Bio/RN to NP or PA

pinay said:

So i've got a sort of unique situation. Last summer, I graduated at the age of 19 from my uni with my Bio degree. I was premed, but being so young, 16 when i first started, 14 when i took my first college courses (AP 1 and 2) i didnt take college as seriously. I had serious potential, was a national merit scholar at my school. When i graduated, I had a low gpa 3.28 and sgpa of 3.14. Contemplated a Master's program, but didnt go that route.

I went to nursing school for my ADN for 8 months and took the boards and passed, but the school was not accredited and is shutting down so my gpa there wont be regarded. I'm enrolling in an RN to BSN program for a year where I could get 30 hours of Nursing courses to bring me up to a max of gpa 3.48 and sgpa 3.37.

During all this, I will be working full time as an RN gaining great healthcare experience in the hospital. I have grown so much in the past year alone. My question is, having requirements for both PA and NP already, what would be the better option? On one hand, NP school would be alot cheaper, allow me to work while being in school, and could lead me to a doctorate (which I'm not sure what the benefit would be). On the other hand, PA school would be 2.5 years fulltime, is more espensive, and would not allow me to work, but I think would be a better foundation clinically.

I know ultimately its my decision, but maybe some input would help shed some light for me.

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NP in a heartbeat. The reason for me would be that PA school costs significantly more, and the result is you end up making roughly the same as an NP (who can often practice independently). Some would say that to start working in the workforce sooner while making good money as a PA is a better plan than taking a little longer to get an NP. However, when I crunched the numbers, tuition, lost income for those two years, lack of tuition reimbursement for PA school from an employer, relocation costs and living expenses for my family....came out to be in excess of 200k. At the conclusion of my PA education, I'd return to a region where PAs start out at roughly 75k, and where there are plenty of them to go around. Right now I'm a working RN making (what I consider) great money, working 3 days a week, and banking as much overtime as I want, when I want. I will use that 200k to build a house. My hospital will pay for a good chunk of my FNP. I can work, and they will probably hire me once I'm done. Im gearing up for FNP school beginning early next year.

I applied to PA school and RN school at the same time, and when I got into RN school, I didn't go to any more of my PA school interviews (I already knew I was denied to my top choice PA program anyway). The only way I would choose PA school over nursing is if I got into one of those rare schools at a community college that cost significantly less than the 100k going rate these days. As it stands, I'm debt free except for an almost paid off house, and I'll be debt free when I get my FNP, while still maintaining a standard of living that allows me cool vacations with the family, decent time off, and a satisfying work environment. Plus, if I want to keep moving up the chain in hospital management, or branch into other areas outside of direct patient care, that avenue is open to me in many more ways than as a
PA.

But, as many will tell you, PAs are trained really well... In fact, you won't have a hard time finding someone who can quote you the hours of training that a PA gets, and compare them to an online NP program with very low entry requirements, or a direct entry NP program and use it to insist PAs are far superior. PAs can also function in surgical specialties without retraining. For that, PA students face a premium that they bear the cost of. You hear a lot about PAs being able to switch specialties, but that seems to be changing as employers want folks with certifications and a focus on the specialty they practice.They also have a relatively ineffectual national organization that seems obsessed with not advancing the interests of their very highly trained members who deserve more. Rather, they seem to focus on being a "mini" AMA, with considerable attention paid to commenting on current events policy while nurses add yet more states where NPs practice independently. Nevada is their most recent prize.

So I went on with my eduction with a lot of these things in mind. I also have a bachelors degree in both bio and medical laboratory science, and have quite a few years of healthcare experience. I toured a couple pa programs and was dissapointed to find they were pretty much filled with very young students with no health care experience whatsoever (the exception being my interview at MEDEX northwest, which I regard as one of the best programs for physician assistants around).

emedpa said:

Sadly I have to agree with most of what pamac said above.
a few caveats:
as mentioned, if you want to do surgery I would go pa.
if you want psych or women's health I would always go np. ditto if you want to run your own clinic.

this is where pamac and I disagree-
If you want em, go pa. nationally there are far more jobs in em for pas than nps and more of the high end/solo jobs are set aside for pas. the physician organization of em physicians(acep) has said on more than one occasion that pas are the "nonphysician provider of choice" in em. pas sit on committees of acep, acep members are advisors to the board of sempa(the em pa organization), etc.
acep presidents helped write the new em pa specialty exam(the caq in em).
in pamacs part of the world there are apparently lots of em np jobs. this is not the trend nationally when compared to pas.

either way you will never be out of a job. best of luck in your decision.

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My part of the world isnt unique, and it's not halfway across the country from where you are, so im not willing to accede to the notion that what ive seen represents an outlier. I'm on mailing lists for PA/NP jobs, and see ERNP jobs all over, even solo types that benefit from NPs independent status. And being endorsed by physicians groups is no surprise given they benefit the most from being supervising physicians to PAs who are dependent providers. Its the same reason cannon wants you to buy their ink to use on their printers.... Makes them more powerful. Guess who physicians groups find to be the provider of choice overall?.... Physicians.

