JustKeepDriving

Why nursing? Why not business, administration or politics - which seem a lot more egosyntonic with your personal beliefs on the allocation of health resources and provision of care?

I've lived in both the US and Canada. I've heard of people that have gone to the United States for procedures but I never met them and generally the procedures I've heard of were more of a luxury thing and not a necessity. I worked healthcare close to the mexican border for a while and knew many Americans that went to mexico to get care for necessary things like rashes, chest congestion and prescription medications. Which I guess was preferable to when I lived in the Southern US (I was not well off and lived in an area where getting shot or robbed was a part of life) and knew people that would take fish antibiotics cause no one could afford healthcare (before obamacare). Sure if you're well off you can get an MRI and surgery tomorrow here. If you're not and can't afford a decent insurance plan? It's rough.

My state has really bad mental healthcare because treating that population is a money sink - they can't pay for it, the insurance often only covers so much of it, and the state is unable to finance community level mental healthcare - cause of the "taxes bad" thing. Lets just put it this way - not much in the community because no funding, hospitals are a business, business exist to make money and having a psychiatric unit is a net lost for the hospital. So there aren't many of them. As someone who specializes in criminal psychiatry - I see so many crimes that could have been prevented if someone just had access to care. I'm talking the forensic report comes in that details a family trying desperately to get their kid some kind of help because they've identified that something terrible is going on with him/her mentally and are unable to get enough care to really help that family member. Then the patient gets arrested and come to me in maximum security after doing something like... chasing their family down with a chainsaw, burning their family's house down, decapitating their elderly next door neighbor, shooting up their school, or seriously hurting their children. All I can do at that point is medicate them and try and help them regain competence to stand trial. Like sure you could go with the no taxes, free market stuff - which is fine for discussing theories. How this plays out in reality though? Is not good. A lot of preventable death - just in my field though - it's not the patients that die.

I'm quite aware of the standardized procedures and patient specific protocols for California and how loosely the Nurse practice act defines scope in terms of certification. I'm also aware of the problems that have come from this. Just a word of advice - the best people to contact isn't a nursing school in Baltimore - but your malpractice attorney, the state BRN and a local nursing school offering a PMHNP specialty in the area. Even if everything with the licencing board is "okie-doikie" you still run the risk of something going wrong and you're sued for malpractice (which is different than a board investigation). The patient or family's attorney will attack your credentials and will point out stuff like the National Organization of Nurse Practitioner Faculties which states stuff like: "Educational programs do not prepare NPs to provide the full range of primary and acute care services. Instead, programs are limited to either primary or acute care and certification eligibility is based on the area of preparation. Although many NPs obtain informal, post-graduate education for specialization, scope of practice is determined by formal educational preparation and certification [...]". You missed my point here as it wasn't a comment about the state of pain management but a discussion point about how practicing the whole gauntlet of pain management procedures and medication management would place a PMHNP at a lot of professional risk (despite practicing some pain management that does fall within our scope). As an RN I worked in an area of psych where getting hit/bit/kicked, having HIV+ blood spit on you, getting shanked by a patient is a real risk (I've seen bright young people get brain damaged in front of me) and where we literally need hostage negotiation training in the event a staff is taken hostage in a patient's room. I've had staff get stalked by patients, find out where they live by looking up license plates, sent threatening mail to their house, showed up on their doorstep and found their kids at school. As an NP I have all those same risks only now additional ones as well - like for example determining whether a patient is fit enough to reenter the community. Now these patients are smarter than me, know the system better than me and many know the right information to say - and providers who are a heck of a lot more educated/experiened than me have made the mistake of letting someone reenter too soon. The risk of that isn't just to the patient but to the population in general - no exaggeration here we've had patient's get out and go on to kill their entire family. That? Would devastate me so much on a personal level that I'd be profoundly negatively affected an the legal repercussions could be huge. I enjoy the population I work with, my job is interesting, the cases are complex but I would not be willing to take on the additional liability without an increase in pay. An NP and an RN are different jobs sure, but if I'm dealing with the same risks as I did at the RN level and then some? Being compensated more than I did when I was an RN is important to me as there is a very real risk of something happening where I couldn't work in this career and to that end the extra income provides a safety net so that I am not financially destitute.

