How do we prevent Nurse Practitioners from undervaluing themselves?

djmatte, ADN, MSN, RN, NP · Apr 10, 2021

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 · Apr 11, 2021

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 · Apr 11, 2021

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.

irvine123 · Apr 11, 2021

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 · Apr 11, 2021

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, MSN, RN, NP · Apr 12, 2021

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.

ThePrincessBride, MSN, RN, NP · Apr 12, 2021

On 4/7/2021 at 4:04 PM, Neuro Guy NP said:

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

It is a new grad residency program. If you have zero NP experience, you get 70k plus bonus. If you have one year experience, it is 80k plus bonus.

ThePrincessBride, MSN, RN, NP · Apr 12, 2021

On 4/9/2021 at 2:09 AM, aok7 said:

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.

So you are saying it is better to refuse job offers and risk become stale and unhireable.

Any experience can be used to leverage for higher pay in the next job and so on. So yeah, I am totally willing to take the 70k, work a year, and then hop off and demand 90k at my second job and so on.

irvine123 · Apr 12, 2021

I think you missed the bigger picture, in an individualistic society like the US where its all about me me me, in situations like this those new grads will accept anything yet know little and be used like a next level RN. The actions of schools allowing those with no nursing experience or even entrance exams into an NP Program degrades the profession. Those studies they teach you in school are a joke. And with everyone thinking they can be a provider the NP role will continue to make less and mean nothing. I remember in my urgent care rotation there were another NP and a PA and DO. When we asked questions to the other NP about 1st line tx for pyelo she was like what's that. It's embarrassing. There needs to be a big change, which starts by emailing the AANP.

MentalKlarity, BSN, NP · Apr 12, 2021

1 hour ago, irvine123 said:

I think you missed the bigger picture, in an individualistic society like the US where its all about me me me, in situations like this those new grads will accept anything yet know little and be used like a next level RN. The actions of schools allowing those with no nursing experience or even entrance exams into an NP Program degrades the profession. Those studies they teach you in school are a joke. And with everyone thinking they can be a provider the NP role will continue to make less and mean nothing. I remember in my urgent care rotation there were another NP and a PA and DO. When we asked questions to the other NP about 1st line tx for pyelo she was like what's that. It's embarrassing. There needs to be a big change, which starts by emailing the AANP.

Yep, it's sad. I'm not sure AANP even cares.

MentalKlarity, BSN, NP · Apr 12, 2021

1 hour ago, ThePrincessBride said:

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.

Or option 3 which is demand a higher wage instead of being taken advantage of?

45 hours per week x 52 weeks a year at 96K is $41 an hour.

MentalKlarity, BSN, NP · Apr 12, 2021

I think another issue is I see a lot of people comparing the salary to the RN salary. They say "Well I am making 2x what I made as an RN"

It's a totally different role. The salary comparison you should be looking at is what other PROVIDERS make, not nurses. Pegging NP salary to RN salary makes no sense at all.