Category: Nurse Practitioner Students

From excitement and elation to fear and anxiety, a brand new nurse practitioner (NP) is likely to experience a wide range of emotions. Transitioning from the role of a seasoned nurse to a novice NP can be particularly stress-inducing. Although the past few years of formal schooling and practicum experiences have certainly been valuable, there is no handbook for handling this transition. When I graduated from NP school, I thought I had to know it all. (Spoiler alert—you don't!) From taking board certification exams to landing a job and establishing a new career, here are some of the things that I wish I had known when first starting out as a new NP.

Board Certification

The two certifying bodies for NPs are the American Association of Nurse Practitioners (AANP) and the American Nurses Credentialing Center (ANCC). New graduates often wonder if taking a review course for the board certification exam is worth it, as this adds another expense to the already costly process of becoming an NP. In my opinion, a review course is worth every penny. It helped me better organize my study materials, effectively prioritize the most important information, and develop a framework to prepare for the exam. I haven't met one NP who did not find an exam review course to be beneficial.

The Job Hunt

In some cases, practicum experiences in NP school can lead to a job upon graduation. However, this is not always the case. The new NP should start searching for a job when they are comfortable doing so. However, it's important to keep in mind that the process will likely take much longer than applying for and securing a new RN job. Some NPs aim to have a job waiting for them prior to graduation, while others prefer waiting until passing board exams to begin the search. The new NP should have an updated resume that suits their desired job and it should be tailored to each position they apply to. Many resources exist for support with resume writing, and these can be highly valuable tools for the new NP.

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Role Transition

Working as an NP involves a different set of tasks and skills than an RN role. However, the critical thinking skills developed while practicing as an RN will serve as a foundation for future NPs. These new skills will continue to build and advance—even many years into practice. Particularly when working in the same location, the line from RN to NP can be a tough one to cross. It can be challenging for others to see you take a new role with different expectations. Give yourself the grace to acknowledge that it's okay to not know everything and gaining confidence in this new position will take time.

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

Ask Questions

It's normal to have many questions as a new NP. Never be afraid to ask them, as this is how learning continues after graduation. Particularly during COVID times, practicum experiences may have had limited clinical opportunities. When starting out, a new NP will have unfamiliar experiences or situations daily. Understanding everything from the very beginning should never be expected.

Find Resources

Whether working in primary care or a specialty, a variety of invaluable resources are available for NPs to refer to. As a medical oncology NP, UpToDate and the National Comprehensive Cancer Network (NCCN) are resources that I continue to use daily— even 10 years into my career. Finding the most useful tools and bookmarking them for future reference will make practice much easier. As time goes on, a great deal of information will be committed to memory.

Collaboration

Serving as a crucial piece of providing excellent patient care, collaboration lies at the heart of the NP role. This includes teaming up with patients, RNs, and other staff members. In addition, the relationship with the collaborating physician should be strong. While some states offer full independent practice opportunities for NPs, many require some level of collaboration with a physician. The new NP needs to work alongside someone that they feel comfortable with and can turn to with questions without feeling judged. Furthermore, the NP should believe that the collaborating physician does a good job in their role. There may be a period of time where the new NP feels that they have to earn their trust and prove themselves. However, the physician also needs to earn the trust of the NP. Having a poor relationship with a collaborating provider can lead to significant job dissatisfaction. Even if working completely independently, establishing a strong dynamic with a more experienced healthcare provider can be invaluable.

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All experienced NPs will be able to recall some things that they wish they knew when first starting out. It's important for new NPs to remember that they will never be expected to know everything immediately and should embrace opportunities to work in positive environments that promote ongoing collaboration. Additionally, keep in mind that the first job after graduation may not be a perfect position. However, it will certainly offer much to learn from.

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.

Are you a nurse practitioner who is saddled with student loan debt? If so, you're not alone!

For many nurse practitioners, the financial burden of getting their degree is the only downside to the profession. With a nurse practitioner degree costing up to $100,000, it is not surprising that many nurse practitioners take out student loans. In fact, according to the American Association of Colleges of Nursing, the average nursing student loan debt is between $40,000 and $54,999.

The good news is there are multiple student loan forgiveness programs to help ease this financial strain. There are strict guidelines to qualify for the programs, but for those who meet the requirements, they are certainly worth applying for.

Federal student loan forgiveness programs available to nurse practitioners include:

• Nurse Corp Loan Repayment Program (NCLRP)
• Indian Health Services Loan Repayment Program (IHS)
• Public Service Loan Forgiveness (PSLF)

Nurse Corp Loan Repayment Program (NCLRP)

The Nurse Corp Loan Repayment Program is an excellent option for nurse practitioners who want to work in under-served communities or in academics. The program repays up to 85% of student loan debt for nurse practitioners who work in a Critical Shortage Facility (CSF) or who work as faculty for eligible nursing schools.

