FCAs are instrumental in helping students refine skills related to advanced practice, practice inquiry, leadership, health delivery systems, and population care in the clinical setting.  

Advanced Practice 

Refining Clinical Skills  

Assessment includes cognitive and psychomotor components.  The student applies the sciences while using assessment skills in demonstrating clinical decision making.  The FCA is an invaluable resource for evaluating the student’s progress towards achieving greater expertise in clinical reasoning. 

The FCA’s initial role involves evaluating the student’s level of knowledge and assessment skills.  As the student progresses from novice towards proficiency in assessing patients, identifying a diagnosis, and formulating a management plan, the FCA evaluates a) the student’s psychomotor skills, b) data collected from the history and physical, c) interpretation of data, and d) the proposed management plan.  

Guiding students in gathering reliable assessment data involves observing the student while eliciting a history and performing a physical exam, followed by validating the assessment.  The student presents findings to the FCA, who evaluates the student’s interpretation of the assessment data.  Incorrect information is corrected by discussion and re-examining the patient as appropriate.  Providing positive feedback reinforces students’ skills and confidence in successful clinical learning.  Students need time to practice their skills and test their abilities.   

Students should identify their individual learning needs in the area of assessment and welcome the FCA’s critique and/ or validation of their skill levels.  A plan for remediation should be anticipated for situations in which the student needs practice and proficiency in either technique or interpretation of patient assessment data.  Refining an incorrect psychomotor skill/ technique can be achieved with a clinical demonstration by the FCA or preceptor.  Interpretation of laboratory data is a skill that requires the student to apply knowledge from the sciences and identify links to the patient’s history, presenting concerns, physical exam, and differential diagnoses.  

As students progress and gain confidence, they become more comfortable with the FCA’s critique and seek direction to achieve higher levels of proficiency in clinical reasoning.  Students need to be apprised that, although they are students, evidence of progressive mastery of content and psychomotor skills is expected.  They should anticipate progressing along the continuum from novice to competent, safe practice. 

Refining Interpersonal Skills  

Interpersonal skills involve the use of verbal and nonverbal communication in a timely and sensitive manner, with attention to another person’s needs, anxiety level, and concerns.  Situations arise within the clinical area that provide students with opportunities to improve their interpersonal skills: 

• Collaborating with colleagues in the clinical setting;  
• Preceptor observation and feedback;  
• Self-reflection and documentation of encounters in a log or diary; and 
• Feedback from patients and colleagues.  

Students should demonstrate basic interpersonal skills.  

• Eliciting historical data by using open-ended questions and allowing the patient time to answer a question before proceeding to the next question.  
• Eliciting a history, comprehensively, and in an unhurried manner before beginning an exam.  
• Asking about the patient’s opinions, concerns about their condition, and how they would like to participate in their plan of care.  
• Verifying with the patient understanding of their concerns, treatment plan, and opinions.  
• Eliciting information from the patient about their family and support systems.  
• Showing empathy: genuine interest, concern or warmth for the patient’s situation, condition, or personal/social problems.  
• Providing the patient with relevant information, demonstrating sensitivity regarding potential impact on the patient’s lifestyle, financial resources, or self-care ability.  
• Providing culturally congruent care, demonstrating awareness of ethnicity, traditions, and beliefs.  

The student should be notified of any need for improvement in interpersonal skills early in the clinical practicum.  By alerting students to focus on problematic areas early in the practicum, FCAs give students the opportunity to refine their interpersonal skills by the time the clinical practicum is completed.  

Clinical Reasoning and Decision Making  

According to Patricia Benner, Ronda Hughes, and Molly Sutphen (2008), clinical reasoning stands out as a situated, practice-based form of reasoning that requires a background of scientific and technological research-based knowledge about general cases.  It also requires practical ability to discern the relevance of the evidence behind general scientific and technical knowledge and how it applies to a particular patient.  In doing so, the clinician considers the patient’s particular clinical trajectory, their concerns and preferences, and their particular vulnerabilities (e.g., having multiple comorbidities) and sensitivities to care interventions (e.g., known drug allergies, other conflicting comorbid conditions, incompatible therapies, and past responses to therapies) when forming clinical decisions or conclusions.  Situated in a practice setting, clinical reasoning occurs within social relationships or situations involving patient, family, community, and a team of health care providers.  The expert clinician situates themselves within a nexus of relationships, with concerns that are bounded by the situation. Expert clinical reasoning is socially engaged with the relationships and concerns of those who are affected by the caregiving situation, and when certain circumstances are present, the adverse event.  Excellent clinical ethical reasoning is called “emotional reasoning” in that the clinicians have emotional access to the patient/family concerns and their understanding of the particular care needs.  Expert clinicians also seek an optimal perceptual grasp, one based on understanding and as undistorted as possible, based on an attuned emotional engagement and expert clinical knowledge.  

