So you want to become a nurse practitioner. You want to work in healthcare, but being a doctor seems like overkill. Why not have many of the doctoring upsides while avoiding many of the doctoring downsides. Here’s how you can decide if becoming an NP is a good career for you.
What is Being a Nurse Practitioner?
A nurse practitioner is an advanced practice registered nurse and a type of mid-level practitioner, similar to yet distinct from a physician assistant, which we covered in a previous episode.
NP’s assess a patient’s needs, order and interpret tests, diagnose conditions, and formulate and prescribe treatment plans. Their training covers disease prevention, patient education, managing acute and chronic conditions, and coordination of care, but they are not trained to the same extent as MD’s or DO’s, and therefore may not be able to recognize and manage more complex and nuanced conditions straight out from graduation. Do note, however, that after working with supervising physicians for some number of years, they may be better equipped to handle more complex levels of care.
Similar to the physician assistant profession, the first nurse practitioner program was developed in the 1960’s to address the shortage of primary care physicians, particularly in rural areas, which were most heavily impacted. By the 1970’s, there were approximately 15,000 NP’s across the United States, and by the late 1990’s, close to 70,000. There are currently over 250,000 nurse practitioners in the U.S.
The scope of practice for an NP varies, and in some states, they must work under the supervision of a physician, whereas in others they can practice independently. The scope of NP work has not been clearly defined, and is not only dependent on state legislature, but also on what the supervising physician is comfortable with.
In terms of specialization, it’s not a matter of choosing a residency or a fellowship. The NP education model is more focused from the beginning, and you should therefore attend a program that caters to your intended area of specialization. These areas include primary care, acute care, family, women’s health, neonatal, emergency, pediatric acute, pediatric primary, and surgery. If an NP school has multiple programs, they may allow for flexibility in changing, as the first year is more general education. But this is an important caveat to note – your future practice and specialization will largely depend on the NP program you attend. In comparison, the medical school you attend has comparatively little influence on the specialty you may pursue as a physician. And similar to physician assistants, if you go into the operating room, you’ll be first assist as a nurse practitioner, not actually doing the surgery, which is the role of the surgeon.
Nurse Practitioner Myths
There’s a broad range of myths that confuse pre-health students considering a career in healthcare. Let’s set the record straight.
First, contrary to what some people think, becoming a nurse practitioner isn’t simply a matter of being an RN for long enough. It requires separate training.
Second, many lump physician assistants and nurse practitioners in a single bucket as “doctor lite”, but they’re under two different training models. Physician assistants go through the medical model, while nurse practitioners build upon the nursing model. While they do have many similarities as mid-level providers, they are distinct entities.
Third, the DNP degree stands for doctor of nursing practice, but that doesn’t make them physicians. As the term “doctor” generally indicates “physician” in the clinical setting, many find it misleading for a DNP to introduce themself to patients as a doctor, and many states have legislation prohibiting this. This is an area of controversy. While nurse practitioners are intelligent, capable, and contribute greatly to the healthcare system, they are not physicians and do not receive the same level of training. On one hand, most physicians are against NP’s calling themselves doctors, as it leads to patient confusion and obfuscation of roles. On the other hand, some NP’s argue they’ve worked hard for their degree and want the right to call themselves “doctor”. My NP colleagues, who helped in the creation of this article, believe that NP’s should not call themselves doctors.
How to Become a Nurse Practitioner
Nursing has a separate training and organization structure compared to medicine. To become a physician, you attend medical school, residency, and test for board certification in a given specialty. In nursing, there are multiple types of advanced practice registered nurses. Nurse practitioners are what we’re focusing on, but there’s also a certified registered nurse anesthetist, or CRNA, who provides anesthesia services in the operating room and intubation in healthcare settings. Certified nurse midwives, or CNM’s, specialize in women’s reproductive health and childbirth, and provide prenatal and postpartum care and deliver babies. Clinical nurse specialists, or CNS’s, focus on advanced clinical knowledge and evidence-based nursing in a specific area.
There are two main pathways to become a nurse practitioner: traditional and direct entry.
The traditional pathway involves first earning your BSN, ABN, or MSN to become an RN after taking your NCLEX exam. Most that take this pathway will work as an RN for a few years, although this is not required. Next, they attend a master’s or doctorate program to become an NP. If you attend a full-time master’s program, it will generally take 2 years, but if you are undergoing a part-time DNP program, it can take up to 5.
Choosing between a master’s or doctorate program is not mission-critical, as it doesn’t change your practice, pay, or licensing exams. More programs are moving toward the doctorate program, which, in comparison, is more focused on research and enables you to teach.
The second pathway, or direct entry nurse practitioner programs, are for those who earned a bachelor’s degree in something else. These are 3-5 year programs, where you will take both the NCLEX to earn your RN but also complete a master’s or doctorate program to become an NP. Again, more programs are transitioning to the doctorate program, which is generally longer by approximately 1 year.
At the end of either path you choose, you’ll take your certification exam, which is the nurse practitioner board exam. It does vary based on your area of specialization. And after that, you can apply for licensing in your state and find a job.
In terms of cost, nurse practitioner tuition costs are lower than PA or medical school paths. In-state tuition averages to about $18,000 to complete a NP program, while out-of-state is around $32,000. Online programs are in the middle, totaling around $22,500 for completion, while private universities are more expensive, around $45,000.