On the opposite end of the spectrum are facilities and groups that I'm familiar with that found it more convenient to have NPs that didn't require the red tape that PAs sometimes do. The core facilities often have PAs vs NPs, but the satelite ERs often staff with an NP to be able to sidestep supervision requirements. I think you might be right about the aggregate numbers for PAs in the ER, but I've never got the impression anywhere I've been that being an FNP would hold a provider back if they have the right kind of experience. If anything, having board certified ER docs is becoming more the norm, and with that means required PA residencies will follow if PAs wish to maintain any credibility. That's another year of training tacked on. Residencies are there for NPs too, if that's what becomes the norm. But no, just look at the job listings, NPs are represented in healthy numbers in ERs, and my area isn't an enigma. The solo spots are for folks with tons of experience like yourself.... otherwise, ER for a PA (or NP) is almost exclusively a fast track endeavor. Just because someone can run a code, doesnt mean risk management will allow them to. I never saw a PA anywhere near a code when they staffed them in ER. I saw an NP in several because they had nursing licenses and could act in either role. That's no to say a PA couldn't be of some use, but what is a PA going to do in there that a doctor cant? ER boarded docs ran the show. Liability protection and patient satisfaction have a lot to do with patients seeing the "Doctor" that they expect to see in that environment. So ER isn't prime on my list of places to practice as a nonphysician provider like it used to be before I rolled as a nurse. Heck If I'm on my fourth shift of the week in the ER as an RN, at that point I'm making close to what a new grad PA does per hour, and I feel like I'm having more fun doing it.

I'm not anti PA by any means. Side by side with a new grad direct entry NP, the new grad direct entry PA probably has a grasp of sciences that exceeds that of the NP. For the most part, even the typical PA is more steeped in sciences that the typical NP. But to echo what someone in the PA forums mentioned, looking at the curriculum of NP programs and comparing side by side might now account for the fact that a lot of the same subjects are covered in classes with disparate titles. And when I went to interview at Medex with my two biological science degrees, I far exceeded the science background of most of the folks that had more HCE than I did. A lot of the concepts that folks in class would have been seeing for the first time, I would be seeing for the fourth or fifth time.

Well firstly, if you're 19, I'd say medical school can be an option for you. You may have to retake some courses (MD schools will average all grades, DO schools will take replace the first grade), and/or a special master program, however I think you're still pretty young, and med school could still be an option if you take some steps.

On the other hand, if you're already an RN, I think NP is the best option. I personally considered PA and RN/NP, and have finally decided on the nursing route. I do agree that generally, PA programs have better training and much more total clinical hours than NP programs. However, I am attracted to nursing for a number of reasons:

1) Many more options available to you. You don't have to stay at the bedside. Whether it's research, hospital leadership (not just the middle management positions like the unit manager, but also hospital wide management), transplant coordinator, etc, there are many options. Now, PAs also have a lot of options too, but nursing is simply larger, more established, and has more areas where your RN/NP/CRNA/CNM/CNS/etc license can be utilized.

2) Ability to work during school. I agree with you on that one, and is definitely a consideration. I already have a ton of loans, and don't want to go into more debt. I can work part-time during the BSN program, as well as continue working as an RN during the DNP program (with the CRNA programs, that is more difficult, however).

3) I like the nursing perspective. As an NP, for all intents and purposes, you are practicing medicine. You will be diagnosing and treating along with the MDs/DOs and PAs. However, your nursing education and experience brings its own benefits and perspective that I enjoy. Simply, you have to love nursing as its own, independent profession, and know that it has something unique to offer to the patient.

4) Also, I think that having RN experience is especially important to NP school and being an NP. NP school should build on what you already know and are capable of doing. That's why I'm in favor of schools that require, as it should be, experience prior to enrollment (many, if not most Acute Care/Critical Care NP programs require at least a year of acute care RN experience, preferably in critical care for some programs). The NP program will add to what you already know and have done. Also, note that most NP schools have the "meat" "hidden" in course names. So, you'll see things like "Acute Care Nurse Practitioner I and II". If you look at the course description, you'll see that ACNP I covers cardio and pulmonary, as well as EKG interpretation, intubation, chest tube insertion and removal, etc. I used to merely look at course names and think, wait, where's the actual clinical education? Looking at the descriptions really helped me see what I'd actually be learning and the procedures you'll learn.

I think that RN experience + a quality NP program can assuage many of the perceived educational benefits of PA programs.

I also like the possibility of independent practice. Now, I don't think a new-grad NP should be independent. However, the opportunity to have that is definitely attractive.

So, if you're already a nurse, and have completely ruled out medical school, I think NP is the way to go. PA is great too, however I personally find nursing more compelling for multiple reasons.

Divergent said:

... however I personally find nursing more compelling for multiple reasons.

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Would you care to elaborate?

docisin said:

Would you care to elaborate?