As an expert clinical practitioner, the FCA has mastered a variety of ways of thinking that contribute to the process of clinical reasoning.  Teaching the student how to use these ways of thinking helps develop clinical proficiency.  The process of teaching clinical reasoning guides the student in learning new ways of thinking in clinical practice.  Teaching clinical reasoning enables students to apply knowledge in practice.  Students should be asked to: 

• reflect and describe the process of identifying a specific diagnoses or differential, select laboratory tests, prescribe medications or recommend a follow-up schedule; 
• use accepted guidelines and standards of care;  
• use the latest evidence in development of management plans;  
• critically analyze the guideline/standard of care and determine how it should be implemented or adapted to the individual patient scenario; and  
• reflect on previous client encounters and compare and contrast components of the assessment.  

The one-to-one relationship with the FCA provides the student with the opportunity to develop competence in diagnostic reasoning, clinical decision-making, advanced practice nursing skills/procedures, as well as self-confidence in implementing the NP role.  Timely and constructive feedback, whenever possible, enhances this learning process. 

Patient Education  

Patient education is an important domain of NP practice and should focus on health promoting behaviors, disease prevention, as well as issues surrounding health maintenance and episodic self-care. Students are expected to: 

• integrate patient education in all aspects of care.  
• demonstrate the ability to perform a learning needs assessment and construct a teaching plan that is appropriate to the learning needs of the patient and/or family members.  
• take into consideration timing and level of patient education, identifying “teachable moments” as opportunities for patient and family learning. 
• determine the patient’s or family members’ ability to understand either verbal and written instructions, in plain English, or their own language.  
• document the patient education plan in the record and reinforce it with subsequent providers, whenever possible.  
• discuss the educational plan with the preceptor.  
• be aware of agency resources for educating patients such as a nutritionist, diabetic educator, or health educator.  Students should collaborate, as appropriate, with other members of the health care team.  Members of the interprofessional health care team can provide resources and links in the community that will best meet the patient’s needs.  

Most students find this aspect of care enjoyable.  It also provides an opportunity for the FCA to reinforce skills in patient education and emphasize its importance in the role of providing direct care to patients. 

Mastery of Documentation  

Accurate and complete documentation enables and ensures quality health care practices, while fulfilling legal and reimbursement requirements.  The clinical practicum provides students with the opportunity to master documentation of care.  In “learning by doing,” the FCA mentors the student in refining the history, exam, decision making, and level of service provided.  The mastery of documentation includes:  

• Clear written communication.  Assessing student documentation should be an ongoing process that takes place throughout the student’s program of study. 
• Familiarity with preferred formats for documenting encounters detailing the comprehensive history and physical, chronic illness, and episodic visits. 
• Use of accepted medical abbreviations and anatomical terms, and descriptors.  
• The recording of only pertinent findings (both negatives and positives) from the history and physical exam. 
• Use of strong writing skills.  Students should also understand that the medical record is not only a legal document.  When read by other providers, a perception of the writer’s knowledge base occurs. For example, low level writing, use of lay terminology translates to a fellow provider as low level knowledge base. 
• Reading the notes of the preceptor and other health care providers.  The patient’s health record will provide exemplars of both good and poor documentation and is an excellent resource early in the student’s clinical experience.  As students review the notes that are documented in the chart, they soon learn the elements for inclusion and the procedure for organizing documentation. 
• Note-taking while in the room with the patient.  The notes can then be organized into a rough draft that includes all components of the patient’s care.  The FCA can rapidly review the student’s documentation and make recommendations for refinement or organization.  
• Identification of agency preferences for documentation.  Preceptors’ preferences for documentation may vary from standard formats and may depend upon the practice setting.  
• Use of the clinical site’s electronic medical record. 

