About Dr. Alvita Nathaniel, Phd, APRN, FNP-BC, FAANP: Dr. Alvita Nathaniel is a Professor and Chair of the Charleston Division of the Robert C. Byrd Health Sciences Center at West Virginia University (WVU) School of Nursing. Prior to assuming her position as Chair, Dr. Nathaniel was Coordinator of the Family Nurse Practitioner Track at West Virginia University School of Nursing. She has also practiced as a family nurse practitioner in free clinics and juvenile detention facilities for over twenty years.
Dr. Nathaniel is active in public policy, and has published numerous articles in journals and other health care-related publications. She is also co-author of the book Ethics and Issues in Contemporary Nursing. Dr. Nathaniel is a Fellow of the American Academy of Nurse Practitioners, The Grounded Theory Institute, and the WVU Health Sciences Center Academy for Excellence in Teaching and Learning. She earned her Bachelor of Science in Nursing from Alderson Broaddus College and both her MSN and her PhD from West Virginia University.
[OnlineFNPPrograms.com] How are clinical experiences structured at West Virginia University?
[Dr. Alvita Nathaniel] Just for context, our program is currently a BSN to MSN program comprised of 48 credits and 500 clinical hours, but beginning this summer, it is transitioning to a BSN to DNP program. There are strict, nationally published guidelines, from our accrediting organization, that dictate to us what content and what courses must be in a nurse practitioner program.
We work very hard to make sure we’ve covered all the essentials for accreditation for our online program. And we also try to keep options open for our students, according to the degree level they wish to obtain. Our BSN to DNP program allows students to take the first two years of courses, and to stop out and actually be awarded an MSN. As mentioned, the MSN portion is 48 hours, and that portion actually meets almost all of the DNP essentials. Then, if they wish, students would continue onto the DNP portion for 19 additional hours.
Clinical experiences for nurse practitioner students also are very closely regulated by our accrediting organization. Just to earn nurse practitioner certification, students must complete more than 500 hours of direct patient care, under a qualified supervisor who is at a nurse practitioner level or higher. To become a masters-level nurse practitioner, one has to complete at least 500 hours of clinical practicum. But to get a DNP, students have to get at least 500 additional hours, so a minimum of 1000 total.
All of our students in the family nurse practitioner and pediatric nurse practitioner tracks of the BSN to DNP program starting this summer will have 1000 hours of direct primary patient care experience. And another thing we pride ourselves at is that students do their clinical experience at a site near their homes. We work with them, the students, to help find a site that meets our criteria. And that is, it has to offer primary care, it has to have a qualified preceptor, and it has to commit to accepting the student.
We do our best to support our students in finding clinical experiences that will be acceptable and which meet our criteria. We don’t say that we can find clinical experiences for everyone from every state, because different states have different regulations, policies, and laws about program offerings and students’ eligibility to work in certain regions. There are several states that, at present, may not allow WVU graduate nursing students to complete their practicums, and in these cases a clinical site would not e guaranteed for students who are residents of these states. A State Authorization Reciprocity Agreement (SARA) must be established in order for a WVU nursing student to participate in clinicals. Prior to applying to our program, students should contact us to ascertain whether their state has a current reciprocity agreement with our distance education program. In addition, while the SARA reciprocity agreement is all that is needed in some states, other states may have additional requirements, including application to their boards of nursing. That said, we have not yet encountered a situation in which a state does not allow one of our students to complete his or her clinicals there. We can make no guarantees, obviously, as it is at the discretion of state boards and their regulations, but we’ve had good results so far. We have never had to dismiss a student or require a student to come to West Virginia to do their clinicals. That’s not to say that will never happen. It could happen, but we’ve done everything that we can, up to this point, to try to help the students.
West Virginia University has a very structured and collaborative approach to clinical placements, in that both the preceptor and the faculty of the clinical practicum course are in regular communication with each other and with the student to ensure that the student meets certain learning outcomes. To begin the process of securing a clinical site and preceptor, students must first meet with their course’s faculty member to discuss their learning goals, academic and professional history, and any geographical restrictions (for example, whether reciprocity agreements exist in a student’s state of residence, or whether facilities in the student’s area actually have the ability to take on and supervise a student). Students then identify clinical sites at which they would like to complete their clinicals, and both students and faculty work together to identify and reach out to these sites to arrange an appropriate preceptor.
We have had students from many different states, and we’ve worked with them to find suitable experiences at places near their homes. We’ve had students in Hawaii, Texas, and Alaska. We had a DNP student who was on active duty in Afghanistan. And we had another DNP student who was in Madagascar during the entire time that he was in the program except for when he came back to the United States for his practicum. But during his time abroad, we worked with him to locate and secure a clinical site and supervisor.