I'm curious how this even works. I get managing stuff like simple anxiety and depression but as far as I know FNP/AGPCNP/ PNP don't get tons of training in managing stuff like schizophrenia, OCD, personality disorders, Bipolar type I etc and many I know generally even refer out stuff like refractory depression. There are a lot of risks in psychiatry. Lets say someone decided to go ahead and work in the scope of practice as a PMHNP without a PMHNP certification - and the patient kills themselves and the family sues. A lawyer is going to ask, "Are you certified to practice psychiatry". The answer to this is going to be "No". I'm no expert, but I'm just going to take a wild guess that would look bad. Like in psych we often manage pain in the context of psychiatric dx (ex. prescribing duloxetine or gabapentin for someone who has anxiety or depression with some chronic pain/neuropathic disorders, or doing CBT for chronic pain etc) but taking a pain management job where I'd be managing complex opiate regimens? Heck no. Even if they told me they'd provide "on the job training" I wouldn't take it. Once again no expert, but if anything were to happen I'm relatively confident I'd be in some serious code brown. It's short sighted to believe that places won't try and take advantage of the NP. Places try to push the limits all the time - healthcare is a business (that's why medicare/medicaid fraud is a thing) and some places really don't care about scope of practice. Believe me I've seen enough to believe that to some facilities - we're just warm bodies there to generate revenue and the first people to get thrown under the bus when things go wrong. Which also goes hand and hand with the pay - like if I can earn that pay an RN (Without even doing overtime! And in California, I totally have) that's a huge problem as the liability as an NP is much higher than that of an RN and one should be compensated accordingly.

The fact that this is a thing: [ATTACH=CONFIG]24765[/ATTACH] While this is also a thing (same facility): [ATTACH=CONFIG]24768[/ATTACH] Where someone can literally make more as an RN than an NP at the same facility - with lower liability? Tells me that there is a glut of Nurse Practitioners. And yes, I know people who have taken this job, no they weren't for profit students, and yes they came from well known schools (plus they had in specialty nursing experience). This is a problem and when stuff like this exists? There tells me that people are graduating desperate enough to sell themselves, very, very short.

Probably the best presentation I've seen on it is: https://doh.dc.gov/sites/default/files/dc/sites/doh/publication/attachments/Medical%20Cannabis%20Adverse%20Effects%20and%20Drug%20Interactions_0.pdf - District of Columbia Department of health on medical cannabis averse effects and drug interactions Cytochrome P45 enzymes involved in the metabolism of tetrahydrocannabinols and cannabinol by human hepatic microsomes. - PubMed - NCBI - Article citation on THC and CBN CYP450 Interactions that's also helpful I'd also check out Scientific Publications as they have a whole center for medicinal cannabis research.

Clinical rotations can vary so, so much and I agree that the apprenticeship model needs changed. My program placed students and even there - it was a lot of variation (and we still had to interview at our placement sites which created differences in student outcomes based on how much experience the student had in the specialty). So the students that entered without psychiatric experience or those who just had limited working nursing experience in general had less diverse placements - they ended up doing only outpatient, only community heath, only crisis houses etc - working one - on- one with the same preceptor for the entire two years while those who had a lot of in-specialty experience were picked up by the teaching hospitals for clinical rotations. I understand to that a lot of it is safety on the side of the site - like in my last semester my site tried to expand to include students with more diversity after the school pushed the teaching hospital site to take on students with the DNP focus over the ones with a MSN focus, stating it would allow people with less nursing experience to have more competence - but man the lack of basic psych nursing experience created some hazards (like students trying to transport patients expressing SI/GD/DTO from the non-LPS facility to the ED down the street alone with the patient absconding), students getting their personal belongings stolen and then trying to offer the patient money to get those belongings back instead of reporting the theft (and then meeting patients alone without telling preceptor staff), playing around on their cell phones (not looking up drugs, not reading articles related to the cases being assessed - but straight up playing on facebook) during intake assessments and students being unable to handle pimping questions/criticisms during case presentations and arguing with the MD attendings. Which is just frustrating as the school totally misrepresented the DNP students to the clinical site. So I can completely understand why some preceptors/sites really just don't want to take on NP students/have that school-site relationship (they have no say in admissions and even with requiring interviews/references for clinical site applicants, the schools will sometimes vouch for the merits of the individual based on the school's agenda - like pushing for DNPs to get the better placements to promote that program - and not the individual's competence).

