Dr Reid Ponte: I'm so pleased to be conducting this interview. Could you tell me how and why you became a nurse and a family nurse practitioner?
Dr O'Reilly-Jacob: I was a member of the St. Michael's Fire and Rescue Squad in my 1st year in college. I was drawn to the idea of helping people during times of crisis. I thought I wanted to become a maternal health nurse, but after transferring to the University of Portland School of Nursing in Oregon, I discovered that I was drawn to caring for people and families across their lifespan. When I graduated, I completed 2 years of postgraduate service at the "Finca del Nino," a Catholic, nonprofit home, school, and clinic for vulnerable children and families in rural Honduras. I learned so much during my time there. We were underresourced and geographically isolated but still provided much needed services to the surrounding community. I was a 23-year-old novice nurse but had a tremendous autonomy and therefore needed to develop expertise fairly quickly. I left there knowing I wanted to become an advanced practice nurse and was accepted at Boston College in their Family NP Program.
Dr Reid Ponte: Have you returned to Honduras since that time or stayed connected to this organization in other ways?
Dr O'Reilly-Jacob: Yes, I have been back and I've served on the board of the organization. We continue to support the organization financially. Experiences like this are formational. On a daily basis, I observed the impact of abject poverty on individual well-being and community flourishing. This heightened awareness of the social determinants of health have shaped both my clinical practice and my research questions.
Dr O'Reilly-Jacob: I understand that once you completed your NP Program you immediately sought out a residency in Margaret Flinter's APRN residency program in the inaugural cohort?
Dr O'Reilly-Jacob: My graduate education was funded by the National Health Service Corps (NHSC), which required that I provide primary care in a high-need area after graduation. Around the same time, Margaret's program was in the design phase, not yet operational. She skillfully collaborated with the NHSC to ensure that the 4 fellows in that year's cohort could become residents in the brand-new program and fulfill our commitments afterwards. Following residency, I was placed in the Holyoke Health Center, a federally qualified health center (FQHC) in Holyoke, Massachusetts. It was an extraordinary learning experience. There were tremendous workforce challenges. While there was a core group of deeply committed providers, there was a fair amount of turnover. This, in combination with a socially and medically complex patient population and frequently interrupted continuity of care, led to high provider burnout, which is not uncommon in FQHCs. I felt the tension of finding meaning and purpose in my patient relationships, but also the stress and fatigue of my care not being enough to overcome the structural barriers my patients faced in maintaining health. I could never have imagined that I was exacerbating the working conditions of my team, contributing to the stress of this practice setting, yet, I discovered I was. One day, the nurse manager asked to speak with me. She told me that the nursing staff felt I was discriminating against a Latino nurse. She explained that I more routinely asked a White nurse to complete orders and patient activities and not making the same requests of the Latino nurse. While this was very painful to hear, I realized they were right. I began in-depth self-reflection, where I recognized that my biases and burnout had led me to mistreat my team. This experience helped me see that there were structural and policy-related changes that needed to be made in healthcare and that if I wanted to have any impact in my career, I would need a PhD.
Dr Reid Ponte: I understand that drive to want to do that. You actually pursued your doctoral degree fairly early in your career. I did the same thing back in the 1980s. I have always been grateful that I made that decision and that I had the support to do so, both in the workplace and at home.
Dr O'Reilly-Jacob: I totally agree; it has been a gift to have my PhD early in my career. I applied to the social policy PhD program at the Heller School of Social Policy and Management at Brandies University in Waltham, MA. I was accepted after the 2nd try, which was then extended another year for me to have our 1st child. By the time I started the program, I was ready to pursue what I was passionate about, which was maximize the capacity of NPs to provide equitable, efficient, timely, high-quality, and person-centered care in underserved communities. NPs, as a workforce, are more likely than MDs to provide care in underserved areas. If the practice remains limited by restrictive scope of practice laws, we are not optimizing their contribution to reducing disparity. My dissertation was a secondary analysis of Medicare data that explored image ordering practices of NPs versus MDs for uncomplicated back pain, which is a very common primary care complaint. The belief at the time was that NPs overtest to compensate for fewer years of graduate education. We found no significant differences in ordering practices.
Since completing my dissertation, I have been examining the implementation of NP full practice authority (FPA) in Massachusetts. NPs were given temporary FPA at the beginning of the pandemic, and it was made permanent through state legislation in January 2021. However, through our surveys, we're finding that organizational and payer policies continue to restrict NP practice, despite the change in FPA at the state level.
Dr O'Reilly-Jacob: Timely access to high-quality primary and specialty care by APRNs are needed to assure timely access to care. What should the readers of JONA know about this?
Dr O'Reilly-Jacob: Thankfully, more states have passed legislation to assure APRNs have FPA. However, many healthcare systems are not changing policies to allow APRNs to practice at the fullest extent of their license and training. We know that many organizations maintain old practices and policies. For instance, in many organizations, prescriptions and clinical documentation done by NPs are still required to be reviewed by supervising physicians. Many payers are not credentialing NPs as primary care providers and, thus, still require NPs to have a supervising physician. It is important for nurse leaders to understand their state board APRN regulations and work to incorporate these new regulations into organizational practices and policies. We know we need to eliminate healthcare disparities by ensuring timely access to high-quality primary care in at-risk communities. Freeing up provider resources to meet the needs of people in our communities is essential. NPs are an underutilized resource to address this need.