For many registered nurses (RNs), graduate nursing school is one of the most challenging times of their academic and professional careers, due to the need to balance work and family with courses and intensive clinical practicums. In addition to completing their degree program, graduate nursing students must also become comfortable with transitioning from working as a staff nurse to being an advanced practice provider. This transition requires that RNs undertake more challenging and complex responsibilities in the medical workplace, and to relinquish some of their direct care tasks in favor of care coordination. Unfortunately, graduate nursing students may not be fully aware of the magnitude of change that becoming an APRN involves, and therefore may miss the chance to better prepare for this transition during their classes and clinical practicums.
APRNs, like RNs, perform health evaluations, patient consultations, treatment administration, and medical procedures to address mild to severe health conditions. However, while RNs focus on implementing a plan of care, APRNs analyze patient information to determine a plan of care. APRNs face the challenge of making complex and high-stakes clinical decisions based on patient data, directing teams of medical professionals, and overseeing medical care at a systems level. For many nurses, this transition can be daunting both during their program and throughout their first few months as new APRNs.
To help graduate nursing students and new APRNs transition effectively from staff nursing and bedside care to staff leadership, care coordination, and other advanced practice provider responsibilities, OnlineFNPPrograms.com created this Guide: Navigating the transition from RN to APRN. Within this Guide, we describe the key ways in which APRNs differ from RNs, and how graduate nursing students and new APRNs can develop the skills they need to successfully make the transition.
Key Skills for Advanced Practice Registered Nursing
To succeed in their work as advanced practice providers, APRNs must build the following skills:
- Critical Thinking and Information Analysis: While RNs follow plans of care and execute on orders, APRNs develop plans of care and coordinate other medical professionals in the delivery of care, which requires that they know how to review and analyze patient information, make differential diagnoses, and make sound judgments regarding patient treatment plans.
- Strong Communication and Presentation Skills: APRNs present patient cases to other medical staff on a regular basis, and therefore need to have strong communication and presentation skills in order to convey important details about a patient’s medical history and health status to develop a strong plan of care in collaboration with colleagues.
- Patient Relationship Management: Depending on their area of specialization, APRNs may serve as primary care providers (PCP). Being a PCP typically involves having regular check-up appointments with patients, answering their queries, refilling and updating prescriptions, and fulfilling other tasks to oversee and manage patient health. It also requires that APRNs have a strong grasp of their patients’ medical history, present health status, and what health risks they may face in the future.
- Task Delegation: APRNs must be comfortable delegating tasks. Their increased responsibilities and patient load mean that they cannot complete bedside care and other staff nursing responsibilities on a regular basis. APRNs need to get accustomed to developing medical care plans and then assigning the execution of these plans to other staff on their team.
- Time Management and Adaptability: APRNs may work more hours than their RN colleagues, and may also be required to work past normal workday shifts due to the need to follow up with patients, answer their questions, and review charts. APRNs also encounter a wider range of patient health challenges due to the fact that they are responsible for a greater number of patients for a longer period of time. APRNs must be organized and adaptable to different medical situations as they arise, and must manage their time well in order to fulfill all their responsibilities efficiently and effectively.
- Understanding the Intersection Between Bedside Nursing and Advanced Practice Nursing: The heart of advanced practice registered nursing and staff nursing are the same, in that both work towards effective evaluation and care of patients. While both APRNs and RNs have distinct responsibilities at different levels within the health care system, both conduct health evaluations, contribute to the development and delivery of medical care plans, and establish important relationships with patients throughout their tenure of care. To be an effective APRN, individuals should view their transition to advanced practice nursing as more of an extension of their existing bedside nursing responsibilities, rather than a replacement of them.
In order to provide graduate nursing students and recent APRN graduates advice on each of these key skills, we interviewed several APRNs who have also served as clinical preceptors for nursing students. Their insights and advice are included below.
