psych nursing

[czyja]

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Gentle Readers,

I don't want to start a "war," however I have a question that some might find provocative. Nonetheless, I need some advice. I am especially interested in hearing from psychiatrists, psychiatry residents, and psych nurses.

I am interested in mental health as a second career and I am about to apply to several advanced practice psych nursing programs - it would be helpful to see what folks in the professiion have to say about my plan. A little background: I am in my very early forties and I left my last profession (the wine business, where I worked for almost 20 years as a sommelier, taster, buyer and manager) four years ago and enrolled at a prestigious west coast university that will award me a degree in microbiology in a few short months. My academic credential are good (decent GPA, published research in radiation biology) and I have experience working in healthcare (worked for a psychiatrist taking hx of workers comp pts, many hours volunteering at a free clinic as an MA and phlebotomist). In all candor I would like to be a psychiatrist, however the length of training at this point in my life is not realistic (for me, I know others have done it). So I am thinking of advanced practice psych nursing - either NP or CNS. I think this might be a good fit for me because I love working with psych patients (they are interesting), even though "progress" in mental health is often measured in small increments I like the feeling of helping people make progress, I am attracted to the bio-psychosocial model of treatment (ie I know I would not be happy as an MFT or PhD, working only in realm of psychodynamics). I envision working in a hospital or community health setting and perhaps doing a little teaching or research at some point in my career. I am a pretty good manager and I suspect that I may find myself in a managerial role at some point.

I am, however, a little concerned about the level of respect that advanced practice psych nurses receive in the profession. In your experience, are they respected? For those with prescriptive authority, have you observed that the Psych NP's with whom you have worked are adequately trained to competently prescribe? Please note I would like to hear from prescribers on this, again I dont want to start a war and I dont really care what you all "feel" about this contentious issue, I would like to know what you have observed. Do they actually manage the care of patients or do they primarily ensure that a treatment plan developed by the docs is implemented? What do those of you who are MD's DO's and nurses think about about my plan?

Thank you.

 

[silas2642]

Well, not that I know anything, since I am just the lowly med student, but first of all, if you really want a debate on this "how good are NPs?" issue, mosey on over to the clinicians NP/PA forum and read the "why does everyone hate NP's" thread. It's kind of interesting.

My general observation with NPs is that they are qualified to help out physicians enormously by taking basic histories, following up with patients with very basic and straight forward illnesses, etc., but that they should always be under the supervision of a doctor. Apparently, not all NPs feel this way, some feel that they are equivalent to physicians and that their clinical opinion should weigh as heavily, which in my opinion, it should not. But again, that's just the lowly med student here. In my town, the nurses have pretty much taken over healthcare, they're the CEO's who are calling the shots and telling the docs what they can and cannot do.

So back to your question-- will you be competent? The answer: with the basic bread and butter cases, probably. With the more complex cases, maybe, but that's why you should be working with a physician looking over your shoulder, to help you out when you don't know. And there will definitely be times when you don't know; there will even be times when you don't know that you don't know, so just try to keep that in mind and keep practicing in the scope of your practice.

 

[Solideliquid]

I am, however, a little concerned about the level of respect that advanced practice psych nurses receive in the profession. In your experience, are they respected? For those with prescriptive authority, have you observed that the Psych NP's with whom you have worked are adequately trained to competently prescribe? Please note I would like to hear from prescribers on this, again I dont want to start a war and I dont really care what you all "feel" about this contentious issue, I would like to know what you have observed. Do they actually manage the care of patients or do they primarily ensure that a treatment plan developed by the docs is implemented? What do those of you who are MD's DO's and nurses think about about my plan?

Thank you.

L.C.-

I haven't had a chance to work with any prescribing NPs in my training. From what I've observed psych nurses mainly follow our treatment plans. On the other hand they also take great care of their patients. We as physicians really only spend a small amount of time with our patient's compared to the nursing staff. However we dictate the treatment plan.

From what I've seen, psych nurses are highly respected within the psychiatric nursing community. What you may run into is sometimes I notice disdain from nurses on the medical of ICU departments towards psych nurses. This disdain is aimed at the psych nurses inability to start and maintain IVs or handle serious medical complications.

 

[OldPsychDoc]

L.C.-

I haven't had a chance to work with any prescribing NPs in my training. From what I've observed psych nurses mainly follow our treatment plans. On the other hand they also take great care of their patients. We as physicians really only spend a small amount of time with our patient's compared to the nursing staff. However we dictate the treatment plan.

