FAQ for Student Nurse Practitioners (Part One)

**BostonFNP**, APRN

Welcome student NPs and prospective student NPs!

Starting your journey towards advanced practice and the provider role is a stressful time (we all know, we have been there) but also is a time to really embrace your transition and have the freedom to be an active learner. This time will be the foundation your career and your practice is built on. Unfortunately, this is a stage that is often mired by anxiety related to clinical placements.

I wanted to take some time and share my personal opinions on some frequently asked questions and frequently discussed topics. I would like to offer some guidance in a two-part post on this topic, this is part one of two.

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 Frequently Hear From Students:

How do I find a clinical placement?
How much RN experience do I need before I start clinicals?
How do I prepare for my first clinical?
What is expected of me at my first clinical?
Do students really fail clinical?

And here are my thoughts on each, perhaps other experienced members will add theirs as well. In part one I will take the first 5 questions as I see them. I will add a second installment with the later five out of ten.

How do I find a clinical placement?

Hopefully you are going to a program that helps you secure quality preceptor spots, this is my personal/professional bias, but your clinical experience is critical to your success as an NP and programs that leave that up to a student are not doing their students any favors. That being said I realize it is a trend for programs to not secure clinical sites and that there are good programs that no longer offer this. Remember there are a surplus of NP students and a relative lack of preceptors, and preceptors are (most often) not paid and often take on extra work and/or lost productivity earnings to take a student while many more are prohibited from taking students by their employer.

Just like finding the right job, finding the right clinical site depends on using your existing network contacts, your school's network contacts, and making a personal effort. Talk to your family, your friends, your coworkers, your classmates, your alumni/ae, and your personal providers to see if anyone can help you get a "foot in the door" with anyone. Getting that initial contact is important. Join both the AANP and your local state NP association; they often have resources to help students find preceptors, it helps you network, and the dues are often very cheap/free for students. Make a professional and succinct resume and cover letter and hand deliver it to local practice managers; focus on small practices where you can get a face to face with the manager but also understand that many offices are very busy and won't have time to sit down with you. Cast a wide net.

Don't expect to have much luck posting on message boards for preceptors.

Lastly, try and avoid any paid services. They are often not helpful and offer limited guarantees and return on your investment.

How much RN experience do I need before I start clinicals?

This is a hotly debated topic and you can do a search on this website for a myriad of opinions. Most importantly is you need to have your RN before you can start APN clinicals.

From my experience, there is no universal answer to this question. There are students with no experience that perform very well and there are nurses with ages of experience that struggle. They are, for the most part, the outliers. It is true that the RN role and the NP role are very different, but there are also important aspects they both share. I normally answer this question with a question: how much experience do you think you need? Self-reflection is very important at the provider level. The first step is to evaluate yourself and understand what you need; shadows some NPs and see if you are totally lost or ready to jump in. The second step is to figure out what your school requires. The third step is to discuss with prospective preceptors what they feel is appropriate.

While RN experience may not be required of everyone there is very little argument that some RN experience won't benefit just about everyone. I don't love that some student NPs are also trying to work their first RN job, learn that role, go to school, and also do NP clinicals. There is, for me, too much confusion there.

How do I prepare for my first clinical?

This is one of the most stressful things for students along with the "what is expected of me" question below, and they are intimately related.

The first step is to do some research on the type of practice you will be joining for your semester. You can search the internet to find the most common reasons for visits to that speciality and the most common diagnoses. You can find through your school resources the guidelines for treating common diseases in that setting.

The second step is to reach out to your preceptor ahead of time and convey that you have done step 1 and ask if there is anything specific that you could do to prepare.

The third step is to assemble an acceptable wardrobe to wear for your clinical rotation: it's ok to find something professional but inexpensive and wear the same thing each day (often once a week) if you don't have the money to buy a whole new wardrobe. Don't show up looking unprofessional.

The fourth step is make sure you can get there on time!

What is expected of me at my first clinical?

As state above, this is intimately related to how you prepare. You will be expected to show up on-time and as scheduled, in appropriate attire, with a basic understanding of the type of patient you are expected to see and some general idea of the type of practice. This is pretty universal.

I expect my first semester students to #1 be safe and #2 to be open to learn and active in the process. I also expect them to communicate with me openly, as I consider that part of #1 (safety). I also expect my first-time students to be able to have a general idea of how to obtain a basic comprehensive history and do a basic comprehensive physical exam. That's all I ask at the start of the first semester.

On the first day I expect students to just get acclimated to the environment; meet the staff, navigate the EMR, shadow me through the day on acute and chronic visits or rounds. I welcome students to be involved with me in discussion between patients and get involved in physical findings I will identify; as above be honest if they can't see/hear/feel them.

From that point on my expectations are dictated by the student: I first challenged to identify normal from abnormal as this is required for safe practice. Next I have students begin to focus their history and exam and to begin to formulate crude differentials with a focus on ruling out the most dangerous possibilities. Next I have students start thinking about potential treatment plans followed by what their actions would be on the next visit if unsuccessful. That is as far as most students will get in their first rotation. It may be basic for some, a challenge for others, but if a student can focus on those things they have a good foundation to build on.

Do students really fail clinical?

Yes. Students fail clinical; when it happens it is (almost) always the fault of the student for breaking very clear and simple rules. For me there are only three ways you can fail your first clinical semester.

The first is that you don't show up or you show up late. There are always situations that can be excused but if you are either chronically late or unreliable you have failed yourself and thus your clinical rotation. This is the worst type of failure because t shows you are not invested in your career.

The second (and most important) is that you are clinically unsafe; this changes every semester with your expectations. For a first semester student being clinically unsafe (to me) is giving medical advice your are not qualified to give, not being able to identify normal from abnormal by the end of the semester, or being unable to consider crude differentials and/or doing what I call "pigeonholing" repeatedly. This is the best type of failure because it protects your career from a lawsuit. Repeat your semester and improve.

The third is not being honest with me. Your job is to be a student and it is ok to make mistakes and it is your time to see and hear and feel and learn. If I ask you to look in an ear and tell me what you think and you say "I don't know what I am looking at" or "I can see" that's fine because it's honest. If you look in the ear and say "the membrane is pearly gray and the landmarks are visible" when there is a full cerumen impaction then you are both unsafe (see the second reason) and dishonest; if you can't see and don't tell me than I don't know you can't see and you will never learn normal and abnormal (see the second reason).

It's rare I fail a student but it is always in that student's control and that student's best interest. I have also had a student I failed come back and be one of the best NP's I know. It's not the end of your career it's the start of it.

Read the 2nd part to this article at