Ep. 118: The Evolving Role of Nurse Practitioners with Dr. Stephen Ferrara

The role of the nurse practitioner (NP) in the health care landscape was developed in the mid-1960s to fill a need for additional primary care pediatrics services for the Baby Boom generation. Today, there are more than 385,000 licensed NPs across the U.S., and their number is expected to grow by 45% between now and 2032. 

Joining us on this episode to discuss the role of the nurse practitioner in the current and future health care landscape is Stephen Ferrara, DNP, FNP-BC, FAANP, FAAN, associate dean of clinical affairs and assistant professor of nursing at Columbia University, and President of the American Association of Nurse Practitioners.

Guest:
Stephen A. Ferrara, DNP, FNP-BC, FAANP, FAAN, President, American Association of Nurse Practitioners

Host/Producer: Carol Vassar

Views expressed by guests do not necessarily reflect the views of the host or management.

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Transcript

Announcer:

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Carol Vassar, podcast host/producer:

Each week, we'll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor's office. I'm your host, Carol Vassar. And now that you are here, let's go.

Music:

Let's go, oh, oh, well beyond medicine.

Carol Vassar, podcast host/producer:

In 1965, about 36% of the total population in the U.S. was under the age of 18, the baby boomers. And with the baby boom, there was an increased need for pediatric primary care. Doctors Loretta Ford and Henry Silver at the University of Colorado recognized that need and created a curriculum model that added physician-led medical training for nursing students and their nursing instruction to help address it. This innovative thinking led to the creation of a new provider role, the nurse practitioner.

Today, there are more than 385,000 licensed nurse practitioners across the U.S., and their number is expected to grow by 45% between now and 2032. To discuss the role of the nurse practitioner in the healthcare landscape of today and tomorrow is Dr. Stephen Ferrara, associate dean of clinical affairs and assistant professor of nursing at Columbia University and president of the American Association of Nurse Practitioners. We met Dr. Ferrara at Health in Las Vegas, and he was eager to talk all things nurse practitioner, including a brief definition of the nurse practitioner role today.

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Nurse practitioner is a registered nurse first, advanced practice nurse that has additional education and preparation at the master's and doctoral level. Nurse practitioners are in all 50 states, can prescribe medications, diagnose, treat, and nurse practitioners are used in all aspects of the healthcare system. As an organization, one of our biggest priorities are the advocacy for nurse practitioners and the modernization of laws and regulations that have not kept up with current practice of nurse practitioners. So we work really hard with states and federal agencies to make sure that legislation is introduced, to introduce modernization of nurse practitioner laws. And also, we work on continuing education for the profession and we have conferences. But the biggest issue, to answer your question, is modernizing laws.

Carol Vassar, podcast host/producer:

Let me ask, my understanding of nurse practitioners has always been they work under the auspices of a doctor. That's changing. That's part of this modernization that you've talked about. Tell us how that is working, how that is going? What different states are doing?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Yeah. It's a great question, and it's really complicated when you dig into it. There are states that nurse practitioners have been autonomous, or we call it full practice authority, from day one. So, a state like Oregon, right? Nurse practitioners never needed to have this written contract with a physician. After board certification, after licensure, they can have their own practices. There are 27 states across the U.S. today that allow nurse practitioners to be full practice authority.

In those other states, nurse practitioners must maintain some collaborative agreement or written contract with a physician in order to practice. Without that contract in place, the nurse practitioner cannot practice. NPs in all states, however, do practice under their own licenses. We are fully responsible for the care that we deliver. We carry malpractice insurance. So nurse practitioners are certainly there taking care of patients frontline.

Carol Vassar, podcast host/producer:

And they are both primary care and specialty care, aren't they?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

That's correct. 385,000 nurse practitioners across the U.S. in all specialties. Primary care largely, but also in specialty care.