From what I've seen, psych nurses are highly respected within the psychiatric nursing community. What you may run into is sometimes I notice disdain from nurses on the medical of ICU departments towards psych nurses. This disdain is aimed at the psych nurses inability to start and maintain IVs or handle serious medical complications.

Don't confuse inpatient psychiatric RNs with psychiatric advanced practice nurses (CNSs), who usually work as outpatient practitioners. I've worked with several prescribing CNS's. I supervise one, as well. She formulates her own treatment plans, and runs the complicated ones past me. She's is a thoughtful, independent prescriber--a little conservative sometimes, but I rarely need to correct her.

To the OP--it sounds like you've thought this out. At your stage it does sound like a reasonable move. Again, I've worked with several, and I see the CNS as a vital teammate.

 

[NewHope]

To the OP:
try www.allnurses.com. You will get a lot more milage out of it.

 

[Anasazi23]

I've worked with a few NPs that had primary care of some psychiatric patients. As expected, they seemed to be able to handle the simple cases...(i.e. continue zoloft for depression - been stable for 2 years).

The disasters came with certain populations - elderly, child, and medically compromised, or those on multiple meds. Chronic debilitating deliriums missed as worsening dementia, gross side effects easily managed which could have been easily taken care of by someone who recognized them, and things like that.

On my geri rotation in particular, I saw quite a few patients admitted with decompensated medical and psychiatric conditions that were in bad shape as a direct result of irresponsible prescribing.

 

[czyja]

Thank you all for your prompt replies. I have posted on Allnurses. It is good forum, however I was interested in the non-nursing perspective. The nurses there are a justly proud of their profession and thus offer a somewhat skewed perspective.

OldPsychDoc - Thanks for your comments. Are your sentiments generally shared in your professional community. Out here in Cali psychiatric mental health NP's may prescribe and tend to be work in outpatient settings under some level of supervision by an MD, whereas psych CNS's do not prescribe and tend to focus on psychotherapy and management of nursing staff in both inpatient and outpatient settings. I am somewhat torn as to which role would be the best fit for me. Certainly it seems logical that the ability to prescribe might give one more flexibility in the job market, however CNS's appear to be more in demand (at least on the west coast). Arghh! It ain't easy being an old man that is a confused college senior!

Anasazi - your post is points me to my worst fear - that I will not be adequately trained (as an NP) to manage the patients I serve. Are these soley primary care NP's prescribing psych meds that you are speaking of or do you also include psych NP's?

Thanks

 

[whopper]

I've worked with several Psyche Nurse Practitioners.

As Anasazi said, I've found no problem with them on simple stuff. I've seen some very good ones too.

I'd have no problem hiring one & working alongside one, and considering there's a supposed shortage of psychiatrists--there's a need for psyche NPs.

In general I've actually seen NPs do better jobs on the technical stuff like H&Ps and progress notes. Lots of attendings--I can't read any of their notes and even when I can, they are sloppy.

I wouldn't judge them as a group, for or against. We're all part of the same team and there's always good & bad individuals. Psyche attendings may have been required to have more training but I've seen so many bad attendings, I'd pit them against a good NP anyday, and put my money on the good NP.

If you're concerned about training czyja, you can attempt to work alongside an attending you like and ask the attending to act as your back up, and involve yourself in CMEs. A good and friendly attending you can trust may be able to give you additional training to the point where you can handle stuff about as good as an attending.

 

[lusyd]

I have seen psych NPs in practise a lot, and as far as midlevels go they are the worst. Psychiatry like neurology and some other medical specialites cannot be done by shortcuts. The main limitation with psych NPs is their ability to diagnose.

 

[OldPsychDoc]

I have seen psych NPs in practise a lot, and as far as midlevels go they are the worst. Psychiatry like neurology and some other medical specialites cannot be done by shortcuts. The main limitation with psych NPs is their ability to diagnose.

I think that the characteristic that matters most is a real desire to practice with the mentally ill. I've seen far worse "diagnosis" done by MDs who don't give a rat's a$$ about psychiatric symptoms in their patients, and who thus prescribe ridiculous med regimens as a result.

Don't dismiss the entire profession based on your limited experience.