Critical Thinking and Information Analysis
Cortney Mazur, MSN, CPNP-BC, who is a Pediatric Nurse Practitioner at the Children’s Hospital of Michigan in the Hospitalist Division, explained how advanced practice providers are required to take more ownership of patient care plans and to use more of their analytical skills relative to their bedside care skills. “[Staff nursing] is a very task-oriented profession… not that bedside nurses don’t use their brains, we all know that’s not true, but the role of the NP is to gather information, analyze that information, and formulate a plan. The NP role is more of a clinician and less of a caretaker,” she said, “The NP’s role is to create an impression from the information gathered and come up with a plan. The NP’s job is to make the best decisions possible given a patient’s particular presentation and unique set of circumstances. This is much easier said than done and takes lots of time and practice, even after the student completes his or her schooling and clinical.”
During their clinical practicums, graduate nursing students can prepare for their new autonomous role as APRNs by observing their preceptor during patient rounds and making note of how APRNs interact with patients and colleagues. Andrew Penn, MS, PMHNP-BC is a Psychiatric Mental Health Nurse Practitioner at The Permanente Medical Group, where he provides individual and group psychotherapy as well as medication management services to intensive outpatient patients. In an interview with OnlineFNPPrograms.com, Mr. Penn explained how, as a preceptor, he guides his students through the process of becoming advanced practice providers and assuming all the care coordination responsibilities that this new role involves.
“When I am precepting NP students, I try to introduce them gradually to the autonomy attendant to the APRN role. This was a model shown to me when I was an NP student and helped me develop the confidence I would need as a NP,” he said, “At first, the student and I see patients together and I conduct the interview so the student has a model to emulate. Then I see patients with them, and let the student do all the talking and deciding. Once I feel confident that they have the basic competencies down, I have them meet with patients on their own and consult with me afterwards. This allows them to develop a set of skills without feeling overwhelmed by the task.”
Asking questions regularly during their practicums is also an important part of how graduate nursing students can learn the skills and strategies to succeed as APRNs. Laura Smith Dziama, MSN, WHNP-BC is a Women’s Health Nurse Practitioner who has precepted nursing students at Boston University for over a decade. In an interview with OnlineFNPPrograms.com, she explained how asking questions frequently was one of the ways in which she built the skills and gained the confidence necessary to succeed as an advanced practice provider.
“When I was a student and RN I gained lot of confidence from my clinical rotations, especially those where I was given a lot of autonomy and freedom to see patients on my own, as well as the freedom to ask questions and get feedback from my preceptors,” she said. Ms. Dziama advised students to ask questions and solicit feedback from their preceptors as a way of learning where they can improve. “I always keep that in mind when working with students. I want them to feel like they can ask me a lot of questions and alternatively I like to give feedback on what they could work on and also what they are doing well,” she said.
Practice is key to how graduate nursing students and new APRNs can hone their critical thinking skills, make accurate diagnoses, and formulate effective medical care plans. In her interview, Ms. Dziama explained how repetition of advanced practice provider tasks both during her clinical internships and her early work as an APRN was essential in helping her master her new role.
“The biggest change I noticed going from RN to NP was being in a position where I was taking a lot of orders to immediately being in a role where I was completely independent and giving a lot of orders,” she said, “I think being able to make this transition successfully takes a lot of practice and repetition.”
“I tell my students that repetition is good, you are never an expert the first time you are seeing a patient for a specific problem but the more you encounter that patient problem you become more confident asking the right questions, knowing what to look for clinically and then formulating the correct plan of care. Most importantly through repetition and experience you become effective at communicating the plan of care to patients in an empathetic and informative manner.”
Communication and Presentation Skills
Another significant challenge of being an APRN is presenting patient cases to colleagues to develop an ongoing plan of care for patients. In her interview with OnlineFNPPrograms.com, Pediatric Nurse Practitioner and preceptor Christine Guelcher, MSN, PPCNP-BC explained how many of her students find presenting patient cases to their colleagues to be a challenge.
