What do ER's hire more: PA-C, FNP or ACNP ?

  1. 0 Hi all. I am at the pinnacle of a very important decision that needs to be made by this upcoming Friday. I am hoping folks on here can help. I have been accepted to a great PA program and a great direct entry NP program (accepted to FNP but could switch to ACNP if desired).

    Currently, I have a strong interest in emergency medicine. I have worked only a little bit as an EMT and an ER Tech. I love the excitement of not knowing what's coming next and thinking on your feet. The pay is great, and I am very attracted to the flexibility in hours/shifts. But to be sure, there might be other specialties I'm interested in, I'm not sure yet. Primary care is also inviting, as is a hospitalist position, and perhaps international work.

    So, first, I need to decide between PA and NP. I know this forum is loaded with discussions on this topic and I've probably read most of them. But it's still not an easy choice. Comparing PA school to direct-entry NP school, the education (in terms on clinical hours and breadth of didactic content) is stronger in PA school. I would come out and be better equipped to work my first ER job (not to mention that there are a number of 12-18 month residencies available for PA's [maybe there are a few for NP's, haven't seen them though]) On the other hand, I relate with the more holistic model of nursing, and also find the possibilities of independence and international opportunities (not to mention possibly more management and academic possibilities) very enticing. However, the fact is the MSN portion of the direct entry only has 700 clinical hours vs 2000+ for the PA program. The NP program is only 3 days a week and they want you to work as an RN simultaneously.

    I also have a hunch that more ER jobs are for PA's but am also aware that many NP's work in ER's too. I plan on living in Washington, Oregon, or California. So does anybody know if ED's on the west coast prefer PA's or NP's?
    Secondly, for those that hire NP's, is FNP or ACNP more desirable? Clearly ACNP is better geared towards to ER and acute care in general, I understand that FNP's are sometimes preferred because their scope of practice includes peds and adults.

    Any thoughts on my decision or as to who is preferred in the ED setting (especially on the west coast) are much appreciated!
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  3. Visit  treejay} profile page

    About treejay

    Joined Dec '10; Posts: 35; Likes: 20.

    58 Comments so far...

  4. Visit  lckrn2pa} profile page
    4
    Of the 30 or so ER's I've worked at over my 19 years (last 8 as a travel nurse) I think I've worked with 6-8 NP's in the ER and most were FNP's. I've mostly seen PA's in the ER and working in several hospitals in California I've only worked with 1 FNP and the rest PA's. Kinda the reason I'm in PA school, well that and CV surg rotation next year really interest me.

    You can teach as a PA but if you want to move in some type of management position then nursing is the route. All the PA's I know either work or teach, not really interested in the management side of it other than being lead PA at whatever ER they are in.

    Just to give you a idea of my typical week (I'm in my didactic year, end of 3rd term). Monday up at 5am 30-45 min bike or swim, reading notes/books/assignments by 6-630am. Class at 10am til 2pm. 1 hour lunch then 3-530. Home, dinner and in office studying by 7pm til 12mn. Tue up at 5 (same routine) class from 10-12 and 2 hour break for lunch and afternoon class 2-6mp, repeat previous evening routine. Wed I'll sleep in til 8am, class from 10-2 with 1 hour lunch then 3-7pm home and dinner and watch TV, hang out with wife. Thur back to up at 5 same routine, class 10-12 with 2 hour lunch and then 2-6, study from 730 til 11-12mn. Friday up at 8am, class at 9 til 1 then done for the week. I don't do anything school related from Friday after class til Saturday around 1-2pm then I'll study til 10-11pm with a dinner break in there and Sunday is a marathon, usually from 10am til 10pm with lunch at desk and dinner with wife then repeat the week. My routine is pretty typical of my classmates. Some weeks I may sleep in or go to bed earlier but for the most part this is my life for the last 8 months.

    Both have their advantages and disadvantages so my advice is just make a list of what you want and what each can give. Good luck in whatever you decide.
  5. Visit  traumaRUs} profile page
    0
    I'm in the Midwest and see both in the ER. However ACNP can only see ages 13 and up which is not really conducive to an ER setting. I'm dual certified in order to see everyone.
  6. Visit  linearthinker} profile page
    0
    In my area only FNPs. I think you need to check the region in which you wish to practice.

