Can you change?

I'm an adult health CNS and work in a large nephrology practice and do prn APN work at a community hospital. It wasn't hard to change specialties at all. ERs in my area don't hire many mid-level providers because we have a large emergency medicine residency program so they want the residents to get all the experience they can and feel that mid-levels would take away from that experience. The ones that do hire mid-levels have a mix of PAs and NPs. In my area, PAs are paid approx 10-20% more than APNs.

How easy is it to switch specialities when you are a NP?

Looking at it from a purist's perspective, this is very much dependent on the nurse practitioner certification one carries. Most NP groups and some BON's contend that the different NP tracks (FNP, ANP, ACNP, PNP, etc.) do not train nurse practitioners to work in specific settings but rather defines the type of acuity and age group of patients the nurse practitioner is trained to care for. For example, as an Adult ACNP working in an Adult ICU setting, I can switch to a different specialty within the confines of my training in caring for adults with high acuity problems. That could include working in Cardiology, Neurology, Neurosurgery, and any other subspecialty field where I can only see adults. FNP's are trained to care for patients across all age groups. But that meets the age group criteria alone because the other layer is the acuity issue. FNP's are trained in addessing primary health care problems. Patients who are acutely or critically ill may be out of scope for an FNP.

Some NP's have had to go back to school for a post-master's program in order to add another NP certification that would allow them to expand their scope of practice. PA's do not have to do this as they are trained as generalists. They have training in managing health problems across all age groups. In addition, their scope of practice is determined by the scope of practice of their supervising physician who is responsible for any additional training they may need after completing the required program for their initial certification as PA's. This explains why PA's can switch from practically one specialty to another without having to go back to school for additional training.

Do ERs hire NP or PA?

It varies based on where you're at. But take a look at what kind of patients are typically encountered in your hospital's ER. All age groups of patients are seen. Triage nurses see patients with complaints varying from those requiring no immediate attention to those that are very critical and are life-threatening. While some universities announce ER-focused NP programs, no NP certification exists for this kind of environment where the NP is trained in all age groups and all patient acuity types. It is therefore more favorable, in my opinion, for PA's to be hired in these settings because of the reasons I already stated in your first question unless a nurse practitioner shows up with credentials in ACNP, PNP-AC, and WHNP for instance.

If I don't like ER, can I just work in another department or do I have to go back to school?

Again, depends on the department if you're a nurse practitioner and not really an issue if you're a physician assistant.

What NP program should I pursue if I want ER (acute care, family, etc.)?

For the NP's that do work in ER's, many are trained as FNP's because they can see patients of all age groups. However, many are typically seeing urgent care patients alone because of the limitations on their scope for patients who are highly acute and critical.

Also do NP's make more or less than PA's?

This is reqion-specific but national survey data do show a slightly higher pay for PA's.

If I sounded like I favored PA over NP, please don't take it as that. I am a nurse practitioner and very much happy with my choice. Your questions seem to point more in favor of PA's. However, I was an RN for a long time and from my experience as a nurse, I always liked working with adults in high acuity environments. ACNP was a natural choice for me and so that's what I decided to do.

I am getting even more confused what to choose - what is the different scope of practice for ANP and ACNP (I live in MD).

ANP - Focus is primary care of the adult. Training includes adolescent health, hence, population seen are ages 13 and up. Clinical rotations in primary care clinics with some in-patient rotations depending on the program. No critical care component.

ACNP- Focus is care of acutely/critically ill adult. Some programs do not include training in adolescent health, hence, variability in age of populations seen. Clinical rotations are in acute care settings - hospital units including ER and ICU, out-patient settings for specialty practices such as cardiology, neurology, neurosurgery, pulmonology. Some programs require a semester of Internal Medicine rotation and then the rest of the rotations are determined based on the student's goals for their future or desired nurse practitioner practice setting. Some programs can be specialty-focused such as Cardiopulmonary, Trauma, etc. depending on availability of faculty and preceptor resources the school itself can offer.

Maryland does not have legislation specifying the scope of practice for each of the NP specialties. This will likely result in you finding that NP's cross over into scopes that they did not get training for in their NP program, i.e., ANP's working in critical care, ACNP's working in a primary care clinic. (see: http://www.webnp.net/archives/pearson.pdf and look for Maryland).

The newer version of the Pearson report does not supply information whether each state has legislation specifying scopes for each NP specialty: http://www.webnp.net/downloads/pearson_report08/ajnp_pearson08.pdf

It's best to check in with your BON for more accurate information.

Nurse Tim. Many hospitals are adding the palliative care model. Keep looking.