“Students are often intimidated by having to present a patient to colleagues in the clinical setting. We work on organizing thoughts, creating differential diagnosis lists and determining next steps systematically so that the presentation becomes second nature over time,” she said. Graduate nursing students may find it helpful to develop a system for presenting patient cases, such as a checklist of information they need to gather from their patients and present to colleagues. In some cases, overcoming the challenge of presenting patient cases to a group can also be an opportunity for new APRNs to support and connect with their peers. For example, Ms. Guelcher explained how one of her students created a template for organizing patient information in a presentable manner. The template was so useful that her student even shared it with her colleagues and fellow students.
“I can remember one particular student who was very anxious about presenting patients, but she focused on this skill and developed an intake sheet that she found helpful during her clinical experience, Ms. Guelcher recalled, “She would use this template to organize the information as she was presenting her patient and it helped her to be more confident with this necessary skill. At the end of her rotation we asked if she would share her tool and we now provide it as a resource to other NP students. It is so nice to see the growth of students during a clinical experience.”
Delegation of Tasks
APRNs’ increased care coordination and patient oversight responsibilities require that they delegate more of the direct care duties they formerly completed as RNs to other individuals. To some APRNs, this delegation can be a somewhat difficult adjustment. Ms. Mazur explained in her interview with OnlineFNPPrograms.com how giving up her direct care responsibilities felt like a sacrifice of an aspect of her job that she enjoyed. “The transition from RN to NP, for me, was a not an easy one,” she said, “I enjoyed my job as a burn nurse immensely and I initially had a moment of regret when I became an NP. I loved being at the bedside and having so much one-on-one time with my patients and their families. I enjoyed doing blood draws, passing medications, performing dressing changes, etc.”
Ms. Mazur advised graduate nursing students and new APRNs to remove themselves gradually from the direct caretaker role by focusing more on their new responsibilities and leaning on their colleagues for support. “The role of the NP involves a lot of delegating and as a new NP I was initially uncomfortable delegating tasks to people with whom I used to work alongside as an RN,” she said, “I found myself performing a lot of the tasks myself (placing NG tubes, drawing blood, etc) because I can do it, so why not do it? There comes a point where you will become comfortable and be able to let go of these things (largely because you won’t have time to do two jobs).”
Patient Relationship Management
APRNs whose new role requires them to be a primary care provider must grow accustomed to building longer-term relationships with the patients they serve, and learning how to manage their patients’ care in between medical appointments. In his interview with OnlineFNPPrograms.com, Mr. Penn explained how his transition from being a Staff Nurse in psychiatric emergency services to being a PMHNP involved a decided shift in his relationship with patients and their care.
“The shape of a day and your role in the clinic when you’re a APRN is often quite different from when you’re a staff nurse,” he said, “For example, when I was a staff nurse, I’d come in at the start of my shift, get report, and tend to whatever those patients needed for the 8 or 12 hours that I was there. Then I’d go home, leaving those patients in the hands of a colleague and regardless of if I returned the next day or the next month, I was done with my responsibilities.”
In contrast, transitioning to advanced practice psychiatric mental health nursing involved, not only an expansion of his responsibilities, but also an increase in his patient load. “As an APRN, I have a caseload of many hundreds of patients. Some of those patients I might see every month, and others might go for a year or more before they need to come in and see me again. Those enduring relationships are one of the things I really like about my role as an APRN,” he told OnlineFNPPrograms.com, “I get to see patients get better, from the start of their treatment until the end.”
The responsibility and privilege of following a patient throughout the tenure of his or her care is one way in which being an APRN can be very rewarding even as it is a challenge. Strong organizational skills and communicativeness with patients are crucial when being an advanced practice provider.