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I already did.

emedpa said:

NICE POST DIVERGENT.
I agree with much of what was stated above. if medschool is an option at 19 that should be your first choice.
physicians are at the top of the healthcare pyramid. we can argue about the next layers down endlessly but very few will argue who is the top dog with the most options.
a note on the part time training benefits of np programs- if working during school is important to you there are part time options out there for pa school as well. these are not online but allow the pa student to do the classroom portion in person over 2 years instead of 1 followed by the normal clinical year done full time.
I did such a program at hahnemann and worked 24-30 hrs/week as a paramedic year 1 and year two and full time in the summer between yr 1 and yr 2. year 3 was a full time clinical year and I only did a few concert standbys that year.
here is the setup for the program I attended(part time description starts 1/2 way down the pg):
http://www.drexel.edu/physAsst/programs/physicianAssistant/curriculum/

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Thanks emedpa, that's definitely helpful, I'll look into this option.

I think the best thing would be the education of PAs plus the autonomy and other options available to NPs. I like PAFT's statement on the highest level of PA practice, especially PAs being autonomous clinicians responsible for their own practice.

Physicians definitely have the most options and best clinical education.

Divergent said:

I already did.

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I thought you had more to add

emedpa said:

pamac- answer this question for me:
2 twin sisters are rn's. both have the same grades and major in undergrad and go to the same rn program and get 4.0 gpas.
both work as rn's at the same hospital for 2 years in the same dept on the same shift seeing the same pts.
one becomes an np over 2 years
one becomes a pa over 2 years
they both get a job in the same clinic after graduation.
all political and financial/cost of school issues aside, who is better prepared to care for their first pt on their first day?
who would you want taking care of your kid as their first pt ever? "the doc" is not an option as they are out of the office for the day and this is the only peds clinic in town.
I asked this same question at the pa forum. one poster there(oneal) dropped out of an np program that they were attending for free in order to attend pa school which they paid for due to the difference in the quality of the education. here is their answer:
"As an RN who is doing PA and has 20 semester credit hours of NP under my belt when my hospital was paying for it: PA no doubt wins."

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I assume you only want that logic to extend only as far as it fits with the point you are hoping to make, and not to argue that any of your patients you see while you are working your solo gigs are seeing less than what they deserve, right? So if we are insisting that PA>NP, then the logical extension to that is that MD/DO>>>>>PA. In that case, why would anything other than an MD/DO be acceptable? Indeed, you are not hoping to take it that far, and we all recognize that while it may not be optimal in all situations to have a solo PA, in many or most cases, it is "adequate". So are you then trying to make the case that NPs are not adequate? The question really isnt whether NPs are not up to the job, but whether you feel that they are up to PA standards. But i've shown you that if we are playing the standards game, lets raise the bar a bit further and ask why not insist MD's are the way to go.

I have no idea why oneal dropped out of his NP program. Maybe it was bad. Maybe he didnt have the undergrad science bonifides, and needed what PA school offered him. I know that looking around the medex interviews, I met plenty of folks with very weak academic background in the sciences that probably went on to become adequate (or fantastic!) PAs, despite not having ever encountered immunology, genetics, or other advanced science prior to their having it put in front of them on thier first day of class. It doesnt mean they won't perform well in medicine, but many PA programs dont agree, and would prefer the bright young student with little to no real decent hce to the experienced folks. This may be ticking you off, but they are pointing to research that insists they are on the right track. In addition, they feel like they are starting thier grads all off on level footing academically, rather than having a few of the seasoned students risk falling behind the pack because they don't cut the mustard academically.

So lets tweak your scenario a bit. First day on the job for two "midlevels"... one is Oneal as an NP (former ccrn). Oneal has been working this entire time through school in the ER. Our other model is his twin brother, who worked at barnes an noble before going back to finish prereqs for PA school, and who is now a new PA. Patient is crashing.

Just to play along in your origional scenario, I have no real problem saying that the best choice might be the PA. But given time, you'd probably see things even out. We know that things don't usually pan out head to head in tidy scenarios, though. My scenario is probably more realistic. In my case, who would you rather have working on you.... me as an NP, with my background, or an OHSU PA school grad with "candystriper" as their only healthcare exposure. By the time this scenario plays out, I will have had over 3 years critical care experience as an RN.

As others have already made clear, OP, you should definitely go the NP route. The only reason to go the PA route is if you feel you only want EM or surgery, and you live in an area that doesn't allow NPs to work in those roles. It's funny, because my program has ACNPs who first assist, work as hospitalists, or in the ER, so it really seems to depend on location.

