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How do we prevent Nurse Practitioners from undervaluing themselves?

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Specializes in Psychiatry. Has 8 years experience.

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I've been an NP for a while, and I am happy and proud to be one. I am well aware of both our shortcomings and our successes. I think we fill a need in the world of healthcare, and "going to see my NP" has become a normal phrase in American households.

For all of our successes, we seem to have a problem with consistently selling ourselves short when it comes to compensation. I have been reaching out to colleagues and previous students, and I have also been serving as a mentor for some new NP graduates looking for advice. As they navigate positions, one common theme is they do not know how much they are worth, and do not understand that as a provider they are revenue producers! We should be paid as such!

Case in point: last week I had a new graduate FNP telling me about a job in a specialty office she intended to accept. She told me she was satisfied with the salary and benefits and shared them with me. It turned out to be a salaried position at $96K annually working 8 AM to 5 PM five days a week. Vacation was 2 weeks paid going up to 3 weeks after FIVE years. It included all the usual benefits but there was no 401K match and no CME.

Sometimes I feel like nurse practitioners are not being taught about healthcare economics at all. Maybe instead of 4-5 classes on research and "NP roles" we should be teaching a dedicated course on billing and reimbursement? I see NP after NP working for peanuts while the practice that employs them is making hundreds of dollars per hour off of their work. The long-term effect, of course, is that all NP salaries will start to flatten out. Those that do the research and demand a salary that reflects what they bring to the practice will be laughed out the door while those who do not know their worth will end up taking their place.

Does anyone else notice this in the NP world? What can we do to bring awareness to it? Let's Discuss! 🙂

LibraSunCNM, MSN

Specializes in OB. Has 10 years experience.

I'm a CNM, not an NP, but can relate to this.  From my experience, I think a lot of nurses want to become NPs because it's a way to advance and (in many cases, although not all) earn a better salary than a staff/floor RN, and still keep a moderate work/life balance, compared to MDs.  This has led to a glut of new NPs, many of whom become generic FNPs, which isn't exactly a lucrative specialty, much less when there are hundreds of resumes in the stack with your own competing for a job.  

I also agree we're not taught enough about healthcare economics in our masters programs, it's still totally fuzzy to me and I've been in practice almost 8 years.  

Just my anecdotal experience.

ThePrincessBride, BSN

Specializes in Med-Surg, NICU. Has 6 years experience.

Because there are too many FNPs and not enough demand. For my first job, I am contemplating taking a pay cut (even though I have been an RN for only six years) to get into an internship making 70k per year. It sucks, but I think I will have to take what I can get.

96k is pretty good for a new grad NP.

MentalKlarity, BSN, NP

Specializes in Psychiatry. Has 8 years experience.

1 hour ago, ThePrincessBride said:

 

96k is pretty good for a new grad NP.

But it's actually not. It's about $40 per hour. The problem is so many people are willing to accept it that it is becoming the norm. Obviously oversupply is an issue but it wouldn't be if more nurse practitioners knew what they brought to the table and how much revenue they bring in and hold out for acceptable wages. When even one person is willing to work for less than they're worth they hurt the profession as a whole.

Neuro Guy NP, DNP, PhD, APRN

Specializes in Vascular Neurology and Neurocritical Care. Has 9 years experience.

23 hours ago, ThePrincessBride said:

Because there are too many FNPs and not enough demand. For my first job, I am contemplating taking a pay cut (even though I have been an RN for only six years) to get into an internship making 70k per year. It sucks, but I think I will have to take what I can get.

96k is pretty good for a new grad NP.

But this is for an internship right, not a regular staff NP job?

Numenor, BSN, MSN, NP

Specializes in Internal Medicine. Has 9 years experience.

Low barrier to entry, glut, not enough demand

Fix those things first

MentalKlarity, BSN, NP

Specializes in Psychiatry. Has 8 years experience.

8 hours ago, Numenor said:

Low barrier to entry, glut, not enough demand

Fix those things first

I'm curious, how do we fix those things? I have actually written letters in the past to the credentialing boards asking why they continue to certify low performing programs that graduate thousands of NPs annually with almost no oversight. I explain how it hurts the profession both by causing a massive oversupply and by graduating subpar NPs that perform poorly and hurts the reputation of nurse practitioners for colleagues and patients. I have never even received a reply.

