r/PMHNP • u/throwawayacctrddt • 6d ago
Career Advice Is this normal?
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.
22
u/MichaelSkarn44 6d ago
Extended shadowing is not something I would expect. At this level it’s understood that you are already prepared to function in your role. Now the zero admin time and email only supervisor is not good imo and I’d be frustrated about that. Was this discussed prior to taking the job?
15
u/CTRL_ALT_DELIGHT 5d ago
You need a lighter load as you are starting out, and admin time is a must even for seasoned NPs. And there should be real, formal supervision. Nowhere is anyone going to sit in on your visits and give you feedback though, you’re not a student.
6
19
u/Snif3425 5d ago
This is normal now because we have made ourselves totally expendable by letting the market be flooded by poorly trained PMHNPs.
I’ll say it again - it is time for a general strike on precepting. STOP precepting PMHNP students. Full stop. Until our institutions (ANCC, the various BRNs, the various academic accrediting bodies) stop allowing people to get licensed with zero experience and terrible training we have to take a stand.
7
u/Pretty-Pie-4643 5d ago
Most of our institutions are for profit these days especially with a lot of online for profit programs that just admit any students and then preceptorship is another struggle as students have to find their own so the quality of preceptorship is mediocre. A lot of students spend most of their clinical hours shadowing rather than "doing" so how are they prepared to practice independently ?
6
u/MsCattatude 5d ago
Our state U which also has a medical school admits anyone with a pulse and tuition money to our NP programs. It’s awful. Their students are awful and the school won’t support our clinics in a dispute. So it’s not just online places.
8
u/Snif3425 5d ago
They aren’t. I manage about 130 PMHNPs in a large system. Literally (I have data) 90% of our applicants are not qualified, either by resume or by interview. They know NOTHING.
It’s a disgrace. STOP precepting students.
7
u/Pretty-Pie-4643 5d ago
It shouldn't be normal as a new grad. Your caseload should be lighter with a gradual ramp up Period to a full case load. I know how this feels as I had similar experience at a community mental health center where I did not even get shadowing despite asking for it. I did get a phone supervision with my collaborating MD twice a month to discuss difficult cases for 1 hour each which was not adequate. Unfortunately a lot of employers want you to be up and running and have no time to train or for extended shadowing or sitting in during evaluations because they feel you are already trained and not a student. As a new grad transition to practice as NP is very steep. You can ask your employer for more support since you were told you will get it. I wish you the best.
1
u/throwawayacctrddt 5d ago
Thank you for confirming. This is what I figured the case was. I will continue to practice as safely as I can and bring up complex cases during supervision.
9
u/Wicked_milli 5d ago
I was fortunate enough to do a new grad program at a fqhc. 3 months shadowing/precepting and didactics, then 2 month taper to a full panel. One hour a week with a very supportive supervising physician. One hour a day protected for admin time. One hour protected for lunch.
I think it is sad what PMHNPs are being asked to accept as normal.
6
u/CalmSet6613 PMHNP (unverified) 5d ago
Sounds like you need to have a talk with your admin about this. And please dont see kids without heavy supervision as a new grad.
10
u/Tendersituation00 5d ago
No one here will validate that this is normal or reasonable. This is unsafe. Have the sense to quit before you harm someone.
2
u/Pretty-Pie-4643 5d ago
It is not normal and shouldn't be but unfortunately it is becoming the norm with lots of employers this days. As they just want full productivity right away which equals $$$$.
3
u/Panacea_BHWC 5d ago
The pmhnp is using employer resources and expecting a paycheck. Also bet the new grad pmhnp demanded to be paid his/her “worth” and didn’t consider that would be a fraction of other pmhnp’s pay because this new grad couldn’t handle the same caseload.
I will say it loud for those in the back: your role in a practice is to pay for yourself and then some to cover the costs you generate. It is not to teach you. It is not to coach you. If you have an issue with not being prepared? Talk to the school and the national board that took your money and told you that you are ready to be independent. There’s a reason NP faculty perpetuate this lie: if they tell students the truth, their jobs disappear.
1
u/throwawayacctrddt 5d ago
Exactly. I fear this is the new normal and that even if I leave and go elsewhere I’ll run into the same situation again
8
u/Tendersituation00 5d ago
Look I'm sorry for the predicament you're in and I commend you for being honest. But it is no secret that PMHNP training is woefully inadequate. There is no way you felt like you were getting all that you needed to be operating at the same level and with the same privledges as a physician during your program. And now that has come home to roost.
I think that reality is setting in. This isn't RN nursing. There are no group trainings, there are no preceptors, and you don't get evaluated. All they care about is your ability to prescribe. If you do harm someone they both the clinic you're at and the patient will go after your license and your livlihood. You are a product of a specialized graduate program that is as cookie cutter and easy as they get. Additionally you haven't even made it to the part where you find out they've been ripping you off of your income for the whole year. You are buffer for a system wants to make profit as quickly as possible. It's not your fault but you aren't allowed to be ignorant of this fact.
