Dumb and Dumber: PMHNP student edition

The following story was posted by a psychiatric-mental health nurse practitioner (PMHNP) in the "PMHNP" Facebook group, as written feedback to the director of a PMHNP program regarding a student being precepted. It was deleted shortly after posting after other midlevel NPs raised concerns that students might also be in the group and that negative feedback might hurt their feelings. For documentary and archival purposes, the complete story is shared below with minor edits for grammar and clarity. The raw image version is available here.

Letter in response to a Director of an MSN-DNP PMHNP Program who was asking for feedback

Thank you for reaching out, Dr. (University’s Program Director).

I was asked by my director, [Director's name] if I would be able to take on an NP student. I told her I was willing, but only had three patients scheduled that day. I was given a copy of [NP Student]’s resume by my director to review. I immediately noticed several errors, which included, but were not limited to grammar, poor spacing, multiple fonts being used, various text sizes, etc. It stated that she is an experienced psychiatric nurse, but her experience is not reflected in her resume; only 90 hours at [hospital name] from February 2013-April 2013. Her work experience does not explain her role or department and/or skills used. Under "Special Skills", it states "computer skills - words".  Her resume also mentioned “exceptional time management"; however, when [NP student] was charting, she apologized for only being able to type with 1-2 fingers at a very slow speed. I encouraged her to use Dragon (voice dictation software). Still, charting on 2 follow-up patients took almost 3 hours. Professionalism and honesty are huge. I hope that before graduating, she is able to take a resume class to better assist her.

I informed [NP student] the day before that she will be conducting the full patient interview so that she would have time to prepare to see 2 follow-ups and 1 evaluation. [NP student] disclosed that she had been with multiple psychiatrists and nurse practitioners, but only [my colleague] (an NP) had allowed her to interview the patient. I told her that “shadowing” does not count as clinical hours. Clinical hours include doing the interview, coming up with a formulation and making recommendations, sharing those with the NP or MD and when approved, teaching those to the patient, and wrapping up the assessment. She stated that this would be her first time doing that. She arrived at 10 am, two hours before our first patient, and I gave her copies of two of the previous follow-up notes along with medication options and a plan so that she could prepare. I also made myself available for questions and clarifications.

Patient #1

Diagnosis: ADHD, MDD, GAD – [NP student] had difficulty with the ADHD assessment. I recommended reviewing ADHD DSM-5 criteria as she struggled to understand this. Also, she had difficulty discussing Vyvanse in any capacity even after given ample amounts of time to review. She also had copies of the Stahl and Carlat books she could utilize on my desk.

Patient #2

Diagnosis: major depressive disorder (MDD), generalized anxiety disorder (GAD) with panic, insomnia – [NP student] had difficulty understanding the vast majority of the elements of the psychiatric interview; for example, she had difficulty understanding the differences between what goes in the chief complaint and what the components of the HPI are. During the psychiatric review of symptoms, she would ask “Do you have symptoms of depression?” with no further systematic questioning, the same approach for anxiety (no questioning of where, when, who, how long, or how frequent), hypomania/mania, or psychosis. Thought content was reported by the patient as “intermittent suicidal thoughts” – [NP student] was unable to assess suicidality by exploring intent, means, etc. She was unable to speak about Lunesta (which she was given an ample amount of time to look up and write down some speaking points). During charting time, I asked [NP student] to put down the primary diagnosis, followed by secondary diagnostic impressions, and any rule-outs based on this encounter. For the primary diagnosis, she wrote “mood disorder”; I told her that she needed to put down a more specific DSM-5 diagnosis, so she replied with “depression”. I told her that this is not a DSM-5 diagnosis, so I then opened the DSM-5 to page 162. I then asked, "what diagnosis do you think she meets the criteria for?" She then said “major mood disorder.” I then pointed to the top of page 163 and she said, “oh, major depressive disorder.” I said, "Perfect!" Then, I told her that she needed to make sure to add episode, severity, and specifiers. I showed her this on page 162. She then wrote "major depressive disorder, recurrent, mild". I then asked her why she had chosen mild, and she responded, “I don’t know.” I then asked her, "What was your assessment of suicide like?" She then said, “oh yeah, it's severe.”

Patient #3

Diagnosis: Adjustment disorder with mixed anxiety and depressive features secondary to medical co-morbidities – [NP student] conducted the interview using the language line as the patient was Spanish-speaking only. She again struggled with completing the HPI and the psychiatric review of symptoms. She struggled with assessing the nature, timing, and sequence of experiences/symptoms, findings, attributes, and behaviors in order to clinically diagnose. Asking questions like “Do you have any depression?”, “Do you have any anxiety?”, “Do you have any PTSD?”, “Do you have any mania?” makes it difficult to form hypotheses about a patient’s mental health difficulties. There is a lack of evaluation of symptom clusters and patterns. We discussed ways to improve assessment skills, understanding of the differential diagnosis, etc.

I asked [NP student] if I was to complete an hours sheet or sign off on patient contact hours, but she said no, there was nothing to sign. She said she used Typhon. I used Typhon when I was in NP school and we had to add a new provider each time to it if we worked with different preceptors; that way, at the end of the semester, feedback and overall assessment of the student can be submitted by every provider the patient encountered.

[Date]

Non-patient contact hours
10 am - 12 pm (2 hours): prep to see 3 patients
2 pm - 4:37 pm (2 hours, 37 minutes): charting on 2 follow-up patients

Patient contact hours
12 pm - 2 pm (2 hours)

I recommend [NP student] be with one consecutive provider (NP or MD) that will treat her as the NP student in training that she is. Clinical hours should not be counted as patient contact when she does not speak to or interview the patient. “Shadowing” is not a clinical experience. All medical students and nurse practitioner students are required to have face-to-face active clinical hours in which they interview, formulate, and make recommendations under the guidance and expertise of the supervising NP or MD; they do not just watch the MD or NP interview, formulate, and make recommendations. I also recommend that she review DSM-5 criteria and how to conduct a psychiatric interview (like Shea and/or Carlat). These sources were given to the student at the end of the clinical days for improvement and reference)

I do not mean to be so critical, but nurse practitioner standards need to be held high as with other medical programs. I wish for [NP student] to be successful, but in the correct way that will benefit her and her future patients.

Please let me know if you need any clarification or further input.

Thank you,

(Preceptor)