Carol Vassar, podcast host/producer:

Well, let's look at primary care at the moment. In the primary care world, we know there are not enough doctors, and we also know that there's a chronic shortage of nurses. Where and how can the nurse practitioner fit in there and help both on providing care that is primary care and maybe fill in some of those gaps where we don't have enough nurses?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Sure. It's interesting. 88% of the nurse practitioners who are educated are educated in primary care. So, we are an ideal workforce to lead and take those primary care spaces. And when we talk about primary care, I am really someone who thinks about a reimagination of primary care. We all have our ideas and concepts of what primary care should be, but it clearly hasn't worked. And I think that we need new approaches to primary care, and nurse practitioners are there, whether it's focusing on screenings or mental health and well-being, which often gets overlooked. And that's a whole nother issue outside of primary care, and it shouldn't be because it's so connected.

I think nurse practitioners can certainly fortify the primary care space and lead in those areas. As far as the nursing shortage goes, yeah, that always has been a problem for years and years. It stems from not having enough nurse faculty in schools. So we have a bottleneck of applicants to nursing schools that can't get in because we don't have the faculty to train them and educate them. So there are some various bills and legislation that would help to incentivize nurses to become faculty, go back to school, get PhDs, DNPs for faculty, but that's a process, and it doesn't happen overnight.

Carol Vassar, podcast host/producer:

You talked about changing primary care. What would be your vision for the perfect primary care system?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

That's a great question. And this is my own opinion. Right? So, full disclosure there. I think that we focused way too long on care that happens inside an office. You go to primary care, right? But the decisions we make every single day, what you're going to have for lunch, where you're going to exercise or get some recreation, that happens all the time. And that affects our health. So I would like to see this asynchronous way of providing care, checking in regularly, focusing on preventative care, which is something we just don't do. Because in healthcare, it's sort of, you don't go to see a clinician unless you have something wrong. Right? Why would you go? Why would you waste your time?

So I'd like to see more proactive and preventative health, focus on screenings and immunizations, all the things that we know that there are decades of evidence that absolutely make a difference in our outcomes.

Carol Vassar, podcast host/producer:

It sounds like what you're talking about is a variation or is the medical home model.

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Very much so. These have been around, but for whatever reason, I think payment is always one of those issues. How is it paid for? How do you get broad-scale adoption if it's not compensated? One of those challenges. But yes, very much so that medical home model.

Carol Vassar, podcast host/producer:

Now, we are a pediatric healthcare podcast to Children's Health podcast. According to some research I've done, the U.S. Department of Labor Statistics has indicated that nurse practitioners, this is a growth area. By 2031, it's going to grow by 40%. Your own organization, AANP, has said that only about 3.7% of these nurse practitioners today, and I'm assuming as we grow, it's going to be similar, are certified in pediatrics. Is this a concern for your organization and how do you want to address that?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Yeah. So I will say, yes, it's a concern. There are not enough pediatric providers out there. However, the vast majority of nurse practitioners in the USA are family nurse practitioners. Family nurse practitioners are educated to take care of pediatrics. So, while we don't have that specialized focus in pediatrics, we do have that focus in family health, but still not enough, and we need to do a better job. And I think that comes down to, we've always had this disconnect between what's required at clinical practice versus what we're preparing. And there has to be better ways to have education or clinical practice dictate where the education is happening.

And that's just working with potential nurses. There's nearly five million RNs across the United States. So, how do we encourage those nurses to go back to school and become pediatric nurse practitioners or pediatric providers? And I think that's where we need to focus and do a better job on.

Carol Vassar, podcast host/producer:

The overall gap or the overall growth, 40%, are you going to be able to accommodate that, or are you still seeing... You mentioned the issues earlier of education. There are people that want to get into the schools, but there's just not the teachers available or the services available at the educational level. How are we going to fill that gap?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Yeah, it's a challenge. We know that, actually, U.S. News & World Report ranked the nurse practitioner profession as the number one growing job profession for 2024 in all of the jobs that are tracked. We know this. And some of the challenges are that some states have a lot of nurse practitioner schools, some states have very few. So we have this mismatch of what we need and the availability. What we do know is traditionally, where nurse practitioners go to school, they tend to stay in those communities, which is very unlike physician training, where physicians do residencies across the country and then they go back wherever they go.