I do agree with you though. Part of the problem is that nurse practitioners who find themselves unable to find a job become desperate and accept jobs that are insulting. 1-2 weeks of vacation, pay that works out to 5-10% of what they bring in to the practice, etc.

Numenor, BSN, MSN, NP

Specializes in Internal Medicine. Has 9 years experience.

16 hours ago, MentalKlarity said:

I'm curious, how do we fix those things? I have actually written letters in the past to the credentialing boards asking why they continue to certify low performing programs that graduate thousands of NPs annually with almost no oversight. I explain how it hurts the profession both by causing a massive oversupply and by graduating subpar NPs that perform poorly and hurts the reputation of nurse practitioners for colleagues and patients. I have never even received a reply.

I do agree with you though. Part of the problem is that nurse practitioners who find themselves unable to find a job become desperate and accept jobs that are insulting. 1-2 weeks of vacation, pay that works out to 5-10% of what they bring in to the practice, etc.

Tough because schools can cash easy checks with their crazy online school presence. Look at online doctorates, most are nursing or education related. It's a racket. The credentialing groups don't care what its like in the "field".They just want to pump out grads under the guise of "profession advocacy"

aok7, NP

Has 12 years experience.

Thank you for the thread.  I think a big part of the issue lies in one of the responses, referring sadly to the new NP thinking a low-pay first job "internship" will lead to higher-paying opportunities.  Unless NP organizational leaders (?) return to more rigorous requirements and standards toward being a NP, there will be more new grads willing to work for even less.  Related, and underlying, we need to protect our reputation.  We do that with high standards, just as PA and MD schools insist.  

Not too long ago only the best and brightest RNs (seen by not only excellent grades, but clinical and social skills earned with work experience) were accepted into NP programs.  It is no accident the timing of quick 'work full-time and go become a NP at your leisure' schools popped up everywhere that we have NPs grateful for even a second interview.  In my setting, speaking of NP hiring is risky, as even basic 101 skills can not assumed of new grads.  Emergency for our profession here!

While respectable pay and NPs with high expectations out in the community is the hoped outcome, I think targeting the inner workings of day-in-day-out development toward becoming a professional who has earned a solid stand to argue for high pay and respect is step one.  You can not jump ahead with quick schemes to be skilled to the level of a provider.  We are shooting ourselves in the foot, and I do not blame the new grad NPs, rather I blame the schools and our nursing organizations for lowering standards.  What a chance we had.  

aok7, NP

Has 12 years experience.

BTW, my first NP job I made $135K between base, on-call, and stipends.  Between education time off, vacation, and sick time about 4 weeks.  I took a pay cut since to enter a specialty practice of my wish, but cost of living balances out the above Seattle pay.  Let's not forget we can always work as a RN before we accept RN pay to be a NP!  Base the pay you expect of your first job of NP pay based about three years ago in your specific geographic area, not based on the pay of the current glut of NPs willing to work for $40 an hour!  This would sincerely stop the problem until we get our inner workings as a profession more aligned with quality outcomes.

MentalKlarity, BSN, NP

Specializes in Psychiatry. Has 8 years experience.

I agree with the above, and also think concrete guidelines would be helpful for those looking for jobs. Some ideas:

 

  • Ask what the average provider brings in to the practice in terms of revenue. You should be getting a decent percentage of that. Time and time again I see NPs in lucrative specialties who being in 350-500K and are paid 95K or less annually. You deserve a piece of the pie!!
  • Make sure you get at least 4 weeks vacation. You'll need it!
  • Don't accept 40+ hour work weeks. I've seen positions that advertise 8AM to 6PM five days a week. That's burnout! If you work those hours, ask for 4 days a week for full-time. 
  • Always ask for paid admin time! It can be a half day per week or an hour at the end of every day but you need time to make calls and finish charts, and otherwise you'll be doing it for free at home.
  • For a full-time, 40 hour work week the average NP should make no less than $120K annually. Shoot for that as a minimum. 

vintagegal, BSN, RN

Specializes in Geriatrics. Has 2 years experience.