Students who apply to graduate nursing programs generally do not really understand one hundred percent what the nurse practitioner role is, or what the expectations are. And so, we have to talk to them about the types of sites that are optimal for the completion of clinical practicums, how to select a good preceptor, and the depth and breadth of clinical experiences we wish them to obtain during their practicums.
For example, we almost always know that a site that’s considered what we call a FQHC–or federally qualified health center–are almost always appropriate for a family nurse practitioner student because there are certain requirements to meet the criteria of being a federally qualified health center, which make them also suitable for primary care nurse practitioner students to fulfill their clinical practicums.
If a student is in a state 2,000 miles away, we cannot drive around the neighborhood and find sites. But we can help them find lists of primary care clinics or FQHC sites that they can investigate, and that’s what students that are at distance will do. And then, once they have done the groundwork, then our faculty take over, and we’ll make contact with those sites and ascertain whether there is a preceptor there that can work with the student, and whether the site is willing to take the student. And once we get all the necessary approvals, we will contract with the site.
So it’s a partnership between the student and a faculty member. We definitely don’t leave the students out there, telling them, “Go find your own site.” There are some schools that do that, but we have a strong belief that we need to have some control over the process, as some sites and some preceptors are not really acceptable because they do not give students the learning experiences and opportunities they require.
[OnlineFNPPrograms.com] What types of support and guidance does West Virginia University provide to students during their completion of their clinical practicums?
[Dr. Alvita Nathaniel] Faculty are in regular communication with students during their clinical practicums, and also reach out to preceptors on a periodic basis to check on students’ progress, identify learning needs, and address any challenges that arise. Students must keep a log of their completed clinical hours. The clinical log is online and the faculty can view the logs in real time and give feedback if needed. Both the students and their preceptors must submit a self-evaluation by the end of the rotation. AT present, students must also make two trips to campus for clinical conferences during the semesters when they are doing their practicums; that said, the two trips to campus during the practicum semesters is a fluid number. In the past we required them to come four times. We have whittled it down to about two, but there is discussion about eliminating the requirement, especially for student who live at a great distance.
In addition to the support that course faculty and preceptors provide students during their practicums, West Virginia University provides each student with two types of advisors: we have faculty advisors, and we have academic advisors. The academic advisors are non-faculty staff members who know the programs, and understand the procedures. And they keep track of all the students, and the students’ progress, continually. And they help students to enroll in certain classes, or tell students how to go about dropping class if they’re not doing well.
The faculty advisors are really good about giving advice for students about effective time management, balancing their different obligations, and keeping their grades up. For example, they tell students, “You’ve gotten to this point, and now we need to work on your study habits, because you’re going to have to improve your grade.” Or they may give students advice to drop a course they’re not doing well in, so they can be successful when they come back and do it again.
[OnlineFNPPrograms.com] In what ways does West Virginia University teach and then reinforce the skills, knowledge, and practical experiences that nursing students need to make that leap from being a deliverer of care to being a coordinator of care and a leader in medical settings?
[Dr. Alvita Nathaniel] That’s an excellent question, and it’s a big question–maybe the biggest question facing nursing programs nationwide. And for registered nurses training to become nurse practitioners, that transition can be a big hurdle. But by the time our students are ready to graduate, they have already essentially made that transition, and I think it happens in a couple ways.
First, the way we deliver our online MSN and DNP programs helps students learn how to make decisions. The courses for our graduate nursing programs are all online, and they’re mostly a combination of synchronous and asynchronous. For the asynchronous portion, students use the online platform Blackboard, through which they access their reading assignments or class lectures that have been archived and taped.
But we combine these asynchronous lectures and course materials with synchronous classroom discussions, and the discussions are case-based. For instance, we will say, “Given a patient at this age, with these sociological circumstances, in this cultural group, and this particular disease, let’s talk about how you would assess that person, what you would prescribe to treat that person, how you would follow up with the patient and other relevant health care parties.” This type of case-based learning we feel is incredibly important for students to be prepared for their clinical practicums, as well as their actual professional practice post-graduation.
How you treat a person depends, not only on their physical health, but also on their mental and social circumstances–everything is connected and makes it important to form a medical care plan based on the individual, rather than see all medical cases in a given category as the same. So our case-based discussions take into consideration all those social and cultural aspects, in addition to the disease itself. Not only does the student learn about the disease and how to treat it, but also how to make decisions in context with a patient’s medical, mental, social, and cultural background.
