Granted Fal

My best friend is an FNP that works in the acute care setting, also, primary care is also referred to as general practice and is exactly what you do an you have a general graduate degree in nursing. I'm thinking you have a chip on your shoulder or something and need to re-read the post as those aren't the things I said, but I respect your opinion. Best

A GP, is a general practitioner, aka FNP. They work in general practice settings or acute care as generalists from infant to elderly, etc. Please don't misinterpret what I'm saying, I'm not "bad-mouthing," and it was the MD I was quoting that had no confidence in the NP as a whole, but I have to say I'm also concerned. Read my post again. I love teaching btw and had very good instruction. This leads me to the concern: I'm inheriting cases with very poor care that opens up potential liability for everyone. If you stand behind your work so be it. I'm just finding that there is some significant disparity in the level of care or, more accurately the, Quality of care, that NPs are in general, as the MD referred to, are getting a name for. I'm hearing it from the MDs, whether they are pompous or not, and seeing it for myself first hand. I'm not excusing the MDs in my field either as I've seen some pretty bad care there too. But have to overcome the stigma being set by my cohorts to be taken seriously and be a proponent for my area of practice in the field.

No, but they aren't licensed and can't be independent like an NP. Recognize.

Thanks for the feedback, I'm finding this to be the case as well.

I've been an NP for over 6 years, and an RN over 13

As an NP that currently specializing in psych, i sometimes attend medication marketing dinners and meet with the reps and found it's a great way to connect with others in the field and with networking. On occasion, you get a doctor who has a really negative and pompous view of the NP. The comment was something to the effect of, "I waited three months to see my doctor and it turned out that it was an NP and then I left to find another doctor." Implying the NP wasn't competent. I didn't know whether to really feel offended or not. I've found I have my own biased thoughts to some extent, hypocritically, with reservations about general practice NPs, however, in the psychiatric arena I've seen concerns from both the NP and the doctors. It sometimes seems that doctors often don't seem to know what they are doing either. This is psych mind you which isn't never a "perfect science," and the negative comment above by the doctor was aimed more at general practice NPs. I've found that there are good NPs and bad NPs as well as good and bad doctors. But I have to say in my field with psychiatry, sadly, I've seen more bad NPs. Is it maybe true at least in my field? Not that I'm the best of all or something but I feel like i've been witness to some pretty shoddy care and have to often left to the task of trying to iron it out. For example, multiple antidepressants, serotonin syndrome, multiple antipsychotics, benzo plus a stimulant, numerous med interactions, no labs or monitoring, no EKG in some cases that are critical, very poor history, questionable diagnoses, no patient teaching, etc. Curious to see if any others have the same experience. Please comment. Study your asses off and know your stuff!!!!

Just buy the ANCC book and online review questions. It'll be a snap. Use your test taking skills

Good question. You mentioned several antipsychotics and the benzo ativan. My suggestion is that you put the free ePocrates app on your phone and it has a good interaction checker. YOu can also check interactions on Drugs.com and on drugdigest.com also. Most med interactions come from meds sharing the same enzyme system in the liver that processes them, some inhibit some induce and this can offset other meds unpredictably and sometimes dangerously depending on the medication. Sure, ativan interacts with all of those in terms of sedation but not so much by the enzyme component. The additive effect with sedation is really related to the antipsychotics antihistamine and anticholinergic side effects and the ativan is a CNS depressant. So, that can make you droggy. Hope that helps, RFal

