NP vs PA: How Do You Choose?

In today’s healthcare world, nurse practitioners (NP’s) and physician assistants (PA’s) have become interchangeable providers. Many facilities view them the same because of their similar education, training and skill level. Often, job positions are fulfilled by one or the other with no change in the defined job responsibilities.

For most of  healthcare, this is the best of both worlds. But for the up and coming student who is expressing an interest in pursuing this advanced role, there is curiosity and confusion on which path to choose. While both disciplines can fulfill a single role, there are some important differences.

What do you need to know before you send in that application?

Every student should be aware of the following eight topics when deciding on a career. So, let’s take them one topic at a time.

Physician Assistant

1. Medicine-based program
2. Masters degree minimum (doctoral terminal degree)
3. Previous patient care experience preferred
4. Operate under a physician license
5. Can have limited prescriptive authority
6. Independent practice opportunities (within state guidelines, which vary widely)
7. Must renew certification every ten years
8. What if you don’t like it?

Nurse Practitioner

1. Nurse-based program
2. Masters degree minimum (doctoral terminal degree)
3. Previous patient care experience preferred (direct-entry MSN programs are available)
4. Operate under own license
5. Collaborative prescriptive authority
6. Independent practice opportunities (within state guidelines, which vary widely)
7. No renewal certification requirement (maintain CEUs)
8. What if you don’t like it?

1. Type of program

This is pretty self-explanatory. NPs have a nursing-based education and PAs have a medicine-based education. This doesn’t mean a whole lot as a pre-student. What you need to know is the structure will vary greatly. Nursing education is holistic and treats the whole patient, not just a disease. Medicine focused education still treats the whole patient, but it tends to focus more on outcome-based evaluations and competency. Some would argue that upon graduation NPs have more empathy and are more comfortable with therapeutic communication, while PAs will need to develop those skills upon graduation. Both are prepared to practice to their fullest extent by diagnosing and treating illness.

2. Degree options and requirements

The entry degree for a PA is a Masters of Science (minimum six years collegiate schooling) and the terminal degree is called the Doctorate of Medical Science (DMSc or DMS, respectively). The doctorate option is very new and not yet widely available. 

The entry-level degree for an NP is a Masters of Science (also six years minimum), and the terminal degree is the Doctorate of Nursing Practice (or DNP). The Doctorate of Nursing Practice (DNP) is approximately four more years of post-baccalaureate education. Some NPs will attain the MSN (Master’s of Science in Nursing) first, start working as a licensed NP, and then return to school to complete their post-master’s doctorate (which is an additional two years). Here’s a great article differentiating between the different graduate options for nurses.  

The DNP degree is a requirement for leadership and educator positions within the NP profession. (Also, there is another terminal degree in nursing, the PhD – but this is a heavily research-based degree and not the typical option for someone seeking to become am NP).

3. Patient care experience

Both NP programs and PA programs prefer applicants to have patient care experience. Simply check out the admission requirements for schools you are interested in attending. There are a few PA programs out there that do not require patient experience, but those are few and far between.

With NP programs, it gets a little less clear.  While most NP programs prefer nurses with experience, you don’t necessarily have to have patient care experience. Some schools may simply require you to be a licensed registered nurse. To complicate things further, there are programs called Direct-Entry Masters of Nursing Science program. Essentially, you enter the program with a bachelor’s degree in another field, go while you’re going through it you’ll obtain your RN and will graduate with your MSN. Major universities offer these programs like John Hopkins, Vanderbilt, and the University Rochester.

4. Type of professional license

This difference has little impact on the delivery of care. The scope of practice for each role is managed and directed by the state in which they are employed. And yes, individual state practice acts can vary.

The PA’s license to practice is through the State Board of Medicine. The licensure of a PA is streamlined and singular. All PAs go through the same entry-level training and collegiate education. They graduate from their credentialed PA program where they have met the minimum standards to take the Physician Assistant National Certifying Exam (PANCE). Every PA student takes the same exam. Once they pass this exam, they submit their application to The National Commission on Certification of Physician Assistants (NCCPA) which is in charge of awarding the Physician Assistant-Certified (PA-C) credential.

Nurse Practitioner’s (NP) licensure is not as straightforward. One’s NP license is through their respective State Board of Nursing – but not every NP is the same. NPs have become specialized and only practice within a specific population or acuity setting. Unlike PAs, there is no universal NP education or training. Please refer to our previous post for a more detailed explanation.