But nurse practitioners tend to reside in those communities and stay there. So, it comes back down to faculty. How can we get more faculty in the right schools so that we could prepare an adequate workforce?

Carol Vassar, podcast host/producer:

Would there be an opportunity to do some training online?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Yes. And we shouldn't think of online as sort of this black hole that if you do something online, it doesn't count. There's definitely a place for online, but we need to make sure that that's mixed with the in-person clinical practice, the adequate way of how we prepare nurse practitioners. And it's in clinicals, they have preceptors, there's a good relationship there, and making sure that what they're learning in the classroom, the virtual classroom, is actually happening in practice, and they're able to learn on those experiences.

Carol Vassar, podcast host/producer:

I want to talk about the idea of... Actually, you raised this about having a lot of nurse practitioner schools in some areas, not so many in other areas. We also have many underserved areas. Just in general, when people are going for primary care, rural areas, rural parts of our country, there's been a growing push to expand the nurse practitioner scope of practice. We kind of alluded to that earlier. Can you talk about how important it is to expand the scope of practice for underserved rural areas?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Absolutely. And when we talk about scope of practice, it's what the nurse practitioner is legally able to do in that sting, right? So we have 50 states, 51 when you count D.C., and then there was some territories. But we essentially have different nurse practice acts across the United States. So what I can do in one state is not the same as what I could do in another. I would push back a little bit on the expansion of the scope of practice because, in reality, we're not looking to do anything more or less than we were educated to do. Like Oregon, as I mentioned earlier, they have this full ability, full practice authority. And the only thing that's different is that they don't need this physician contract.

It doesn't change what they can do. They're not looking to do something outside of what they've been educated and prepared for. But if they don't have that in place, they can't practice at all. So, just to level set. And I know when we talk about scope of practice and expansive scope of practice, it puts people on a, "Oh, nurse practitioners are trying to do things that they weren't educated to do," and that's absolutely not the case. But rural and underserved areas is so important. Estimates are anywhere between 80 and 100 million Americans lack access to primary care.

And again, I think we know from tradition and where the nursing workforce is, if we're able to set up educational components for nurses that are returning to school for nurse practitioners in those underserved areas, they will stay in those communities. So it has to be an intention, and again, it needs to have some sort of invisible hand, if you will, so that we are encouraging people in certain areas to become part of that community and be providers in that community.

Carol Vassar, podcast host/producer:

As we sit here at Health today, I don't want to neglect the part of your job at Columbia where you are, and I want to get this right, associate professor at Columbia University School of Nursing. You are also involved in AI and innovation. This is the perfect time to talk about that in your role at Columbia. What are you learning here? What are you doing at Columbia? What kinds of research are you involved with that's going to benefit the overall practice for nurse practitioners?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Yeah. Thank you for asking that question. So this role, I'm the associate dean of artificial intelligence at the School of Nursing. I've been in this role just a few short months. So it's a new role. I've been at Columbia for 10 years, but it's a new role. So in essence, my task is to make sure that AI is integrated into the three pillars at the School of Nursing, which is education, clinical practice, and research. So, how can we make sure that our students are understanding what new innovations in AI is coming because they're going to be using these applications? How can we make sure our faculty is implementing AI from a teaching and learning perspective? We have to rethink everything of how we have students write papers because AI can do that. So, it's not a very good exercise if AI is doing a better job than what students could do.

So how can we leverage AI and get the outputs from AI, and have students critique that? That's a new way to think about that. And in our clinical practice, again, how is AI going to help with things like ambient scribe where we're having a conversation, it's being transcribed somewhere, and at the end of the session, we have an actionable note that we can edit. And it allows that clinician to spend that time in front of that patient and not have to document behind a computer screen. Amazing technology. And that's only skimming the surface in clinical practice.