In terms of being a psych APRN, it really depends on the school you got to when you're doing a preceptorship. Mostly the patients love attention from any staff. My suggestion is to work some shifts on a psych unit and get a feel for the atmosphere. It is really about three things, connecting with people, communicating effectively and respectfully, and crowd control. For me that part was no big deal, but it was finding preceptors to help you while you're in school. For RN school the school takes care of the preceptor stuff and you just go do what they tell you to do. For NP school, if your school already has affiliation agreements in place (agreement that your school can send students to their hospital )then it's just making a bunch of calls to find preceptors that are willing to take you. The struggle sometimes is in the stupid policies some facilities have, e.g. the therapy department telling you "all interns have to do a 750 hr block of time, " and you explain, e.g. "I only need 56 hours for this rotation, I'm not an intern I'm a nursing student." Going to different disciplines can be challenging because they aren't nursing disciplines and don't understand what you're doing, and the majority of psychiatrists don't do therapy, esp. in an inpatient setting. So if the school doesn't have affiliation agreements in place then you really have a task to find independent practice people to allow you to sit in, or creating affiliation agreements. Affiliating a hospital could take months and depends on legal dept crap often times and they aren't in any rush to help you out. THis could make or break a semester depending on timing. As far as shadowing, only very few patients typically disagree with that, and if they do, you're better off with that. Most have no problem at all. Be humble and supportive. For what you do for the day: Psych RNs pull orders, give meds and do unit based work. There can be adversity in a psychiatric setting and even violence. By you have to be very attuned to the environment or stuff can happen. Deaths, suicides, self-injury other sentinel events. It can be demanding but rewarding, interesting and exciting work. As an NP you prescribe and give supportive therapy in the psych field. You manage labs and side-effects, you do crowd control sometimes but generally not. I also draw labs, but most don't do that. You never do what the RN does so don't get lost with that idea. Emulate the physician's role. And if you position yourself well and negotiate you can make triple what an RN makes on average. Hope that helps, Best RFal

It's a great plan, you can graduate quickly without too much debt and triple your earnings as an NP, once you have experience and if you're able to travel you can make really good money.

That's true you have a point

Just FYI, There's a book that spells all this out in glorious, but concise detail for all the states: "The Nurse Practitioner's Business Practice and Legal Guide, Third Edition," Carolyn Buppert ISBN: 9780763749330. You can also, of course look at the state practice acts to determine this too.

Zenman, If done professionally and, of course, at the discretion of the patient, 3 won't destroy a therapeutic alliance. But the third party has to also build rapport. This is done best I think in serving in an assistive and supportive way to the clinician and integrating into their practice. In other words the apprentice should know that patient just as well as the clinician and may serve as a liaison in the absence of the clinician. Unfortunately, this rarely happens at the graduate schooling level and you may just sit around doing stuff during clinicals on a unit or in a clinic somewhere in even lesser a capacity than you did as an RN. This is a travesty as you can't learn that way and it sets you up to not be prepared after you graduate. I found that many clinicians aren't vested at all in perpetuating the field by not accepting students into learning roles. However, I think the mentoring or shadowing piece is extremely important in the learning process in too many ways to count and it seems that many states' laws actually may inhibit that from occurring after you graduate. It's more like, "oh, ok, you're a graduate now with no experience, go ahead on and start prescribing now..." Medical interns had to do thousands of hours observing and shadowing during residency like this, why should APRNs be any different?

I would strongly suggest you get some real medical experience, preferably in the psychiatric field, as a nurse before you enter any such program. This will only make you a more well rounded clinician and increase your overall capacity. Frankly, I think it really should be mandatory for anyone that will eventually be dealing with, managing, and prescribing to patients that may also have numerous medical comorbidities. I could go on but I won't diatribe here.

If you're getting the symptoms of burnout: Fatigue even though you've slept for a million hours, Irritablility, Cynicism, Impatience, Indifference, Numb, extremely Low stress tolerance.... etc. TAKE TIME OFF! You'll be back in the game afterwards.

The amazing and unchallenged " B-52 " that's Haldol 5mg and Ativan 2mg works 98% of the time. :zzzzz

I think these posts are really helping, Thanks. I'm feeling more motivated. Especially what jbudd was saying about clearing out the non-essential personnel. I think the last trauma I was primary in must have had 30 people in there.

I ran into a mental health patient that was doing this ( drinking her own urine ) not just because of psychosis but also because she was high in meth. Amphetamines just so happen to exit the body in the urine chemically the same as when they were ingested. So, she stayed with some "meth" on board for 10 days plus, We searched and searched again and finally figured it out.

