Moving the Needle on Nurse Practitioner Education and Training

At the Core of Care

Published: July 26, 2021

SARAH: This is At the Core of Care, a podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families, and communities. I'm Sarah Hexem Hubbard, Executive Director of the Pennsylvania Action Coalition and the National Nurse-Led Care Consortium. 

As part of our special access to care series, we're going to spend this episode with Dr. Barbara Todd talking about the role of mentorship and education in nurse practitioner training.

Our conversation will delve into Dr. Todd's own clinical and teaching experience, the importance of diversity in the workforce, and supporting nurse practitioners who work in underserved communities.

Dr. Todd is an experienced nurse practitioner certified in both family practice and acute care, and she currently holds a leadership position at the end. She currently holds a leadership position at the hospital of the University of Pennsylvania as the director of practice and education advanced practice. Dr. Todd also teaches at the University of Pennsylvania School of Nursing and is a senior fellow at the Center for Health Outcomes and Policy Research.  

Dr. Todd, Welcome to At the Core of Care. 

BARBARA: Thank you, Sarah. 

SARAH: We always love to start our conversations with the nurses who come on our show about why they decided to pursue nursing as a career. So, can you take us back to what led you to choose nursing?

BARBARA: I always wanted to be a nurse. Even, you know, sometimes people say they're born to be nurses. I don't know that that's exactly true. But I always wanted to be a nurse from the age of three. When I articulated what I wanted to do. I was constantly saying I wanted to be a nurse according to my parents. And when I was six, I wanted to be a nurse. When I was 10, I wanted to be a nurse. When I was 15, I wanted to be a nurse, and then a way you go to college and I was a nurse. So, I went to nursing school. So, I always had a passion and desire to be a nurse. I had some early exposures to healthcare settings. And I saw some of the consequences of health care, and I saw health care disparities on full display. And I think that perhaps is also was what led me to consider nursing and be such a staunch advocate and steadfast in my decision to be a nurse. So, I often reflect on that, but I never changed or waffled on what I want it to be. And I just continued to pursue that my whole career.

SARAH: Oh, that's incredible. And so, you've worked as a nurse practitioner in the Philadelphia area for more than 30 years. And I know you're certified in both family practice and acute care. Could you share with us some of your impressions about the support and training that you received as you were going through your career, especially in those early stages?

BARBARA: I went to Howard University for my undergraduate nursing, that was my first entree into nursing. So, there I really just got the foundation. And as I reflect on it, I feel like it was a very strong foundation, which allowed me to think about healthcare, healthcare disparities, and actually think about healthcare in a very different way. So, fast forward, you know, I spent some time as a clinical nurse, and then I went back to pursue my master's and became a nurse practitioner. I had this notion that I was going to work in Appalachia and really do primary care. And actually, I spent one of my clinical rotations out there when I was in the FNP track at Virginia Commonwealth. But I also had this burning desire for cardiovascular care. And so the kind of the mission of the cardiac care and my primary care education as a family nurse practitioner, allowed me to really provide comprehensive care to patients who were coming for cardiovascular procedures. So, it's a little bit of a long way from rural America, you know, came right to the heart of Philadelphia, right at a major academic medical center. And pretty much my career has centered around that. But always wanting to know more, learn more, be on really the cutting edge of care, so that I could then provide that to the patients that I served.

SARAH: So, given your experience, and your dedication to graduate nurse education and your career, how would you say NP training has evolved since when you started? So, when you're looking at that next generation of nurse practitioners, what are you seeing in the training space?

BARBARA: I think the role of nurse practitioners has really evolved exponentially over the last several decades. You know, I became a nurse practitioner in 1984. We were relatively infants at that time, in ‘84. But now fast forward to ‘21. You know, there are multiple nurse practitioner programs available throughout the country, there are multiple opportunities to not only practice in primary care, but really practice across all different types of specialties, and to really take care of patients across the continuum of life. So I think if you just reflect on that, and you also think of the aging populations that we see, if you look at the constructs around racism and the effects that that's really had in society, and you see the chronicity of disease and the lack of support systems to help people to maintain health, I think that creates the perfect opportunity to think about educational models, and what is it that's missing so that we can actually start to make some dents into healthcare disparity? I think COVID-19 kind of showed us that there were real healthcare disparities in this country. I think we all knew that on some type of level. But I think COVID-19 put it front and center. And we could no longer ignore that there were disparities between whites and blacks and people of color in this country when it came to health care outcomes, and having this realization that people's zip codes really determined their health care outcome. That's mind-boggling to me in a place like the United States.

