PsychiatricNP

This is the exact same thing that I have heard from PA colleagues countless times. In fact, earlier this year, in one of the facilities that I work in, they reassigned the PAs working in the psychiatric emergency department to other units because the medical executive/credentialing committee felt that PAs lacked the appropriate training to work in psychiatry. The two impacted PAs both said that they wished that they had pursued the PMHNP route rather than PA route (in this organization NPs have a higher pay band than PAs, they can take call and have admitting/discharging privileges).

Hi hbbenton - I have to let you know that I am feeling particularly disenchanted with working as a psychiatric nurse practitioner today, so know that my response may be a bit jaded by this :) In terms of pursuing nursing school while attending graduate school for your MSW…one word - IMPOSSIBLE. Seriously, you will be completing at least 16 hours per week of practicum placement hours every week for at least 4 semesters in your MSW program…attending nursing school is just not possible. I notoriously stretch myself way too thin and I couldn't even manage that…there aren't enough hours in the day. I would recommend completing your MSW and practicing as a social worker for a year or two. You could potentially work part-time as an MSW while you attend an associates/BSN program (I did this). You will have to find a way to balance class time, clinicals, homework and working, but I am proof that it can be done. If you enjoy mental health practice and feel that psych/mental health is the right place for you and you get through nursing school and work for a bit as an RN, then I would suggest applying to a PMHNP program. You could likely continue to work part-time or full-time as an MSW or RN while you complete a PMHNP program full-time (or potentially part-time). I personally worked full-time in a very unique role that utilized both my RN and MSW providing psych consults in a large hospital system and worked nearly full-time during my PMHNP program. My PMHNP program was hybrid requiring on-campus (out of state) visits regularly. My work schedule was very flexible (it was in a hospital and the psychiatry service provided 24/7 coverage) and my PMHNP clinicals were also flexible. I was fortunate that I had very supportive employers, preceptors and family to get me through the program. Again, I really suggest spending some time in mental health first before committing to the PMHNP route. Most days I am really content with my career choice/path, but recently I have been increasingly disenchanted with psychiatry. Nearly every patient I am encountering is medication seeking / addicted to a benzodiazepine or stimulant and isn't willing to consider non-psychotropic treatments that might have a healthier, longer lasting positive impact on their mental health. Few are interested in diet changes, sleep hygiene, exercise, meditation and instead want to know if I can give them more/another/a different/extra/stronger medication…it has become exhausting and disappointing…at least as an MSW I could engage the patient in therapy, encourage change, provide tools and then refer to psychiatry when the patient wasn't interested in doing the work anymore. Ultimately, I would recommend spending some time working as an MSW and then decide if nursing/PMHNP is right for you. Remember, before you can become a PMHNP you have to become an RN (and do the clinical work associated with this). The market is really good for LCSWs right now and wages are quite high (at least in my area). Best of luck to you!

In my PMHNP program we were required to take the same pharmacology course that all NP concentrations took (FNP, WHNP, ACNP, etc.) and then also took a specific psychopharmacology course. Both were required to graduate.

Thanks for the suggestion. Proliability = Mercer…I most recently attempted to take out a policy with them (because their rates are great)…but they won't write a policy if you practice (any speciality) in a correctional facility. It looks like my only options are NSO or medical protective.

I hadn't heard of them either. An FNP friend recommended them to me - she has been with them for several years. My current rate continues to climb each year (never had a claim against me or my policy) and I had one insurer who wouldn't issue a policy to me because I spend part of my time practicing in a correctional facility. Medical Protective's quote was about $400/year less than NSO. S&P rate Medical Protective with the highest financial strength rating (higher than NSO/CNA) possible. Any other experiences would be appreciated!

Does anyone have any experience with Medical Protective (Medical Protective - The Leader In Healthcare Malpractice Insurance) malpractice insurance?

This was similar to my most recent interviewing experience. I interviewed for an inpatient position and it was a two day long experience. I interviewed with physicians, NPs and PAs within the medical group at three of the hospitals in the area that the medical group practices in. I had several interviews with administration (chief medical officer, CEO, CNO, chair of the department, practice administrator, practice manager, human resources/recruiter). This process spanned over a two day period and provided me with an opportunity to visit most of the facilities within the organization as well as interact with nearly everyone that I would be working with, both directly and indirectly. It was the most comprehensive interview process I have had - and I am really glad that the organization arranged the interview process this way. I wasn't ever interviewed in a group and I felt that each interview had both a formal and informal component. When I accepted their offer, I felt like I was making a well informed decision about the organization and the people that I would be working for and with.