Practice Inquiry 

The FCA is instrumental in facilitating the student to synthesize and apply scientific knowledge and evidence to interpret subjective and objective data, assess the patient, and to develop management plans.  Students should use analytic methods to critically appraise existing literature and other evidence to determine and implement the best evidence for practice.  Students’ ability to synthesize and apply scientific knowledge to the care of their patients should increase as they progress in the program.  In particular, they should demonstrate progressive mastery of physical assessment, pathophysiology, and pharmacotherapeutics.   

Practice inquiry and clinical reasoning can be supported by having the student present the patient case to the FCA and provide evidence-based rationale for their decisions.  In addition, the FCA may suggest topics for further research, based on the patient encounters.  This strategy will enable students to gain confidence in and reinforce their knowledge base. 

Health Care Systems 

To fully function in the nurse practitioner role, students must learn to navigate health care systems.  Broad based skills including negotiating, consensus-building, and partnering are important to effect health care change.  Students can practice these skills during contacts with other health care professionals, interagency referral processes, and with processes related to managed care, home care, securing durable medical goods, and writing prescriptions.  As students progress through their NP program, they should demonstrate comprehensive care that includes collaboration with other health care professionals.  Students should know how to analyze organizational structure, functions, and resources to solve clinical problems and improve delivery of care in a way congruent with the agency/institution’s policy. 

Students should be encouraged to advocate for patients as part of providing comprehensive care.  Students should initiate referrals and team conferences and seek financial and social supports for patients/families.  Students’ self confidence in decision-making can be enhanced by providing feedback on their ability to achieve patient care goals and objectives through skillful negotiation of health care systems.  Students can create a reference guide for commonly used community resources.   

Interprofessional Practice 

As members of the health care team, students learn how to collaborate with both professionals and other caregivers to achieve optimal care outcomes.  Students learn effective communication and collaborative skills in the development and implementation of practice models, peer review, practice guidelines, health policy, standards of care, and/or other scholarly products.  This skill of integrating the role of the NP as a member of the interprofessional health care team is perhaps the most challenging for the FCA to demonstrate and teach.  The following examples are possible activities:  

• Demonstrate collaborative management with other health care providers.  This is an important way of teaching the student to respect the knowledge and expertise of other disciplines, and thereby earning respect for the NP’s unique contribution to the health care team. 
• Initiate team conferences where all members of the health care team discuss and develop a plan of care for a patient or family.  
• Encourage students to be creative and contribute to the smooth operation of the clinical setting. Students may contribute ideas to enhance the efficiency of operations.  Their contributions enhance their self-confidence as valuable contributors to the health care team.  Students may choose to develop teaching materials for patients and their families.  These materials may complement resources available in the clinical setting. 

Population Health 

NP practice includes not only direct care but also a focus on the needs of a panel of patients, a target population, a set of populations, or a broad community.  The FCA can encourage students to think about current concepts of public health, health promotion, evidence-based recommendations, determinants of health, environmental/occupational health, and cultural diversity and sensitivity as they care for populations.  Students should be able to: 

• Synthesize concepts, including psychosocial dimensions and cultural diversity, related to clinical prevention and population health  
• Develop, implement, and evaluate interventions to address health promotion/disease prevention efforts, improve health status/access patterns, and address gaps in care of populations. 

Leadership 

Organizational and systems leadership are critical to improve patient and healthcare outcomes.  The FCA guides the student as they develop leadership skills and strategies in the clinical setting.  Examples of leadership activities include: 

• Fosters collaboration with multiple stakeholders (e.g. patients, community, integrated health care teams, and policy makers) to improve health care. 
• Leads interprofessional teams in the analysis of complex practice and organizational issues. 
• Advocates for improved access, quality, and cost effective health care. 
• Develops and implements a practice innovation incorporating principles of change. 
• Develops and implements an institutional, local, state, federal, and/or international health policy. 
• Evaluates and resolves ethical and legal issues within healthcare systems relating to the use of information, information technology, communication networks, and patient care technology.    
• Communicates practice knowledge to other health care professionals, both orally and in writing. 
• Guides, mentors, and supports other nurses to achieve excellence in nursing practice.  
• Educates and guides individuals and groups through complex health and situational transitions. 
• Participates in professional organizations and activities that influence advanced practice nursing and/or health outcomes of a population focus. 

Adapted from: Partners in NP Education: A Preceptor Manual for NP Programs, Faculty, Preceptors, and Students. (2012). National Organization of Nurse Practitioner Faculties.