I personally am not a fan of the deinstitutionalization movement - mainly because although I understand the necessity of it, some places are overly zealous about it and the community treatment model doesn't work for everyone. States and counties rave about how they're helping people integrate into the community but generally it just turns in to "We closed a bunch of units and are saving money, Yay!" without the installation of community facilities and services for the clients who are now back in the community. The general trend I've found (now, I work predominantly corrections and jail - so I probably have some confirmation bias here) is that, as institutions close and bed space in the remaining inpatient units and state facilities gets overwhelmed there tends to be a direct correlation with incarceration rates of psychiatric patients (as they fall through the cracks within the community). Basically, making the jails and prisons into the new psychiatric institution, sadly. To that end - I don't see psychiatric nursing going anywhere. Personally, I dislike the corporate healthcare culture of the hospitals and shy away from them - and have never had a difficult time finding a psychiatric nursing position outside of the hospital. With the push for community care you have Assertive community treatment teams, Psychiatric emergency response teams, Psychiatric Emergency departments, case management, correctional psychiatry (Jail & Prison) as well as state hospital psychiatry (The community might rally to get them closed however, at least in my state they're never able to do so because that same community isn't comfortable when they try to set up a group home for violent sexual offenders in their neighborhood - go figure) and many other options available. I wouldn't worry about job prospects in mental health overly much - there are many people that require mental health services (and that number is not diminishing) and there are more places for psychiatric nurses than in the hospital setting.

Yep - one of the good things about my program is that we did a lot of our rotations in tandem with the residents and it put into a very harsh perspective how many deficits the NP program has in comparison to medical education (even the good ones). One of my rotations was done on the consult-liaison team and not having that experience in FM or neurology meant a lot of late nights reading research articles on stuff like CNS lupus, temporal epilepsy, post-chemotherapy cognitive impairment etc. Psych has so many medical rule outs that are part of a differential, it's actually really terrifying that most programs just don't grant a more solid medical background (like mine at least had us on consults, ER, doing physical assessments - mainly enough time to get a very clear understand about all the things we DON'T know - but I also know people from the "find your own placement" kind of program and seriously wonder what kinds of experience they come out with).

One of the biggest frustrations for me as a new grad PMHNP is that in my specialty we just aren't exposed enough to the medical realm and yet, so many of the patient's we work with have a ton of comorbid medical issues (many caused by the medications we prescribe). Without being duly certified in another specialty - FNP, AGPCNP, ACNP etc. - we can't really manage medical issues, and so many of our patients don't have access to primary care. One class of general pharmacology in combination with my psychopharmacology course and clinical rotations gives me knowledge about general pharmacological principles, mechanisms and interactions with the medications I prescribe but not enough were I would feel comfortable (or safe license/liability wise) where I would feel okay managing conditions like metabolic syndrome, diabetes, hypothyroidism etc. I chose the facility where I will be starting at based on the fact that I worked there as an RN and have a very clear understanding of the client population, what my caseload will look like, the fact that I have already built relationship with the MD's that work there and can go to them for help, and what supports I will have with medical management - however I know from recruitment stuff I've gotten not all facilities understand the limitations of the PMHNP position (and it seems some definitely try and push medical and psychiatric management on the practitioner). I've been an RN for a few years so I have no problem turning down places where I have a pretty good gut intuition would try and work me outside my scope (some facilities really don't care - you're just a way to make them revenue) or those that will low-ball me while having me work long hours on a salary (no thanks). However, one has to think - someone out there is taking these positions (seriously one of the county ED's was trying to hire a PMHNP on for $35/hr - and someone filled it). Like in a perfect world (on top of adding a lot more sciences to the NP degree and making admission standards more stringent) I really wish that they divided the specialties into two general tracks - Primary Care & Acute care - with every specialty starting with a year of doing general medical rotations (outpatient or inpatient depending on track) and then a second year of specialty rotations. Because honestly, I have absolutely no desire managing chronic medical conditions but I would like to have some proficiency in doing so (and not have it be a huge mess of liability) if I was in the position where it was necessary. I also really, really wish that other specialties got a lot more experience with psych - one thing that I found when I was doing ED consults was just how many primary care providers try to manage psychiatric issues and have no clue what they're doing. Like seriously - doing R/O Dementia on a 65 Y/O being managed on Xanax 1 mg PO TID for Anxiety, Percoset 10/325 PO Q6H BID PRN for Chronic pain, Ambien 20 mg PO QHS for Insomnia; sometimes with a stimulant thrown on top for chronic fatigue. Holy cow I'm half that person's age and spend my free time weight-lifting and I would be floored under the table and unable to remember anything with that regimen. No wonder they're having memory problems. These are just some of my thoughts on the whole thing.