I have a couple of different thoughts about this. After I graduated from my NP program (outside of my home state), I already had several jobs waiting for me (in my home state), so I can't say whether or not the school that I attended mattered. Several months ago I decided to look for a position outside of my home state and found that the NP program that I attended did matter, at least to some degree and mostly to physicians who were involved in the interview and hiring process. There were several occasions during the time period that I interviewed at multiple organizations, when I had an interviewer comment that they had completed their residency/training at the school I had attended or had a colleague that had trained at the same school. I attended a flagship, public/state institution, home to the state's only medical school. From talking with colleagues, I have found that (because the hiring of NPs is often physician driven) the NP school that you attended matters only in so much as whether or not a medical school is housed within the same university system - and it doesn't necessarily need to be a high ranked medical school. I ultimately took a job with the organization that had the medical director that had completed his residency at the same school that I did my NP program at - in part because I had some indication of his approach to practice might be similar to mine because we had been educated in the same system/climate. Hope this helps!

You might take a look at University of New Mexico's DNP program. They have developed their DNP program for Nurse Executives and it is completed entirely online. In fact, it is not open to advance practice nurses for admission. When you completed a online program at UNM, I believe that you pay in-state tuition. It might be a good fit for your professional objectives. Here is a link to the program: Program Overview :: nursing.unm.edu | The University of New Mexico

I currently practice in a number of different settings: acute inpatient, correctional, emergency department and have a small outpatient private practice. The environment that I feel safest in is probably the correctional setting, I have never been threatened or felt even remotely unsafe. The environment that I feel most unsafe in (though I still feel safe) is in my outpatient office. This is an environment that I have little control over other than use of therapeutic communication and respect when a session escalates - this is pretty rare - with some experience you will have a pretty good sense of when you have "pushed" a patient to his limit - when I see that we are approaching this threshold by watching body language, affect, etc., I start to wrap up the session. I have had a few patients who have left my office upset, but have never threatened me or made me feel unsafe. When I round inpatient and in the emergency department, if a patient is violent and cannot be de-escalated by staff, then I will likely order IM Haldol/Geodon/Ativan/something to calm the patient. Most times, when staff who have mental health experience approach the patient they can de-escalate the situation without meds, this is usually not the same for the average ED nurse (no offense intended, we all have our talents). When I am on the unit, I can also count on the experienced MHTs to control the milieu and intervene before a situation becomes dangerous to other patients or staff. I sometimes find that the MHTs are more therapeutic than our unit therapists. The key is ensuring that you are part of a team that you trust to intervene when a situation escalates - this includes MHT/RN/MD/NP/SW/security. An MD/NP who is on the wrong side of the unit MHTs can expect little support during those situations. About examining uncooperative patients - I usually redirect the encounter and remind them that the encounter is their opportunity to get the treatment that they are in the hospital for. If they continue to be disruptive or otherwise inappropriate, I terminate the encounter and move on to my next patient. If I know that a particular staff has a good rapport with the disruptive patient, I might ask them to come in with casually during the first few minutes of the encounter and then drift out. On the inpatient unit, I typically have as much or as little time as I need to evaluate new patients - sometimes I spend 10 or 15 minutes with the patient (if they are uncooperative, sedated, etc.) and gain the rest of the history from collateral sources, other times I spend 50-60 minutes with the patient for the evaluation, especially if they are insightful and can/want to engage in the therapeutic process. Overall, violent/disruptive patients are manifesting maladaptive behavior - our job is to model appropriate behaviors and set limits. I offer respect and courtesy to all of my patients and expect the same in return - if the patient cannot provide this in return, then our job is to set limits and help the patient to learn appropriate behaviors. Just my thoughts - maybe others will chime in.

I echo what zenman has said - make it clear to your patients what you are comfortable doing/prescribing from the onset and don't waiver. My website makes it very clear what my policies and practices are surrounding controlled substances, disability paperwork, medical cannabis etc. If my practice philosophies are not a good fit for the patient, they know this before they schedule an appointment and are free to find a provider that is a better fit for their care. I also outline my approach to treatment in my informed consent that every patient signs to again serve as a reminder to patients as to what they can expect in my practice. I use my state's prescription monitoring program before I ever write a controlled substances prescription (and I also place a copy of this report in their EMR). If an existing patient desires a treatment plan that I am not clinically comfortable with, I provide them with education using current literature and if they are still insistent, I provide them with a referral to a colleague in the community that I am familiar with who might be more comfortable with the patient's desired treatment approach. Private practice is tough, especially without a lot of experience as you mention - hopefully you can develop a network of colleagues who you can run issues by (this has been helpful to me). Best of luck!

