FAQ For Student Nurse Practitioners (Part 2)

**BostonFNP**, APRN

Welcome student NPs and prospective student NPs! Part 2

This is the second part of a two part series, if you haven't read the first installment, start there, if you have, welcome back.

First off, a little about me. I am a board-certified Family Nurse Practitioner and I work in a mixture of both inpatient and clinic settings with a small independent adult internal medicine practice. I live in a state that requires a collaboration agreement but I practice almost fully independently (as fully as I am comfortable with, see below). I have been on the clinical and didactic faculty at a local NP program as well as a lecturer and clinical preceptor for a local medical school. I have been an active preceptor for most of my NP career. I am active in the local and national NP association. I am not, however, the be-all-end-all of NP advice, so take everything as the opinion of one person with some experience.

5 Questions I Hear From Students In School/Practice:

What is the most important goal for my first clinical rotation?
What do I do if I am not sure about something?
How do I handle a disagreement with a preceptor?
What if I make a mistake?
What if my preceptor does something different from what I have learned in school?

This is the second installment and I will address the latter five questions from above. If you have questions/thoughts/comments, please share.

What is the most important goal for my first clinical rotation?

At the start of each semester I sit down and discuss two goals with each of my students; their goal and my goal for them. For first semester student my goal is that they start to think and act like a safe provider.

To me, a safe provider:

1. listens to the patient,

2. asks the appropriate questions regarding life threatening issues,

3. identifies critical abnormals,

4. rules out critical differentials,

5. formulates a simple plan,

6. knows when to ask for help.

Listening to the patient is crucial for novice providers, especially now with the distractions of EMRs. Providers need to train themselves to really listen to what patients are saying, not giving a patient complete attention can lead to missing something important. It is also important to take patients seriously when they tell you something isn't right. After a patient tells you they don't feel right two things can happen: they can live or die. The latter is obviously what we want to avoid so take every complaint seriously. Patients can also give you important insights when you are new: have they had this before, what worked for them, etc.

Learning to ask appropriate questions is one of the most important aspects of the role transition. It takes experience and time to develop the skill. In the beginning, I stress with students that they needs to ask the appropriate questions to rule out life threatening concerns. What do you need to ask to ensure that the patient's cough is not a manifestation of PE or pneumothorax? What should you ask to make sure that a patient's vertigo is not brain metastases? If the right questions aren't asked then your risk of missing a life threatening diagnosis is elevated.

As I mentioned above, in the first semester my focus is on the student identifying normal versus abnormal; in my view this is essential for entry to practice. Identifying critical abnormals spans the triage, the history, the physical exam, the diagnostics review, the plan, and the sum of all these components. When we are in clinic I expect students to identify a critical abnormal at any and all of these stages. You can be safe if you miss critical abnormals such as crushing chest pain on triage, a history with suicidal ideation, a surgical abdomen on exam, a hemoglobin of 6 on review of the CBC, or a major interaction of a medication in the plan. The best tip here is to take your time and be very cautious, just like you should be in practice.

Just as alluded to above, I feel strongly that when a patient leaves a visit there needs to be no question about a life threatening diagnosis. It will never be absolute but there needs to be no reasonable doubt. If the patient presents with a cough, if you are going to diagnose him with bronchitis you should be able to clearly articulate why it is not a PE, acute heart failure, or pneumothorax.

Developing a simple plan based on current EBP and guidelines develops with time and I don't expect first semester students to be able to do it all the time, but I expect them to at least try, and when they can't, I expect them to ask for help. The most important (in my opinion) still a novice provider can learn is to understand their own limitations and overcome any fear of asking for help.

What do I do if I am not sure about something?

As a student you are not expected to know every answer; once you are in practice you (hopefully) realize that you learn new things every day. With that in mind, the student should learn to handle this as a provider would. You will forget things you learned. You will see things you have never learned about or seen before. You will see complex and atypical presentations of common illnesses. You will be confronted (frequently) with things you don't know from clinical presentations to physical findings to lab tests to medications and dosages.

You should have readily accessible resources at the point of care, there are many of these available, I use UpToDate constantly but that is my personal preference. As a student you should use these resources before talking with your preceptor; it's good habit. I spend the first week or two with my students saying "look it up and tell me, one day I won't be here to ask". Once you have researched then it's time to talk to an experienced provider or colleague/mentor. Don't be afraid to call radiology and ask, call the specialist and ask. It's ok to not know, it is not ok to pretend you do. Another phrase I use on my first day with students is "no more faking-it-till-you-make-it": when a provider fakes it people can die. If you don't understand then you need to ask.

How do I handle a disagreement with a preceptor?

Disagreements with your preceptor, just like disagreement with your colleagues or your patients, may happen from time to time. The most important advice I can give to students is to handle these disagreements like a professional. Stay calm and objective. If you can, sit down and discuss the issue from a perspective of gaining understanding of your role in the issue and the opposite point of view.

Remember you are a guest of the clinic you are in. Never escalate the situation. Speak immediately to your assigned faculty member without making accusations, again as calm and objective as you can. These can be a challenge, however, it is a challenge you will experience again and again in your career. I have to be honest, with some students, I will create a superficial disagreement and let it play out in a safe environment.

What if I make a mistake?

Mistakes are a part of life, we all make them, some are small others are tremendous, and I have yet to meet someone who has an absolute technique to avoid them. You and your preceptor will work very hard to avoid mistakes, but should one happen, there are a few important things to consider. The first thing you need to do when you realize you have made a mistake is admit it and get you preceptor and whomever you need to involved in fixing it. Maybe you just sent a medication to the pharmacy that a patient is allergic to or maybe you just missed a STEMI on an EKG. You can never, ever try and hide your mistake or hide from your mistake. The second thing to consider is how to make that mistake into a learning experience. You can learn from every mistake you just need to engage in self-reflective practice.

What if my preceptor does something different from what I have learned in school?

In all likelihood, during your first clinical rotation, you will see a preceptor do something different from what you learned in the classroom or from your textbook. There are a number of potential reasons (your textbook or lecture is out of date in their practice, your preceptor is out of date in his/her practice, your preceptor has adapted their practice to the specific patient or patient population, or the theoretical doesn't translate to the practical) but is likely multifactorial. First and foremost remember that you are their to learn the practical application of your theoretical knowledge. If you notice a difference, try and establish a dialogue with your preceptor about it. This dialogue is the cornerstone of your relationship: you learn from your preceptor and your preceptor learns from you. You may develop a relationship with your preceptor where you can challenge a him/her on these topics, but don't start that way!

That concludes my thoughts on 10 (five in part 1 and five in part 2) of the most frequently asked questions relating to a student nurse practitioner's first clinical rotation. In closing I want to again reiterate that clinical rotations will be the foundation your career is built on and should be a fun. interesting, challenging, and active learning process. The habits you build during rotations will shape your practice. I know many students have commitments to family, school, and work, but I honestly feel that outside of family, your clinical rotation should be your primary focus. The more effort you engage the more you will get out of your rotation. I hope this has been some help to you and I wish you the best of luck as you move forward and transition into a role so many of us love.