Time Management and Adaptability
APRNs may also experience an adjustment period due to the increased workload they often face as an advanced practice provider. Jodie Marcantoni, MSN, DNP, FNP-BC, ANP-BC is a Family Nurse Practitioner and Adult Nurse Practitioner specializing in Infectious Diseases. In an interview with OnlineFNPPrograms.com, she explained how many of the students she has precepted in the past found that the sheer time commitment necessary to review patient information and coordinate patient care can be almost overwhelming in the beginning. “One of the biggest changes when stepping into the role of provider is the amount of time spent reviewing information, both from the chart as well as literature and clinical resources. Medicine is increasingly becoming more evidence-based, and knowing what to do as well as why is of the utmost importance when formulating a plan of care as a NP,” she noted, “There are so many specialties in nursing and medicine, and it can often be overwhelming when determining which individual to contact for questions and/or referrals.”
To manage their time effectively and ensure they develop effective medical care plans, Dr. Marcantoni recommended that graduate nursing students and new APRNs develop a system for communicating with colleagues and following up with patients. Staying organized and creating habits and procedures to ensure best practices can help advanced practice providers become effective practitioners. “Creating a foolproof follow-up system is also a new responsibility for NPs,” Dr. Marcantoni said, “[This system should include] ensuring patients received an appointment within the appropriate timeframe, and that you receive all necessary information from specialist visits.”
Adaptability is also an important trait in APRNs, as advanced practice providers encounter many different patient scenarios and medical situations during their daily work. Ms. Mazur advised graduate nursing students to try and gain as much experience as possible across a wide variety of medical settings, in order to learn how advanced practice providers are expected to handle different patient scenarios. “My advice for any clinical placement would be to learn as much as possible and not be afraid to break outside of your comfort zone,” she said, “In those placements, one will learn ‘a lot about a little’ and there are valuable clinical pearls that come with such a specialized learning experience that one can only learn from a subspecialist. In rotations like ER, a clinic, or hospitalist team, you learn ‘a little about a lot’ which is equally beneficial to have experience in a broad range of diagnoses. I encourage students to seek out clinical opportunities that are out of their comfort zone. That is where optimal growth and learning take place.”
Dr. Marcantoni similarly suggested that students seek as varied a clinical experience as possible during their graduate nursing education; not only does the variety help students become more adaptable, but it also helps them hone their time management skills. “Some programs allow students to obtain approval for several preceptors for a given term. Multiple preceptors and medical settings can lead to more juggling work on the student’s part, but results in teaching from multiple providers with a range of experience and teaching styles. This also results in a more varied clinical experience, which I strongly suggest,” she said.
With a strong work ethic, sound critical thinking skills, in-depth clinical knowledge, and a collaborative mindset, students and graduates of MSN and DNP programs can successfully make the transition from delivering bedside care to supervising and improving this delivery of care as an APRN. Graduate nursing students should try to apply the aforementioned skills and new responsibilities frequently during their clinical practicums, so that they can gain sufficient practice in working as an APRN while under the supervision of their preceptors. Patience and self-care are also key for new APRNs, as the transition to advanced nursing and patient care management takes time. Being compassionate with oneself as one becomes comfortable with the new responsibilities of being a provider is important in maintaining resilience and avoiding burnout.
Understanding the Intersection Between Bedside Nursing and Advanced Practice Nursing
Even as they learn new care methods and advanced skills, graduate nursing students working to become RNs should not forget the importance of bedside nursing skills and connecting with patients directly. Advanced practice nursing and staff nursing are intimately linked–while the former focuses on the development of plans of care, the latter is the attentive delivery of care according to these medical plans. RNs who know how to create a rapport with patients, deliver good bedside care, and evaluate the effects of treatments and procedures are primed to excel as advanced practice providers. Kristen Campbell, PNP-BC, who is a Pediatric Nurse Practitioner at New York Methodist Hospital, explained in an interview with OnlineFNPPrograms.com her belief that APRNs should see their role as an extension (rather than as a replacement) of their duties as a bedside nurse. “I’d like to start by saying that I think the best NPs are the ones who don’t forget their roots. Every one of us got the RN behind our name before the NP. My experiences as a bedside nurse challenged and shaped me in ways I’ll never forget,” she said, “Whether I was administering medications I would someday prescribe or recognizing a clinical change that required immediate intervention, my time as an RN taught me to pay attention to details, to advocate for my patients and their families, and to trust my clinical instincts. […] While I respect that every student, schedule, and journey is different, I think RN experience before becoming an APRN is invaluable. I believe that I am a more confident, compassionate, and knowledgeable NP because I always remember that I was a nurse first.”