Another thing I find fascinating about this topic is how PAs are often so quick to eschew and make fun of the "nursing approach" and "fluff" in nursing education, while they simultaneously complain about their inept lobbying organizations or limited leadership opportunities. Classes like nursing theory, research, and management/policy are typically used as an argument that NP education isn't as "hardcore" as PA education and that those classes are useless. I'm starting to wonder if writing a few more papers and taking some management/leadership coursework wouldn't help the PA field get its lobbying and self-advocacy act together. I'm not saying I love all my NP classes and I also think NP programs should add more basic sciences and clinical training, but I do not think that the softer classes are useless. I actually think they help train nurses to be huge advocates for the profession and teach them how to use the system to get things done. Nursing teaches the members of its ranks how to push for the advancement of its profession. Just something else to consider.

AnnoyedByFreud said:

As others have already made clear, OP, you should definitely go the NP route. The only reason to go the PA route is if you feel you only want EM or surgery, and you live in an area that doesn't allow NPs to work in those roles. It's funny, because my program has ACNPs who first assist, work as hospitalists, or in the ER, so it really seems to depend on location.

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I agree, though I think more often than not, PAs would have an easier time having intraoperative responsibilities (i.e. first assist) than NPs, simply because they have surgical rotations in their curriculum, as well as various 1 year post-graduate surgical residencies. But yes, I have also seen ACNPs with first assist responsibilities in their clinical practice.

And yeah, I've seen plenty of NPs practicing inpatient, as hospitalist NPs, ER NPs, cardiology NPs, cardiothoracic surgery NPs, neurosurgery NPs, ICU NPs (especially NICU), urology NPs, etc. I don't think an ACNP would have any difficulty finding a job in any inpatient/specialty setting.

Another thing I find fascinating about this topic is how PAs are often so quick to eschew and make fun of the "nursing approach" and "fluff" in nursing education, while they simultaneously complain about their inept lobbying organizations or limited leadership opportunities. Classes like nursing theory, research, and management/policy are typically used as an argument that NP education isn't as "hardcore" as PA education and that those classes are useless. I'm starting to wonder if writing a few more papers and taking some management/leadership coursework wouldn't help the PA field get its lobbying and self-advocacy act together. I'm not saying I love all my NP classes and I also think NP programs should add more basic sciences and clinical training, but I do not think that the softer classes are useless. I actually think they help train nurses to be huge advocates for the profession and teach them how to use the system to get things done. Nursing teaches the members of its ranks how to push for the advancement of its profession. Just something else to consider.

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Thanks for that! I never really heard that perspective before, and I appreciate it, especially as I go from considering PA to nursing. The advocacy for and advancement of the profession is something I find attractive, as well as nursing theory (though maybe once I go through the theory I'll have disdain for it that I notice many nurses have, though many times simultaneously expressing appreciation for it).

I'm curious: have you found your NP education (coupled with your BSN and RN experience) lacking clinically? Have you been satisfied so far?

emedpa said:

pamac- I understand your personal reasons for going np. if pa school had been the same cost, paid for by your work, and allowed a part time option what would you have done? I'm honestly curious about this.

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No. There are more reasons than I usually state, because they are mostly pertinent to me vs the whims of someone asking for advice, but i can lay a few reasons out that are big for me.

For one, AAPA serves you guys very poorly. Getting a glimpse of the mindset of some of the folks (former and current) that participate in AAPA from the PA forums was a huge turnoff. I won't willingly attach myself to such an ineffectual group, nor depend on their efforts to advocate for my professional prestige. I feel like many of them seek to use the AAPA to be a vehicle for their personal ideology vs the advancement of the profession. ANA dabbles plenty in the realm of ideology, but they have the correct mindset that the primary goal should be to control their own destiny before they try to wield influence.

I've been trying to develop an eloquent way to explain one of the other core concepts that influenced me, and I think I'm closing in on adequately explaining my gut instinct: I don't want to ever feel like I'm an after-thought of another profession. When you look around, what other profession is like the PA profession? RTs run their own profession. Rad techs run their own profession. Lab folks run their own profession. Nurses run their own profession. Yet PAs have such high abilities and responsibilities that it seems strange that they are still within the fiefdom of physicians. It's a prestigious fiefdom, but I just don't like the way you guys adhere to an organizational structure that is similar to the way cna's and LPNs fill, especially given the talents you guys have. To me there is no good reason to not have PAs exist as your own body of providers, especially when you have NPs as an example of providers with some daylight between them and physicians. If anyone could handle more autonomy, its the well trained PAs. Its a bit condescending to insist that things just wouldnt work if PAs weren't joined at the hip with physicians. So to wrap up what I'm trying to say here: I find it unappealing that of the different healthcare professions, the profession of PA needs explicit approval of another profession (physicians) so as to be allowed to exist in the first place. Granted, the other professions serve to either provide information to the physician, or otherwise carry out the physician's prerogative, but they act in their own realms and behave as they are a discipline among themselves. I personally enjoy the distinctness of my roles, and don't like the idea of having to seek approval of a separate profession in order to do my job.