To make matters even more complicated, once an NP student graduates, they have to decide on which certification exam to take. Yes, there are multiple exams offered. The two certifying bodies are the American Nurses Credentialing Center (ANCC) and the American Association of Nurse Practitioners (AANP). Both exams meet the minimum standards needed to apply and obtain state licensure. In past years there were organizations that would not hire NPs with the AANP certification vs. the ANCC certification, but I believe this discriminatory act has been resolved. As of the writing of this post (Nov. 2017, updated March 2018), your choice of exam does not matter, only that you pass the exam. Once you pass the exam, you submit your application to the State Board of Nursing to obtain licensure as an NP in your respective state.

5. Prescriptive authority differences

The NP and PA who have met the minimum requirements within the state of which they practice have the authority to dispense (prescribe) a controlled substance in the course of professional practice. From the Drug Enforcement Agency (DEA) website:

“Drugs, substances, and certain chemicals used to make drugs are classified into five (5) distinct categories or schedules depending upon the drug’s acceptable medical use and the drug’s abuse or dependency potential.”

These are medications like Ativan, Ambien, Adderall, Ketamine, marijuana and almost all opioids that were outlined in The Controlled Substances Act (CSA) Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970 which are regulated by the DEA. The lower the Schedule number, the higher the drug potency (Schedule 1: marijuana vs. Schedule 4: Xanax).

Many advanced practice providers (APP’s) have limits set on which scheduled drugs they can dispense. For instance, an NP in the state of Montana can prescribe a Schedule 2 drug, but a PA in Montana cannot. This will vary from state, to state and all this information is available to the public.

6. Independent practice

Independent practice is the ability of the APP to assess, diagnose, and treat a patient without physician oversight (supervision). Both NP’s and PA’s have made legislative efforts to gain independent practice, much to the dismay of the American Medical Association.

Generally speaking, NPs have more of an option to practice independently than PAs, but only in select states.

7. Certification renewal

Once you pass the big exam and begin your journey as a new clinician how do you maintain your certification and licensure? For the NP, it will resemble the requirements of a registered nurse. You will need to maintain a certain number of Continuing Medical Education (CME) requirements, sometimes also referred to as Continuing Education Units (CEU). For the prescribing clinician who dispenses medication, you will also have to maintain a certain number of pharmacology education hours. This requirement varies by state, so be sure to verify your requirement with your state.

The PA will also need to maintain CMEs, but they are also required to recertify. The PA mimics a physician in this aspect. A PA will have to take their ‘big exam’ every ten years. Yes, you read that right. You will retake and relive that experience every decade. Be thankful; they recently changed the interval from six years to 10. For many potential students, this is the deal breaker.

8. What if you make the wrong decision and don’t like it?

What if after all that studying, class time, sim labs, stressful exams and anxiety-laden clinical rotations you graduate and start practicing as a new clinician and discover that it’s not for you?  What if you don’t like it?

As a new PA, you will have the ability to choose a new clinical setting or environment. Maybe a new inpatient setting or a different patient population? You could also try moving between inpatient and outpatient settings.

Now, as an NP you have a little bit of flexibility. You can experiment a little bit while you are an NP student. You see, as an NP, you are required to first be a registered nurse. Many programs require you to to have roughly 1-2 years of nursing experience before (or during) you attend NP school. You get almost two years to ‘find yourself’ and find your path. You can do travel nursing, you can attempt per diem work, you can be a float pool nurse, or you can pick maybe a top 3 focus areas and figure out how you can gain experience in those areas while you are attending NP school. And ideally, work shoulder to shoulder with NPs.

When you finally graduate from NP school, you will not be flying blind. You will at least had the opportunity to help you decide if becoming an NP was for you.

As you can see, as an NP, I have a bit of a biased opinion. I strongly support a career as an NP for all the listed reasons. But at the end of the day take all of my suggestions with a grain of salt. Be sure to ask questions, be diligent with your research and do a thorough self-assessment before you make such a big decision – and do what is best for you.

Helpful links

• How to Become a Physician Assistant in Pennsylvania 
• ANCC vs. AANP: Which FNP Exam Should I Take?
• Mid-Level Practitioners Authorization by State
• DEA Drug Scheduling
• Nurse Practitioner State Practice Environment