SARAH: So, I'm curious as you as you look at the health disparities that were made more visible by COVID-19 and you think about access to care, how do nurse practitioners fit into that?

BARBARA: I think what nurse practitioners did, they really showed up during COVID-19. I think we showed that, despite some of the restrictions that we have at the state or local level, or wherever your jurisdiction may be, that we could still deliver on our care, and we could deliver to our patients to care that they need it. I think also we leverage technology probably in a way that we had never leveraged technology. If you think about the number of tele-visits that we had during this time, it was staggering compared to like, you know, months previous. So I think nurse practitioners really showed that they can deliver competent care across the continuum in all practice settings, not only in primary care but in hospital settings. Because, you know, it really allowed us to be nimble with how we staff different areas, particularly as we dealt with surging in hospital admissions as a result of COVID. So really we utilized our nurse practitioner workforce to really help meet those demands.

SARAH: And you've been interested in studies on the value of clinical preceptorship models. First, can you break down what that is? How do preceptorships work? And what can you tell us about how effective preceptorships are? And to what degree are they integral to an NP becoming competent and professionally engaged?

BARBARA: Preceptor models are critical. They're mission-critical to NP education. Because if you think about NP education, it's a clinical education. And in order for nurse practitioners to become successful, they have to have this guided experiential learning that takes place over the course of a time period, to really become comfortable with patient assessment, management, diagnosis, and really outlining plans of care. So you can't have NP education without some type of preceptor model. Traditionally, we as nurse practitioners have served as that trainer to the trainee. But there are other healthcare disciplines that also support the NP education, whether it be physicians, or other specialty groups as well. The preceptorship is really over the course of the experiential learning. And it allows you through repetition, to start to see patients to manage disease, optimize plans of care, look at community-based resources, and how we might utilize those to support patients and really manage the population. So that preceptorship is just really critical. It's the cornerstone of NP education, and it can't move forward without having that critical preceptor in place. But the demand for preceptors is really great. The demand, particularly in our Philadelphia region, as you know, is based on some of our experience doing a graduate nurse education demonstration. The same preceptors that nurse practitioners need, physicians need, physicians in training need, the residents, the medical students, and also the physician assistant students. And we all sometimes are competing for this small group of, clinical preceptors, which are just a precious jewel in my mind when it comes to the clinical education.

SARAH: And so how did that work when Philadelphia was engaged in the graduate nurse education demonstration, and just as some background, this was a CMS-funded effort on a demonstration project and in five areas, looking at graduate nurse education. So, Barb, I guess, actually, if you wanted to provide a bit more background on that project. 

BARBARA: It really was a landmark project for Philadelphia and also for nursing education. In 2012, we were one of five centers across the U.S, as Sarah has stated, that became the recipients of the funding from CMS for the graduate nursing education, which was to really try to increase the number of primary care, educated nurse practitioners who could then support patients in primary care as well as transitional care models to show that it was actually feasible for CMS funding to support it, very analogous to what we see with graduate medical education in terms of CMS funding. So at the Hospital of University of Pennsylvania, in collaboration with Dr. Linda Aiken at the University of Pennsylvania School of Nursing, we were selected as one of the sites. Other sites included Duke University, Hermann hospital system in Houston, Banner Health in Arizona, which was across the state of Arizona, Rush University, as well. What we did prove was that we can increase the number of nurse practitioners to really start to meet the demands of primary care. The demonstration was, in part secondary to the ACA. And as you can recall, with the ACA, it really then gave insurance to a number of individuals who previously were not insured. So those individuals needed to have health care and nurse practitioners were the perfect solution to provide that health care.  

The demonstration in Philadelphia was the largest demonstration project of all five. We worked with nine schools and nursing in the Greater Philadelphia region, all who prepared nurse practitioners at the Advanced Practice level, including other advanced practice nurses as well, clinical nurse specialists, certified registered nurse anesthesia as well as midwifery. So those were the four APRN groups that were involved in the demonstration project. So, it was a significant project. And I think that we showed that the funding can be utilized to offset the cost of graduate nursing education and increase access to patient care.

SARAH: And that was a demonstration project. So, for those of you who are listening, that means that that it ends, right, it's a pilot. So, the demonstration project has concluded. You had great outcomes. 