On 4/6/2021 at 1:15 PM, ThePrincessBride said:

Because there are too many FNPs and not enough demand. For my first job, I am contemplating taking a pay cut (even though I have been an RN for only six years) to get into an internship making 70k per year. It sucks, but I think I will have to take what I can get.

96k is pretty good for a new grad NP.

I am in the DNP program currently working on my AGNP. I politely disagree with you. I think it depends on where you reside. The rural area in which I live makes it hard to get to my state university 4 hours away for classes, however, in my town there is such a demand for primary and specialty care that people are waiting up to 8 months to see a specialty and up to 6 months to see primary care, if they are lucky enough to get an appointment and if that particular practitioner is accepting patients. 

djmatte, ADN, MSN, RN, NP

Has 7 years experience.

4 hours ago, vintagegal said:

I am in the DNP program currently working on my AGNP. I politely disagree with you. I think it depends on where you reside. The rural area in which I live makes it hard to get to my state university 4 hours away for classes, however, in my town there is such a demand for primary and specialty care that people are waiting up to 8 months to see a specialty and up to 6 months to see primary care, if they are lucky enough to get an appointment and if that particular practitioner is accepting patients. 

Demand of primary care and access to work can be vastly different things. Specifically because most states have restricted practice or some barriers of entry before a NP can work autonomously. For those with restricted practice you’re limited to joining a practice and competing for job slots. Should you decide to go it alone, finding a collaborator can both difficult in practice and financially burdensome. If we all had some form of FPA in every state, the saturation wouldn’t be so palpable as we could in theory hang your own shingle and scoop up all those patients in waiting. It is always region specific. But Even in my part of Michigan where access to care isn’t great, lots of NPs and PAs are striking out in the job market a they have limited ability to work autonomously. 

FullGlass, BSN, MSN, NP

Specializes in Adult and Geriatric Primary Care. Has 3 years experience.

We don't know if the new grad in the OP's example was selling herself short.  NP pay varies greatly by area and specialty.  That is also true for MDs.  $96K could very well be good pay for a new grad NP, depending on her location.

NPs need to be REALISTIC and know their local market salary ranges.  My first NP job paid $125,000 including base pay and bonus, but it was in California, in a rural area where it was very hard to attract providers.  The same job in a city like San Diego would have paid about $100K.  

It's supply and demand, people.  This is basic economics.  If there are more NPs in a given area than there are job opening, pay will be less.  The opposite is also true.  This also applies to specialties.

djmatte, ADN, MSN, RN, NP

Has 7 years experience.

2 hours ago, FullGlass said:

We don't know if the new grad in the OP's example was selling herself short.  NP pay varies greatly by area and specialty.  That is also true for MDs.  $96K could very well be good pay for a new grad NP, depending on her location.

NPs need to be REALISTIC and know their local market salary ranges.  My first NP job paid $125,000 including base pay and bonus, but it was in California, in a rural area where it was very hard to attract providers.  The same job in a city like San Diego would have paid about $100K.  

It's supply and demand, people.  This is basic economics.  If there are more NPs in a given area than there are job opening, pay will be less.  The opposite is also true.  This also applies to specialties.

I won’t disagree that there is a realm of realism that should apply to expectations. Specifically when cost of living between locations (California vs say Arkansas). But there is a valid argument for understanding what you bring into a practice and the cost of your clinical overhead. I have a firm belief that many NPs even making 100 to 125k are making less than their justifiable wage regardless of the back end overhead or cost of living. From what I could tell, I brought in over 290k for my last year ( actual not billed). My boss calculated my overhead at 280k. Based on my 109k salary and 3 weeks of pto, the cost of my MA which I frequently had to share, benefits I never used (or company wide 401k which I paid for on my own billing). The only reasonable expectation is that they are vastly over calculating actual overhead based on four clinics across and x providers regardless of what we actually utilize. Mostly to make a profit they aren’t technically disclosing.  Hard part is most providers don’t know this game going in (some never understand it).  And it further increases the likelihood they drag the overall salaries down.  

On 4/5/2021 at 8:05 PM, MentalKlarity said:

I've been an NP for a while, and I am happy and proud to be one. I am well aware of both our shortcomings and our successes. I think we fill a need in the world of healthcare, and "going to see my NP" has become a normal phrase in American households.