So that's the inner idiological reactionary in me speaking far too philosophically. I don't want to be doctor PAMAC DNP, that runs his own noctor clinic and gives interviews telling people about how I feel I'm equivalent to a family practice physician. I dont feel compelled to have the last word on patient care just to flex a muscle within my ego. I just want to be a free agent that is proud to be part of a distinct profession, just like I am as a nurse, or like I was as a medical lab scientist. Just the simple nature of the Pa profession denotes that what they need to practice their trade is the equipment of the trade, their talents, and a supervising physician. So you parachute in and are ready to go on paper, but only if you have arrangements made to have proper agreements in place. As a nurse, I can show up somewhere and practice nursing functions without regard to who is looking over my shoulder. I don't have to provide for my own supervisor in order to get started. Even if the SP arrangement is just a formality that is easily bypassed, it's still there. That means that PA is not your profession... it belongs to physicians.... And they allow you to participate. I want my own profession, I don't want to be a guest in someone else's. I could never shake that feeling.

Another reason I was drawn to nursing is that I like to be a pocket knife rather than a scalpel. I'll walk into a room as an NP, and know what's being done by the nurses to take care if the patient, and I'll know what is being done from my perspective as a provider. I also have my lab background to draw from and will know what is being done in the basement to serve my patient. I could do the same thing as an RN/PA I guesse, but even though I feel like PA education may be better, I don't think it's leaps and bounds ahead of NP training.

Mobility within the PA world was very appealing, but being a nomad has its disadvantages as well, and I asked myself how much I really felt I expected to jump around between specialties. I decided I wasn't likely to want to do much of that, so that didn't seem the kind of perk I needed to dwell on.

So those are a few issues that rounded out the financial considerations. Looming just as large was the fact that i liked my job, and wanted to stay for a bit. I liked my hospital, and wanted to guarantee more time there. I wanted to see how fluid my transition would be to move to a different field and take advantage of the ability to use my contacts to help me along the way (and it did... I work exactly where I want to, when I want). And I like the time I've been able to spend with my family. Not only am I able to work, my wife has continued to work in her field without disruption or relocation. So that's another financial plus.

When all is said and done, and I hit the ground on my first day as an NP, I'm not at all worried about a new grad PA showing me up if we were to be practicing head to head. I'm not direct entry. I have considerably more biological science education than most nurses, and most of the PAs being cranked out these days (or even cranked out in the past). I have significant and broad HCE. I worked full time and went to school full time and performed very well. I do very well where I'm at and am well regarded by my peers. Stressful situations don't get the best of me. I have a lot of things I struggle at, but Im not afraid to confront them, and I'm not afraid to ask someone to highlight them for me. I'm not all that, but I work hard to do my job. While I acknowledge my NP education may lag a little because I'll be on the floor keeping patient's alive by titrating pressers while a 23 year old is learning about blood pressure for the first time, I'm fine with having to play a little catch up. I've never advocated at all for DE NP programs so I take little pleasure in running through mind exercises involving whether a new grad DE PA is better than a new grad DE NP. I don't care who is better because I feel like I have little in common with either of them.

emedpa said:

do they want to be a nonphysician provider and own their own clinic, work in psych/women's health/peds and/or take online courses? go np

do you want to be a nonphysician provider and have the closest thing out there to a physician level education without going to medschool and/or work in em/surgery/hospital based medicine? go pa.

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I'm not so sure about this generalization. While I do tend to agree that PA education, in general, is very rigorous, and that having intraoperative roles in surgery is easier and more available to PAs by virtue of their education, I don't think that one should choice NP because they want to work in psych/women's health/peds (all areas I have absolutely no interest in). Indeed, there are plenty of Acute Care Nurse Practitioners, Neonatal Nurse Practitioners, Pediatric Acute Care Nurse Practitioners, Nurse Midwives, and Nurse Anesthetists around the country that practice in the inpatient setting.

For example, the Vanderbilt ACNP program says:

As an Adult-Gerontology Acute Care Nurse Practitioner, you will provide advanced nursing care to adults with acute, critical and chronic conditions. You will practice in settings where patients require specialized care such as complex and continuous monitoring, intricate or invasive therapies or interpretation of diagnostic testing. In delivering patient care, your goals will be to stabilize the patient, minimize complications, manage additional on-going health care problems and promote physical and psychological well-being.

Where Will You Practice? (clinical sites)

With the increasing intensity and shortened length of stay of acutely ill patients in hospitals and the decrease in medical resident hours, a shift in hospital employment trends has increased demand for Adult-Gerontology Acute Care Nurse Practitioners. The AG-ACNP frequently practices in acute care, hospital-based and many other specialty clinical settings. These will be available to you for practice during your Vanderbilt clinical education and upon completion and certification as an AG-ACNP.

They include:

Specialty Clinics (e.g., cardiology, transplantation, oncology, nephrology, neurology, HIV, sports medicine-orthopedics)
Emergency Departments
Trauma Centers
Hospital Inpatient Units (e.g., cardiology, oncology, nephrology, neurology, surgical, medical)
Intensive Care Units (e.g., medical, surgical, coronary, trauma)
Rehabilitation Units


UCSF says:

Adult-Gerontological Acute Care Nurse Practitioners (AG ACNP) are needed to help assess and manage acutely ill patients within the inpatient/hospital setting and across hospital-to-clinic settings, including the emergency department, intensive care unit, specialty labs, acute and sub-acute care wards, specialty clinics, or any combination of the above.

