Author: Amy Quynh L.N. Tran, FNP-C

Prior to enrolling in the nurse practitioner (NP) program, all students are registered nurses who typically already have experience in various clinical settings. However, the NP program can still present additional challenges, particularly as it pertains to the clinical rotation portion of the curriculum. Becoming a lifelong learner is part of being a successful nurse, but for an RN with prior clinical experience, it can be hard to take on these NP opportunities with fresh eyes. Here are four tips to maximize your NP learning experience.

Tip #1: Get to Know Your Clinical Preceptor, Staff, and the Community

Arrive early on the first day to clarify expectations and preferences with your preceptor.

Address the following questions:

• How should the NP student present themselves at each patient visit?
• Will the preceptor come in and see the patient first, with you seeing them afterward? Or will you and the preceptor come in at the same time?
• What are the preceptor's preferences for case presentations?
• Do you only observe on the first day, and can you take notes? Should you ask questions while seeing the patients, or wait until you are out of the room? Also, see tip #4.

Learn the names and roles of the clinical staff and consult with them as appropriate. Be sure to say "thank you" often!

Regarding the community, proactively ask about the patient's age, gender, ethnicity, socioeconomic status, and typical conditions seen in their population. You should also know how to locate all nearby ER, labs, hospitals, pharmacies, and specialists. Do a drive-by to explore the housing conditions, demographics, neighborhood safety, and environmental hazards. This will give you a sufficient understanding of your patient's experiences.

RELATED: Securing Nurse Practitioner Preceptors: Why Are Some Schools and Students Paying for the Privilege?

Tip #2: Prioritize a Patient's List of Concerns at Every Visit

Many patients will have a long list of active medical diagnoses. While you should be knowledgeable about these conditions, you might not be able to address everything in one single visit. Therefore, it is important to prioritize and shape patient expectations. You may start with asking the patient, "What brought you in today?" It is critical to avoid missing new and potentially serious concerns while still addressing key management goals of chronic conditions. It may be helpful to set an agenda with the patients. Try saying, "There are a lot of important concerns. Let's focus on your new onset of heart palpitations and hypothyroidism management today. We will discuss your diabetes, gout, and chronic back pain management at the next visit since we only have 15 minutes for today, okay?"

Tip #3: Learn to Communicate Well with the Patient

Prior to seeing the patient, aim to review charts, look up conditions as needed, and formulate a tentative plan. When seeing the patient, introduce yourself while maintaining good eye contact, listen carefully, and establish the agenda and expectations. It is imperative that you ask for permission before laying hands on your patient's body. Additionally, as you perform your physical exam maneuvers, make sure to communicate your findings and clarify what you are looking for to ease your patient's comfort.

RELATED: How NPs Can Tackle Difficult Conversations with Patients and Families

Tip #4: Learn to Give a Well Thought-Out Patient Presentation to the Preceptor

Check with your preceptor to determine the process for presenting new and established patients. Keep a go-to template to adjust as needed to suit your preceptor's preferences. Here is an example:

TEMPLATE: Patient's name, sex, age, presenting concerns, list of medical diagnoses, current medications, and newest lab results.

Concern #1: Chronological history of present illness. Relevant physical exam findings. Treatment plan. Questions for the preceptor.

Concern #2: Same as above.

Other concerns: Follow-up plan.

CASE EXAMPLE: Mrs. Jane Doe, 63-year-old female, is here for a new onset of chest palpitations. History of hypertension and hyperlipidemia, diabetes, and hypothyroidism. On Metformin 500mg BID, Atorvastatin 20mg QD, Levothyroxine 100 mcg QD. Latest lab results from 3 months ago at annual visit include HbA1C at 7.1, TSH at 2.8, Lipid panels (list lab values), CBC (list lab values), CMP (list lab values).

Chest palpitations. She noticed the chest palpitations about two months ago. It occurs abruptly while at rest at a frequency of approximately once a week and a few seconds at a time. No other associating symptoms such as tingling in the arms, shortness of breath, or dizziness. Heart rate and rhythm normal with pulse at 88, 12-lead EKG shows normal sinus rhythm. Because she has hypothyroidism, her Levothyroxine may not be at the therapeutic level, causing the palpitations. My plan is to re-check the TSH level. Could there be other explanations and treatment plans for her concern?

Hypothyroidism. She has had hypothyroidism for one year and it is currently well-controlled. Her Levothyroxine dosage was increased to 100mcg from 75mcg at the annual visit three months ago. During the exam, skin is warm, dry, and intact with no lesions; thyroid is not palpable. I would like to re-check her TSH lab level due to a recent increase in dosage and the new onset of palpitations. Is there anything else I should be checking?