 

[OldPsychDoc]

...
OldPsychDoc - Thanks for your comments. Are your sentiments generally shared in your professional community. Out here in Cali psychiatric mental health NP's may prescribe and tend to be work in outpatient settings under some level of supervision by an MD, whereas psych CNS's do not prescribe and tend to focus on psychotherapy and management of nursing staff in both inpatient and outpatient settings. I am somewhat torn as to which role would be the best fit for me. Certainly it seems logical that the ability to prescribe might give one more flexibility in the job market, however CNS's appear to be more in demand (at least on the west coast). Arghh! It ain't easy being an old man that is a confused college senior!...Thanks

My practice setting is somewhat "Kaiser-like"--in that it's a collegial large multi-specialty practice in the Upper Midwest. We are WAY short on psych providers (my next open new patient intake appointment is in mid-JULY, fercryinoutloud!). Our PAs and CNSs are really important to all of us.

Like I said, what we really want are people who want to take care of the mentally ill here.

 

[lusyd]

I know alot of people who WANT to take care of mental illness and have no clue how to do it. If I see another overweight, overeating patient get put on Paxil, or a pregnant woman put on Rozerem, or a thyroid patient put on any AD without proper medical tx, by a midlevel I may just scream.👎

 

[czyja]

Looks like things are degenerating to the level I thought might happen.

lusyd thanks for your input. I am sorry your experience with mid-level providers has been less than satifactory.

OldPsychDoc - you seem wise as well as old. It strikes me as quite reasonable to assert that their are crappy mid-levels out there just as there are crappy docs. I know there is a shortage of psych providers throughout all of the country with the possible exeptions of Boston and the Upper West Side of Manhattan. I anticipate that our recent military endeavors may well provide us with a good number of people needing help for many years to come🙁 . I hope that can be of service to them. Thanks for your thoughts.

 

[OldPsychDoc]

...
OldPsychDoc - you seem wise as well as old. ...

😳 Actually, I just feel old.
I've only got a couple of years on you...

(And the only times I've ever been called "wise", it was followed by another word which starts with "a" and followed by a pair of s's...)

 

[sasevan]

Hi Czyja,

I'm a psych PsyD going for psych DO.
When I started to consider changing careers, because I wanted prescriptive privileges, I first looked into becoming a psych NP.
During my psychology residency at a medical school affiliated healthcare center I worked with a psych RN turned psych NP in the C and L service, especially in the cardiac and geriatric units.
She seemed to me to be a competent provider and I never heard negative comments about her from any attending or resident; HOWEVER, she only treated patients with anxiety or depression and those with a limited formulary. She never treated patients with mania, schizophrenia, or delirium and instead referred these to residents.
Overall, my impression was that she could treat very well BUT only a limited number of disorders.
Because I didn't want those kinds of limitations I ultimately decided to become a psychiatrist but I can definitely appreciate the assistance that a psych PA or psych NP could provide a psych MD/DO and the benefit that they could bring to underserved patient populations.
Good luck with your decision.
Namaste.🙂

P.S. Have you fully explored the possibility of becoming a psychiatrist? OldPreMeds, like SDN, has a lot of info on the whole process and they're having their annual convention very soon.

 

[DebDynamite]

Dear OP,
From your original post, I think the question you need to ask yourself is this:
"How content will I be in the role of mid -level?”

I entered nursing school briefly in my mid twenties, and it was there that I realized that if I stayed in health care, I would have to go to med school. Honestly, nursing was just not academically challenging to me. Sitting in the nursing pathophys class one day, the instructor asked us to name "the" organelles in the cell. People listed the basics- golgi, er...ser, nucleus etc...I piped in "lysosome". She stated (granted she was old at the time and is probably retired now), "no...that's not an organelle...oh, wait, wait---yes I do believe it is!” On the floor, med students would ask each other questions and I would be more interested in joining in their conversations than those of my nursing classmates. So, after a brief time it became clear to me that my enormous ego coupled with my inquisitive nature made nursing a horrible choice for me. I would not have been a good nurse in any shape or fashion, because, I would have been bitter and resentful that I wasn't a doc. I think that the best nurses want to be nurses, not doctors- it shows up in their attitudes. The best mid-levels I've met have wanted to take on that role, not the role of doctor. Of course I have no idea if this would apply to you... but it's my story and worth sharing before you make any big decisions.

Given all of that, I was able to get into med school by 30. I don't know what I would do in my early forties. Good luck to you in your decision.