Sick of other NPs abusing patients - psych practice

[FullGlass]

Would greatly appreciate advice on dealing with this situation.  I am a PMHNP working in a psychiatric outpatient practice in California for 3 years.  The type of behaviors described below have happened a lot here and for the past 1.5 years, I have been one of the primary providers cleaning up these messes and I am sick of it.  I have repeatedly complained to management, to no avail.  NP AA, in particular, has done this over and over, also trying to dump any pt taking a controlled substance, including ADHD pts, on me.  This is a long post.

This pt, Jane, an older female, had her first appt with me recently.  Prior to that, she was seen by NP AA and NP BB (neither are PMHNPs).  I was appalled by what the patient told me and what was documented in her chart by AA and BB.  A summary of events is provided below.

1st appt - Intake by BB.  The pt reported that her previous psychiatrist, that she had seen for 20 years, had very suddenly died recently.  He had prescribed PRN Xanax for many years.  Pt was very distressed by his sudden death, as she liked him very much.  [The pt was stable on her med regimen at that time and did not ask for any adjustments.]  The pt does not take Xanax every day .   According to the pt, BB told pt that after her current RX of Xanax ran out, it would not be refilled.  BB insisted that pt switch to clonazepam instead. Per my CURES review, pt had only had 2 refills of clonazepam in 2 years prior to this appt.  Dx:  anxiety and depression.

2nd appt – Talk therapy intake

3rd appt – F/U w/BB.  BB wrote an RX for clonazepam and noted pt was compliant.

4th appt – F/U w/BB.  Per the chart note, the pt reported the clonazepam was not working.  This is consistent with what the pt told me.  Pt was switched to diazepam.

5th appt – F/U w/AA.  AA noted in chart:  "Patient has no HX of BZD dependence "can go days without taking it" . . . emotional dependence 30 years of Xanax noted.  States " No I won't take 80 mg of Prozac [this would be large increase].”  Comment:  Given pt's CURES record, this statement is ridiculous.

For some unfathomable reason, AA then proceeded to diagnose the patient with Narcissistic Personality Disorder!  She noted the following behaviors in the pt's chart:  "Jane exhibits symptoms of narcissistic personality disorder, characterized by a long-standing pattern of grandiosity (either in fantasy or actual behavior), an overwhelming need for admiration, and usually complete lack of empathy towards others. Jane has a grandiose sense of self-importance. Jane expects to be viewed as "special" even without appropriate achievement. She feels that her problems are unique and can only be understood by special people. Jane fishes for compliments, often with great charm. She has unreasonable expectations and expects favorable treatment from others. Jane has explosive outbursts, in which others are taken advantage of in order to gain an advantage.”

AA further documented:

N0 XANAX refills provided as requested - denied

NO future refills of BZD recommended

Vistaril 10 mg PRN

increased prozac 50 mg to 80 mg x 2 W recommended --patient resistant

FU w/ different provider in 2 W recommended

AA added following diagnoses to pt's chart:

Narcissistic personality disorder, F60.81 (ICD-10) (Active)

Patient's other noncompliance with medication regimen, Z91.14 (ICD-10) (Active)

Comments:  AA is NOT qualified to diagnose Narcissistic Personality Disorder, or any other personality disorder, for that matter.  In addition, personality disorders can't be diagnosed in one appt.  The talk therapist did not note any indications of a personality d/o.  Furthermore, during my appt with her, the pt did not exhibit ANY of the NPD behaviors noted in this chart note.  She was very pleasant.

Why did AA dx the pt with noncompliance?  The pt tried clonazepam and diazepam and reported those meds did not work for her.  The pt did not want to take an increased dose of Prozac, which is her right.  Her previous med regimen was working fine, and the pt was justified in not wanting to change it.

