About Andrew Penn, CNS, PMHNP-BC: Andrew Penn is a Psychiatric Nurse Practitioner III at The Permanente Medical Group California, where he provides patients with psychiatric evaluations, individual and group psychotherapy, and ongoing psychopharmacological treatment and monitoring. Mr. Penn is also the primary psychiatric prescriber for the intensive outpatient program at the Permanente Medical Group, and developed a group therapy curriculum for bipolar patients that has been in use for more than seven years.
Mr. Penn also serves as an Assistant Clinical Professor at the University of California, San Francisco’s (UCSF) School of Nursing, where he lectures on psychopharmacology, bipolar disorder assessment and treatment, and therapeutic interviewing skills. Mr. Penn also helped to develop continuing education curricula and lectures for mental health professionals as a Member of Contemporary Forums’ Psychiatric Nursing Conference Steering Committee and as a Steering Committee Member for the US Psychiatric and Mental Health Congress. He has lectured nationwide on bipolar disorder, cannabis psychopharmacology, medication adherence, and psychedelic assisted psychotherapy.
Prior to his work as a nurse practitioner, Mr. Penn was a Staff Nurse for Psychiatric Emergency Services for the County of Marin and for Kaiser Permanente as a Medical-Surgical Staff Nurse. He also served as an Activity Leader for San Francisco General Hospital’s Mental Health Rehabilitation Facility and as a Milieu Activity Therapist for EMQ Children & Family Services.
[OnlineFNPPrograms.com] Could you please describe your past and current responsibilities as a preceptor? How do you collaborate with your students to set learning objectives for the academic term, what kinds of tasks/responsibilities are your students expected to take on, and what kinds of guidance do you provide them with?
[Andrew Penn, PMHNP-BC] I’ve been an assistant clinical professor of nursing at the University of California, San Francisco since 2009. It’s my alma mater, so it was an easy choice.
Each year, I have a second year student from the Psychiatric/Mental Health NP program rotate with me, ideally for the entire second year (9 months). During that time, they spend 1-2 half days with me in clinic and are part of our Intensive Outpatient Program (IOP) staff, as I am.
Our IOP program serves as a place to receive patients who are leaving an inpatient psychiatric stay or are at risk for going into the hospital because of an increase in acuity of symptoms. As the NP in the program, I work with these patients to initiate and adjust medications, to provide additional clinical assessments, to educate patients about the medications they are taking, and to provide medical consultation to the rest of the IOP staff, which is comprised of psychologists, marriage family therapists, licensed clinical social workers, a recreation therapist, and a nutritionist.
My students learn to do the same job that I do. For the first few weeks, I have them shadow me in my duties. After they have demonstrated a grasp on rudimentary clinical skills, I have them begin to see patients while I observe, and then I encourage them to start seeing patients on their own. They meet with patients while they are in IOP, then come to me for consultation. They get practice in charting and collaborating with other care providers. I encourage them to continue to see the same patients during the tenure of the patient in IOP so that they can see their progress over the 2-4 weeks that the patient is in the program.
[OnlineFNPPrograms.com] In your opinion, what is the ideal working relationship between preceptor and student? Is it more collegial or is it structured more like a mentor-mentee relationship? How frequently do you typically interact with your students on a daily and weekly basis, and for what span of time during students’ clinical placements?
[Andrew Penn, PMHNP-BC] I see precepting as a process of independent, adult education. It is a highly collegial relationship because that’s how actual practice will be, and I want them to be comfortable in that culture.
I expect my students to come to clinic prepared, curious, engaged, and interested in the work. I always leave time for students to ask me about whatever is on their mind, be it differential diagnosis, how to use a particular medication, or what approach to take with a difficult patient. I usually start out each day with the question, “what do you want to learn or get out of today?” and then I try to shape the learning experience to meet their needs. I always pass on the advice that I was given as a student: at the end of each day, ask yourself what you didn’t understand that day, and then go look up the information. Don’t wait to learn. Do it now.
At this stage in their learning process, I expect my students to go seek out information that they don’t know, and not to wait for it to be fed to them. So really, my students get out as much as they put into the experience. I don’t create a lot of formal structure – most clinical practice is autonomous and self-directed, so I want them to get used to pursuing their own continuing education, be it in a formal setting such as a class or a conference, or just to get used to jumping on PUBMED when they have a question.
[OnlineFNPPrograms.com] What are some of the primary questions and concerns your students have when preparing for and completing their clinical placements? How do you help your students address these concerns?
Most of my students want to know how to best prepare for their placement. I tell them to have a good grasp on psychopharmacology, interviewing skills, how to engage with patients, and basic psychotherapy. If they have not developed adequate skills in this area, I use the interviews where they observe me meeting with a patient as a way of probing their skills. I want my students to get good at identifying the things that they don’t know. I don’t have a problem with a student not knowing something, as long as they’re willing to remediate their deficits. If I see a strength, like a student being able to comfortably engage with patients, I praise it and help them grow that strength.