Eligibility Requirements For Nurse Practitioners

• Applicants must be U.S. citizens or lawful permanent U.S. residents.
• Nurse practitioners must work full-time, which is a minimum of 32 hours per week, at either a CSF or an eligible nursing school.
• Applicants must have an active, unencumbered license and have a post-graduate degree from an accredited nurse practitioner program.
• There are no income requirements, but priority is given to applicants with the greatest financial need.

Amount of Debt Forgiveness

• The baseline loan forgiveness is 60% in exchange for working two years in a CSF or working as a nursing faculty at an eligible nursing school.
• After completing the minimum two year requirement, nurse practitioners have the option of working a third year in their approved practice location to earn an extra 25% reduction, for a total of 85% loan repayment.

How to Apply

• Nurse practitioners interested in the program may apply online using the Health Resources & Service Administration (HRSA) loan repayment application portal.
• For questions about using the portal or the application process, applicants can call 1-800-221-9393.

Indian Health Services (IHS) Loan Repayment Program

The Indian Health Services (IHS) Loan Repayment Program pays a maximum of $40,000 in student loan debt of eligible healthcare professionals in exchange for working two years in healthcare facilities serving American Indian and Alaska Native communities. After the initial two-year commitment, providers may continue to work with IHS until their student loans are paid off in full.

Eligibility Requirements for Nurse Practitioners

• Applicants must be U.S. Citizens.
• In order to apply, applicants must have an unencumbered license or be in the final year of a postgraduate nurse practitioner degree program. Applicants must be licensed prior to starting employment.
• Priority is given to American Indians and Alaskan Natives, but any nurse practitioner who is committed to working at IHS facilities is encouraged to apply.

How to Apply

• Nurse practitioners must have an IHS web account in order to apply and it can be created online here.

Public Service Loan Forgiveness (PSLF)

Public Service Loan Forgiveness (PSLF) is an excellent option for nurse practitioners who have worked at least ten years for a qualified employer and still have student loan debt. In order to be eligible for the program, nurse practitioners must have made a minimum of 120 student loan payments. Unlike income-based loan repayment programs, repayment from the Public Service Loan Forgiveness Program is not taxable.

Eligibility Requirements for Nurse Practitioners

• Applicants must work full-time for a qualified employer, which includes federal, state, or tribal healthcare facilities and non-profit healthcare facilities.
• Only Direct Student Loans or student loans that have been consolidated into a Direct Student Loan are eligible for repayment.
• Applicants must have made 120 student loan payments while being employed by a qualified employer. Individuals who pay ahead on their student loans will not qualify before the ten-year mark.

How to Apply

• Complete the PSLF application and submit it to the US Department of Education via mail, fax, or upload via the MyFedLoan Portal.
• The Department of Education recommends that applicants update and submit the PSLF application annually for each year working for a qualified employer.

State Level Loan Forgiveness

Each state offers loan forgiveness opportunities for nurse practitioners in addition to federally sponsored loan forgiveness programs. The requirements, eligibility, and work commitments vary by state. Information for specific state programs can be found on individual state websites.

If you're a nurse practitioner with student loan debt, don't hesitate to apply for a loan forgiveness program. Paying off your debt is the best way to reap the financial benefits of earning your nurse practitioner degree.

Whether you are an undergraduate, new graduate, or a seasoned nurse, entering a nurse practitioner (NP) program is an exciting time. However, it can also be a stressful one. In fact, you may discover that NP school will be one of the most difficult academic endeavors you experience. At the end of the day, any advanced practice health provider role requires a great deal of studying and the ability to put complex material into practice.

Despite being a full-time graduate student who was no stranger to hard work, I still remember the stress of my first semester. Luckily, my program provided some insightful resources that helped me recognize the importance of learning how to study to achieve success. Based on my experience, here are some useful strategies for new NP students.

5 Tips for Didactic Study

Most NP programs will begin with one to two semesters of didactics. This means that there are no clinical rotations just yet. Whether they are enrolled part-time or full-time, students will juggle two to three classes at a time. Here are my five tips for success during didactic semesters.

1. Time Management

Prior to beginning the program, reflect on when and where you study best. Also, understand that you need a resting period. Someone once told me that graduate school is like a job and it should be treated like one. When working as a nurse, consider a per diem or part-time schedule to help ease the transition into NP school. Remember that graduate school is not like undergraduate work.

2. Invest In a Tablet

If you have the funds (and that is a big if), a tablet can boost efficiency. You can write, type, download notes, and more, and it is highly portable. While it's not a necessity, having a tablet was beneficial throughout my entire graduate experience.

3. Student-Life Balance

You will likely hear that NP students "have no life." While I had to learn to say no to certain social events, I also knew that life existed outside of school. I would typically study from 8AM to 5PM every day including weekends, reserving evenings for time with family and friends.