UPenn says:

Acute Care Nurse Practitioners manage the care of acutely, critically or complex chronically ill patients where ever they are located. That can be in critical care, stepdown/telemetry or med/surg units in hospitals, but can also be in specialty care offices (such as a Cardiology or Vascular Surgery office), long-term acute care hospitals, sub acute settings, ventilator dependent units and clinics such as those who care for Heart Failure patients or those requiring Warfarin management. Acute Care Nurse Practitioners are also finding employment in less traditional areas such as on Palliative Care teams, Pain Management teams, Transitional Care teams, in E-ICU's and in home care settings.

Etc.

I want to work in specialty practice, inpatient, but that doesn't mean that I should rule out NP since it's not women's health, psych, or peds (ughhh). There are plenty of jobs for NPs in the inpatient setting (and there are plenty for PAs as well). I have many friends (well, former coworkers is more accurate), around the country (California, Alaska, New Jersey, New York, DC, Maryland, Missouri) that are practicing NPs in hospital based practice, including cardiothoracic surgery, neurosurgery, emergency (main ER), cardiology, and internal medicine (most were ER nurses for many years. Another friend (ER nurse for many years) is enrolled in Maryland's Trauma/Critical Care/Emergency-ACNP DNP program, looks pretty interesting, and a current coworker is in an Adult NP program hoping to focus his rotations in cardiology and interventional cards, and wants to work in that setting (our hospital has NPs in cards, interventional cards, and cardiothoracic surgery. PAs are in ortho).

Oh, and I like looking at UMaryland Med Center's NP Group website. It seems as if NPs are pretty integral to the inpatient setting there, this is the kind of hospital I'd like to work at in the future:

http://umm.edu/professionals/nurse-practitioners/clinical-services

So, while I definitely find many benefits to being a PA, including the educational model, I also think that NP done right (i.e. no Direct Entry, experience as an RN + a quality program) provides a comparable advanced practice clinician. That's the way I plan on going about my education.

pamac, you said exactly how I feel about my decision for NP instead of PA. The issue of nursing as its own, self-managed profession, along with practically every other health profession (medicine, optometry, podiatry, dentistry, radiology tech, respiratory therapy, etc) was something I actually thought about recently, as well as the bedside nursing perspective + provider education adding to the NP as an "advanced practice nurse" providing a unique perspective (in addition to the usual diagnosing and treating in the same way as the PAs and MDs/DOs.

And of course there are people that choose PA over nursing/NP as well, and that's okay too. A coworker of mine is focused on PA and not nursing.

pinay said:

Wow! Thank you for all your responses and healthy discussion its definitely brought up a lot of points and it seems the NP is a better fit for me. Divergent, I have ruled out medical school because its too long and expsv for my goal of starting a family. Personally, i would be content being a mid level provider and the lifestyle it could provide. My mother is doctor who took care of three children during residency and her first years starting off while my dad was in Italy and Afghanistan. When he came back, it was still the same way. Working crazy hours as a hospitalist and comjng home to cook and clean up. Not saying this is everyone's case obviously. But I think mid level is a good balance for me.

I'm actually looking at PA and ACNP programs so the question of pa preference is very real for me. But I see that many of the positions are listed as np or pa. Hopefully I will be as resourceful as you Pamac, in getting good hospital experience and making contacts that would help me in the future. I also like the idea brought up that with nursing, there are so many other opportunities beside bedside such management, research, etc. and that nurses have so much lobbying power that it can only lead to improving the profession.

I'm not applying for another year, but this is certainly a lot to think about. For now, im leanjng to NP. ill be working as much as I can to develop and hone my clinical skills.

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Yes, many inpatient jobs are listed as PA/NP. Also, when looking at ACNP programs, the actual "meat" is frequently hidden under course descriptions. So, look at the course catalog when you are deciding on which programs to apply to. Also, many masters level NP programs are now switching to DNP programs, so there will be more clinical hours.

And yeah, definitely continue working to develop your clinical skills. This is the way NP should be done, to advance the knowledge and skills you already have.

Good luck! I'm pretty excited to get in and begin my BSN program .

emedpa said:

pamac- excellent explanation. I wish you all the best in your continued studies and am sure your dedication will pay off and you will be a fine clinician.
-e

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Your posts over the last few years played a big part in me wanting to broaden my HCE. I feel like med techs have a lot to offer on their own, but I also wanted to have broad skills to diversify what I could offer. And if I'd have gotten into Medex, I think I'd have done PA. But in the year after getting denied, I got so much done that I wasn't going to disregard what I accomplished. Taking some if the things you said to heart made me picky about where I wanted to spend two years training.

emedpa said:

I should have included NICU with the np jobs.
I did not consider crnas and nurse midwives as nps when writing my prior post.
obviously if you want to deliver babies nurse midwife is a great way to go.
obviously if you want to do anesthesia crna is a great option.

