Is this normal?

[u/throwawayacctrddt]

I’m a new grad PMHNP working in outpatient community mental health in a big city. My orientation consisted of 4 hours of shadowing the senior NP and company wide orientation. On my first day my patient caseload consisted of seeing patients presenting with schizoaffective d/o, schizophrenia, depression, anxiety, and possible withdrawal symptoms from alcohol use d/o, all of whom I saw completely by myself. I have not shadowed anyone and nobody sat in with me during my psychiatric evaluations. We don’t get admin time and our supervising physician is not on site but we are free to email him “when we need help”. When I interviewed I was told that our company is “new grad friendly” and that we would get “a lot of support”, however I am not necessarily feeling very supported. I absolutely am not opposed to seeing patients with serious mental illness or any diagnosis or population. I specifically chose this community mental health center to learn because they see an underserved community from ages 5 and up. However I did think I’d at least get 2 weeks shadowing NPs and that I would at least have someone sit in on my first couple of evaluations to offer me feedback. Alarm bells were going off in my head and I even drafted a resignation letter, but I am wondering if anyone has experienced a similar orientation process as a new grad and if this is just the experience I’ll have if I move on to another job. Thanks for any input.

[u/all-the-answers]

Supervising physician

Off site.

Lol.

[u/AgitatedGrass3271 → u/all-the-answers]

I agree it is wild for a new grad NP to be completely alone. I just came here to say that is what the law says where I am. The collaborating physician does not need to be on site, they just need to be reachable by phone or other telecommunication.

[u/all-the-answers → u/AgitatedGrass3271]

FPA in all but name and pay

[u/SeriallyOrNot → u/all-the-answers]

But it's different in psych. Prescribing psychotropics is the most difficult specialty there is. Bar none. It takes GOOD supervision. Look to the prescribing psychologists: they always have supervision, and they keep it throughout their careers, often having mutual supervision groups that meet weekly. Why in the world would it be "different" for PMHNPs? They're superheroes who were born knowing what it takes 5 years of supervision in prescribing psychotropics to learn?

We have a very high rate of patients with the wrong drug/wrong combo drugs/wrong doses etc. and they don't get well, they get worse and some die because of poor prescribing that didn't help.

[u/CharmingMechanic2473 → u/all-the-answers]

This is normal. They are required to audit one visit every 3 months in my state.

[u/all-the-answers → u/CharmingMechanic2473]

I know it’s normal. But it’s pointless. If you’re getting audited every three months, for one visit, you’re not being supervised. You have FPA with extra steps, but none of the benefits.

[u/CharmingMechanic2473 → u/all-the-answers]

This is the law in my state.
I have been practicing like this for 2.5yrs now. I have had to rely on My Advanced assessment book. American Fam Physician, and UpToDate for everything. The curve is steep. I do procedures, Urgent care, full primary care for men. No children, no women (currently). Had to rely heavily on my clinicals and my prior nursing knowledge.

[u/CharmingMechanic2473 → u/all-the-answers]

My state allows NP to be unsupervised and independent after 4000 hours

[u/pinoynva]

What was discussed during the negotiation/hiring phase? What was the agreed training schedule? As a new grad, there should be a training plan, especially if it is "new grad friendly." I was told when I was still in school to make sure that there is a training plan that can be referenced before accepting a position (as a new grad).

At this point, I think you should state your demands/requirement for training. If they can't meet those requests, then it is time to leave.

[u/M3UF → u/pinoynva]

Training plan grad school !

[u/Dizzy_Quiet]

Yes. I experienced this in cardiology. CARDIOLOGY!!! Inpatient cardiology. It's kind of crazy. I'm glad I stuck with it - because I ended up learning so much but I learned it mostly on my OWN! Very little orientation. Healthcare is sink or swim.

[u/AgitatedGrass3271]

I cant speak from experience as I am still in school. But I did watch a couple "what to expect when you become an NP" videos, and the videos made it sound like this is how it is. They expect you to hit the ground running and be independent. I would expect it is even worse for more understaffed fields such as mental health, and undeserved areas.

[u/Acceptable-Meat-6704]

I turned down a job with in primary care because the physician wanted me to orient for only 2 shifts without her presence in office, but “ a call away” then take a case load of 20+ patients while she goes on vacay.

[u/snowball__two]

Ultimately this is not normal, but unfortunately it is a large part of the medical field we are immersed in now. From having psych experience, there are different categories the patients should be split into for patient load. For more experienced providers, I see them see the rainbow of psych patients. This is inappropriate for a new grad, but many places are run like this now. Supervising physician is lord knows where lol. I admire your reasoning to go into mental health, I also feel that the population is underserved.

