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Nursing Network - Fall 2013

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From MHS to Certified Psychiatric/Mental Health Nurse Practitioner

Working as a Mental Health Specialist (MHS) at McLean inspired and supported Molly Jepsen as she planned her career path. In fact, serving as an MHS has also clarified work choices for many of her colleagues. Some decide to attend nursing or medical school, while others train for social work or counseling. “Being an MHS at McLean is great experience. It means being immersed in the milieu and learning to recognize changes in a patient's status,” she said recently. “I also learned to communicate with patients, which is something I didn't know how to do before I began at McLean. An MHS learns to understand the nursing process.”

Molly Jepsen, PMHNP-BC
Molly Jepsen, PMHNP-BC

Molly did not arrive at her present role as a certified psychiatric/mental health nurse practitioner along a traditional route. After graduating from Middlebury College in Vermont with a major in psychology, she worked in Gulf Coast communities and taught English in Uruguay for several years. Her experiences in Lake Charles, Louisiana, and Pascagoula, Mississippi, where she assisted individuals who had experienced the trauma and loss of Hurricane Katrina, confirmed her desire to work in the field of psychology. At that point, though, she was not sure whether she wanted to do social work or nursing. Having grown up in the Boston area, she knew of McLean Hospital and decided to seek employment there as she considered her next steps.

As an MHS on the Short-term Unit (STU), Molly was usually assigned to check in with four patients to assess their safety status, thought process, current stressors, physical complaints, and energy level, and to report her findings to the RN. Different days and shifts bring their own challenges, but she understood that patient safety is always the top priority for an MHS, who is often the first to respond to a crisis. She also ran groups that promoted goal-setting, social interaction, or fitness.

“We're always out on the floor,” she said. The interdisciplinary aspects of working with psychiatrists, social workers, expressive therapists, and charge nurses appealed to her, and she thinks that experience as an MHS is excellent preparation for becoming a registered nurse. As she worked with the nursing staff and sat in on morning report, she realized that she wanted to become a nurse practitioner in the mental health field. She worked full-time on the STU while she took pre-requisites for nursing school. When she began attending the MGH Institute of Health Professions, a Partners-affiliated graduate school, to earn her bachelor's in nursing (BSN), she continued working on the STU on a per diem basis. After she passed her nursing board exams, she joined the staff on the STU as a registered nurse.

Her time as an MHS also convinced her that she wanted to become a prescriber. “I saw how psychiatric medications could help patients, so I wanted to learn to prescribe.” She continued taking classes, and in May 2013 she completed requirements for a Master of Science in Nursing (MSN) degree, with a focus on psychiatric/mental health nursing across the lifespan, which means that she is qualified to treat children, adults, and geriatric adults. In June, she passed the board exams and is now a certified psychiatric/mental health nurse practitioner.

The MHS position provides a rich work experience in the milieu and gives the specialist close contact with both patients and the nursing staff. Molly Jepsen's journey illustrates that working as an MHS can be a fulfilling experience that may also guide an individual toward other careers in the psychiatric/mental health field.

Reflections from the First Nellie Blumenthal Fellow

When Katherine (Kate) Cederbaum, MA, MSN, PMHNP-BC, applied to become the first ever Nellie Blumenthal Advanced Practice Psychiatric Nursing Fellow at McLean, she felt highly motivated to win the fellowship, but she could not anticipate how emotionally charged the process would become. After earning a degree from Boston College as a nurse practitioner in May 2012, she wanted support and experience as she transitioned from school into professional practice. “I couldn’t fathom going straight into a clinical setting without better preparation,” she said during a recent interview. Her goal matched many of the purposes of the Blumenthal, which is awarded to an Advanced Practice RN to help the recipient enhance skills in assessment, differential diagnosis, psychopharmacology, and patient teaching.