And so, when you look at, you know, growing the workforce as a whole, it's certainly not only the quantity of nurse practitioners but also who those nurse practitioners are and their background and training. So, when you think about the NP field as a whole, can you give us a sense of how diverse is the workforce? And are there areas where you see a need for more direct outreach or engagement?

BARBARA: If we look at the populations that we serve, and the race concordance, there's a clear disconnect. And we have some opportunity, I think, in nursing at all levels, whether it be at the clinical nurse level, the advanced practice nurse, nursing leadership, as well as nursing executives, I think there's opportunity at each one of those levels. One of the things I've seen is that the pipeline to nursing I think is changing, but it's really slow. I looked at some of the earlier data about, you know, statistics in terms of minorities and nurses, particularly black nurses, and I looked at information from the American Association of Colleges of Nursing, which shows that there is really not been much difference in terms of the enrollment of black nurses in traditional BSN programs. But where we have seen increases in the PhD programs, and also in the DNP programs. And we've also seen a slight bump in like our master's program. So, I think there's trends in education, when you look at enrollment, the key is really understanding the trajectory of the nurses, once they are in these programs, are they finishing these programs? Are they actually going into the workforce? So, I think we have some opportunity to look at that a little bit more critically. When I look at the nurse practitioner workforce and black nurse practitioners, we're probably talking somewhere less than 7% of the nurse practitioner workforce actually being, black or brown. 

So, I think we just have to start to put our money where our mouth is, in terms of we say we value diversity in nursing. And I think even as I look at the report on the Future of Nursing, and there's lots of discussion about the need to diversify the nursing workforce, I think now this is our prime opportunity to really start to look at that in a meaningful way and really decide how are we going to address it and really address it in meaningful ways and also address it in ways that are going to be sustainable. I know lots of minority nurses who leave the field or get enrolled in programs but don't complete the program. So, I think we need to have some intentionality around support mentorship, guidance for them once they are actually admitted to these university settings.

SARAH: So, if we're looking at 7% of the NP workforce, and knowing the diversity of the United States as a whole, and then looking at communities as well, what are some of the ways that we can build up the NP field to be more diverse? You know, what does mentorship look like? What are the hallmarks of a strong mentorship program?

BARBARA: I think that's really a huge question, Sarah, in terms of mentorship. If I think about programs that are really strong in terms of mentorship, it's really just being able to identify that you need a mentor sometimes. And then once you identify the mentor, really coming to mutual goals on how you can help develop that person and is there the time and space for both the mentor and the mentee to develop that relationship? When I think about the nurse practitioner profession and trying to increase minorities, I think we have to do a lot more outreach. And we have to talk to nurses that are in undergrad nursing programs about nurse practitioners and the value of nurse practitioner care, and the value of really diversifying the nursing workforce through that mechanism. When I think about a grant that I had a while back, actually one of our goals in the grant was to increase exposure of undergraduate nursing students, and actually, precept registered nurses to the field or primary care nurse practitioner to really know that it's an option for them and to also map out what that career trajectory would look like if they chose to become a primary care nurse practitioner. So I think we have some opportunity to think about capacity in terms of exposure to the career, creating shadowing type opportunities, which I did in the grant that I had, and letting them know that this is a possibility. You know, sometimes it's hard to think it's a possibility. If you don't see folks who look like you. It's almost like, I don't think I could be a nursing faculty because I don't see nursing faculty that look like me is, likewise I don't think I can be a nurse practitioner, because perhaps I don't see, like a nurse practitioner who looks like me. And I remember even early in my career when I came to University of Pennsylvania, I was the first black nurse practitioner at University of Pennsylvania. And it was very isolating feeling and a very lonely feeling to have, that you don't have others that look like you occupying the same role.

SARAH: And so how did you find that support? I mean, you know, when you look at where you are in your career, obviously you not only managed but you excelled. So how did you find that support? What did that look like? 

BARBARA: It came in the forms of a lot of different people. Having a lot of faith, I'm very faith-based. So, having faith, having a really strong family who believed in me, having people along the way that I connected with who believed that I could do what I could do, and not necessarily think about it from a racial context. But really about this person can do the job that needs to be done. And then I think also just working really hard. If I think about it, you know, and reflect, and I think I probably overcompensated it by working very hard to show that I deserve to be in the same space as my other counterparts who were doing similar types of jobs.

SARAH: I've heard that reflected from other diverse nursing leaders who really have to work twice as hard for the same amount of recognition. So, thank you for sharing that. 