    If I had it to do all over again, I'd still go NP. I fell it offers me more flexibility and long term potential. Good luck in whatever you choose!
  7. Visit  kyboyrn} profile page
    0
    I agree with linearthinker. You need to explore the region in which you wish to work. I'm a FNP and got my first job in an ER, but I also worked there as a nurse for 5 years so I knew the staff, medical director, etc. You said something about Oregon. I've heard that Oregon is one of the better states as far as NP autonomy. I don't think you even have to have a collaborative agreement or anything, you're completely independent. Whether that's good or bad is an entirely different discussion, but it's something to think about. Still, I'm kinda not familiar with the west much, because I live in KY. There are benefits to both. I would have considered the PA route more if I hadn't have been a nurse, but I'm not sure if I was doing direct entry. It's a tough call, but good luck with your decision.
  8. Visit  nomadcrna} profile page
    0
    In the Montana and Alaska, it is almost all FNPs.
    The reasons are independent practice and being able to see all ages.

    In the hospital that I'm currently at, they make every effort to get doc, FNP, PA,in that order.

    No matter who can do the better job,I've seen crappy physicians and good PAs.
    It comes down to the FNP not needing a collaborating physician.

    Ron
  9. Visit  SkiBumNP} profile page
    2
    I have just graduated with my FNP and I am about to start an EM fellowship. It is in this fellowship that i will gain allot of the skills (Chest tubes, Central Lines, intubation, etc) that wasn't covered in my program.

    I picked the FNP program for my lifestyle during the program. My wife is getting her Phd and has a crazy schedule, i wanted to be able to take care of the house and her, and still be in a program that prepared me to practice medicine. I also picked the NP program for the versatility, If i want to move to a state that lets NPs work on their own then i can. as a PA you wont have that option. That said, if you are working in the emergency department you won't need to worry about it.

    In hindsight i wish i went to a PA program for the stronger didactic classes and the more organized clinical placements. This is why i have pushed to make this fellowship happen, so i will be a stronger provider when i am done. I am not a fan of the "nursing" approach, and i work with ALL my patients from the medical model. I don't see a place for any other mindset when practicing medicine.
    SilentfadesRPA and mhinds12 like this.
  10. Visit  TakeBack} profile page
    0
    Quote from nomadcrna
    It comes down to the FNP not needing a collaborating physician.

    Ron
    Is this state-dependent, especially when an hospital employee?
  11. Visit  nomadcrna} profile page
    0
    It is totally state dependent, at this time. The NP organizations are pushing for big changes though. One of which is the scope of practice through the national certifying board instead of the states. All 50 states will have the same NP certifications and such.

    Right now it is state dependent as well as hospital bylaw and credentialing dependent. In an independent state, the hospital would have to be totally stupid to not credential you as independent if state law allows. That is a huge decrease in liability. Being an employee has no bearing on independent practice.

    Here in Alaska (same with Montana when I was there), I have full independent practice, to include admitting my own inpatients.
  12. Visit  TakeBack} profile page
    0
    Interesting that the rates of NP independent practice remain so low.
    A political battle, it seems, to overcome the legislation in the majority of states which still require collaboration.
  13. Visit  reeya} profile page
    1
    I can tell you about WA state. I used to work as a telemetry RN in a hospital for 2 yrs & I often used to get floated to ER when overstaffed. We had both PA & NPs in ER. Basically, the collaborating MD/PA had same schedule as MD & MD had to sign off all PA orders w/i 24 hrs because they worked under MD license. If pt. was transferred to floors & PA orders were not signed off w/i 24 hrs, we used to call MDs & remind them to come and sign off. After 24 hrs all orders were automatically voided if it wasnt signed off by supervising MD. Whereas, orders from NPs were not voided because they worked as independent providers under their own license & no supervising MDs were needed. We had lots of hospitalist NPs (palliative/hospice in onco floors, GI, IM) & lots of PAs worked in trauma team. A lot of MDs were irritated by that 24 hr signing protocol and they preferred to work with NPs than PAs in ER. So, most of our PAs were slowly switching to trauma/surgery 1st assist team where as NPs worked as hospitalists. It really depends what you wanna do.