When they’re getting towards the end of their rotation (and when they complete with me, they’re usually just about to graduate), they often want to know how to look for work, what to seek out in a first job, and resources they can use as they continue their learning. I always emphasize the need to never stop learning, and try to model this for them by my own actions – I am always in the process of doing research for a future continuing education presentation, so my desk tends to be littered with medical journal articles, and my mind is active with all the things I’m learning.
[OnlineFNPPrograms.com] What have been some of your most educational and/or rewarding experiences thus far as a preceptor? On the other hand, what challenges have you encountered as a preceptor, and how have you managed these challenges?
[Andrew Penn, PMHNP-BC] I’ve been really fortunate in the students who were assigned to rotate with me. UCSF really attracts the best, brightest, and most engaged students, so they are a teacher’s dream. They come to clinic excited and eager to learn, hungry for clinical experiences. I love the conversations that we have after a student sees a patient. It can go in a hundred different directions, depending on what came up between the patient and the student.
There’s so much to learn, and so little time to do it, that sometimes students get anxious that they will never learn it all. The honest truth is that they won’t. None of us do. Being an adult learner and being a clinician means a commitment to lifelong learning. Not knowing the answer isn’t a sin. Refusing to go learn the answer is, as is pretending that you know everything. No one can know everything, and it’s ok to admit (to colleagues and to patients) that you aren’t sure about the answer, but you’re going to go find out.
[OnlineFNPPrograms.com] For current and prospective MSN students, what advice do you have for them in terms of making the most of their clinical placements?
[Andrew Penn, PMHNP-BC] Increasingly, it seems that students have to find their own clinical placements. If you have to do this, your best bet is to begin networking early, because people are far more likely to take you on as a student if they know you, or know someone who knows you. Precepting is a lot of extra work added to an already busy clinical day, so I don’t want to work with someone who has the reputation of being unprepared or unreliable.
Come to clinic prepared and curious. Don’t expect to be spoon-fed information. Those days are behind you by this stage of your career. Be excited and hungry to learn. As cliché as it may be, it’s true that you will get out of the experience what you put into it.
Remember, you’re not just there to learn information, you’re there to find role models to emulate as you become a new clinician. Look for people who think in innovative and interesting ways and learn from them. Allow your beliefs to be challenged. This is the richest time of learning you will ever have. Dive in deep.
[OnlineFNPPrograms.com] Why did you decide to become a clinical preceptor, and what steps did you have to take to become a preceptor?
[Andrew Penn, PMHNP-BC] Precepting is a great way to shape the future of nursing. We are all so fortunate to be in such a generous profession. I think of all the preceptors who put in extra time and effort when I was a trainee, and I want to pay that back. Precepting is a way to do that.
[OnlineFNPPrograms.com] For graduate nursing students, clinical placements are an opportunity to apply what they have learned in their classes to actual patient scenarios, and to gradually step into the role of an advanced practice provider. Could you explain what goes into this transition from RN to APRN?
[Andrew Penn, PMHNP-BC] 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. 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 responsibilites. As a 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. I get to see patients get better, from the start of their treatment until the end. Increasingly, I manage my caseload electronically, as patients can email me to address simple concerns, like refills or side effects, and I need to decide who it is most important to have come in and see me in the office. Fortunately, I don’t take calls when I’m not in the office, but that’s not always the case, and will depend on where you work. But the point is that the patient care responsibilities are different in the different roles.
[OnlineFNPPrograms.com] How did your own experiences transitioning from an RN to an APRN inform your work with nursing students during their clinical rotations? Do they meet similar challenges that you did during your graduate clinical education?
[Andrew Penn, PMHNP-BC] Health care training, regardless of the specific discipline, remains largely based on the apprenticeship model. Each profession has trainees begin to see patients and begin practicing at a beginning level with real patients at a designated point in training. In medicine, this traditionally came after the second year of med school. For nurses, our clinical rotations often begin very early in our training, which I think is an excellent model, especially for adult learners, because it allows the student to contextualize what they are learning in the classroom. This model is so important that many medical schools have taken a page from nursing training and are having student doctors see patients even earlier than the third year. I think this is critical, because there is no substitute for seeing the condition you were just reading about embodied in a real, live patient.
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 an NP. 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. I am pleased to report that my former students are some of my most competent colleagues whom I treasure having as colleagues.
For nurses who have worked for a while in a staff RN role, the clinical rotations are critical not only for learning the role in patient care of the advanced practice role, which is considerably different than the staff RN role, but also for them to gain confidence with the task of making independent decisions, without the direction of a physician. This is probably the biggest challenge I have seen for nurses transitioning to advanced practice, especially those who have worked for a while in the staff RN role. When one is a staff RN, our assessments help to inform patient care, but ultimately, we are carrying out orders made by someone else, usually a physician. While this lack of autonomy sometimes frustrates staff nurses, especially when working with a difficult or disagreeable physician, I have seen staff nurses transitioning into advanced practice roles sometimes struggle with making a decision about a patient’s treatment that they are used to being made by the physician. In an advanced practice role, the responsibility (and the power) of a decision, rests with the APRN. This autonomy is an exciting part of the role, and one of the things that drew me to being a NP, but it takes some getting used to having that level of responsibility.
Thank you Mr. Penn for participating in our Nursing Preceptor interview series!