Oh, the places you’ll go
I’ve been a psychiatric nurse practitioner since 2018 and in no other period of time have I grown so much as a person or provider. The past six years are marked by many experiences and lessons.
I’ve had the opportunity to work in many different settings – community mental health, crisis stabilization, addiction treatment, intensive outpatient eating disorder, and a tribal clinical working with a rural Native American population.
I’ve done full time work, contract work (locum tenens), part time, and telehealth. I’ve worked in a few different states – Ohio, Connecticut, and Wisconsin.
I experienced more stress and challenges than I anticipated. Dr Seuss said it right when he wrote in Oh, The Places You’ll Go, “I’m sorry to say, but sadly it’s true, that bang ups and hang ups can happen to you… You’ll come down from your lurch with an unpleasant bump, and chances are then that you’ll be in a slump. And when you’re in a slump you’re not in for much fun, un-slumping yourself is not easily done”.
Right Dr Seuss was – “un-slumping” myself has occurred in every lesson I’ve learned over the past six years.
While not a seasoned nurse practitioner, I’ve been introspective along my journey as a psychiatric nurse practitioner and there are several tidbits I’ve learned over the years. The following are lessons I’ve learned – one lesson per year of work as a nurse practitioner.
2018
Not all patients respond the same to medications and patient presentations vary.
I was very “by the books” when I was a new psych NP grad and as a result, I was very much frustrated by the nuances and complexities of the patients I saw. My patients didn’t always neatly match case studies and they weren’t always presenting how the DSM stated they should.
I slowly learned that mental health treatment is greyer than I thought. And as a new grad, this lack of clear structure and direction was stressful. It took much of that first year, and beyond, to relax into the lack of black and white treatment in psychiatry and become more comfortable in the gray.
2019
Your employer doesn’t always understand your role as a nurse practitioner.
The role of nurse practitioners has been around for a shorter period of time than Tom Cruise has been alive – let that sink in.
So, it’s understandable that not everyone, your employer included, will not fully know your scope of practice. For example, in my first job as a psych NP, my employer didn’t realize I needed two separate collaborating psychiatrists for me to see patients across the lifespan, one who was licensed to treat children/adolescents and one who was licensed to treat adults. Because I live in a state that requires I have a collaborating physician, the collaborating physician needed to be licensed to treat the types of patients I was seeing; if that involved kiddos, the physician needed that license too!
I had just assumed that my role as a nurse practitioner was established and understood by all. It took time to take ownership of my scope of practice and make sure to educate myself, my patients, family members, and employer at times, of my role as a nurse practitioner.
2020
Know when it’s time to take a step back from a job, attuning to your needs.
I had jobs in previous years where my stress levels were wild. Where the Wild Things Are level wild. In 2020, pre-pandemic, I was hired for a job where I would help create and integrate medication management services into the organization. Prior to my being hired, the practice was solely therapists. I was excited for the opportunity to help forge a new branch of the practice.
What I hadn’t planned for was the level of stress I would experience. I was the only prescriber, had no ancillary support staff such as a nurse or medical assistant, and I was the scheduler of all my patients. Again, this was a job where there was no prior medication management so I was establishing protocols as I helped build these services.
But after almost a year, I was stretched to my limit. Burned out. 2020 was a year I learned when it’s time to take a step back and attune to my mental health and energy needs. I quit this job after just under a year of practice there.
2021
Setting boundaries, and breaking the norm, is key to longevity.
This year, my lessons of learning involved creating more systems to help preserve my energy. Psych NPs, and nurse practitioners in general, are expected to have an Energizer Bunny degree of emotional bandwidth and multitasking skills, while simultaneously skilled at sitting for prolonged periods and maintaining ninja-speed charting talents.
In 2021, I decided to explore more non-traditional career options. As an NP, I had thought my path would look like working 5, 8 hour days in an outpatient setting – this had been the dream for me when I was a registered nurse (no weekends?? No brainer). But over the years as an NP, I became tired more quickly and stress mounted. I learned about locum tenens contract work and took on three-month assignments in various states.
These short periods of work allowed more flexibility and control over my time with taking several months off after assignments. I grew a lot from my locum tenens experiences and I share more about challenges such as fear of failure in this blog post.
2022
Patients’ progress is not a reflection of how good of a provider you are.
This is something I really struggled with, and sometimes still do. I carry a lot of personal responsibility for the wellness of my patients – if they’re not getting better or doing well, its because I’m not effectively treating them.
This is way too egotistical of a perspective and not accurate. So many factors play into the mental wellbeing of patients. This is even tougher with complex patients with multiple psychosocial stressors. I didn’t realize that though. In fact, I took a year-long course to become certified in Cognitive-Behavioral Therapy (CBT) because I felt that just medications wasn’t enough – if I’m effective with prescribing and providing CBT-based treatment will my patients get better I thought.
I needed to learn that my role is to be present, meet patients where they are, provide evidence-based treatment, and help them find wins (and find them myself). Progress no matter how small is progress.
This year I had to learn that not every patient will come to optimal mental health when working with me. Sometimes you’re just getting to see some small steps in the right direction – a patient not having suicidal thoughts in a month or being sober for the first time in their life for 7 days. When I started releasing personal responsibility for patients’ global health, some stress was released.
2023
HOW you prescribe has as much effect as WHAT you prescribe.
It took me a long time to realize this and only truly internalized it after attending a grand rounds lecture through a local university for psychiatry residents.
The lecture by Dr David Mintz was about the science of the art of pharmacotherapy. And in this lecture Dr Mintz discussed how in this era of evidence-based psychiatric practice, its really important to recognize that evidence shows that how one practices may affect outcomes as much as what one prescribes.
The research on this blew my mind. I always thought the key to improved patient outcomes is getting the right diagnosis and medication. With this, patient outcomes will improve. Or so I thought. It seems completely counterintuitive that how you prescribe will have a significant impact on patient outcomes.
Your patient’s belief that a medication works, their involvement in selecting the medication among other factors, can actually affect how effective a medication is.
There’s an art to pharmacotherapy and some key points I came away with are to make sure you’re developing a patient centered alliance that supports your patients ability to help make decisions and also adapt your prescribing behaviors to the specific needs of your patient – avoid one-size-fits-all cookie-cutter prescribing.
This year, I started appreciating how my presence, empathy as well as confidence with treatment planning effects how effective medications are.
I’m humbled by my experiences over the years. The more time that passes, the more I learn that there’s more to know, mostly about myself and less about the nuts and bolts of prescribing (but there’s more to know there too). I’ve softened my reins on rigidity over the years and become a better provider for it; and I’ll take that as success.
Maybe Dr Seuss had it right when he finished, “And will you succeed? Yes! You will, Indeed!”.
While these lessons are simple, and I highlight less about diagnosing and treatment, there is ease and comfort with feeling confident in the nuts and bolts of being a psych NP. So if you want quick a 60-minute intro into a framework for how to diagnose and treat mental disorders, you can sign up for my free Mental Disorders Training.
If you want my most detailed, step-by-step support, you can sign up for my Mental Disorders Crash Course.