And then in research, Columbia actually has some renowned nurse researchers who've been using natural language processing and machine learning for years before generative AI became so broadly available. I'm amplifying that work, making sure that that research gets to see the light of day and that we're able to have research-informed practice.

Carol Vassar, podcast host/producer:

I'm curious: the students that you see coming into the doctoral program, coming into the nursing program, what are the skills that they need to adapt to a generative AI-centered hospital system or provider office?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Yeah. This is something that I think about a lot, right? How much into the tech do we go to make students understand or to have students learn? And I think, so far, the approach has been understanding the technology and the limitations of it, but at the end of the day, how can we use this technology to be better clinicians to get better outcomes? So that's where we're at right now. And the students are very excited and they are very passionate, and it helps me when I have a bad day. And they're so really excited to improve patient lives and have meaningful work, and they believe AI is one of the resources that are going to be able to allow them to do so.

Carol Vassar, podcast host/producer:

I'm curious how we can remain empathetic because nurses are some of the most empathetic people I have ever met, I've been fortunate to meet. How do we maintain the empathy, the humanistic angle of care provision with all of the tech that's coming in, the generative AI, the chatbots, etc?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Yeah, it's a wonderful question. I was just talking about this with a colleague this morning. We need to make sure that technology is a tool and it is not a replacement for who we are and what we do. And I think that's where it's critically important. And I take exception to some of, like, the AI nurse, right? Nurses, we're not replacing nurses or physicians or any other healthcare providers. But what is going to be different is that those who have the ability to understand the technology and use it to improve patient outcomes are going to fly. And those who are not are going to struggle because it's kind of where everybody's pointed. And I'm excited. I'm excited about it.

Carol Vassar, podcast host/producer:

I want to take it out of the educational realm and bring it into care today. How are nurses adjusting to, especially nurses who are experienced and maybe not as tech-savvy, how are they adjusting to this new paradigm?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

There's been some surveys that have come out about nurses and their understanding of AI and the implementation of AI. And this is where I think it's critically important. Nurses need to be involved in the planning and implementation phases of the rollout of AI. When you don't do that, it becomes something that nurses are going to mistrust. "Well, I'm not following what the computer said. I'm a human being with a license, and I'm liable for the license that I hold." So I think if nurses have an understanding of the technology, the limitations of the technology, where it excels, where it doesn't, I think we'll see much broader acceptance from those nurses who've been nurses for years and years and years.

And in fact, that's one of the findings from the recent AI survey that came out, that if nurses are involved, the level of mistrust goes down. So they understand it. It's not a tool that's saying, "Oh, you have to use this new tool, and you have to follow it." Nobody's going to want to do that, right? So we get people involved in the early stages and we see just better adoption. And not only better adoption, but when the end user is there in the planning, we can have the ability to tweak something that somebody might not have thought of that impacts that frontline care.

Carol Vassar, podcast host/producer:

Have you seen here at Health some nurse-led innovations that are exciting to you?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Yes. Yeah. So what's been great this year at Health is that there's a whole nurses innovation pavilion, and there's been technology that's been developed by nurses, by nurse practitioners to look at care gaps that are EMR agnostic. So it doesn't matter which electronic medical record you have. But they're able to pull insights from patient records. And EMRs are great. There's a lot of information in it. But there's a lot of information in it, and it's hard for any one human being to read through every single note or look at every data point. That's where AI is going to come in, help us look at what the national guidelines are for screenings.

And so, for example, patients with diabetes, they need certain regular checks, their foot checks, there are retina checks, and all these things. AI can make sure that those are being addressed at the point of care. So that's just one example. I've seen some other innovations from devices that help to make the actual work of the nurse easier. It is really exciting. And I think what this has shown is that it's given permission for nurses to think outside of the box and to be the innovators that we are.