6th appt - f/u w/BB.  After the appt, BB wrote a rather hysterical and spiteful non-chart note containing many untruths:  "Patient had an appointment scheduled with me. She previously seen AA and was appalled that her medications are not working. She has been receiving Xanax from her previous provider, and per her story he cut her off Xanax.  [Comment:  Untrue.  Dr. Rogerson died].  She was unhappy with me as well and asked "Who in the damned office can prescribe me Xanax ? I stated that per our medical director this office/ practice does NOT prescribe Xanax.  [Comment:  Untrue. While efforts are made not to do so, sometimespProviders here do indeed prescribe Xanax if other antianxiety meds do not work].  She said that "well, I guess we have nothing to talk about, do we?" and hang up on me.  Patient does have a lengthy dependence on Benzodiazapines.  [Comment:  Untrue, and this is clear from CURES review].  In February 2023 I prescribed her 0.5mg of Clonazepam #60.  She complained that it " did nothing for her" explaining she has panic attacks all day long.  In March 2023 I prescribed Valium 5mg #60 and that did not work for her as well.  She is, as it seems has a benzodiazepine addiction and plans on doctor shop.”  [Comment:  This is not true, based on CURES review and there is nothing to indicate the pt plans to "doctor shop.”]  I advised for her to seek treatment before and she refused.”  [Comment:  Why would pt seek addiction treatment when she is not addicted?]

7th appt – f/u with me.  I restarted pt on her original med regimen, as she had been stable on that for a long time.

Conclusion:

This sequence of events almost made me cry and I alternated between sadness and anger for quite some time.  My philosophy when treating patients includes "if it ain't broke, don't fix it,” especially with older patients, as change can be upsetting for them.  I learned this from my mentor on my first NP job.  The conduct of the other NPs only further increased this pt's anxiety and caused her great distress.  BB and AA also had ridiculous interpretation's of pt's statements.  If a med does not work for patient, the patient has a right to say so and request an alternate med!  That is NOT "noncompliance.”  In addition, when a pt is treated as if they are an addict, they tend to get defensive!  If pressed, the pt can become frustrated and irritable, as well.  That does not mean they are an addict.  In criminal law, one is presumed innocent until proven guilty.  AA takes the opposite approach, guilty until proven innocent.  Treating patients who take controlled substances with such suspicion is not conducive to developing a therapeutic alliance, which is the most important factor in treatment success. 

It is clear that BB and AA either did not bother to actually review the pt's CURES hx or did not understand it.  As noted above, per CURES, the pt's RX history does NOT indicate benzo addiction!  The pt on had 2 Xanax refills in 2 years! 

AA wrote false documentation.  This is unethical and it is also a crime.  She is NOT qualified to dx narcissistic personality disorder and that dx can't be made based on 1 appt.  This was simply spiteful and vindictive, as well as unethical.  It is libel and could be viewed as elder abuse.  Therefore, it represents a significant liability risk.  This type of false documentation (personality d/o and addiction), if not corrected, can follow the pt and cause them a great deal of harm.  This is an additional liability risk. 

I am wondering if I should report the NPs to the State Nursing Board.  I am sick of complaining to management and they seem to do nothing, because the behavior does not change.  An especially outrageous example:  I was on Xmas vacation.  One of MY ADHD pts had his regular monthly appt w/another provider b/c I was out.  That provider demanded, on Xmas Eve! That the pt go get an MRI or he would not get a refill.  The pt was about to travel for his Xmas vacation, leaving later that day.  Mgt tells me they will talk to these NPs, but it keeps happening, especially by AA!

[subee, MSN, CRNA]

FullGlass said:

I appreciate what is being said, but this was seriously impacting my ability to work.  First, so many controlled substance patients were being dumped on me by some other NPs, I ended up with about 90% of my patients on controlled substances.  Those patients take more time, as I have to check the state database, can't do refills, etc.  Second, when patients are justifiably upset, it can take quite awhile to calm them down.  This means I end up running late, which is not fair to me or my other patients.  Third, these idiot NPs were also making serious mistakes that needed to be corrected - abruptly stopping benzos and patients ending up in the ER, prescribing meds that did not work, had serious side effects, etc.  Fourth, I had to document all those issues and convey them to management, talk the management, etc., which was very time-consuming.  Finally, in order to be a good mental health care provider, or any kind of NP, a good provider has to be compassionate and caring, in order to establish a therapeutic alliance.  In other words, a completely indifferent person is not going to be a good NP.  While I am generally good at establishing boundaries, seeing patient after patient needlessly suffering horribly takes an emotional toll on me.  If it didn't, then I shouldn't be an NP.

