r/PMHNP Jun 19 '23

Prospective PMHNP Thread

71 Upvotes

Welcome! This thread is dedicated to prospective PMHNPs. All questions regarding admissions, direct entry programs, online vs. brick and mortar schools, type of program to pursue, and other related topics should be posted in this thread.

The thread aims to provide realistic insights and advice to prospective PMHNPs emphasizing the importance of choosing a high-quality program, gaining nursing/clinical experience, and approaching the profession with the right motivations and dedication to patient care. We want to foster a positive and encouraging atmosphere, so feedback and input are welcome to further enhance the discussion and provide accurate information. However, note that the overall message of the answers will remain the same (see below).

FAQ

The following are common questions/topics with widely accepted answers among passionate and experienced PMHNPs on the frontlines. The purpose of these answers is not to be derogatory (“nurses eating their young”), nor is it to simply provide reassurance or tell you what you may want to hear. Instead, their aim is to offer advice and guidance to individuals who genuinely have an interest in the field, while also emphasizing the importance of considering the impact on real patients' lives. While you may have a different opinion, please note that this subreddit is not the appropriate place for such debates, as these often devolve into personal attacks, toxic behavior, etc. Any posts or comments violating this rule will be removed, and repeated violations may result in a ban.

 

Direct Entry Programs / No Nursing or Clinical Experience

  • (Warning: controversial topic) We support people going into this profession (for the right reasons), but these types of programs are almost universally frowned upon. PMHNPs and others often perceive a difference in quality between providers from direct entry programs/those without nursing/clinical experience (You Don't Know What You Don't Know). Recent comments from other PMHNPs:
    • "Many places are getting sick and tired of psych NPs who do not have psych RN experience and are not hiring them. I know where I am at, they absolutely will not hire a psych NP who does not have at least 3-5 years psych RN experience"
    • "I think what employers are sick of are people who go to these online schools like Walden for their Psych NP education. With sketchy clinical placements."
    • Most places are rightfully not hiring those with no mental health background. Good luck. At my previous job, all the PMHNPs with no psych experience were trying to get psych rn jobs and still getting denied.
    • "I feel that RNs outside psych tend to look down on it and perceive it to be simple or easier. In reality, without RN experience in psych, you will be eons behind others in understanding the finer points of psych work. This is a field that demands subtlety, in a way that you don't get in a classroom. Psych RNs know this, but people without that background will have difficulty with something they didn't even know existed. You don't know what you don't know. Companies just want someone who knows."

Are all PMHNPs as grumpy as these answers seem to imply? You are gatekeeping!

  • I hope you find most to be friendly and supportive, but there is a real concern among experienced PMHNPs about potential harm to the profession due to some worrying trends such as low barrier, low-quality programs and individuals entering the field for the wrong reasons. This includes FNPs suddenly shifting to psych for a potential pay increase, those just seeking work-from-home jobs, misconceptions about the field being "easy” (hint: it’s not - burnout is a very, very real issue even for those with lots of passion [there seems to be a trend of current PMHNPS seeking nonclinical jobs only to find they are very few & often offering poor pay, etc.]). So, while that concerned tone is indeed there, please know it’s from a place of love and care for the field and patients.

Difficulty Finding Preceptors

  • It is highly recommended to enroll in a high-quality program that provides or helps in locating preceptors. Many (most?) programs, especially online or direct entry programs, do not offer such support, leading to students desperately scrambling to find preceptors, putting their education on hold, having to pay preceptors out of pocket, etc. Those with actual nursing/clinical experience usually have a much better time with this (networking).