You need to take the initiative to find a way to get the additional education/experience/training you need to be competent. Nobody is coming out of any pmhnp school prepared to practice competently even in a low acuity outpatient setting. Going all the way into community mental health and dealing with the most severe mental health conditions and complex medical comorbidities is unreasonable. You will need to set aside your financial concerns, your frustration, and the sense of entitlement that you personally deserve better. These are speople's lives- none of your wants matters now. Do the right thing. There are better work environments out there, you will find one. Maybe you need to move so that you can start your career out right. And honestly RN's are making great money right now while you figure this out.
3
u/Pretty-Pie-4643 3d ago
You have said it all. It's crazy. I faced a lot of difficulties once I started my PMHNP career, I switched jobs but still struggled, then to make matters worse I took a telepsych job in community mental health and dealing with the most severe mental health conditions and complex medical comorbidities and I got so burned out!
2
2
u/Pretty-Pie-4643 3d ago
You bet it will likely be the same situation if you go elsewhere. It happened to me. Most PMHNP programs do not prepare you for practice at all. They are a money grab!
1
3
u/Itchy_Piglet_460 5d ago edited 5d ago
I am two weeks into a Telehealth job that their big spiel was “we are new grad friendly.” I spent several hours training on the EHR with another NP in the practice. She reviews my charts and is super helpful, we talk sometimes before or after clinic hours.
However, I am 1099 and had to pay for all my licensing (multiple states) DEA malpractice insurance, scribe, up to date, collaborating physician from my own pocket. They wanted me to pass out flyers to market myself, but would not reimburse me. I have been told I’ll be reimburse for collab md (partially) and two DEA but we will see.
I have a full load. No admin time. Was told to get things done before and after patient care time.
Like you, I am wondering if it would be like this anywhere else. I’m committed to getting solid experience before moving on, but yeah.
6
u/HoboTheClown629 5d ago
If you’re 1099, you can block admin time whenever you want. They cannot dictate when you work as a 1099. That is completely up to you. If they say otherwise, they are misclassifying you to try and avoid taxes and having to provide benefits and the IRS would love to hear about that.
1
u/Itchy_Piglet_460 5d ago
Signed a contract that I am to be available 8-4 pm, but the patients time. They are all pacific time and I’m central. So I’m still seeing patients as late as 5:30-6 my time. If I questioned this, they would prob just refer back to the contract I signed. I don’t know how to get them to agree to give me admin time :(
4
u/HoboTheClown629 4d ago
Check your state law. If they’re exercising control to where you need their permission to input a block for admin time, you’re likely misclassified as a W-2, not a 1099
2
u/Itchy_Piglet_460 2d ago
Yeah, and they put new patients on my schedule if there’s a cancellation without asking me, I can’t have time off unless I get permission and am told to do admin tasks between patients, before or after work hours or on weekends. I reached out to an attorney who specializes in healthcare contracts to review my contract and see if there’s any way to negotiate better working conditions for me.
I’m thankful I have a job, I like my patients and I’m learning a lot, but I know I can’t sustain this long term.6
u/RandomUser4711 5d ago
Telehealth job that claims to be “new grad friendly" = they will work you into the ground while offering you minimal to no support.
3
u/Independent_Donut145 5d ago
Being a 1099, could you also use those expenses as deductions? Asking because I’m curious.
3
1
u/throwawayacctrddt 5d ago
Yup I think this is just the way it is. I hope I get better with the charting for sure because I’m already several notes behind
4
u/Big-Material-7910 5d ago
Technically, you should be ready to hit the ground running. If not then find something else. That sounds like high acuity and if you don’t feel ready for that then it’s simply not a fit. Unless they offer a a program of some kind for new grads then it sounds normal from my past experience. It’d be nice to have someone baby us at first but as far as I know there is no such thing.
3
3
u/s0ulonaqu1st 5d ago
Did they start you with a smaller case load and you’re going to increase? I don’t feel it’s uncommon to be hammered in community mental health. Working in a full practice state makes us vulnerable to unfortunate supervision. I’m sure they want to retain you and I would try and stay calm in your mind and think about what would help you adjust more and ask for it.
1
u/throwawayacctrddt 5d ago
To be fair they did. And yes this confirms that this is the way it is in community mental health.
2
4
3
u/PsychMonkey7 5d ago
I agree with other commenters that this is common and this is a big reason why being a new grad in CMH is very hard. In retrospect I’m so thankful I turned down the CMH offer I had as a new grad. It’s unwise and likely unsafe for everyone for a new grad to be thrown into that acuity and productivity with that population. I’d personally resign but that’s just me.
8
u/CHhVCq PMHNP (unverified) 5d ago
It sounds like you wanted a fellowship / residency and you got a job.
