By far, the most rewarding aspect of my work are the relationships I have with my patients. My patients allow me a window to their greatest vulnerabilities and trust me to partner with them to help them get better. This is a great privilege that I will never take for granted. I learn something new from patients all the time, and this allows me to get better at what I do.
About Andrew Penn, CNS, PMHNP-BC: Andrew Penn is a Psychiatric Nurse Practitioner III at The Permanente Medical Group California, where he provides extensive psychiatric evaluations, ongoing individual and group psychotherapy, and psychopharmacological treatment initiation and monitoring. At the Permanente Medical Group Mr. Penn is also the primary psychiatric prescriber for the intensive outpatient program, and developed a group therapy curriculum for bipolar patients that has been in use for over seven years.
In addition to his clinical responsibilities, Mr. Penn serves as an Assistant Clinical Professor at the University of California, San Francisco’s (UCSF) School of Nursing. At UCSF, he lectures on psychopharmacology, therapeutic interviewing skills, and bipolar disorder assessment and treatment. Mr. Penn has also helped develop continuing education curricula and lectures for mental health professionals as a Steering Committee Member for the US Psychiatric and Mental Health Congress and as a Member of Contemporary Forums’ Psychiatric Nursing Conference Steering Committee.
Prior to becoming a nurse practitioner, Mr. Penn worked as a Staff Nurse for Psychiatric Emergency Services for the County of Marin and for Kaiser Permanente. He was also an Activity Leader for San Francisco General Hospital’s Mental Health Rehabilitation Facility and a Milieu Activity Therapist for EMQ Children & Family Services.
[OnlineFNPPrograms.com] Could you please provide us with an overview of your professional path in nursing?
[Andrew Penn, CNS, PMHNP-BC] I earned my Bachelor of Arts in Psychology from the University of California, Santa Cruz. I worked for several years in community mental health, working both with emotionally disturbed children and severely mentally ill patients. I worked for several years at San Francisco General Hospital, where I first met nurse practitioners and became inspired to become one myself.
Several years out of college, I returned to school to become a nurse practitioner. After taking some prerequisite science classes at my local community college, I entered the University of California, San Francisco School of Nursing’s Masters Entry Program in Nursing (MEPN). This program allows people who already have a Bachelor’s degree, but are not yet nurses to enter an accelerated RN certificate program, followed by a standard 2-year Masters degree preparation to become a nurse practitioner.
After a very accelerated 12-month program, I took the NCLEX exam and obtained my RN license and joined Sigma Theta Tau, the national honor society in nursing. I was fortunate to be a new nurse at a time of a severe nursing shortage, and I was able to quickly find a job on a Medical-Surgical unit at Kaiser Hospital in San Francisco. I continued to work there, part time, for the next 2 years while I earned my Masters degree. I also worked as a staff nurse in a psychiatric emergency room in Marin County, California while going to graduate school.
My Masters degree prepared me to be an adult psychiatric nurse practitioner by combining both the Adult Nurse Practitioner curriculum (essentially a primary care, internal medicine program) with the Psychiatric Clinical Nurse Practitioner curriculum. I had multiple rotations in many mental health clinics in the San Francisco area, with special focus on addiction medicine and psychiatry at San Francisco General Hospital.
Upon graduation, I passed the American Nurses Credentialing Center certification exams to become a board certified Adult Nurse Practitioner (ANP) and Adult Psychiatric-Mental Health Nurse Practitioner (PMHNP).
I began working for The Permanente Medical Group (TPMG), the medical group exclusively associated with Kaiser Permanente, in 2006, employed in outpatient psychiatry and have remained in that position for 10 years now.
In the time that I have been working with Kaiser, I have also become extensively involved in teaching, earning an appointment as an Assistant Clinical Professor at the UCSF School of Nursing in 2009. Around that same time, I began working in continuing education for psychiatric nurses, psychotherapists, and psychiatrists, first serving on the steering committee of the Contemporary Forums psychiatric Nursing conference from 2009-2013 and have been on the steering committee of the US Psychiatric Mental Health Congress since 2010. In that capacity, I help to develop curriculum delivered at national conferences attended by over 2000 mental health professionals each year. I have taught on subjects ranging from bipolar disorder, improving treatment adherence, the risks and therapeutic potential of cannabinoids, and psychedelic-assisted psychotherapy. I teach around the country and maintain a blog about my professional interests: http://www.psychcongress.com/blog/92082. Other appointments include my election to the American Psychiatric Nurses Association, California Chapter, board of directors as a member at large in 2008. I served in this capacity for two years.
[OnlineFNPPrograms.com] Could you please describe your role and responsibilities as a Psychiatric Nurse Practitioner III at the Permanente Medical Group? What kinds of medical conditions and challenges do your patients face, and how do you help them manage their conditions?