    I am in a NP school now. NP school really builds on RN skills. For eg. if they are teaching CV system, they totally skip EKG analysis, chest tube care etc because they expect you have mastered that skill as RN. They skip a lot of things like diagnostics tests/ reasoning because there's certain expectation that as a RN you've mastered them as well. Even in health assessment, they skip lot of things (heart/lung sounds--you must have mastered them--diff type of murmurs--for eg, diff. between murmur sound like mitral regurgtitation vs. aortic stenosis, systolic vs diastolic murmurs etc) and jump directly to adv diagnosing. If I hadnt worked as a RN for 2 yrs in a tele floor doing own EKG strips q shift for last 2 yrs & listening to diff heart/lung sounds etc, I would have been so LOST in assessment class in NP school. They assume, you have mastered most of the skills/assessment. The only new assessment for me was pelvic exam in women. Honestly, I think PA school teaches from scratch which is better for people w/o experience. When I worked as a nurse, I learned a lot from fellow nurses, charge nurses, NPs, MDs etc. & I believe my experience of 2 yrs (more than 2000 hrs) & 800 NP clinical hours easily compensated for the 2000 hrs of PA. Without experience though, I would have definitely felt deficient. I would say go to PA school since you dont have that skill/education to build on.
    ktliz likes this.
  14. Visit  reeya} profile page
    0
    oh, forgot to add: those NPs that worked as hospitalists were all FNPs.
  15. Visit  TakeBack} profile page
    2
    Quote from reeya
    I can tell you about WA state. I used to work as a telemetry RN in a hospital for 2 yrs & I often used to get floated to ER when overstaffed. We had both PA & NPs in ER. Basically, the collaborating MD/PA had same schedule as MD & MD had to sign off all PA orders w/i 24 hrs because they worked under MD license. If pt. was transferred to floors & PA orders were not signed off w/i 24 hrs, we used to call MDs & remind them to come and sign off. After 24 hrs all orders were automatically voided if it wasnt signed off by supervising MD. Whereas, orders from NPs were not voided because they worked as independent providers under their own license & no supervising MDs were needed. We had lots of hospitalist NPs (palliative/hospice in onco floors, GI, IM) & lots of PAs worked in trauma team. A lot of MDs were irritated by that 24 hr signing protocol and they preferred to work with NPs than PAs in ER. So, most of our PAs were slowly switching to trauma/surgery 1st assist team where as NPs worked as hospitalists. It really depends what you wanna do.

    I am in a NP school now. NP school really builds on RN skills. For eg. if they are teaching CV system, they totally skip EKG analysis, chest tube care etc because they expect you have mastered that skill as RN. They skip a lot of things like diagnostics tests/ reasoning because there's certain expectation that as a RN you've mastered them as well. Even in health assessment, they skip lot of things (heart/lung sounds--you must have mastered them--diff type of murmurs--for eg, diff. between murmur sound like mitral regurgtitation vs. aortic stenosis, systolic vs diastolic murmurs etc) and jump directly to adv diagnosing. If I hadnt worked as a RN for 2 yrs in a tele floor doing own EKG strips q shift for last 2 yrs & listening to diff heart/lung sounds etc, I would have been so LOST in assessment class in NP school. They assume, you have mastered most of the skills/assessment. The only new assessment for me was pelvic exam in women. Honestly, I think PA school teaches from scratch which is better for people w/o experience. When I worked as a nurse, I learned a lot from fellow nurses, charge nurses, NPs, MDs etc. & I believe my experience of 2 yrs (more than 2000 hrs) & 800 NP clinical hours easily compensated for the 2000 hrs of PA. Without experience though, I would have definitely felt deficient. I would say go to PA school since you dont have that skill/education to build on.
    Just to clarify a few things here:

    PAs are licensed, they don't practice "under an MD license". They have their own license to practice medicine (at least that's what my WA state license says). We have supervisory relationships whose terms are state dependent (not unlike the majority of NP states).

    Second, I'm surpirsed at your description of NP education. EKG analysis, diagnostic tests, murmurs, lung sounds- too trivial? Not all NP students are former tele nurses I'm sure. NP and PA programs have students entering with vast clinical backgrounds. The average PA student has 1-2 yrs experience; our local program at MEDEX UW has students with 4000-10000 hrs as the standard. And yet they are all taught these fundamentals. Pre-PA or Pre-NP experience is valuble but it doesn't supplant the clinical experience gained in a professional training program to practice medicine (or advanced nursing if that's what it continues to be called).

    TakeBack, PA-C
    SilentfadesRPA and SkiBumNP like this.


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