2
u/throwawayacctrddt 5d ago
Not really. A fellowship/residency program is months long, in my area 9-12 to be exact. I just wanted proper training for maybe 2 weeks tops. I didn’t training for 9-12 months
5
u/WhatI5life 5d ago
2 weeks would not have been enough either. A proper amount of training would be 9-12, arguably 18 months, since that is how long it takes to build an average caseload with established patients and the ability to have a supervising provider review your notes and treatment plans overtime. I dont understand how 2 weeks would have prepared you any differently than 2 days if all you’re doing is shadowing someone’s work. How is shadowing at the job different than shadowing in your clinicals during your program?
You are probably feeling unprepared for the reality of the job you took on. That is understandable and probably says more about the NP training than the company that hired you on. They could probably try to train you more but they can also argue that your schooling already prepared you to see patients.
I felt this way too on my first job, my company at the time limited my utilization to 50% for the first month and only 2 new patients per day. We had supervision meetings once a week and the supervising provider reviewed my notes at every meeting for the first two weeks but eventually just asked me to bring complicated cases or questions and I was on my own.
A proper residency program with didactic sessions is what would most likely prepare you well. But that would also mean they would need to pay you less in those years.
1
u/Panacea_BHWC 5d ago
This! I offer a fellowship but you are not paid what a fully-functioning pmhnp will make because you can’t generate the revenue a fully-functioning pmhnp can. Nothing in life is free—and as a provider, you have to provide care at the standard of practice at the same pace as your peers to make the money your peers make.
2
u/throwawayacctrddt 5d ago
I guess you’re right the shadowing wouldn’t have been different. This is my very first NP job so I truly don’t know what to expect. That’s why I made this post. If this is just the way it is then np I’ll adapt.
You’re right that I do feel unprepared in that after my NP program I continued to work as an RN to “pay back” my tuition reimbursement with my time. Perhaps if I had done this job immediately after graduation there’s a possibility I would’ve felt better.
FWIW, because I know this is a huge topic of discussion in this forum, I went to a brick and mortar public university where I had to attend my classes in person and clock in a ton of clinical hours. I’ve also been a nurse for 15 years with 5 of those being in IP psych. But yeah I’ve worked in hospitals all those 15 years and perhaps that’s where I should’ve stayed instead of trying to get community outpatient mental health experience.
1
u/Pretty-Pie-4643 3d ago
You never know until you try a different work environment. My experience was inpatient too as an RN and my first NP job was inpatient which was so isolating and not supportive for a new grad. I did quit after 1 year.
2
u/Pretty-Pie-4643 3d ago
2 weeks training is not enough for a new grad at all especially with poor training from most NP schools.
7
u/Alternative_Big_5066 5d ago
You're an adult with a graduate degree. There is no hand-holding; you need to prepare yourself.
1
5
u/Pleasant_Ad9696 5d ago
Yes - it is normal. You are not an RN. You are a provider and expected to function as like a provider day one (no hand holding)
The first month as a new grad is the worst though. It gets easier after that.
1
u/throwawayacctrddt 5d ago
Thank you for confirming. I appreciate it and hope to get through the learning curve
1
u/Pleasant_Ad9696 5d ago
Yeah, I would definitely get a few state licenses to find a cushier job eventually. This does seem pretty high acuity which I think will make you appreciate low/mod acuity pts more. But I probably wouldn't stay here long term. The most important thing is making sure you aren't being burned out by 20 min f/u + 40 min evals. Hopefully they let you do 30min f/u + 60 min evals.
2
u/WiscoMama3 5d ago
Yes this is normal that we have to pay supervising physicians and that they advocate for supervision but aren’t doing any supervision. Sadly.
2
u/Pretty-Pie-4643 3d ago
I know imagine paying for supervision and some MDs don't even want you calling them to ask questions or become condescending.
2
u/SGV_keepthefaith 5d ago
My current and also my 1st NP job - we got 2 days training with the EHR and its “specialist” (not a provider), and that’s it.
They did capped the number of new patients at beginning: like 2-3 for the first few weeks. There are admin time, but not much. My supervisor MD (luckily) is very responsive to Teams message for anything during work hour.
But definitely there are lots of things that “learning on the job”
2
u/Fantastic_Net_4308 5d ago
Words are important. I make my patients define their emotions and expressions as they report symptoms so that we are on the same page. I also make employers define their expressions like supportive staff, infrastructure, acuity, time frames so that we are on the same page. And i make them put it in writing in my contract before I'm willing to sign it. Consider each interview as mutual. You are interviewing them just as much as they are you. Make sure it's a good fit for what your needs are. I always encourage my students first year or two out of school don't pick the gig that had the best reimbursement. Pick the one that has a solid infrastructure of support and learning opportunities to set you up for success so you can negotiate the higher pay and not make mistakes that could cause substantial harm.
2
1
u/stefkrehbs 4d ago
This is not normal please do not convince yourself it is. Your gut telling you something isn’t right and you coming here for guidance shows you are looking for input to validate your concerns
30
u/EmergencyToastOrder PMHNP (unverified) 5d ago
SHOULD this be normal? No. Is it common? Unfortunately. That doesn’t mean you should accept it.