So, as part of the 2020 to 2030 Future of Nursing report, there are calls for advancements in nursing education, and you know, we really see it in all different ways, right? So, there's curriculum changes centered around diversity, looking at where nurses are being trained, preparing them to work in more diverse settings and populations, you know, reflecting that population change that we're seeing, making sure nurses faculties are more diverse, making sure nurse faculties are more diverse. And then we also, you know, have, as we've touched on looking at the looking at access to care, looking at health equity and social justice. So that's a lot of different approaches to the issues around diversity. What are you seeing in terms of these shifts taking place? And where do you think that there's more work that needs to be done?

BARBARA: I think we have a lot of work to do in this space. I think the recommendations as they’re proposed in the Future of Nursing report, I think some of them are in place, but they're not explicit. So, when I think about curricula that really addresses, you know, social determinants of health, health disparities, social justice, it really needs to be more interwoven in the curriculum at all levels of nursing, not just at the Baccalaureate level. You know, when I think back about social determinants of health, I remember talking a lot about this in my basic nursing program in the 1980s. And even when I looked at an IOM report, almost 20 years ago, it really talked about the health care professionals really needing to understand the impact of social determinants of health on health care outcomes. So here we are, fast forward a few more years, and we still are talking about the need for not only nursing, but all healthcare professionals to really understand what is social determinants of health, and how does that truly, you know, impact care. I think the NLN, and in terms of their curricular also have made recommendations about the importance of social determinants health to the mission of nursing, and really making it integrated in nursing education. And nurses themselves even identified in a survey back in 2017, and ‘18, and nurse practitioners that they, in fact, really need more education on how to work with marginalized patient populations, when they are caring for them, particularly within the complexity of their disease processes. So, I think we have some work to do in this space. Having that be front and center, in the Future of Nursing Report actually gives us opportunity to think about this in probably ways that we perhaps have not thought about before. I know we've done some simulation, you know, around social determinants of health also, which is just another instructive way for students to really learn these concepts, and really understand the importance of them and having some intentionality around clinical training that they actually are exposed to populations and learn how to manage this in real-time. And it's not just a theoretical construct, but really, you know reality.

SARAH:  I think it's great that you highlighted the work that's being done, you know, with the National League of nursing or NLN. So, what would that practically speaking look like? Can you give us a sense of what would NP curriculum look like? Or an NP curriculum that's going to better prepare practitioners who are working in underserved communities?  What have you seen be successful?

BARBARA: I think this is going to be a journey for all of us who are involved in the education of nurse practitioners. And I think oftentimes when we think about social determinants of health, we think about it in a primary care context, but it really is across all care settings. I think we really have to focus in on really building the capacity to address these inequities. There needs to be health and training on really how to manage populations, you know, understanding social determinants of health, working in underserved communities, and really caring for patients who have both complex physical and social needs, and really look into establish competencies, you know, how do we establish competencies and capacity in the nursing workforce to really start to address this in in different types of ways. You know, establishing community-based partnerships, really looking at being able to advocate for public health equity and policy changes and really start to address the care needs of the patients and the population. So some of the competencies maybe around you know, population health looking at not only our aging population, but also some of the pressing needs as it relates to mental health in the community, looking at more how we can utilize innovation and design thinking in terms of thinking about solutions, really leveraging technology, perhaps in ways and having a digital footprint that we haven't previously had in this space, really collaborating, you know, with disciplines, really focusing in on the well-being of nurses as even they provide this care, and also really preparing us to address pandemics, current, and future, on how we approach it in ways that will support marginalized populations. So, I think, just really rethinking those competencies, and how we then take those competencies and really move across all educational settings, with nurses to really get them to where they need to be in order to start to address it effectively. I think there are some knowledge gaps. So, I think we got to fill the knowledge gaps. And then after we fill those knowledge gaps, then we can have a plan of action to really start to address this in meaningful ways.

SARAH: You spoke to how important mentorship is, and in retaining a diverse workforce and, and even in this sort of training and cultivating that NP workforce? How do we make sure that that's widely available and integrated into the training, our models of training?

BARBARA: You know, mentor to shift for years has been more of a voluntary type action. So, I think it I think it calls for a reframing of mentoring and really stressing the importance of mentorship to the sustainability of a profession. When I think about mentorship, I really view it as kind of the handoff to the next generation of providers. And if it's not happening, then the profession can suffer. So, I think hardwiring that more in the curriculum, and really stressing to students the importance of giving back, reaching back, pulling someone else along and up. And really give them the skills and tools to do it. Oftentimes the terms get conflated when we think about mentorship, we think about some time training, we think about preceptor models, they're very different. So, I think there's probably is some space and opportunity here to educate around mentorship, and then we can start to build a capacity for mentors and, and have formalized structures and programs that are kind of embedded in the university settings as well as in the working settings. But it's hard sometimes to identify who's that person that can be my mentor and will we have mutual interest? And will they have a mutual interest in supporting me to grow and develop and give me essentially the playbook to be successful in my career.