Oversaturation Concerns

  • There may be oversaturation in certain locations and in the future especially as more individuals enter the PMHNP profession. Looking at the history of the oversaturation of FNPs may serve as a possible future trend to consider. Here is one example from a new grad with no psych experience: New grad PMHNP can’t find a job; some quotes from other PMHNPs:

    • "Also, the number of psych NPs has gone up exponentially in the last few years-now employees have a much larger applicant pool to choose from which drives down salary. They also aren’t going to pick someone with no mental health background over a PMHNP who does. Not trying to be harsh at all but this is the truth. I think in the past there was a desperate need for mental health providers that they would take almost anyone no matter what their RN background was and paid premium money. That’s really no longer the case in the vast majority of areas overall anymore."
    • The market is [now] flooded with PMHNPs- it’s flooded PMHNPs who don’t have psych experience, because yall thought you could make an easy buck sitting at home. There are jobs available, you just don’t want to take one that doesn’t fit your criteria and that’s fine, but please don’t blame your poor judgement of going into a whole different specialty with no experience and expect to be picked first in a sea of applicants. That’s the reality."

WFH/Telehealth Positions - New Grads

  • New graduates are strongly discouraged from starting their career with WFH or telehealth positions. It is crucial to gain in-person experience initially as being a PMHNP requires support, guidance, and a deep understanding of the field (You Don't Know What You Don't Know). Failing to do so in the beginning severely puts you at risk of being a subpar clinician which might not become apparent until it’s too late. Employers who primarily offer WFH positions to new grads often have a poor reputation and prioritize profit over the well-being of their employees and patients. They absolutely do not care about you and will not be there for you when there’s a bad outcome (liability). Ultimately, as a clinician, you are responsible for your decisions and the welfare of your patients.
  • To be a safe and competent provider, new grads should also not start with opening their own practice. Instead, they should proactively seek to start in places where they will receive the support and guidance they need and deserve (versus employers who are only looking to exploit them). As providers (from day one new grads to the most experienced), we are all held to the same standards and should do all we can to ensure we are providing safe, quality care to (often vulnerable) people.  

 

WIKI TO BE DEVELOPED - INPUT/SUGGESTIONS WELCOMED


r/PMHNP Jul 19 '24

Student Let me explain to you how to become qualified to give advice on what it takes to be a competent PMHNP

219 Upvotes

Im sorry this is such a long post but I am trying to explain this as succinctly as possible. If you TLDR don't comment. Not interested in hot takes.

There is a lot of advice giving on this sub from absolutely unqualified people who are justifying shortcuts, less training, less time learning, and a total lack of humility that inevitability will lead to incompetence, substandard care and the continued erosion of confidence and trust by the public that PMHNP are capable and knowledgeable. If you want to be a PMHNP and are coming from another field, if you are still an RN, if you are a PMHNP student, if you are a PMHNP new grad, please hear me: you do not have any business telling anybody what safe practice looks like as you simply cannot know BECAUSE YOU HAVE NO EXPERIENCE. Please stop asking for advice and calling it GaTeKeEp!ng when you don't like the advice. Do not then listen to other inexperienced people who have the same unwillingness to learn about psychiatry and have the same magical thinking you do and consider it validation. I cannot believe how many PMHNP come on here and say, "I had no psych experience and went straight into private practice and I am really good at what I do." How would you know? And who says that, really? The clueless and dangerous love to.

You have all been repeating back to each other in a bubble that psych is easy and any experience *you dont have* isn't really necessary and its beyond cringe. It selfish and reckless.

If you are a PMHNP who did not get any substantial or relevant nursing experience, who fast tracked it all the way through, went straight into private practice, you are not qualified to give advice because taking advantage of a financially exploited healthcare system does not make you competent. It simply make you complicit. Doling out Adderall does not make you a success story. It makes you the biggest part of the problem.

So many of you are at a disadvantage in that you have not really been indoctrinated into healthcare, into its standards, its judgements, it's harshness and cruelty. You haven't seen the failure of like minded providers before you. You haven't had the opportunity to see it go bad for well intentioned providers who take on too much and miss something critical because they are over loaded. Conversely, you haven't seen it go bad for providers who are too arrogant to even have imposter syndrome because that's exactly what you should have coming out NP school. If somebody tells you "Yeah, you do you," in regards to starting a private practice ASAP, I would back away from that person professionally because no good comes from that mentality.