 

Sorry, but I have do disagree here.  You think you have good boundaries?  Not if you can't separate the visit from experiencing emotional pain. Just because you are  an NP does NOT mean you have to take their pain home,  It's THEIR pain, not yours.   What good are you if you can't master that skill?.  I'm sorry that the other NP's are so incompetent.  It is shocking that a person supposedly educated in psych would ever cut people off cold turkey from benzos.  But I am not surprised considering that anyone with a BSN can get a graduate degree for the price.  I could never do meditation (kept looking at my watch) but I can to TaiChi and yoga and these practices can help you calm down and center yourself.  

[subee, MSN, CRNA]

FullGlass said:

After a lot of complaints, things are getting better, slowly.  It also appears that bunch of new PMHNPs were hired out of the same crappy school and those were the ones causing problems.  I've been asked to help recruit better people

That school will never do anything to improve unless you don't hire them.  Good luck.  I know recruiting is hard but some people will see that you are a change maker and it will get even "betterer."

[FullGlass, BSN, MSN, NP]

subee said:

Sorry, but I have do disagree here.  You think you have good boundaries?  Not if you can't separate the visit from experiencing emotional pain. Just because you are  an NP does NOT mean you have to take their pain home,  It's THEIR pain, not yours.   What good are you if you can't master that skill?.  I'm sorry that the other NP's are so incompetent.  It is shocking that a person supposedly educated in psych would ever cut people off cold turkey from benzos.  But I am not surprised considering that anyone with a BSN can get a graduate degree for the price.  I could never do meditation (kept looking at my watch) but I can to TaiChi and yoga and these practices can help you calm down and center yourself.  

Well, then you also disagree with the excellent psychiatrist mentors I have.  Also, you don't know me, so how are you in a position to decide if I set good boundaries or not?  I've been doing mental health for 3 years and it is only recently, after having to clean up messes, deal with crying patients constantly, oh, and I forgot a lot of patients got evicted and lost their jobs b/c idiot NPs couldn't be bothered to do the disability paperwork, etc., they were paid to do and on and on and on.  Prior to that I worked in primary care in a very poor rural area and did not have these issues.  

I don't know how any person with an ounce of compassion can witness endless needless suffering and just feel fine and dandy at the end of the day.

Also, I come to this blog for support, not to be lectured by people who don't know me that I need better boundaries.  

[djmatte, ADN, MSN, RN, NP]

And just like that history repeats. ?

[subee, MSN, CRNA]

FullGlass said:

Well, then you also disagree with the excellent psychiatrist mentors I have.  Also, you don't know me, so how are you in a position to decide if I set good boundaries or not?  I've been doing mental health for 3 years and it is only recently, after having to clean up messes, deal with crying patients constantly, oh, and I forgot a lot of patients got evicted and lost their jobs b/c idiot NPs couldn't be bothered to do the disability paperwork, etc., they were paid to do and on and on and on.  Prior to that I worked in primary care in a very poor rural area and did not have these issues.  

I don't know how any person with an ounce of compassion can witness endless needless suffering and just feel fine and dandy at the end of the day.

Also, I come to this blog for support, not to be lectured by people who don't know me that I need better boundaries.  

You are the one who who is complaining about the burdens of your job.  Setting boundaries on what you take home with you is not "indifferent" to the patient.  No nurse every went home without nagging thoughts about the day but when these throughts start making you miserable, that's a different scenario.  We can listen to sad stories and sometimes tear up when we interact with patients but that doesn't mean I have to go home so troubled I'm miserable with my job.  