And for the nurse practitioner courses that involve discussion of actual clinical practices, we talk about pharmacology assessment and diagnoses and treatment, we use what’s called a flipped classroom. A flipped classroom involves taking a case, discussing it, and then putting a twist on it and asking the students how they’d approach this new scenario given the principles and concepts just discussed. Let’s say, “Okay, so now we know that this person also has asthma,” or, “This person also had an amputation and can’t make it down the street,” or a similar unconventional scenario. And so then we talk, and we ask the students, “Okay, let’s talk about how you make decisions about how you would change that person’s care.”
So, they’re learning a lot about critical decision-making, which prepares them for their clinical rotations and real world practice. We have found that this is a very effective way to teach, and our students enjoy it. Furthermore, if structured correctly, it’s also a way for every student to participate in the class, which is a distinct advantage of online learning platforms. When we have our live synchronous classroom, generally, the way it’s done, students and faculty may connect by audio supplemented with Powerpoint, or the faculty member can click on a button, and he or she will have a channel on where students can see her. In a large and live online classroom, students can either speak into a microphone or they have the option of typing responses like a live chat as a way to interact with faculty and their peers.
So a professor using our online platform can present the question, “What do you think the most important problem this patient has is?” and then prompt his or her students, “Everybody type his or her response in right now.” And just in a second, you can see everybody’s answer. Whereas, if you were in a live classroom, you would ask a question, then two or three people would put their hands up, and other people would just sit back, and they would be passive learners, not active learners. So, online actually creates an environment where every learner can be an active learner. It can be really effective.
West Virginia University started distance education way back in the ’80s; we’ve gradually moved to different modalities over the years. Decades ago we were using microwave technology which we used to pipe our lectures into classrooms around the state. This was back in the late ’80s, maybe early ’90s. At one point in time, we had a diaspora of faculty going out to different locations and teaching courses in this town or that town, and we would have cohorts in those towns.
And then we started online teaching, and we used various modes and methods of doing that, until we got to where we are right now. So we were the first school of nursing in the country to use Mediasite webcasts for teaching. I cannot say what year we started that, but it was probably 15 years ago. A lot of schools are doing it now, but we were very early and have had a lot of practice learning the ways to optimize online education. Our tests are conducted online, and we have ways to minimize and address academic dishonesty during exams and the completion of assignments.
In addition to the visits to campus that students must make for clinical conferences, we also require four visits to campus for students’ physical assessment classes. During these visits, they learn the manual skills, such as how to hold an otoscope, how to hold the ophthalmoscope, etc. Such tasks and skills are really hard to learn from simply reading instructions or concepts on a page, so these visits give students the opportunity to handle the equipment and apply what they’ve learned to concrete tasks.
You could teach physical assessment fully online–and we do have an online portion of this course–but we feel very strongly that we need to know that the student can examine a patient correctly, because you can’t make a diagnosis if you can’t do an assessment. So, the students have to come in, they have to learn those skills, and they have to pass a proficiency test with simulated patients in a simulated clinical setting.
Students must pass this proficiency test with a high grade, before they’re ever allowed to enter the clinical setting. So, the first day they go in the clinical setting, they already have some decision-making skills and know what goes into a thorough and accurate physical exam; physical assessments are one of the foundations of taking care of patients. Another foundation is how to listen to people, get their story, and take their history. And we do really in-depth classes on doing that, and we have them practice that, and then we make them do that extemporaneously, and we grade it, so we know that they can do that. So they go into the clinical setting as novices, but they’re well prepared, and they have the tools to do it.
We have a huge group of preceptors that have been really good as teachers. Preceptors do a lot of our teaching, and preceptors in West Virginia, at this point in time, are not paid. They’re volunteers. It’s a wonderful thing. It’s a service, I guess you could say, to society as a whole, to help teach the new students how to be providers.
The preceptors are guided in how to gradually give students more responsibility, so that by the time students are in their last semester, or in the last part of their last semester, in their clinicals, they’re actually doing all the patient care. So they see the patient, they take the history, they do the physical exam, they write it up, and then present it to the preceptor for comment. They do that – of course, the patient doesn’t leave until that’s all done, and those preceptors will go in and see the patient, and make sure that what the students have done is correct.
But we transition them up, gradually learning more and more, so that by the time they’re ready to graduate, they can step right in to the clinical setting. It’s really about guiding students through building a solid foundation of concepts and skills, and then allowing them to apply their knowledge and abilities by gradually taking on more and more clinical responsibilities until they feel proficient and largely autonomous. And we’ve had sites that employed our graduates tell us that they were very well-prepared. We’ve had many sites tell us, when our students entered the clinical site, that their preparation is excellent, at that point in time. So, we feel fairly good about that.
Thank you Dr. Nathaniel for your insight into the clinical placement process at West Virginia University’s online graduate nursing program!