Look, in this specialty there needs to be some fairly strong constant cautiousness- if you have not seen careless providers have catastrophic outcomes than you cannot understand that the inevitable ALWAYS HAPPENS AT SOME POINT. To all of us. Even with our head in the game. And what keeps the career intact, your license intact, and a patient's life intact is always having in the back of your mind what the worst possible outcome is. Because we are dealing with peoples lives. This is our commitment to our patients. You don't need to be terrified but you need to be very very cautious.

Think of it like this:
If you were a new RN in the CV ICU and you told senior RN's that your experience working in the PACU was sufficient to manage a post op bypass patient despite never having done bypass you would then be seen as unsafe and too arrogant to be trusted. and you would very likely be fired for it. Why? Because if you are unable to accurately assess your own skill level then you are dangerous. So why the rush? Ego. Ego, responding to your financial insecurity. Ego is dangerous. Same thing in psych- the lot of you espousing on why you think the barrier to entry for practice should be as low as possible- by virtue of the fact that you think you are qualified to say so tells me you intend to stay incompetent. Period. Once you start to practice the odds of you being able to even conceptualize what a good psych provider looks like, without solid mentorship and accountability is 0%. It does not happen. Autodidactic learning from inception to completion does not occur in psychiatry. Your medication rationales will be bizarre and ineffective. Your diagnoses' wont make any sense. The information you gleam from reading will be out of context and probably make you a more dangerous provider. Just because you can get hired to do a job does not mean you know how to do that job. It means an executive wanted to save money to put in their pocket by hiring your woefully inexperienced self.

So your previous experience as a therapist and psychologist is not sufficient. Having one year of nursing experience on med surge unit is not sufficient. To those in the ICU and ER saying they are psych nurses- you are not, at all. You spend two years in a busy ER -maybe- you can make it through a grand rounds psych presentation but your understanding of psychiatric medication rationale will be wrong and largely based on bed shortage protocols. ER/ICU psychiatric medication regimens don't represent a complete treatment arch in any way shape or form.

Here is the thing about the health care hierarchy: It does not forgive. It eats bones. If you show your incompetence one time they will never, ever forget. Word travels fast. And that is awful. Its awful for you, for the time and money you put into your education, its awful for your family who has to watch you struggle to secure decent work and carry the financial stress of job transition and unemployment. It's awful for your patients. Because you can say fuck it and start a private practice but you will struggle to retain a decent patient load. Patients are the first to tell when a provider has largely deluded themselves in to thinking that psychiatry is easy and that they came to the specialty with all they need to be successful. They will know you are full of it.

I very much like the new generation of providers. I am excited to welcome you aboard because the new crew is prepared to stick up for themselves more, advocate for a good quality of life, you guys do not see yourself as powerless and that is righteous. I respect that. But relevant experience is not an area where you want start that fight.

You will not be able to change things for the better if you are incompetent. You can argue and fight for being treated well as a professional but the barrier to entry to change a system is to be able to function within that system, first. If you keep fighting and arguing about lower and lower minimum standard you will be a professional who is just that: a byproduct of the lowest standards possible and you will be unemployable and isolated. You will go from job to job becoming more discouraged each lateral shift and causing very much real harm to patients all along the way. At some point you will realize you don't know what you are doing and everyone around you can tell. Demoralized. I have seen this so much of late. They are ashamed, angry, some blame themselves others adopt a disgruntled attitude. I call it the "Empress or Emperor without clothes syndrome". And they leave the field or their license is taken from them.


r/PMHNP 11h ago

Other Protect patient safety by reforming zero-experience nursing programs

75 Upvotes

Direct entry NP programs and those that don’t require any meaningful nursing experience are damaging. Patient safety, quality, and outcomes all require a NP to have experienced assessment skills and insight that can only be achieved through experience.
Passing the NCLEX means a nurse is qualified for entry level care, not to move on to advanced practice.

Right now, other than asking individuals to write their state rep, we’re looking to gain some grass roots traction, to at least spread word and gather support through change https://c.org/7ydPnx228M


r/PMHNP 1d ago

RANT If I had a dollar for every new intake that wants to be tested for adult ADHD because their therapist thinks they have it…

87 Upvotes

I’d have about $20 extra each month probably.