Dr. Marcantoni also noted in her interview the significant overlap between the roles of the APRN and the RN. “A day in the life of a RN in the acute care/hospital setting typically starts with a shift report, prioritizing which patients to assess first, and identifying acute versus non-acute needs. The tasks of administering medications and treatments, monitoring for clinical responses and/or changes, utilizing clinical tools and policies/procedures literature, documenting clinical information, and teaching patients and families are constantly in motion throughout the day. NPs in the hospital setting utilize many of these same skills,” she said, “In the outpatient/clinic setting, RNs and NPs also have quite a bit of overlap in regard to responsibilities and daily tasks. […] Patient assessment and teaching are also important for both roles. The RN role in this setting requires patient assessment, medication and treatment administration, and patient teaching in regard to care plan changes, lab results, etc. The NP role focuses on more in depth chart reviews, advanced examination/assessment techniques, consideration of insurance coverage for diagnostics and medications, coordination and communication regarding consultations, and follow-up regarding results.”
Ms. Campbell, who worked as a staff nurse in a pediatric acute care setting as she earned her MSN, also explained how this work allowed her to practice her provider skills and understand how the RN and APRN roles overlap. “Working in the Pediatric ICU and Hematology/Oncology Unit while I was working towards my advanced degree gave me the opportunity to put on an NP hat while working as a bedside nurse. I would try to ask thoughtful questions on rounds and come up with treatment plans and care goals in my head before they were developed by the team. I checked dosing on orders and tried to offer helpful suggestions to newer residents based on my intimate knowledge of my patients and their families. There is ample opportunity to think like an NP while you’re working at the bedside, and being at the bedside gives you direct and sometimes immediate feedback about which interventions work, which don’t, and why.” Understanding that the RN and APRN roles have a degree of overlap that is just as important as their distinct responsibilities can help prospective APRNs prepare for their new job even before they enroll in a graduate nursing program.
Transitioning from RN to APRN and the Importance of Learning Through Teaching
Prospective and new APRNs should also note that, regardless of where they are at in their nursing career, opportunities for growth and improvement abound in the medical workplace, long after they leave school. Forging strong relationships with colleagues and giving back to the nursing community by working as a preceptor are just two ways in which APRNs can ensure they continue to develop personally and professionally.
Ms. Dziama recommended in her interview that new APRNs work for at least a year post-graduation before becoming a preceptor, in order to give themselves the time to hone their own care coordination skills and better understand the advanced practice provider role. “I always recommend completing a full year or two of professional practice before precepting. There is so much growth and learning that takes place during that first year,” she said, “Rookie NPs are busy enough learning how to be independent in their role that they should focus on becoming experts and then when they feel 100% confident in their role they should consider precepting.”
In her interview with OnlineFNPPrograms.com, Ms. Guelcher explained the rewards she has experienced working as a preceptor, and encouraged other APRNs to consider supervising students for their practicums. “I think that some nurse practitioners worry that they don’t have enough time to precept. It can be hard to think about going through a busy clinic explaining everything that we do, but I have found that precepting keeps me energized and enthusiastic,” she said, “I realize how many things that I know now that I take for granted and students are so motivated to absorb the information. Moreover, precepting keeps me on my toes because I focus on evidence in the literature that I can share with students during their clinical rotation. I love nursing and I enjoy sharing my experience, but I find that I continue to grow and learn as I precept students which makes me a better nurse and preceptor.”