SARAH: So, what are the effective characteristics of a strong NP preceptorship?

BARBARA: Some of the characteristics are really just that desire to be a nurturer able to provide feedback and constructive ways to allow for growth. So really creates a growth mindset in the learner. So that they when they receive that feedback, then they know it's really to help them grow into the clinician that we want them to be. I think there also has to be a recognition of expectations on both sides, expectations of what they can expect from the learner, and then expectations of what they can expect from the teacher, slash the preceptor. So I think clearly setting clear expectations, and really, how is that performance going to be evaluated? And really setting up those expectations at the beginning of the relationship so that there's no surprises along the relationship on how any of it unfolds. So, I think those are kind of the keys to the preceptorship and ongoing frequent communication, whether it be with a student, or whether it be with the academic partner that you're working with to support the student.

SARAH: As you stated, you got to where you are, in part just by working really, really hard. How do you talk about this with younger nurses and with the with the folks that you mentor?

BARBARA: Yeah, I talk about it, you know, just in terms of I think, with anything in life, you have to learn something from it. So that you can impart to others. So, you know, I talk about my beginnings in terms of nursing, the passion that drove me into nursing and continues to drive me every day. And I talked about really finding your space. I think it's so important to find your space in nursing, and then also map out your path. Oftentimes, I'm talking with folks who don't quite know what they want to do yet, but they know they want to do something different. And I'm really just talked about how do we almost start with the end in sight, and map our way back so that you can really have a clear path on how are you going to move forward. But I enjoy the mentoring. I think that's kind of the, at this stage of my career, I think that's one of the most important things that I can do is to really mentor other nurses.

SARAH: So, if we set that future vision at 2030, what does it look like? So, you know, that way, we can all be working our way back? What do you think we can realistically accomplish by 2030?

BARBARA: We've got to move the needle on diversity in nursing by 2030. And I think we have to hold accountable if it's not reached. And what does that accountability look like? I'm not quite sure. But I think there has got to be some accountability for diversifying the nursing workforce. I think also just thinking about nurses in all settings, and how we can really build capacity. And really realizing the importance of nursing and all kinds of teams, I think, traditionally, we think of nursing in the traditional models, but nurses can play such an important role in all phases of healthcare delivery, from roles like yours at the, you know, nurse manage clinic to, you know, being at the bedside, to being the executive to be the practicing nurse practitioner, but realizing just the capacity for nursing, in all phases of healthcare. So, in 2030, I would really like to see diversification of nursing in significant ways. I would like to see that people really understand the impact of structural racism and its role in nursing education. And I would like to see us really optimize patient outcomes, particularly for marginalized populations. I, I would like to see a report that didn't necessarily talk about disparities in health care outcomes stratified by race. 

SARAH: So, when you said, moving the needle? More specifically, are you thinking like, looking at nursing, diversity in nursing, enrollment, diversity, and practice?

BARBARA: I think moving the needle to more nurses in practice. But also making sure that nurses graduate from nursing programs, and that they ultimately go into practice. There's a sense that nurses are not finishing programs, they sometimes get lost between that junior and senior year of nursing program. So really looking at data about successful completion of minority candidates from nursing programs. And also, making sure they get through the door, I think, is one part. Once they're in the door, making sure that they're successful, that they're graduating, that they're going out into practice. And lastly, that they're moving into leadership roles. So, I think we have real opportunity to diversify the nursing leadership structures in this country as well, at both the academic level as well as at the practice level. 

SARAH: Dr. Todd, thank you so much for joining us on At the Core of Care.   

BARBARA: Thank you.

CREDITS

SARAH: Funding for our special access to care series comes from The Center to Champion Nursing in America, which is a joint initiative of the Robert Wood Johnson Foundation, AARP, and AARP Foundation. For more about us and our programs, log on to paactioncoalition.org and nurseledcare.org.  

Definitely continue to stay up to date with us on social media @PaAction and @NurseLedCare

At the Core of Care is produced by Stephanie Marudas and Emily Previti of Kouvenda Media and mixed by Brad Linder.

I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.

 

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