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Agreed.

I just think that wanting to be an inpatient/hospital-based advanced practice clinician shouldn't be a reason to disregard NP.

Divergent said:

I agree, though I think more often than not, PAs would have an easier time having intraoperative responsibilities (i.e. first assist) than NPs, simply because they have surgical rotations in their curriculum, as well as various 1 year post-graduate surgical residencies. But yes, I have also seen ACNPs with first assist responsibilities in their clinical practice.

And yeah, I've seen plenty of NPs practicing inpatient, as hospitalist NPs, ER NPs, cardiology NPs, cardiothoracic surgery NPs, neurosurgery NPs, ICU NPs (especially NICU), urology NPs, etc. I don't think an ACNP would have any difficulty finding a job in any inpatient/specialty setting.



Thanks for that! I never really heard that perspective before, and I appreciate it, especially as I go from considering PA to nursing. The advocacy for and advancement of the profession is something I find attractive, as well as nursing theory (though maybe once I go through the theory I'll have disdain for it that I notice many nurses have, though many times simultaneously expressing appreciation for it).

I'm curious: have you found your NP education (coupled with your BSN and RN experience) lacking clinically? Have you been satisfied so far?

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The RN experience was definitely not lacking clinically. It was quite intense, and went above and beyond the regular state requirements for licensure. I feel very confident in that level of education. I am at the beginning of my NP training, so it's early to say how I feel. I am excited about my classes, including the choices for textbooks (I looked them up on amazon and they appear to be used by med students and PA students as well). I also like the approach of training at my school, which is that we do 3 quarters of physical health assessment training (including clinical training) before spending 4 quarters focusing on psychiatry. I am in a PMHNP program.

AnnoyedByFreud said:

The RN experience was definitely not lacking clinically. It was quite intense, and went above and beyond the regular state requirements for licensure. I feel very confident in that level of education. I am at the beginning of my NP training, so it's early to say how I feel. I am excited about my classes, including the choices for textbooks (I looked them up on amazon and they appear to be used by med students and PA students as well). I also like the approach of training at my school, which is that we do 3 quarters of physical health assessment training (including clinical training) before spending 4 quarters focusing on psychiatry. I am in a PMHNP program.

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That sounds like a good program.

And yet, perusing the PA forums, you'll read from Pre PAs, PA students, and new PAs with little to no previous healthcare experience and who aren't nurses themselves talk about how lacking you will be as a provider, not knowing you, your background, your abilities, etc. It always comes down to them comparing the best PA programs (which many of them won't, don't or didn't attend because thy didn't have the HCE) to direct entry NP programs, or wielding the word "online" like there is no value to watching a lecture on a screen vs sitting in class (and many PA programs have broadcasts to satelite campuses). I guesse what is missing for them is the ability for the slow learners to hold up class while they have a concept clarified to them. I've found that one of the biggest perks of online courses is not being lumped in with the folks who do that. You hear detractors insist that it's good experience to interact and even help teach your peers. My response : it's good for some. But it's not really in line with my learning style, and it's my learning that I'm concerned about, which is why I pay so much for it. My peers aren't paying me for the time they take out of class because they didn't read ahead.

When I was a TA, the professor had powerpoints that were effective enough that it negated lecture.... The students were pulling great grades on the tests, and were even able to expound upon the concepts to the point where thy weren't just regurgitating material during the tests. Nobody came to class... I didn't even come to class the semester I took it (and landed one of the best grades I had up to that point). Well, it was all about the "learning environment" to him, so the amazing powerpoints we're replaced with heavily redacted ones that required regular in person attendance to gain key portions. If he couldn't draw a crowd, he ran the risk of not justifying his existence. So close to 130 students were required to marshal their resources to arrive to class for an hour and a half several times a week to accomplish something that had better delivery in another form. Education ceased to be about what could be accomplished for he masses, and more about what the masses could accomplish for education. For me, "online" isn't a dirty word.

Another thing I chuckle at is Pre PAs, PA students, and new PAs raging about articles favorable to NPs, when most of the NPs featured probably could run circles around them in a clinical setting. I sat at an outdoor table at a restaurant with my wife one afternoon, and overheard an ambitious young coed talking to her beau about how she was going to apply to PA school the following year. I seem to come across folks who say this all the time. PA school has been the new black, especially for those lacking real HCe, for a long time now. She apparently was an uncertified type of MA in a doctors office and mentioned NPs with slight condescension. I'm not a jerk, and it was none of my business, so I didn't butt in and ask her when the last time she caught a life altering problem on her own was. But for me, it was that day. And the day before. And the day before. And the day before. And the day before. So she scribes for a physician. Yay. Go post on PA forums about what you've watched someone else do, and dress it up like its an English essay. There are some studs over there that I really enjoy insights from, and some of those folks are equally critical of NPs, but they aren't usually knee jerk haters.

emedpa said:

I hope you don't count me as a "knee jerk hater".
I know there are good and bad pa and np programs as well as pas and nps.