I am a PMHNP and am practicing in a number of different environments. I am an attending provider on an acute inpatient unit, have a contract with several correctional facilities, provide services in several long-term care and skilled nursing facilities and have my own outpatient practice. I am generally able to make my own schedule and work as much or as little as I would like to in any given week and can take plenty of vacation. I did not do a loan forgiveness program. Best of luck!

I would say that it largely depends. I started working on an inpatient psychiatric unit as a clinical social worker and continued to work on the unit as social worker while in nursing school. I took a position on the same unit as an RN and continued on the unit until I graduated from my psych NP program. After I graduated, one of the psychiatrists left and I moved into the role of attending provider on the unit and regularly continue to work on the unit admitting, rounding, discharging, etc. with the same psychiatrists who were on the unit when I started five years ago as a social worker. My experience was definitely positive and I am glad that I have had the opportunity to "grow-up" in the same system that I started in with peers that I am comfortable with. I find that I have a positive relationship with all of the disciplines on the unit and that I am well received and respected by nursing (perhaps even more so than the MDs because I understand their role and can be supportive of this). Never have I had an issue with being disrespected by any of the RNs that I formerly worked side-by-side with. The medical director of the unit has been supportive of me and has mentored me as I have opened my own practice. Overall, I have nothing negative to say about returning to the same unit / system as an NP and in fact, I really recommend it - it has been one of the best career moves that I have made.

Hi priorities2 - I have some friends who I graduated with who were interested in doing some psychotherapy and they were able to negotiate the opportunity to have a few patients that they saw for both therapy and medications. One classmate had a specific interest and training in equine therapy. She negotiated with her employer to do equine therapy for 2-3 hours per week, but she was still expected to meet her productivity goals for the practice. My personal interest is in evaluation, psychopharmcology and the use of brief/supportive psychotherapeutic interventions in conjunction with medication management, so I haven't ever asked any of my employers for time in my schedule to carry a therapy caseload. My guess is that I would be told no because it isn't a cost effective use of my time and because all of the settings that I work in already employ clinical social workers / counselors who provide therapy and need to do so to meet their productivity goals. If you consider that the average insurance company might reimburse an agency $50-$75 per hour of therapy versus ~$50 per E/M encounter (depending on coding) at 3-4 E/M encounters per hour ($200 an hour), you can imagine that your employer is likely going to expect you to spend most (all) of your time doing E/M encounters. While I agree that the ideal practice would be for the PMHNP to provide both therapy and medications (and the evidence supports that this produces the best patient outcomes), we have followed the path of psychiatry and have been forced to spend most of our time in medication management because of the demand for psychopharmacologists and the economics of healthcare/managed care. This has just been my experience and you may find an organization that is willing to allow more psychotherapy time, but this may be at the expense of your take home pay (may or may not be important to you).

Hi luckylady5 - I can't speak to the market in the Boston area...but I am both a PMHNP and an LCSW. I never had an issue with employment as an LCSW - there was always work, of course, I have found that this is the same with the PMHNP. I was first a clinical social worker and then went back to nursing school to become a PMHNP - I certainly don't regret the decision to pursue this educational path. My MSW provided me with a solid foundation in psychotherapy as well as an understanding of the more psychosocial aspects of patient care. My PMHNP program obviously prepared me to add in the psychopharmacology in my practice. I feel that this was the perfect marriage of careers and educational preparation, though not the most expeditious! The best advise that I can offer is to consider the type of work that you hope to be doing - psychotherapy or medication management. As a PMHNP I do minimal psychotherapy and only within the context of medication management (supportive and solutions focused work), so if you are looking to do therapy, I would suggest that you look at an MSW program, because very few employers are going to hire you at an NP pay rate to do psychotherapy only (this isn't cost effective). If you lean toward more medication/physical/psychopharmacological management of patient problems, then the PMHNP route is probably for you. Of course, there isn't anything saying that you can't do both :) Best of luck to you!