Other concerns. We did not discuss her diabetes today. I would like to schedule an appointment in two weeks to address this.

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With a few tips like this in your back pocket, you can rest assured that your NP clinical rotations will help prepare you for a long and rewarding career.

Simply put, the objective of a nurse practitioner (NP) student is to become a competent clinician. Through clinical rotations, he/she will need to develop and implement foundational skills and knowledge for their future clinical practice. To accomplish this, the NP student should be actively and enthusiastically involved in patient care as a member of the diagnosing and treating team—not a scribe or errand-runner. However, the NP student is not an independent practitioner just yet. Therefore, they can only participate in patient care under the guidance and supervision of the authorized preceptor. The NP student should have a clear understanding of their roles and responsibilities to maximize their time during clinical rotations.

RELATED: Securing Nurse Practitioner Preceptors: Why Are Some Schools and Students Paying for the Privilege?

What to Expect During an NP Preceptorship

There are several key hands-on duties that NP students are responsible for during their preceptorship.

1. Take Patient History, Perform Physicals, and Propose Differential Diagnoses and Treatment Plans

Depending on the clinical setting, a new patient's history may be collected in one visit (such as in urgent care, the emergency room, and the hospital) or over two or three visits (as done in family or internal medicine, pediatrics, and outpatient clinics). Regardless of the setting, the NP student should begin the visit by introducing themselves and asking the patient what they would like to address.

If the patient has one pressing concern, the NP student should address that acute issue without neglecting other chronic conditions and perform the physical exam that's appropriate for the problem at hand. For example, if the patient presents an aching leg, the exam should be focused on the lower extremities. An exam for the eyes may not be needed, unless there is another reason. Based on the clinical findings, the NP student should learn to formulate three to five differential diagnoses and an appropriate treatment plan.

RELATED: How NPs Can Tackle Difficult Conversations with Patients and Families

2. Present Patient Cases to the Preceptor

During the first initial meeting with their preceptor, the NP student should ask about any format preferences for the presentation. Some preceptors prefer abbreviated versions, while others prefer comprehensive formats for teaching purposes. The purpose of the verbal presentation for the preceptor is to convey the problem-oriented essentials of the patient case. This requires more than just a simple reiteration of what the patient and the labs show. A good patient presentation demonstrates the patient's most concerning issues and includes the NP student's clear plan of treatment and critical analysis.

After seeing the patient, the NP student should spend at least a few minutes organizing their thoughts before presenting the case. They should also aim to keep the presentation concise (about three to five minutes for new complex cases), organized (with history in chronological order, pertinent findings, and labs), and well thought-out (three to five differential diagnoses and rationales for each, as well as recommended treatment and follow up). If the NP student is unable to formulate a diagnosis or plan, they should ask for the preceptor's help. This offers an opportunity to conduct further research online or through textbooks, which demonstrates strong enthusiasm and a "self-starter" attitude.

3. Complete Patient Write-Ups

The note that comes from the NP student should demonstrate a comprehensive grasp on the patient's presenting case. It should follow the SOAP format (Subjective, Objective, Assessment, Plan) as learned in NP programs. Since the preceptor is ultimately the person who is legally responsible for the patient's care, the NP student should review the plan with the preceptor first before discussing with the patient. The ‘plan' includes ordering further screening or diagnostic tests, writing prescriptions, and providing patient education. It is important the NP student learns how to write the prescriptions appropriately under the preceptor's guidance. All notes, orders, and prescriptions need to be reviewed and co-signed by the preceptors.

4. Obtain Constructive Feedback from Preceptors

After presenting the case to the preceptor, the NP student may directly request for any suggested improvements to the presentations or write-ups. If the NP student has a specific need for further instructions, they should ask the preceptor if they can go over a certain physical examination such as a cardiac or ankle exam. Additionally, the student should schedule a mid-term evaluation with the preceptor to gauge how they are doing and where they can improve.

RELATED: New Graduate Nurse Practitioners: Keep Learning to Build Confidence

5. Read for More Insights

Reading is a great way to expand your understanding of diseases and different patient cases. Before each visit, it's helpful for the NP student to read the patient's charts and pertinent scientific literature to formulate an approach ahead of time. By understanding the patient's primary concern, the student can determine appropriate questions to ask during the history-taking and establish a physical exam to focus on. Proper preparation before seeing the patient will save time during the interaction.

Before the physical exam, an NP student may briefly read over the patient's chart again or their own notes to ensure that the proposed approaches are correct.

In advance of each case presentation, NP students should review their findings to solidify the rationale and clarify any aspects they are unsure about.

Between patient visits, reading critical medical literature that relates to patient cases can improve overall understanding.