Nurse Practitioner or Physician's Assistant?

Nurses General Nursing

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Well, I graduated with an associate's degree, and passed my NCLEX in January. I've been working in an LTC since Feburary. I have an opportunity to return to school, and I've already been accepted to a local college to complete a bachelor's in Nursing. This is the quandry I am in. I'm realizing that nurses are not respected or well treated, and I don't like it. I don't know how long I'll be able to put up with it. I have been headed toward Nurse Practitioner. Is physician's assistant a better goal? What are the differences? Is the same amount of schooling from associate degree RN?

By the way, I would really like to be corrected if I'm wrong about nursing curriculum, I will admit I've only had a chance to look at curriculum from 2 major nursing schools.

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Quick questions for Gila RN, what do you think of the APN push for independent practice. Some nurses I know are for it, where others are afraid it may be detrimental, especially among the MD community

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Specializes in Emergency, Occupational, Primary.

I was planning to go to PA school. As a long-time medic it seemed a natural extension. The problem was, when I started looking into it, there are simply NO PA schools where you can work full time while getting your education and clinicals. On the other hand, NP programs are made for the working nurse. Most of them actually say they expect you to work while schooling. Additionally, there are several nurse practitioner distance programs from exceptional schools (Gonzaga, SLU, Frontier) where you do the didactic online and the clinicals in an approved site in your home area. This makes life a lot easier while still providing for a quality education.

And in the end, in my state NP's have a lot of autonomy, far more than PA's. Almost every single job listing for a mid-level practitioner is "NP or PA", so I haven't seen any difference in work availability or salary. There are plenty of ER NP positions out there.

These factors have swung me to NP. The schools I have talked to are not going to the DNP requirement until 2015, so I have plenty of time to get into an MSN track.

--Equusz

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Specializes in Family Practice, ICU.

Bajasauce07, great comments. I agree, I believe that the NP clinical requirement should be much greater. Most CRNA programs have a least a year to two years of hardcore clinical immersion, which seems more appropriate. I'm not a big fan of the "online NP" type schooling. When I go on to an Advanced Practice Nursing program, I'm specifically looking for one with a great reputation and a heavy emphasis on clinical instruction so I can be well prepared.

As far as having to know the mechanism of drugs, nurses are educated on them. As a 2nd semester nursing student, I've had to memorize the mechanisms of pretty much all of the drugs we've learned so far (i.e. Allopurinol is a xanthine oxidase inhibitor, the difference between direct acting and centrally acting muscle relaxants, the various mechanisms of hypertension drugs such as Calcium channel blockers (breaking them down into calcium blockers and dihydroperidines), ACE inhibitors, Beta blockers (knowing which are cardio specific), all the types of anti-infectives, and so on).

I think the big difference here is the attitude of the nurses. Some just know the bare minimum, i.e. "this is a drug for hypertension" and that's it. Some nurses, however, know the mechanisms well. It really annoys me when students in my class say things like, "is this something we need to know or is it just for the doctor to know?" In my opinion, it's good for you to know these things, as they help facilitate communication between all involved healthcare personnel and they make you look less like an ignoramus. And if you can't spout all of the mechanisms on prompt, at least make efforts to remind yourself of them.

As far as Nurse Practitioner programs preparing you to know the really rare syndromes and diseases, obviously they aren't going to have near the knowledge or experience of a medical student. Mid-levels weren't meant to replace physicians. They are trained to help manage the more common diseases and conditions, and the most complex stuff they usually differ to the physicians. This isn't meant to be a knock on NP's, it's just their role. Same with PA's.

Personally, whether I go CRNA or NP, I'm going to definitely work under physician supervision for 3-5 years before I even think of shooting to be an independent practitioner. I think aiming to be an independent straight out of school is pretty insane.

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Specializes in Family Practice, ICU.

Equusz, good points. If you're a nurse anyway, it makes sense to just be an NP. Becoming a PA would require a lot of extra work to do basically the same thing (except without the possibility of independence). From what I've seen, the main difference is that PA's tend to work more in surgery, first assisting and doing the closing sutures. If you want to do ER or primary care, NP would be fine.

Frankly, seeing what the PA did in surgery in my last OR clinical didn't make me super pumped to work in surgery. My tastes are more along the lines of primary care / ER.

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I am in PA school right now and it's EXTREMELY intense--it is medical school in 2 years instead of 4 which is probably why docs have more respect for us than NPs b\c whatever they learned we have to learn in less time. But let me break it down for you because we have this discussion all the time. PAs and NPs generally do the same thing, however, PAs are trained under the medical model and NPs are trained under the nursing model. PAs get paid more because their scope of practice is broad and negotiable because it is defined by their laws in addition to their supervising physician. Basically, they can do everything the doctor can as long as the doctor allows it which is probably why they get paid more. NPs have a little bit more freedom but it depends on the state--I know NPs that have to have collaberating doctors. But again depending on the state they can practice independently which is probably why a lot of people go this route. However, PAs can specialize now and surgical PAs can make up 250 K. So if you wanna be your own boss go the NP route, if you want the extra pay go the PA route.

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250K is rare for a surgical PA. I've seen it, but it is NOT the norm. 90-115K is much more appropriate with experience, and PA school is not medical school in 2 years, it is about 75% at most.

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Specializes in Emergency, Occupational, Primary.