When we have a patient and we encounter a problem, there's nobody to call, really. We have to solve that. We are there at the bedside. And we've been doing that forever. How can we now take the ability to max that with other disciplines so that we can get solutions that make patient outcomes and the nurse's life a little bit easier, and not so task-driven, but more hands-on care, making differences in patients' lives, providing that health education and information that patients need?

Carol Vassar, podcast host/producer:

Tech, AI brings in a bunch of data, loads and loads of data. How are you leveraging that to do research that will benefit the nurse practitioners you serve?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Yeah. So there's a lot... For example, one of the research that's been done at Columbia is looking at patients who have resided in nursing homes. And nurses do a lot of notes. We make a lot of notes. And not everybody reads those notes. Like if a patient has been admitted long-term somewhere, we just don't have the time to go back and look at day one. We get reports; we transfer care from one shift to the other. And what AI and technology is able to do is summarize that data, get more data points to be incorporated into the plan of care. And I think that is definitely making a difference for nurses.

And when we talk about things like wearable technologies and monitoring, again, it's more data. More data is not something that we have the capacity as human beings to process and do it in a way where you're doing a million other things. So that's where I see AI being a huge benefit and making a huge difference in outcomes.

Carol Vassar, podcast host/producer:

Any downsides to AI from your perspective?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Of course. We always have to be concerned about the ethical use of AI. And then the bias. Right? We know that healthcare traditionally has not been the most non-biased environment, and we want to make sure that we don't repeat the mistakes of the past. And if the training data that was used to train AI was biased to begin with, we know that we're going to get outputs that are biased today. So I think the good news is that we're aware of that, we're conscious of that. And I think as we move forward, we're ensuring.

The other thing that was raised by my students just this morning is the energy capacity that's required to run AI. It is a huge issue from an environmental perspective, the energy that's required. So, how do we deal with that? Hospitals are known for waste, like physical waste. We know we throw... Everything's a one-time use, and you throw it out. That's how we can ensure sterility and safety. But this is another thing we'll have to deal with and figure out the responsible use of AI from a climate perspective.

Carol Vassar, podcast host/producer:

Where do you see the nurse practitioner profession in a year, five years, 15 years?

Stephen Ferrara, PhD, DP, President, American Association of Nurse Practitioners: 

Yeah. I'm going to say nurse practitioners across the U.S. will have full practice authority in all states and that those nurse practitioners are increasing access to care in the communities, especially where patients need access the most. And I think we will see AI... I'm using AI, but I'm going to say technology as well, being married to what we're doing. We'll have data. We'll be able to make good decisions based on the data, assuming it's good data. And hopefully, we're working with all members of the healthcare system. It's not just nurse practitioners that are charting this, of course. No one profession can do it all.

So we truly need everybody to use AI as our moment to all get on the collective same page and work together to change all of the challenges that face us today in healthcare.

Carol Vassar, podcast host/producer:

Dr. Stephen Ferrara is associate dean of clinical affairs and assistant professor of nursing at Columbia University, and president of the American Association of Nurse Practitioners.

Music:

Well Beyond Medicine.

Carol Vassar, podcast host/producer:

Thanks so much to Dr. Ferrara for taking the time to talk with us on the Nemours Well Beyond Medicine Podcast.

Did you know that the Nemours Well Beyond Medicine Podcast is on the Nemours YouTube channel? You can catch all of our audio podcast episodes there and selected video podcast episodes, too, including this one. You'll also find all of our audio podcasts on your favorite podcast app and at nemourswellbeyond.org.

Our production team for this episode includes Cheryl Munn, Susan Masucci, Lauren Tata, Steve Savino, and Sebastian Riella. Join us next time as we celebrate women and girls in sports. I'm Carol Vassar. Until then, remember, we can change children's health for good...well Beyond Medicine.

Music:

Let's go, oh, oh, well beyond medicine.