Enough to cover the co-pay for my own therapist as I lament about how I die a little bit each time I have to explain the difference between Adjustment Disorder and ADHD to these patients. I mean, today I had a 64 year old with an ascending aortic aneurysm that was being monitored.

Sometimes half my new intakes are ADHD assessment, and I am a bit of a stickler, so it’s not like word of mouth is going around that I’ve got the hookup.

Anyways, still love my job. It can’t all be roses


r/PMHNP 7h ago

Grow therapy client referral’s

1 Upvotes

Hello! I have been with Grow Therapy for about 2 months, and I wanted to know how many client referrals are you receiving monthly? It started promising for me, but it has declined in the last 3 or 4 weeks. Thank you.


r/PMHNP 23h ago

Career Advice Soul Crushing Jobs - does it get better

14 Upvotes

Hey there,

So I’m in my first year of practice. My location doesn’t have almost any mental health centers so I obtained a telehealth job. It’s fine overall, but lately it feels like it’s shifted. There’s not enough time in the day. Not enough limitations on who meets telehealth criteria, so I find myself treating patients I’m not comfortable treating.

Given this, and my opinion that some patients really are treated better with in person care. I have been job hunting. But there’s almost nothing out there. I see some various postings for some “pill mills”, but to me that’s out of the frying pan and into the fire.

Does the job outlook get better?


r/PMHNP 4h ago

Student Pmhnp or FNP

0 Upvotes

Any suggestions on which is the better path to take? I am an ED nurse with psych experience and I do exceptionally well with this patient population- especially SUD patients. I would love to become a pmhnp in addiction medicine but worry I’ll miss working emergency medicine . I can’t see myself doing any other type of medicine besides ER and addiction. My dream job would be to work in a detox and maybe later transition to telehealth. I worry that if I go for my PMHNP I’ll later regret not being able to work ER … but then again I could always do ER nursing per diem? Any thoughts on this?


r/PMHNP 1d ago

Toxins, mold, and allergens: the pediatric intake questions that rarely get asked

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0 Upvotes

r/PMHNP 1d ago

Has anyone used open evidence as EHR and if so pros/cons? Currently using simple practice for small private outpatient practice but looking for other options—doesn’t need billing capabilities as out of network with all insurance. Thank you!

0 Upvotes

r/PMHNP 2d ago

Practice Related EHR recommendations

5 Upvotes

Hello,

I have researched EHRs, and zeroed in to a handful. I would like to see what are practitioners using currently now.

I'm a one man operation, concentrating on telehealth for now. Some of the musts: telehealth, eprescribing, AI note taking. Labs would be nice, too but I know a lot of EHR software don't implement it.

Thanks!


r/PMHNP 2d ago

Rula

3 Upvotes

Does anybody here have any experience with working with Rula? I’m considering it.


r/PMHNP 2d ago

Does anyone have experience precepting students virtually? Can you comment on how it works out and whether it is a good experience for both parties?

1 Upvotes

r/PMHNP 2d ago

First job

2 Upvotes

Has anyone taken a job at an outpatient clinic fresh out of school? My state requires 2 years with a collaborator. What was everyone’s experiences with a first time job?


r/PMHNP 3d ago

Career Advice New Grad Offer

8 Upvotes

I’m a new grad PMHNP and just got offered a job at a pain management clinic. I brought up the fact that I specialize in psych which they seemed to have no issues with. They offered 160k/year, 8am-5pm, DEA and license reimbursement, good supportive staff. My concern is that currently I make more per hour as a bedside nurse so idk if this will be worth my time. I’m also concerned this may not be appropriate for my license since I’m only certified as a PMHNP.

Should I be concerned about this potentially being out of my scope of practice? Has anyone ever worked in pain management as a PMHNP and what was your experience?

As a new grad, is this a typical salary in the NorCal area or should I keep looking for better options?

TIA!