[CommunityRNBSN, BSN, RN]

FullGlass said:

Well, then you also disagree with the excellent psychiatrist mentors I have.  Also, you don't know me, so how are you in a position to decide if I set good boundaries or not?  I've been doing mental health for 3 years and it is only recently, after having to clean up messes, deal with crying patients constantly, oh, and I forgot a lot of patients got evicted and lost their jobs b/c idiot NPs couldn't be bothered to do the disability paperwork, etc., they were paid to do and on and on and on.  Prior to that I worked in primary care in a very poor rural area and did not have these issues.  

I don't know how any person with an ounce of compassion can witness endless needless suffering and just feel fine and dandy at the end of the day.

Also, I come to this blog for support, not to be lectured by people who don't know me that I need better boundaries.  

You sound really defensive.  You came on here for advice, and you got good advice.  I'm sorry you're in a tough spot, but lashing out about how anonymous online nurses-- all of whom tried to help you-- must not have "an ounce of compassion" and are sociopaths who "feel fine and dandy" when they see suffering is not a sign of good boundaries.

[FullGlass, BSN, MSN, NP]

CommunityRNBSN said:

You sound really defensive.  You came on here for advice, and you got good advice.  I'm sorry you're in a tough spot, but lashing out about how anonymous online nurses-- all of whom tried to help you-- must not have "an ounce of compassion" and are sociopaths who "feel fine and dandy" when they see suffering is not a sign of good boundaries.

 

subee said:

You are the one who who is complaining about the burdens of your job.  Setting boundaries on what you take home with you is not "indifferent" to the patient.  No nurse every went home without nagging thoughts about the day but when these throughts start making you miserable, that's a different scenario.  We can listen to sad stories and sometimes tear up when we interact with patients but that doesn't mean I have to go home so troubled I'm miserable with my job.  

Telling someone to just set better boundaries is not compassionate and is a misuse of the term.

Let's look at an extreme example:

1.  Pretend you are an Army nurse during WWII.  At the end of the war, you are sent to a concentration camp to help care for the former inmates to assist them in regaining their mental and physical health.  You are deeply affected by the experience and also become very troubled internally.  Do you think that someone telling you to "set better boundaries" is appropriate?  Does anyone here think that our hypothetical RN can just do some yoga and take a warm bath and feel all better?  Only a psychopath could.  And I don't think we want psychopaths as RNs or NPs.   

I was very upset when I wrote my original post.  I do not have time to list all the instances of patient abuse I had to deal with.  I will say that the conduct amounted to malpractice:  refusing to fill prescriptions that resulted in patients going into withdrawal and going to ER, knowingly maliciously misdiagnosing patients with psychiatric diagnoses that carry stigmas, threatening to call law enforcement on patients that receive legitimate controlled substance prescriptions, knowingly falsifying chart notes, and so on.  I had to deal with several of these patients per day, which caused me an enormous amount of extra work and psychic/emotional energy.  Some of these patients were close to committing suicide because of this abuse.  Then, on top of that, total administrative chaos resulting in issues like patients not receiving disability extensions on time so they got evicted, patients not being able to get their prescriptions renewed because staff literally argued over who should send the fax for 3 months!, patients losing their jobs because staff either refused to write off work or return to work letters or did not notify appropriate providers this was needed, and so on.  

I am good at setting boundaries for normal work stressors.  Treating psychiatric patients can take an emotional and psychic toll on anyone.  However, what I can't handle is when that is compounded by other providers committing malpractice and maliciously abusing patients, along with administrative malfeasance that results in things like patients getting evicted and losing their jobs.  And this was CONSTANT, not just an occasional snafu.

At any rate, I was able to resolve the situation with management and things are going better.