Katherine Cederbaum, MA, MSN, PMHNP-BC
Katherine Cederbaum, MA, MSN, PMHNP-BC

The problem for Kate was how to support herself while waiting for the fellowship winner to be announced in September 2012. She took a risk and stopped applying for other positions, while she worked as a bartender, did an internship at Solomon Carter Fuller Mental Health Center in Boston to keep up her skills, and lived at home with her parents. Her father, an oncologist, and her mother, a rheumatologist, both strongly supported her choice. Her father urged her to hold out until she knew about the fellowship. When she won the honor of becoming the first Blumenthal Fellow on September 4, 2012, she and her family rejoiced. On October 1st, she began the fellowship.

She recognized almost at once that the working environment at McLean presented a different picture from the flawed treatment settings that she and her parents had often discussed when considering the American health care system. “Collegiality and a shared intellectual interest in what we are doing existed here, even as everyone coped with the many demands of daily clinical practice,” she observed. “There are no dollars in the health care system to support clinicians talking to each other about their patients, and yet that is such an important part of what we do.”

Kate was quick to praise the four clinicians who have supervised her during the fellowship year: Dost Öngür, MD, PhD, director of the Psychotic Disorders Division; Rakesh Karmacharya, MD, PhD, known as Dr. K, medical director of the First Episode Clinic and of the Schizophrenia and Bipolar Disorder Research Clinic; Linda Flaherty, MSN, RN, CS, Senior Vice President, Patient Care Services; and Beth Murphy, MD, Medical Director, The Clinical Evaluation Center. Meeting with each of these supervisors for an hour every other week has provided an invaluable opportunity to interact with senior clinicians, who answer questions and discuss cases with her.

Another ally has been Kirsten Bolton, LICSW, program director for McLean OnTrackTM (First Episode Clinic for Psychotic Disorders). She and Kirsten have run a therapy group together. “We have been a great team,” Kate said. “Kirsten, who has four more years of experience than I do, provides therapy, and I handle meds, so we share our impressions of patient needs and adjust our approach accordingly.” Working on the CEC unit “has been so great, a completely informal but essential form of education on the job.” Kate appreciates the value of working with experienced nurses and residents, who delve into cases with her. Observing grand rounds and listening in on the residents’ didactics has also enlarged her understanding of her practice, while attending morning rounds on the inpatient unit specializing in psychotic disorders has been another invaluable experience. “Numerous educational opportunities are intrinsic to simply being at McLean,” she added.

Another important aspect of her experience this year has been patient and family work in the McLean OnTrackTM Program. “I didn’t train for family work, but I soon realized how key it is to helping patients recover.” She knew, theoretically, that family would be involved when a patient, typically an 18-25 year old, is treated at the clinic. Reality is different from theory, however, and Kate gratefully acknowledges how valuable staff supervision and support have been as she enhanced her skills in working with patients and families.

For a variety of reasons, a patient may be discharged from the hospital before he or she is entirely well. The patient may even remain psychotic and dependent on family. Kate has seen individuals return for follow-up visits, who look disorganized even though the discharge notes indicate that they have been stabilized. Kate sees her role as a mediator between patients and their families as an important component of their transition from the hospital to life outside. She checks in with families once a day, and may make medication changes based on the feedback she hears.

After discharge, Kate sees patients once or twice a week. She must determine whether a patient needs to be admitted again or if another day or a good night’s sleep will smooth the transition. She doesn’t set boundaries with patients for how they should behave at home; that is the role of their families. However, she can help patients and families communicate better about the issues that may cause friction between them.

Kate’s fellowship year is drawing to a close, but she looks forward to continuing at McLean in a position that involves many of the same duties. She will be a prescriber in the First Episode Clinic, the only on-staff nurse practitioner in that role. Her research and development interests focus on developing a group therapy program; preventing and treating metabolic syndrome; and standardizing the course of care for First Episode patients. Next month, she will also begin working on development of a dual diagnosis program in the McLean Substance Abuse Program.

Kate Cederbaum’s intelligence, compassion, and dedication to becoming the best possible clinician motivated her to take full advantage of the opportunities that the Nellie Blumenthal Fellowship opened for her. She has set a fine example for the other Advanced Practice nurses who will follow in her footsteps.