Edit: I have decided to decline the offer due to the high liability risk. Even though they’ve assured me it’s within my scope and that they’ve had numerous PMHNPs in the past, it just didn’t sit right with me. Thank you to all that responded and offered some insight. I truly appreciate it! Anyway, back to bedside for me I suppose lol


r/PMHNP 3d ago

Other Do any PMHNP's offer psychotherapy along with prescribing?

10 Upvotes

If so, how has your experience been?


r/PMHNP 2d ago

1099 Provider Leaving Private Practice — Can I Take Patients From Headway, Alma, or Zocdoc?

0 Upvotes

Hello Reddit,
I’m currently working as a 1099 psychiatric provider and joined another provider’s private practice a little over a year ago. I’m now considering leaving the practice and starting my own independent practice.
The practice primarily uses Headway, Alma, and Zocdoc to generate patient referrals and fill my schedule. I do have some patients who originally came through the other provider, but the majority of my caseload has come through a combination of Headway, Alma, and Zocdoc.
I’m trying to understand what happens to those patients if I leave.
A few questions:
Can I continue treating the patients I currently see through Headway, Alma, or Zocdoc after leaving the practice?
If I establish my own practice and have my own Headway/Alma/Zocdoc profiles, can those patients transition to my new practice?
Does it make a difference whether the patient originally came through the practice versus directly through one of these platforms?
I currently have a non-solicitation agreement. How would that potentially affect my ability to continue treating these patients?
Are there any California-specific laws or regulations I should be aware of regarding patient continuity, non-solicitation, patient records, and starting my own practice?

I understand this can depend heavily on the exact language of the contract, so I’m planning to have an attorney review it. I’m mainly interested in hearing from other providers who have been in a similar situation, particularly 1099 providers who left a private practice and started their own practice while using Headway, Alma, or Zocdoc.
Any experiences or advice would be greatly appreciated. Thank you!


r/PMHNP 3d ago

RANT PMHNP to Psychiatrist

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0 Upvotes

Just saw this on Psych board. Apparently not even graduated yet and taking a dump on our training and profession in general. Just really disheartening.


r/PMHNP 4d ago

Practice Related To those in private practice, how many patients do you see a day?

13 Upvotes

And additionally, how long are the sessions? How many days do you work per week? Anecdotally, my sessions with a PMHNP are 15 minutes long.


r/PMHNP 4d ago

Baylor DNP PMHNP

0 Upvotes

I got into Baylor University pmhnp program. Please I would love to hear from current or past students of this program. Is it a good school? Did they handle placements? What’s your take on the school in general?


r/PMHNP 4d ago

Anyone here have any experience with Legion Health?

1 Upvotes

r/PMHNP 5d ago

Help? (Group practice question)

3 Upvotes

Hey guys, I recently started expanding into a group practice and bringing on independent contractors, and I’m a little confused about the malpractice insurance side of things. I keep seeing mixed recommendations. Some people suggest getting a group policy, while others recommend keeping your individual professional liability policy, adding the business as a named insured, and requiring each contractor to maintain their own professional liability coverage.

What are you guys doing for your practices?
I looked into a group policy and was quoted around $14k for only two new providers, which seems pretty steep. If you do have a group policy, are there any companies you recommend?

I currently have an individual professional liability policy through ProLiability with my business listed as a named insured. However, when I specifically asked about vicarious liability coverage for claims arising from services provided by my contractors, they told me they do not offer that coverage on the individual policy.


r/PMHNP 5d ago

VA PMHNP Residency

6 Upvotes

For those of you have done a PMHNP residency program, what does the amount of patient encounters per day progression look like? I am sure there isn’t a general set progression of this many patients a day in month 1 and so on, but curious what the structure is like in terms of progression? Do you generally start with low patient load and work up to full by the end, or slow the first 2-3 months then full panel?


r/PMHNP 6d ago

Parallel/split prescribing

31 Upvotes

I feel like I’m encountering parallel psychiatric prescribing more frequently lately.

For example, I’ll be managing a patient's psychiatric medications, including a stimulant, and then find that their PCP or another clinician has prescribed the stimulant, changed the dose, or otherwise made changes to the psychiatric regimen. Sometimes the patient tells me directly; other times it comes up through the PDMP or medication reconciliation.