[Andrew Penn, CNS, PMHNP-BC] As a Psychiatric Nurse Practitioner at the Permanente Medical Group I provide individual psychiatric evaluation interviews for patients seeking psychiatric medication treatment. I make a diagnostic case formulation, order appropriate diagnostic tests, and develop a treatment plan for the patient. If medications are indicated, I prescribe them and monitor the patient going forward for effectiveness and side effects of the medications. If monitoring of other physiologic functions is required as part of medication treatment (for example, monitoring kidney and thyroid function in patients taking lithium), I order and interpret those lab results. If therapy is indicated, I sometimes provide brief psychotherapy within the context of medication management or if more extensive psychotherapy is indicated, I will connect the patient with one of my psychotherapist colleagues. I continue to work with the patient going forward, and have had some of the same patients for the last 10 years. I estimate I have somewhere around 1000 active patients in my caseload.
My patients often come to me with medical comorbidities that must be considered when starting psychiatric medications. Fortunately, Kaiser Permanente is a sophisticated and integrated healthcare delivery system, and it is easy for all clinicians treating a patient to see notes from other providers, look at all medications the patient is taking, and to have access to the same lab and imaging results. This leads to significantly better and safer care for patients.
I treat the entire range of psychiatric conditions, ranging from fairly straightforward cases of depression and anxiety to significantly complicated presentations including mental illness, substance abuse, and personality disorders. My youngest patient is 17 and my oldest is 95.
In the current mental health model, care is often delivered in a “split model,” meaning that medication providers such as myself see patients, sometimes briefly for medication management and psychotherapists such as psychologists, marriage family therapists, and licensed clinical social workers provide psychotherapy. I find it difficult to provide psychopharmacologic treatment without including at least some psychotherapy. I was once counseled by a mentor to make every interaction with a patient therapeutic by providing respectful, engaged treatment, and I try to bring this to every patient I see.
I am also fortunate to precept psychiatric nurse practitioner students from UC San Francisco. This is one of the most rewarding aspects of my work, as I watch students begin as new learners and emerge as competent, confident clinicians. http://scienceofcaring.ucsf.edu/profiles-nursing/what-volunteer-clinical-faculty-do-andrew-penn-and-psychiatric-nursing
[OnlineFNPPrograms.com] Who is on your team at the Permanente Medical Group, and how do you collaborate to provide patient care? In general, what role do PMHNPs play on a larger team of healthcare providers in medical settings?
[Andrew Penn, CNS, PMHNP-BC] In my clinic at Kaiser Permanente, I am part of a team that is comprised of psychotherapists (Licensed Clinical Social Workers, Marriage and Family Therapists, and Psychologists), another Psychiatric Nurse Practitioner, Registered Nurses, and Psychiatrists. In my particular clinic, my responsibilities are very similar to those of my psychiatrist colleagues–we all see patients for initial intake assessments, start and monitor medications, and follow these patients over time.
I also spend half of my time in the clinic working with our intensive outpatient program (IOP), a day treatment program for people who are in psychiatric crisis, or have recently been discharged from the hospital. In that program, I provide medical consultation to my non-medically trained colleagues and make medication adjustments if needed for patients in the IOP.
[OnlineFNPPrograms.com] In your opinion, what are the main differences between PMHNPs and people in other helping professions, such as clinical social workers, psychotherapists, and psychiatrists? Is one of the main differences that PMHNPs can do health evaluations and administer medicine? What is the difference between a PMHNP and a Psychiatrist?
[Andrew Penn, CNS, PMHNP-BC] I was recently asked a similar question by a young person considering entering the mental health profession. I answered that we are actually a lot more similar than we are different, but we spend a lot of time and energy trying to highlight the subtle differences between our different professions.
We all provide high quality, professional mental health care to our patients. That’s the most important thing. We are far more alike than different.
Functionally, the key difference is the training and authority to prescribe medications. Psychiatric nurse practitioners, psychiatrists, and physician assistants have this privilege. Psychiatrists are medical doctors who complete specialty residency training in psychiatry. Some have pursued specialized training, such as child psychiatry or addiction medicine in a post-residency fellowship. They put many years into this training.
Advanced practice nurses, such as nurse practitioners are registered nurses who have sought out additional, graduate level training. We are taught to assess patients in multiple areas (mental health, physical health, psychosocial functioning, etc) and to create an appropriate multi-modal treatment plan, then to follow those patients going forward. Functionally, we often perform a very similar job to that of a psychiatrist.
[OnlineFNPPrograms.com] What motivated you to work in psychiatric/mental health nursing, and what professional experiences helped you determine that this area of advanced practice nursing was the right one for you?