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It's not the seasoned folks that seem to trend that way. New folks are a bit overexcited... Have some tunnel vision.

pamac said:

It's not the seasoned folks that seem to trend that way. New folks are a bit overexcited... Have some tunnel vision.

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Yeah... I have unfortunately met some PA students (and hopefuls) who seem to truly despise nursing, think RNs are glorified maids, that all PAs are innately superior to NPs, etc. It's an unfortunate trend. Ah well, once they start practicing I'm sure they'll get a wake-up call. I also think it's a defensiveness thing, since NPs have much better PR and lobbying than PAs. I should say, I have met some really great PAs. When I fell and sprained my ankle, a PA took care of me and he was fantastic. I do think I see more PAs "hating" on nursing than the other way around.

AnnoyedByFreud said:

Yeah... I have unfortunately met some PA students (and hopefuls) who seem to truly despise nursing, think RNs are glorified maids, that all PAs are innately superior to NPs, etc. It's an unfortunate trend. Ah well, once they start practicing I'm sure they'll get a wake-up call. I also think it's a defensiveness thing, since NPs have much better PR and lobbying than PAs. I should say, I have met some really great PAs. When I fell and sprained my ankle, a PA took care of me and he was fantastic. I do think I see more PAs "hating" on nursing than the other way around.

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pamac said:

It's not the seasoned folks that seem to trend that way. New folks are a bit overexcited... Have some tunnel vision.

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As a former RN, I've never seen that. I've seen it slung equally both ways. Usually it's a inferiority complex or a defense mechanism to cover up their own flaws.


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emedpa said:

debateable...every time pa legislation comes up it is almost always opposed by state nursing agencies...something we don't do to you guys...and state nursing boards do bs stuff like tell nurses they don't need to follow pa orders without real time cosignatures. total bs and I'm tired of it.

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Point taken. I was referring more to speaking with individual PAs and nurses, not the organizations as a whole. I agree that it is BS and I wish PAs and NPs would work together, since we have mutual goals.

Denatured said:

As a former RN, I've never seen that. I've seen it slung equally both ways. Usually it's a inferiority complex or a defense mechanism to cover up their own flaws.


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Go to the paforums and you'll see threads and comments with new PAs, students, and Pre PAs sharing their ire. I think hitting the workforce gives them more perspective... At least the decent ones. But I agree about the inferiority complex going on with the bigger blowhards talking tough.

I've yet to encounter with a pa in person talking as much smack as some nurses I've heard. But even nurses talking smack is rare for me to hear. I don't think as many folks pay as much attention on average to PA/NP issues as I do in my environment, and they would probably be surprised to know how much info I watch for on the subject on a given day, because I'm more subdued about how I gather info. It would be a little wierd to have a nurse going around asking all the pas he encountered what they think of NPs and vice versa. Don't want to be known as the dude obsessed about PA/np topics. So most of my knowledge comes from casual observation.

As far as nursing groups being vicious... No surprise there. They aim to win. PA advancement is collateral damage. Gotta admit that AAPA could use some folks who treat career advocacy like a blood sport instead of a victorian gentlemen's foxhunt wager. I keep thinking back to the national teachers union president that said "as soon as students start paying union dues, I'll represent their interests". I don't think it's cool for them to actively lobby against PAs, but when you are dealing with nurses with enough aggression to go after physicians, you also have to deal with all the other negative energy/enthusiasm that comes along with that, and sometimes that includes their view that we all live in a zero sum game. I may not agree with them 100%, but when you hire a lawyer, you don't go looking for the one that is going to pull punches... You get the meanest bastage around.

I've said before, PAs get the respect they deserve from me that I give every provider. They carry the physician's flag. I'd do what I could to come down on anyone I saw obstructing them. I'd definately report to supervisors anybody gumming up the works for a PA or NP (I don't agree with delaying patient care to fight a turf battle). Nurses don't all automatically love NPs either. You get some serious envy issues among some of the RN crowd over getting told what to do by another nurse, especially if the NP is young, and some old battle ax thinks they haven't "paid their dues" by languishing in bedside nursing for an appropriate period of time. Believe me, nurses with these attitudes are a joy for other nurses to deal with as well... Everyone gets a slice of their turd pie, not just the PA student on rotation that gets their orders questioned. In fact, their peers and subordinates often get it worse.... For 12 freaking hours at a time.

pamac said:

Nurses don't all automatically love NPs either. You get some serious envy issues among some of the RN crowd over getting told what to do by another nurse, especially if the NP is young, and some old battle ax thinks they haven't "paid their dues" by languishing in bedside nursing for an appropriate period of time.

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Very true statement. RN's that question PA's will also question NP's, sometimes even more so. There aren't many like that in my unit, but they are there. Now residents, that's entirely different. We all question the residents.