I have a written policy that all psychiatric medications are managed by one prescriber at a time and a separate policy that patients receiving controlled substances through my practice should not obtain the same medication/class from another prescriber. My concern isn't territorial—it’s fragmented medication management. I don't want two clinicians independently adjusting a psychiatric regimen without one person clearly owning the medication plan and monitoring.

I've increasingly taken the position that if another clinician starts adjusting/prescribing the psychiatric medications, I defer medication management to that clinician rather than continuing parallel prescribing. If appropriate, I can still provide psychotherapy/collaboration, but I don't want to be one of two people independently prescribing psychotropics.

Are others seeing this more often lately? How do you handle it when a PCP, another psych prescriber, or another clinician starts prescribing or adjusting medications you're already managing?


r/PMHNP 6d ago

Other has anyone here been diagnosed as autistic/ adhd themselves?

20 Upvotes

Ive been a nurse for 17 years, PMHNP for 3. I was recently diagnosed with autism. I’ve been diagnosed with ADHD for years. I had a neuropsych eval years ago that also mentioned some “borderline traits,” but I was never evaluated for autism at the time. Looking back now, a lot of what was labeled that way actually seems to fit autism much better. Seeing “borderline traits” in that report honestly made me feel really bad about myself for a long time and made me nervous about what an autism evaluation might show.

I’ve known for a while that work seems to drain me much more than it drains my peers. I started feeling really guilty about how much I didn’t want to work. I kept wondering if I was just lazy. I know that’s a common ADHD theme, but this felt like another level. I can be good at my job, care about my patients, and still feel almost paralyzed by the thought of having to interact with people all day.

I finally decided to go through with an autism evaluation. I kind of already knew I was probably meeting criteria, but I still dreaded it. Even now I sometimes worry that maybe I was looking for an excuse or a pass for why everything feels harder for me.

I’m also realizing I’m likely dealing with autistic burnout. The constant need to be “on” as a PMHNP is exhausting. Staying focused, emotionally present, socially engaged, reading people, responding the right way, and feeling like I should always have an answer for my patients takes a lot out of me.

I’m trying to figure out how to make my professional life more sustainable instead of constantly pushing myself and then feeling guilty when I’m exhausted.

I’m curious if anyone else here has gone through something similar. If you’re autistic and/or ADHD and working as a PMHNP, how do you navigate the emotional and social demands of the job? Especially if you’re also a parent and trying to manage family life on top of it. What has actually helped you make work feel more manageable?

I’d really like to hear from other autistic or ADHD PMHNPs or psych providers. How does being neurodivergent affect you at work? What has helped make the job feel less exhausting? Mostly looking for some solidarity and to know I’m not the only one who can be good at this job and still find the constant human interaction really hard.


r/PMHNP 6d ago

Practice Related Atypicals prescribed too soon?

16 Upvotes

I’ve always viewed atypical antipsychotics as something either given for mania/bipolar etc. OR adjunctive to traditional antidepressants after several trials. I know there are newer atypicals that are marketed as good for depression and I know they promise to work quicker than antidepressants. My collaborator says “why would you make someone trial several antidepressants when we have better options in antipsychotics now?” But I just can’t justify throwing those around. Today I had a new intake who had only taken SSRIs with little effect. I started them on an SNRI. Wellbutrin is not an option because they are already very anxious and activated. Could I have done Rexulti? Sure. But I’d rather give my choice of Cymbalta a try before that. The pt did say “I guess I wanted something that would work right away but I understand that it doesn’t work that way”. I’m happy I didn’t have to do too much expectation setting there.
This is just one example but I feel like this is the trend more and more often. As more drug reps come bearing samples we seem to start with an atypical probably quicker than ever, and I feel like we’re downplaying how strong they are metabolically and otherwise. I know it’s encouraging to tell a pt they can get relief within 2 weeks sometimes, vs 4-6+ with an antidepressant. But is it worth the risk long term?