For all of our successes, we seem to have a problem with consistently selling ourselves short when it comes to compensation. I have been reaching out to colleagues and previous students, and I have also been serving as a mentor for some new NP graduates looking for advice. As they navigate positions, one common theme is they do not know how much they are worth, and do not understand that as a provider they are revenue producers! We should be paid as such!

Case in point: last week I had a new graduate FNP telling me about a job in a specialty office she intended to accept. She told me she was satisfied with the salary and benefits, and shared them with me. It turned out to be a salaried position at $96K annually working 8AM to 5PM five days a week. Vacation was 2 weeks paid going up to 3 weeks after FIVE years. It included all the usual benefits but there was no 401K match and no CME.

Sometimes I feel like nurse practitioners are not being taught about healthcare economics at all. Maybe instead of 4-5 classes on research and "NP roles" we should be teaching a dedicated course on billing and reimbursement? I see NP after NP working for peanuts while the practice that employs them is making hundreds of dollars per hour off of their work. The long-term effect, of course, is that all NP salaries will start to flatten out. Those that do the research and demand a salary that reflects what they bring to the practice will be laughed out the door while those who do not know their worth will end up taking their place.

Does anyone else notice this in the NP world? What can we do to bring awareness to it? Let's Discuss! 🙂

I took the AANP exam  last month and was surprised how simple it was. It was kinda ridiculous that most of the questions were one liners and just asked you to remember facts, very little critical thinking involved. Which is a reason why the NP profession is going downhill with so many online diploma mills where anyone can just grab a degree, now to your point about NP's undervaluing themselves, its because we are undervalues, there so many of us and anybody that studies a test bank can pass the tests, thats how easy it was. LOL and Doctors and PA's know this and is quite embarrassing especially in clinicals when I saw other NP's didn't know how to do a McMurray test.

FullGlass, BSN, MSN, NP

Specializes in Adult and Geriatric Primary Care. Has 3 years experience.

16 hours ago, djmatte said:

I won’t disagree that there is a realm of realism that should apply to expectations. Specifically when cost of living between locations (California vs say Arkansas). But there is a valid argument for understanding what you bring into a practice and the cost of your clinical overhead. I have a firm belief that many NPs even making 100 to 125k are making less than their justifiable wage regardless of the back end overhead or cost of living. From what I could tell, I brought in over 290k for my last year ( actual not billed). My boss calculated my overhead at 280k. Based on my 109k salary and 3 weeks of pto, the cost of my MA which I frequently had to share, benefits I never used (or company wide 401k which I paid for on my own billing). The only reasonable expectation is that they are vastly over calculating actual overhead based on four clinics across and x providers regardless of what we actually utilize. Mostly to make a profit they aren’t technically disclosing.  Hard part is most providers don’t know this game going in (some never understand it).  And it further increases the likelihood they drag the overall salaries down.  

You make some excellent points.  However, new grad NP is not in a position to make this argument.  I think a good NP who has been at a practice for awhile could certainly make this argument.  There are some practices that would consider this.

What has occurred to me is that in primary care, NPs and PAs may be subsidizing MD pay.  In most professions, pay is relative to revenue generation.  In its simplest form, the salesperson that sells the most earns the most.  However, in primary care, I don't see how this is possible.  I don't think MDs in primary care are really generating more revenue, yet they get paid 2x as much!  

In certain specialties, MDs can focus on procedures, which generate more revenue, and leave more mundane task to NPs and PAs; tasks which do not generate as much revenue.

I don't know what the solution to this is.

ThePrincessBride, BSN

Specializes in Med-Surg, NICU. Has 6 years experience.

On 4/6/2021 at 6:01 PM, MentalKlarity said:

But it's actually not. It's about $40 per hour. The problem is so many people are willing to accept it that it is becoming the norm. Obviously oversupply is an issue but it wouldn't be if more nurse practitioners knew what they brought to the table and how much revenue they bring in and hold out for acceptable wages. When even one person is willing to work for less than they're worth they hurt the profession as a whole.

No, it is actually 48/hr, which is twice what a new grad RN makes in my area.

Having NP experience with a lower salary to start is better than becoming a stale new grad and not getting hired at all.