A lot depends on your program - my first semester was light on clinical hours but heavy on theory/sciences and working full time was not a problem; however as it progressed I started picking up more and more clinical hours till it was almost a full-time job and even picking up a per-diem shift on the weekend was terrible. However, the way my program worked was that we were placed at a major academic medical center where we carried a consistent outpatient caseload for the entirety of the program and then had specialty rotations (Peds, Geriatric, Emergency, inpatient, forensic and refugee psychiatry) that we completed (some voluntary, some mandatory). I picked up all the extra clinical hours that I could and didn't work at all the last year of my program - just did classes, clinical hours and board prep (which even as a single person, left me with not a lot of free time). Only a few people in my cohort were still working by the end of the program - with only one doing full time. Not all schools work like that though and there is a lot of variability in clinical hours and experiences - so it really depends on what you personally can handle and hour your clinical rotations are structured.

So, a good look at the link shows MEPN admission with a list of MS specialty area's on the right hand side that admit master's entry students and include AGPCNP, FNP, PMHNP, WHNP ect. I've worked with graduates of such programs before my attending barred anyone without at least 2 years of RN experience in specialty prior NP licensing from working at my facility. There are some MEPN programs (UC Irvine for example) that will grant a generalist master's degree to individuals without a BSN and they would have to obtain a post-masters certification as a NP in order to get credentialed and licensed as an NP. There are also MEPN programs that take individuals with an unrelated bachelor's degree straight to NP without a BSN - UCSF (linked) is one of those programs. No post masters necessary and they are eligible for credentialing and licensing post-graduation.

Honestly, my piece of advice would be to contact the college of nurses in Ontario and ask them. They more than anyone could give you all the details on what is expected to get licensed and practice there as an APRN.

I'm have dual citizenship (US & CAN) and gotten all of my education in the states and have looked in to going back to Canada as I miss my family and friends. Unfortunately - it's a heck of a process. The first step is to start with the Canadian Provincial body with which you want to apply - for Ontario it's the College of Nurses of Ontario Outside Canada and to get your education reviewed by the NNAS NNAS / SNEI as they need to compare your US RN education to the Canadian requirements. Going through the NNAS requires transcripts, syllabus information/course description from the University you attended looking at course equivalency, references from all nursing boards where you are licensed to practice stating you're in good standing and references from any employers from the past 5 years stating you're in good standing. Then they give you a report stating that your education is either equivalent for the license in which you're applying or that it's deficit. The whole process can be pricey and more often than not the US education is not equivalent. There is a long thread on the NNAS process here https://allnurses.com/nurse-registration/nnas-experience-966912.html At that point you are then eligible to apply for the province in which you want to be able to practice. Many applicants from the US have had to do some kind of remedial testing in order to be given the go ahead to practice as a RN. I'm also not entirely sure how different or difficult the process is for is for Non-Citizens of Canada. All in all it can take about 2 years to get licensed to work in Canada. In terms of Nurse Practitioner - you'd do an additional application for extended class and see if you've taken an equivalent board certification exam: Outside Ontario. There are also certain NP specializations in the US that do not have Canadian equivalency: PMHNP (my specialty) or the Acute Care Nurse Practitioner specialties. I haven't done the process and have pretty much decided that if I want to go back to Canada I'll have to do something else.