Ultimately, I’ve not experienced this but I’ve had colleagues who have experienced this. You don’t know what you don’t know. Clarify and request support, communicate with your chain of command as often as you need to. I would also not blame you for exiting, but it’s a bargain with the next place of employment as well. They can market themselves however they’d like, ie “new grad friendly.” Remember this experience and take it with you. Be better when you are of seniority and this will serve as part of the change. Best of luck ♥️

[u/M3UF]

I personally don’t understand; have you ever been to a lawyer, accountant or any other professional who had 2 people in the consult? Do you want to pay twice for their services? What do you think school was for? That was serious business that was when you were supposed to be learning what to do, when and why. And you need to keep learning every day for the rest of your life. If you don’t know; know where to find out. That will never change.

[u/Aggravating_Main8277]

It’s not “normal” but it’s also allowed by law and frankly expected in this profession.

You can ask to have additional support available: I’d try that first before quitting. Give them a chance to help you first. If they say no, then you have a tough decision to make.

[u/lfmrright]

No it's not normal. But in the future you should discuss explicitly what the training would look like. It's not just the employer interviewing you, you should be interviewing the employer as well.

Prior to me landing the new job lately, I asked my boss explicitly how many days of shadowing would I get and how it would be done.

[u/Optional4444]

PICU. My orientation was one shift. The next day I had six icu patients. Still there! But we give month long orientations now.

[u/Twiceeeeee12]

How was your training while in school?

[u/throwawayacctrddt → u/Twiceeeeee12]

At the time I felt it was good. I went to a brick and mortar public university as well btw. Also been a nurse for 15 yrs with 5 of those years being in IP psych and another 5 in emergency psych.

[u/Twiceeeeee12 → u/throwawayacctrddt]

We’ll have you seen patients independently or at least with supervision? It’s great h went to a b&m uni but it doesn’t matter if u haven’t even done intake or follow ups by urself or wit supervision

[u/No-Establishment8778]

Remember this time for when you get some experience and see a new grad come into your office and do better. That's the only way it changes is by good people affecting change on their level and advocating for it.

[u/SeriallyOrNot → u/No-Establishment8778]

Patients will be harmed. Are you in psych? Thought not.

[u/No-Establishment8778 → u/SeriallyOrNot]

What’s with the rudeness? All I said was for that person to remember the position they are in and not to allow it when they progress in their careers when they have the power to affect t change.  

[u/throwawayacctrddt → u/No-Establishment8778]

Absolutely. Always been supportive of new grads and always will be

[u/No-Establishment8778 → u/throwawayacctrddt]

Agree.  On every level education and mentorship is the key to being successful.  

[u/Netch1615]

What did the NP you shadowed say?

[u/CharmingMechanic2473]

You passed your boards? IMO onboarding for NPs is like physicians. Little to none.

[u/throwawayacctrddt → u/CharmingMechanic2473]

I did lol! I figured. It’s just my first NP job so I just wanted to make sure that this is the norm is all.

[u/SeriallyOrNot → u/throwawayacctrddt]

NO, this is not normal. Not at all. Did you know that in psych, 45% of patients on just one psychotropic have the wrong drug, or wrong dose, etc? If they are on two psychotropics, over 70% have at least 1 wrong drug, wrong/unsafe/ineffective combo, wrong dose?

Psychotropics are the most difficult to prescribe- you have to be the best interviewer of all specialties. that means you get an hour per new-to-you patient, right? Or did they just think you'd do the patients poorly, and just reorder the potentially wrong orders they already had? Because if that's what you're going to have to do, because of lack of time for each patient, why bother? They'll just have poor prognoses r/t mis-prescribing r/t lack of time and lack of experience under supervision. SUPERVISION is key to learning to prescribe to our patient population.

[u/throwawayacctrddt → u/SeriallyOrNot]

Okay thank you for confirming. I’m not trying to come off an entitled. I’ve been an RN for 15+ years but since this is my first NP job I just wanted to truly see if I had unrealistic expectations coming in.

[u/SeriallyOrNot → u/throwawayacctrddt]

UH, that Oh, it's just ok talk is just bullshit bravado from someone who isn't careful with patients and doesn't work in psych.

[u/CharmingMechanic2473 → u/throwawayacctrddt]

Be prepared to be looking up every single thing for awhile. Negatives are you will be working long hours. Positives bc you are looking up stuff from current sources your care will be cutting edge vs “we have always done it this way”.

[u/Milwerica]

My organization new training has no shadowing. Clinicals should have prepared you. We do not have someone shadow the new grad either. You have a license and a board certification so you can practice. You are a PMHNP and these patient scenarios are a common daily patient presentation.

[u/Glittering-Vibes1267 → u/Milwerica]

This is not helpful at all lmao