You've been a tech for 17 years. You are familiar with your environment, take luxury in that. You are learning a new role and you'll get it if you keep trying; Don't give up. Each shift is a learning experience to add to your repertoire. Always prioritize your most critical interventions first. I think your existing knowledge base can be a real asset for you.

I went directly into the ER from RN school and I'll tell you the learning curve is pretty huge. I used to wake up still processing patients in my dreams. sheesh. The place I worked at while in school before the ER only had about 8 employees at any given time and the ER was huge and had about 30 employees. IF you like the ER, I would look into getting a job there as a tech now, like tomorrow. If you want to learn more pathophys and have a bigger grounding in caring for vented and post-op pts and the like then take the floor job. I could never do that, the pace alone -- yikes! As a tech in the ER, you'll have the benefit of being in that environment without all the responsibility and you get to observe the role of the RN and doctor. I would particularly encourage you to get as much tech trauma experience as possible. When you're precepting this will take you lightyears ahead of someone coming cold into that environment which can often be quite intimidating. Good luck ! And looking back, this is what I would have added to my education.

I've witnessed and been part of some pretty hairy traumas that can get disorganized pretty quickly. In part, some can become a symphony of errors often recognized later when you rehash the event. These trials become the common sense of any experienced truama nurse but may or may not be so obvious to others without that same wealth of experience. I'm a novice, less than three-year RN. I find myself in situations in trauma that are seemingly outside my experience and often times, taking into account the trauma docs' attitude and demeanor , can become a real train wreck. :doh: I try not to beat myself of too bad about them... But it's still stressful. Now, before you devour me with the, 'you got no business in there attitude..." I'd like to hear some of the well-earned or well-taught lessons of trauma bay based on experience; The things that may just only have to be learned from being thrown into the fire. :angryfire What experiences may have yeilded new protocols, because when you looked back on the experience with hindsight you knew it could be done better? What are some of the main anticipations and delegations you consider before a particular trauma comes in? I'm eager to hear your stories, and happy Holidays :icon_wink:

Let's put it this way, In a year I've wiped about 4 butts, occasional bed changes when you space out that the 80 yr old hip fracture has to pee every 5 minutes. I now automatically ask for a foley so I don't have to deal, it really eats up time doing this type of care, uh bed baths? never. "housekeeping with a mop to 1414 please...." ER is nothing like the floor.

I was/am a new grad in an ER in Colorado that often sees upto 350 pt's per night, the thing you want to realize is that the ER is also an urgent care center for people that don't have insurance and that the really sick people are probably about 3-5% of the incoming. You won't get shoved into traumas like they shows on t.v. as a newbie and if you do, you'll probably being doing tech scut like IV's foley's etc, which the experienced RN's do anyway. It's basically alot of IV's and IV med pushing, so knowing your meds is crutial. I had a really rocky start with a moody pregnant preceptor that wasn't reliably there, as a result I got shuffled around and got to see many approaches. The thing to focus on, depending on your ER is what is their goal? PT satisfaction? Throughput? etc. All I really care about is pt care so I try to provide the best I can, if a Dr. reams you for spacing out on labs needing to be done or you find yourself drowning because you have three ambulances coming in at the same time and you call for a float and no one comes and your tech abandons you or gets pissy with you etc...... then you just realize that all the other RNs are getting screwed the same way... so relax! Prioritize, and if your pts aren't dying, you're doing the right thing.... Seriously though, we have a chest pain center and I do still feel underqualified to be in there with many of the drips we hang, and when the code begins, you'd really like to feel solid, but this comes with experience. I suggest to study your butt off till you feel confident in getting up to speed with the things that come through your station time and time again. I ask and you should ask tons of questions, usually the docs in the ED are really cool, unlike some on the floor I've heard, and they'll tell you where they are going with their tx plan. Some don't, but oh well.... I like best the autonomy and the fast pace. So if that scares you, it should..... hope that helps.

Are there any independently practicing psych CNSs out there and what is your practice like. Do any psychiatrists employ you? Any input is helpful. Thanks.

I'm glad you like the post, and boundaries are a huge issue.