For a PA student you seem pretty ill informed...

a) Docs don't respect PA's more than NP's. The ones that think PA's are better do so simply because, as you say, PA's train up through the medical model. It's a bias only, and not held by the majority.

b) PA's don't make more than NP's. 95% of the advanced-practice listings I've seen (and I've viewed literally thousands) group PA's and NP's together. "Wanted: NP or PA." The pay is the same, based on experience.

Sure surgical PA's can make a lot of money (I've never heard of one that makes $250k though). I also know cardiac surgical NP's (like those at Stanford) that make crazy money too. And CRNA's (yes a different kettle but still an advanced practice nurse) start off making $120k right out of school.

NP's have a lot more freedom. Sure, there are some states where the NP has to have a collaborating physician. But a PA has to have a supervising physician in all states. Personally I think it's silly, and at the end, Nurse Practitioner and PA do the same thing and study just as hard so they should have the same privileges. But for whatever reasons, the powers-that-be have decreed that NP's have more autonomy. It could simply be that it's because nurses really know how to get together and lobby. I mean Nurse Practitioners were inside on the new healthcare bill negotiations, laying the ground work for a federal scope of practice so nurse practitioners can take up the slack in the ensuing critical shortage of primary care docs. That's organization!

In my opinion, the PA "establishment" is doing itself a disservice by making it impossible to work during the program. By doing this it culls out a lot of great talent that exists in the mature, working adult population, because they simply can't afford to take 2 years off school. NP programs are generally geared for the working nurse; some of them (like SLU) flat out say they expect to work as a nurse during the program while some say you may need to cut back during the clinical year. But in general they are a lot more friendly, with more options for full vs. part time, for the working healthcare provider.

Having said all this, I'm not sure why NP programs tend to have less clinical hours than PA programs, since they're doing the same and don't have a physician to take liability if something goes south. I will definitely migrating toward a program with the most clinical hours, just to make sure I'm really prepared for that responsibility.

--Equusz

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250K is rare for a surgical PA. I've seen it, but it is NOT the norm. 90-115K is much more appropriate with experience, and PA school is not medical school in 2 years, it is about 75% at most.

Median in 2008 for CV PAs was $106k. 90th percentile was $150k so yes its rare but not unheard of.

Contrary to what was posted above the difference is salaries is probably because of the percentage of PAs in surgery as opposed to medicine/medicine specialties or primary care. Also the percentage of PAs that are self employed is almost exactly the same as for NPs at 2%. So if autonomy is the goal its difficult but possible for both professions.

David Carpenter, PA-C

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Specializes in Emergency, Occupational, Primary.

One other thing: Nurse Practitioners specialize just as much as PA's do. Emergency NP, Family NP, Acute Care NP, Adult/Geron NP, Pediatric NP, etc. In fact, that's what defines their scope and prescriptive authority in most states.

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Specializes in Emergency, Occupational, Primary.
...the difference is salaries is probably because of the percentage of PAs in surgery as opposed to medicine/medicine specialties or primary care. Also the percentage of PAs that are self employed is almost exactly the same as for NPs at 2%. So if autonomy is the goal its difficult but possible for both professions.

David Carpenter, PA-C

I don't see any difference in salaries, David. Listings are all the same. Salary surveys are all the same. Do you have a source that shows the PAs are consistently offered higher salaries than NPs?

And I'm not sure why autonomy would be a difficult goal for NP's when they are automatically autonomous (provided they're in a state where that is the case, like Oregon and Washington).

--Equusz

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One other thing: Nurse Practitioners specialize just as much as PA's do. Emergency NP, Family NP, Acute Care NP, Adult/Geron NP, Pediatric NP, etc. In fact, that's what defines their scope and prescriptive authority in most states.

The problem is that most employers are physicians or organizations run on physician lines. For example ENP. There is no certification for that specialty. The two programs that I am aware of give out different certifications (ACNP and FNP). The problem with that is the ACNP will not allow you to see children and the FNP (according to the AACN) should not be seeing critical care patients (limited to ESI 4 and 5). So if you have a small ER who do you hire? Or say you are an orthopod and you want to hire someone to assist, round and see patients in the office. Since many orthopods also see peds patients who do you hire? Nursing certifications are built along nursing domains which translate poorly into medical practice.

I don't see any difference in salaries, David. Listings are all the same. Salary surveys are all the same. Do you have a source that shows the PAs are consistently offered higher salaries than NPs?

And I'm not sure why autonomy would be a difficult goal for NP's when they are automatically autonomous (provided they're in a state where that is the case, like Oregon and Washington).

--Equusz

From Advance for NPs (probably the best source of NP salary data):

http://nurse-practitioners.advanceweb.com/article/2007-salary-survey-results-a-decade-of-growth-3.aspx

The $5000 difference was the smallest ever and probably represents a shift of NPs from primary care to specialty care.

For example in 1997 the average NP salary was $55k and the average PA salary was $65k. If you follow the advance data as more NPs have left primary care the salary difference has shrunk.

As for autonomy there are good reasons that very few PAs or NPs own their own practice. The regulatory environment is skewed toward the dominant provider which is physicians. Even if the NP lives in a state where there is no requirement for physician practice, Medicare requires a collaborative agreement to bill. Most insurance companies are not equipped to credential an independent NP etc.

David Carpenter, PA-C

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