only of lay midwives, and I know there is a lack of respect in the medical profession for that field. I'm on the West Coast (aka the "Left Coast" ), and midwives are very, very popular here (both kinds).

I graduated last year from a "bridge" program (Vanderbilt), where I entered with a bachelor's in biology and came out with an RN, MSN, FNP. This question has plagued me throughout my education and to today. I am six months into my first job as an FNP, and some days I think more experience as an RN would help me, and other days I don't. The main time I feel it would help me would be in the coordination of care and how different specialties can fit together. I still get paranoid when I call the ER to let the charge nurse or MD know I'm sending a patient. And there was no way a program can teach that. I moved back to Oregon, and there is a rule through the BON that a graduate of a "bridge" program could not be licensed as an NP in the state without working as an RN for 280 hours. After graduation, I worked at an urgent care as an RN for six months before starting my current NP job. There were definite advantages to that exposure, and at times I wished I would have gone the slower way - 2-year BSN, then 2-year master's, if only for the ability to work while doing the master's in order to have less student loans. I think this is an extremely personal decision, and I don't believe there's a definite right or wrong answer. I had several years experience working in medical offices as an assistant and as a family planning assistant in a women's clinic (like a CNA but not licensed :uhoh21: ), and felt like I had good patient contact, advocating, and medical experience. Some of my classmates had no experience with patients and made horrible and insensitive errors.

Peglu - I know just how you feel... I graduated August of 2004, and even at the end of my program I was still presenting every single patient. I've been in my first FNP job for six months now, and it has taken me quite a while to get the confidence to stop doing that. You say your brain shuts off, but I'm sure it doesn't - sounds like you're doing your thinking out loud when you present to your preceptor. I find that I still do the same thing with my complex cases, and I find that I do know the answers to my own questions! You are at a tough part of the learning, and you will get through it. The easy stuff - allergies, colds, strep throat, will start getting much easier and you'll feel less need for help. It really does happen. I didn't believe it ever would, but it does. Best of luck and keep at it! It's a wonderful feeling to really be out there practicing... catch