4. Know Your Study Style

There is an overwhelming amount of material that NP students are expected to learn. In addition to adjusting to the transition of graduate student life, you're also required to maintain certain grades to stay in the program. My recommendation is to know your study style. Louisiana State University has a great resource with surveys to help you determine your best study methods.

5. Know the Course's Objectives

This is something that I wish I knew sooner. The course's objectives offer incredible insight into what students should focus on when studying. Most of these objectives align with the necessary knowledge for boards. Therefore, be sure to review them in the course syllabi and weekly modules.

Clinical Rotation Study Tips

When you enter the clinical rotations phase, it's important to factor in travel time and patient entries as well as other additional assignments. Both can be time-consuming. Here are some tips to study effectively.

1. Listen to Relevant Podcasts

I often played medical podcasts in the car while driving home. As a Family Nurse Practitioner student, my favorites were American Family Physicians and The CurbSiders Internal Medicine. Many of my colleagues purchased MP3s from multiple board review sources such as APEA and Fitzgerald.

2. Learn in Rotations

Rotations offer an opportunity to apply didactic knowledge in hands-on situations. From suturing cysts to pelvic exams, it's critical to advocate for your participation. Learn how to assess for abnormalities while allowing preceptors to educate you. You will utilize these skills when practicing professionally.

3. Review Material

If there is material that you're unfamiliar with as a student, take the time to review it and gain an understanding of differentials and treatment plans. Even after graduating, it's crucial to become accustomed to reviewing and staying updated on current guidelines for treatment and preventive care. Making this a habit during rotations is important for doing well in clinicals and achieving long-term professional success.

Becoming an NP is a path that can only be understood by those who have experienced it. As a new graduate, I can empathize with the difficult transition to student life and working to pass exams every semester. I hope that new students can learn from my experience and utilize my tips. The journey is tough, but ultimately it is a rewarding one.

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.

"Get a medical student. The medical schools pay you."

As a nurse practitioner (NP) student, it was shocking and discouraging to hear my physician preceptor say this to his colleague. Whether students are attending a school that supports them with placements or working toward securing one independently, securing preceptors for clinical rotations is a challenging task. Unfortunately, many are desperate enough to pay agencies to find preceptors for them. Has advanced practice education really come to this — all because medical schools pay offices to take on students?

According to a 2014 article from the Society of Teachers of Family Medicine, 23% of medical schools offered payment for community preceptors. In fact, 63% of those who received payment for precepting were also paid by other learners. The article cites the increased competition among other healthcare schools to place students in community settings as the leading reason for providing payment. This ultimately leads to decreased opportunities for NP students, which is why many are having a difficult time securing placements.

RELATED: How to Become a Nurse Practitioner

The Difficulty with Precepting Nurse Practitioner Students

During NP school, I saw the many challenges that preceptors faced. From meeting quality measures to seeing patients and charting, providers were required to fit teaching students into their already hectic schedules. According to "Incentives & Barriers to Precepting Nurse Practitioner Students" the stress involved in the daily workflow of the clinic makes it difficult for providers to precept students – despite their desire to give back to the next generation. If productivity is impacted, a provider's income is affected as well. It is not uncommon to hear providers question their capacity to take on students when they can barely sustain themselves. This is why many providers ultimately choose not to precept students, although they would ideally like to teach.

In the same article, the authors mention the potential benefits of providing some sort of stipend to preceptors as an incentive. While this may help students secure preceptors more efficiently, it won't be useful for a student who is already paying a hefty tuition to serve others.

Thoughts About Payments to Precept

As a newly minted family nurse practitioner (FNP), I decided long ago that I would eventually precept the next generation of FNPs. As one of my preceptors put it, "I'm going to be under the care of you one day. Therefore, I'm going to teach you my ways so that you can care for me and not kill me!" These words always stuck with me, and I've since committed to give back to the next generation by becoming a mentor. Seeing the work that NPs and other providers put in, I know it won't be easy. However, I also know that the issue of paying for preceptors isn't going anywhere.

Precepting students as a nurse practitioner has traditionally been done free of charge. It was a service that NPs committed themselves to as a way to encourage and empower new NPs to effectively serve their communities. However, the shift of medical schools now paying clinical sites to host students has affected both NP and physician assistant students. Some schools are paying up to $100-$450 per week, with anecdotal research revealing that agencies such as NPHub will pay preceptors up to $3,000 per month. Whether it's the school or students who pay for preceptors, it's the student who is ultimately affected.

Looking back at my experience overhearing my physician preceptor and his colleague, I recall my hours being rushed to completion in order for them to take on a medical student. This led me to the realization that incentivized stipends for preceptors can lead to poor clinical experiences. If clinics and their providers are interested in empowering the next generation of practitioners, more support needs to be provided outside of stipends and financial incentives. Should this trend of paying for preceptors continue, I'm curious to see the implications on students' clinical experiences at rotations and the way they practice upon graduation.