Interesting post on this topic:

"Healthy boundaries has got to be one of the most overused terms in the therapy world. Along with 'self care' these concepts are easy to talk about and even easier to advise on but complex enough to write books about. What do we even mean by a healthy boundary? What's healthy and what is unhealthy? What even is a boundary? How do we know if we are creating an unhealthy boundary? In this post I discuss how the whole concept of a healthy boundary is actually quite unhealthy, because it's more likely to keep you in a paradigm of emotional and energetic separation and self preservation which is a paradigm built on fear."

https://www.kimiyahealing.co.uk/post/why-it-s-time-to-stop-talking-about-healthy-boundaries

"Setting boundaries" is more about doing so when circumstances are under one's control.  For example, the boss keeps asking you to do things that are clearly not within your job scope, like picking up her dry cleaning, or saying no to a colleague that keeps asking you to trade shifts with him, treating the normal range of patients during clinic hours, etc.  One can't easily set boundaries for things that are completely unexpected and out of one's control.  For example, my house burns down.  I am going to be very emotionally upset!  Who wouldn't be?  A patient comes to me suffering from PTSD because she is a police officer and one of her colleagues was shot in front her; he died in her arms.  Should I tell her to "set better boundaries?"  When I was in primary care, one of my patients developed a rare and very serious infection and almost died.  I was very worried about him and visited him while he was in the hospital; fortunately he made a full recovery.  I worried about him and made a 100 mile RT multiple times (I was in a very rural area at the time).  Should I have set "better boundaries?" 

Just because advice is "free" does not mean it is OK for it to be hurtful or thoughtless.

As a mental health professional, I urge caution in using the term "setting boundaries" as some sort of panacea when dealing with emotional distress.  

[subee, MSN, CRNA]

FullGlass said:

 

Telling someone to just set better boundaries is not compassionate and is a misuse of the term.

Let's look at an extreme example:

1.  Pretend you are an Army nurse during WWII.  At the end of the war, you are sent to a concentration camp to help care for the former inmates to assist them in regaining their mental and physical health.  You are deeply affected by the experience and also become very troubled internally.  Do you think that someone telling you to "set better boundaries" is appropriate?  Does anyone here think that our hypothetical RN can just do some yoga and take a warm bath and feel all better?  Only a psychopath could.  And I don't think we want psychopaths as RNs or NPs.   

I was very upset when I wrote my original post.  I do not have time to list all the instances of patient abuse I had to deal with.  I will say that the conduct amounted to malpractice:  refusing to fill prescriptions that resulted in patients going into withdrawal and going to ER, knowingly maliciously misdiagnosing patients with psychiatric diagnoses that carry stigmas, threatening to call law enforcement on patients that receive legitimate controlled substance prescriptions, knowingly falsifying chart notes, and so on.  I had to deal with several of these patients per day, which caused me an enormous amount of extra work and psychic/emotional energy.  Some of these patients were close to committing suicide because of this abuse.  Then, on top of that, total administrative chaos resulting in issues like patients not receiving disability extensions on time so they got evicted, patients not being able to get their prescriptions renewed because staff literally argued over who should send the fax for 3 months!, patients losing their jobs because staff either refused to write off work or return to work letters or did not notify appropriate providers this was needed, and so on.  

I am good at setting boundaries for normal work stressors.  Treating psychiatric patients can take an emotional and psychic toll on anyone.  However, what I can't handle is when that is compounded by other providers committing malpractice and maliciously abusing patients, along with administrative malfeasance that results in things like patients getting evicted and losing their jobs.  And this was CONSTANT, not just an occasional snafu.

At any rate, I was able to resolve the situation with management and things are going better.

Interesting post on this topic:

"Healthy boundaries has got to be one of the most overused terms in the therapy world. Along with 'self care' these concepts are easy to talk about and even easier to advise on but complex enough to write books about. What do we even mean by a healthy boundary? What's healthy and what is unhealthy? What even is a boundary? How do we know if we are creating an unhealthy boundary? In this post I discuss how the whole concept of a healthy boundary is actually quite unhealthy, because it's more likely to keep you in a paradigm of emotional and energetic separation and self preservation which is a paradigm built on fear."

https://www.kimiyahealing.co.uk/post/why-it-s-time-to-stop-talking-about-healthy-boundaries