Average compensation is around $110,000 per year, but there is variation depending on the certification. Women’s health are at the bottom, around $98,000, whereas acute care NP’s and psychiatric mental health NP’s are at the top, around $114,000.
What You’ll Love About Being an NP
There’s a lot to love about being a nurse practitioner. There’s a favorable work/life balance, usually without call. You’ll also have varying levels of autonomy, where you can be a provider making decisions, yet the training is not nearly as hardcore or as lengthy compared to that of a physician.
NP training is shorter than becoming a physician, lasting generally 2 to 4 years compared to 4 years of medical school plus 3 to 7 years of residency. The cost is much lower too, so you’ll likely graduate with substantially less debt than if you went the MD or DO route.
As an NP, you also won’t have to take work home with you or deal with things like overnight call — these are all factors that come with the added responsibility of being a physician. And because you’re not the person on the line, there’s less stress about malpractice or things going sideways, unless you’re practicing independently. If you’re ever unsure about something, there’s often a supervising physician to run things by.
Most RN’s don’t get the opportunity to build longitudinal relationships, but as an NP, particularly in a primary care role, this is the norm, and many find it highly gratifying.
Hours are usually regular and predictable, depending on your practice setting. While it depends on the specialty, you can expect to work around 40 hours per week.
What You Won’t Love About Being an NP
While being a nurse practitioner has its perks, it’s certainly not for everyone.
If you’re interested in primary care, the NP route is great, but if you want to keep your options more open and possibly consider something surgical, there tends to be more opportunities going the PA route.
While the training is much shorter, you will also be making 1/2 to 1/3 of the average physician’s salary. If you care about prestige and respect, which are not great reasons to base your future career on, then the MD or DO route may satisfy that to a greater degree. On the other hand, if you’re able to put your ego aside and understand your role on the team, including your responsibilities and scope of practice, this likely won’t be an issue.
If you want to have extensive knowledge of the human body and how to manage various ailments, the NP route will give you the foundations, but it won’t offer you the same level of training as going the physician route. You’ll be able to handle the majority of bread and butter primary care, but when things get more complicated, you may want to seek physician guidance.
Between PA, NP, and physician, NP’s usually receive the fewest clinical hours, somewhere between 500 and 1,500 depending on the program. In comparison, PA’s are required to have 2,000 clinical hours and physicians between 16,000 and 20,000 at minimum.
There’s a tremendous deal of controversy over the scope of practice for NP’s. The American Association of Nurse Practitioners has been lobbying hard for increased scope of practice, allowing nurse practitioners to provide more care independently of physicians. After all, with greater scope comes greater autonomy and compensation — but so does liability, as some are learning the hard way in malpractice cases.
You should know that if you are treated by a CRNA and they make a mistake, they will not be held legally liable.
In a court ruling filed on June 16, 2020, an appellate court decided that “nurses are not supposed to be experts in the technique of diagnosis or the mechanics of treatment” even if they work as nurse practitioners or CRNAs. This ruling occurred after a CRNA made a completely avoidable mistake that led to the death of a 3-year-old child. Even after the death of the child, the CRNA was not punished and is still working in a hospital today.
Opponents to increased scope push back about the implications on patient safety. After residency, a physician has accrued approximately 20,000 or more hours of clinical experience in their particular specialty. In comparison, a DNP only needs a fraction of that, between 500 to 1,500 hours of patient contact hours to graduate, which aren’t necessarily focused in their ultimate specialization. My NP colleagues tell me that those pushing for increased scope of practice are a vocal minority, but that most NP’s don’t share this mentality.
Don’t get caught up in the online hype – this isn’t about physicians versus nurse practitioners. The healthcare team needs to work together to serve the patient. When both groups of professionals work together and as intended within their scopes of practice, everyone, including the patient, wins. In recent years, given the growth of diploma mills and online-only programs in conjunction with the increasing scope of practice, there are growing concerns regarding patient safety. If you’d like to learn more about this issue, I recommend checking out the Physicians for Patient Protection, an organization with great articles and presentations about this subject, which go much deeper than I can cover in this video.
Should You Become an NP?
How can you decide if becoming a nurse practitioner is a good fit for you?
If you enjoy being a team player, educating patients, and making decisions regarding patient care, the NP route may be a good fit. Those who may not like the patience or cost required for medical school will likely appreciate the shorter and less costly option of going the NP route.
If you are currently on the nursing track and want to go to the next level, consider becoming an NP. If you prefer the medical model, then you may want to consider the PA route instead.
If you want more control, autonomy, and depth, knowing all the ins and outs of various diseases, including the obscure ones, and be at the pinnacle of patient care and research, go to medical school and become a physician.
These are all tradeoffs and there’s no right or wrong here. No specific path is better or worse than another path. You have to figure out what type of life you want. Look at the future paths of each, and see which is better suited to your personality, values, and long-term desires.
If you enjoyed this article, check out our other installments in So You Want to Be. In this series, we highlight a specific specialty or profession within medicine, such as nurse practitioner, and help you decide if it’s a good fit for you. You may also like our other piece comparing the competitiveness of PA school to NP school to Medical School. As with all my So You Want to Be articles, this piece was created with input from experts in the field. After all, I’m an MD, not an NP, and I relied on practicing NP input for guidance and accuracy.