[Andrew Penn, CNS, PMHNP-BC] I have always imagined I would work in mental health. My mother is a psychotherapist (a licensed clinical social worker) and from an early age was inspired by how she would talk about her work. I studied psychology in college, and initially thought that I would become a psychologist. However, after college, while working in several mental health settings, I became interested in the biology of the brain, and how medications could effect change in mental health conditions. I also wanted to understand the brain in the context of how it is impacted by the health of the rest of the body.
After college, when I was working in a para-professional capacity with mentally ill patients at San Francisco General Hospital, I was fortunate to work with two amazing nurse practitioners. Prior to that time, I had never interacted with a NP, and had no idea about the profession. I was so impressed by this combination of intelligence, savvy, caring, and capability that I saw in these two NP’s that I wanted to become one myself. They were kind enough to mentor me and help me get connected with the UCSF MEPN program, where I trained.
[OnlineFNPPrograms.com] What have been some of the most rewarding aspects of working as a psychiatric mental health nurse practitioner? On the other hand, what specific challenges have you encountered in this field of work, and how have you managed these difficulties?
[Andrew Penn, CNS, PMHNP-BC] By far, the most rewarding aspect of my work are the relationships I have with my patients. My patients allow me a window to their greatest vulnerabilities and trust me to partner with them to help them get better. This is a great privilege that I will never take for granted. I learn something new from patients all the time, and this allows me to get better at what I do.
The next most rewarding thing about my profession is the collegiality that I encounter with my fellow professionals. Some of the brightest, most compassionate, most intelligent people I have ever met are fellow mental health professionals, and I feel fortunate to work with them to help our patients heal (when I am in the clinic) and to help our colleagues and students hone their skills (when I am in the classroom or on the conference stage).
Probably the biggest challenge as a psych NP is the lack of immediate recognition of what the profession is and is not. There are not as many of us as there are psychotherapists or psychiatrists, so a lot of people I meet just don’t know what the role entails.
Most everyone knows what a psychiatrist is, and many people can imagine the role of a psychiatric nurse. Since my role has aspects of both professions, sometimes people both inside and outside the medical profession are unclear on the degree of autonomy and skill possessed by NP’s. However, I think this will change as time passes and there are more of us providing health care. Patients feel well cared for by NP’s, probably because of the emphasis on patient education in nursing training, we do a good job of explaining our interventions, and getting patients to participate in their own care.
[OnlineFNPPrograms.com] For current and prospective MSN students who are interested in becoming psychiatric mental health nurse practitioners, what advice can you give them about optimally preparing for this field while pursuing their degree?
[Andrew Penn, CNS, PMHNP-BC] The best advice I ever got in school was at the end of every day, go back over your time in the clinic or in the classroom, and ask yourself “what didn’t I understand? What could I understand better?” and then go look up the answers. Self-direction is at the heart of adult education. If you expect a teacher just to feed you “what you need to know,” you will get the basics, but you won’t learn the richness and depth of the subject that you are studying.
Get curious and stay curious. Go deep into your subjects. Learning should be exciting, not a chore. If you can master this mindset, you will excel at all that you take on.
Get a solid foundation in the sciences. If you don’t understand anatomy, physiology is going to be hard for you because it will be like being given directions through a city without a map. If you don’t understand what normal physiology is, you won’t be able to grasp pathophysiology. Pharmacology is going to be difficult if you don’t understand basic chemistry. Work hard and learn as much as you can in these fundamental classes.
Seek out mentors who have been in the field for a while and avail yourself of their experience. Learn to ask intelligent questions from them. Learn how to take feedback without getting defensive. No one likes to be corrected, but when you’re a student, you should expect to be corrected, otherwise, why are you there? See your ignorance as an opportunity, not a liability.
If you’re working in a hospital, and doing the hard physical work of lifting and moving immobile patients, start working out with weights and get strong. Many nurses by the middle to end of their careers have incurred chronic back injuries. Don’t be one of them.
Before you enter the field, talk to a lot of people who work in the field. Go volunteer in a hospital or in community health organizations. Grey’s Anatomy is a fun TV show, but that’s not really what medicine is like or how hospitals work.
Health care is increasingly specialized, and having a specialization will help you find a job. You can always choose to use less of your specialized knowledge, but you can’t use specialized knowledge that you never learned. That said, the more specialized you are, the fewer jobs will be available to you. The good news is that there will be less competition for those specialized jobs. Pay attention to what the labor markets are doing. Nursing shortages are cyclical, and often, by the time people have heard of the great need for new nurses and are entering nursing programs, the shortage is starting to correct itself and those new nurses are surprised to find few of those promised jobs upon their graduation. The good news is that nursing is a very flexible career, and nurses work around the world, in every state in hospitals, in clinics, in administration, in teaching, for health insurers, in pubic health, in community organizations, and in the military. There is always going to be a need for nurses. It’s a great profession.
Thank you Mr. Penn for participating in our APRN career guide interview series!