"Setting boundaries" is more about doing so when circumstances are under one's control.  For example, the boss keeps asking you to do things that are clearly not within your job scope, like picking up her dry cleaning, or saying no to a colleague that keeps asking you to trade shifts with him, treating the normal range of patients during clinic hours, etc.  One can't easily set boundaries for things that are completely unexpected and out of one's control.  For example, my house burns down.  I am going to be very emotionally upset!  Who wouldn't be?  A patient comes to me suffering from PTSD because she is a police officer and one of her colleagues was shot in front her; he died in her arms.  Should I tell her to "set better boundaries?"  When I was in primary care, one of my patients developed a rare and very serious infection and almost died.  I was very worried about him and visited him while he was in the hospital; fortunately he made a full recovery.  I worried about him and made a 100 mile RT multiple times (I was in a very rural area at the time).  Should I have set "better boundaries?" 

Just because advice is "free" does not mean it is OK for it to be hurtful or thoughtless.

As a mental health professional, I urge caution in using the term "setting boundaries" as some sort of panacea when dealing with emotional distress.  

Wow.  You really know how to gaslight the situation.  No one here ever thought they were giving you a panacea.  We were giving suggestions to YOU; not a a police officer who's partner was killed in from of them.  You think you are the only person here that suffers emotional pain from their work?  Maybe we don't suffer enough to suit you? Have our experiences no comparison to yours?  And, BTW, did anyone here tell you to take a warm bath?

[FullGlass, BSN, MSN, NP]

subee said:

Wow.  You really know how to gaslight the situation.  No one here ever thought they were giving you a panacea.  We were giving suggestions to YOU; not a a police officer who's partner was killed in from of them.  You think you are the only person here that suffers emotional pain from their work?  Maybe we don't suffer enough to suit you? Have our experiences no comparison to yours?  And, BTW, did anyone here tell you to take a warm bath?

Wow.  You are the one overreacting now.  I explained why the term "setting boundaries" should be used carefully and is not always appropriate.  You provide no refutation of my argument. 

To try and explain this better, "setting boundaries" is overused.  It is more applicable to situations regarding ACTIONS, not feelings.  And actions that one can take to mitigate a problem.  For example, your friends from out of town announce (not ask) that they are coming to visit you and will be staying with you for 2 weeks in October.  You can say no and "set boundaries" around visits and houseguests.

"Setting boundaries" is not a good term to use regarding a person's emotional distress, because it is invalidating their feelings, in essence.  Per the example above, you are annoyed with your friends' behavior.  Well, that is understandable!  I wouldn't tell you that you need to "set boundaries" regarding being annoyed. 

We were all taught this in nursing school (or should have been) - when someone is very upset, do not invalidate their feelings.  Say something like, "I am so sorry you are going through this . . . "  "That sounds like a very disturbing situation . . . "  "It is understandable that you are upset . . . "  

I would expect NPs working in mental health to understand this.

And as for the suffering of other NPs on this forum, I never belittled anyone else's suffering.  During the recent COVID pandemic, many RNs and NPs had to work grueling schedules to provide patient care.  They were understandable exhausted physically, mentally, emotionally.  It was horrible to see so many sick and dying patients.  They had to deal with many frustrations such as administrative morons and so forth.  Some RNs and providers spent long periods of time away from their families.  When they vented or showed a need for support, do you think it would have been helpful to tell them to "set better boundaries"?!

Instead of being defensive, it would be better to consider what I have said and be cognizant of not simply throwing out the term "setting boundaries," especially in mental health situations.

[djmatte, ADN, MSN, RN, NP]

I feel like this is three years ago repeating... ?

[FullGlass, BSN, MSN, NP]

djmatte said:

I feel like this is three years ago repeating... ?

I guess you missed me!  ?

 

[djmatte, ADN, MSN, RN, NP]

FullGlass said:

I guess you missed me!  ?

 

Don't flatter yourself. Nobody here misses the desperate pleas for validation and empathy that only turn into long winded retorts and self victimization when people simply offer advice. It's a persistent theme with you around here. As evidenced by this and a few other recent posts.