Is There a Physician Assistant to Nurse Practitioner Bridge?

The great English scientist Isaac Newton is credited with saying: “We build too many walls and not enough bridges.” This site began as a bridge of sorts. But there’s a new bridge everyone is talking about: a physician assistant to nurse practitioner bridge. 

A PA to NP bridge?

Say, what? A PA to NP bridge? The very thought is incomprehensible to some. 

“Why would you even want to do that?” responded one PA when the question was raised on social media. I can imagine the respondent, with one eyebrow raised, lips pursed, genuinely confused. Perhaps even wondering if the original poster was a burned out, disillusioned PA asking for help or an internet troll looking for a few laughs. 

Others commenting on the post were quick to point out where nurse practitioners trail physician assistants in clinical training. “You’re just about as likely to find a PA to airline pilot bridge” quips another. 

Are PAs and NPs the same?

Are the two professions even that different? As Virginia Hass explains, “The two professions enjoy significant areas of overlap, yet are still distinct in their education, initial certification, maintenance of certification, and licensure.” Ms. Hass ought to know–she’s both a PA and an NP. 

Yes, NPs and PAs are different. Dr. Hass (also a Doctor of Nursing Practice), goes on to explain how the average PA program averages 27 months and includes almost 2,000 clinical hours while NPs train for 15-24 months, accruing just over 700 hours of clinical instruction. 

Nursing Model vs Medical Model

Then there’s the old nursing model vs medical model, thing. Whats the difference? 

According to one article, nurses “implement a nursing care plan based on the nursing process, using both nursing theory and best practices derived from nursing research.” Huh? 

Some might try to explain the difference by saying that the nursing model considers the whole person while the medical model focuses only on the disease. Nonsense. No good clinician would take a patient’s condition out of the context of their lives–where they live and work, what they eat, what hobbies they may have, etc. It’s all pertinent information. 

According to another article, ‘It is argued that nursing cannot be a distinct profession unless it has its own knowledge base, organized into a model for practice, against which nursing activities and interventions can be evaluated.” Ok, so it’s just a way to say that nurse practitioners do things differently–that makes sense. 

“Brain of a doctor, heart of a nurse.”

What is that difference then between the way nurse practitioners and PAs and physicians practice?  One physician explained it like this: NPs are trained in pattern recognition while the medical model teaches physicians and PAs to understand why certain patterns emerge in the first place. 

Understanding this fundamental difference, it makes little sense for a physician assistant to want to practice on a more superficial level. That’s not to say pattern recognition has no place in the practice of medicine, however. 

This brings up another salient issue: Do nurse practitioners practice medicine or advanced nursing? Honestly, it’s another silly argument that really depends on how your state defines the terms. The answer also depends on who you’re talking to. Defending their day-to-day practice, NPs might borrow more from medicine but when it comes to regulation, it’s all nursing governed by nursing boards. 

Physician Assistant Bridge to Anywhere

So why would a physician assistant want to bridge to become a nurse practitioner then? It really comes down to 3 little words: Full. Practice. Authority. 

Full practice authority can also be a tough term to pin down. Critics see it as a claim of independence and “scope creep” while proponents argue that it’s more about responsibility. In their response to the AMA’s “tone-deaf” initiative to promote physician-led care, the AAPA notes that “This is not only contrary to what evidence shows is best for patients but is also out of touch with how medicine is practiced today.”

How is medicine practiced today?

This gets to the heart of the physician assistant to nurse practitioner bridge argument. The American Association of Nurse Practitioners indicates that NPs have “full practice” in 25 states and US territories. Full practice is defined as laws allowing “all NPs to evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing.” 

State laws in the rest of the country limit NPs to certain tasks or require them to work with a collaborating physician. Up until very recently, a similar map illustrating PA practice laws would have been a lot less interesting. And even today, no state has true full practice authority in the way nurse practitioners have been able to achieve it. [Update: Since this article was first published, significant advancements have been made in several states.]  

Stopping Scope Creep

Physicians often criticize NPs and PAs for wanting off the leash (remember the cringe-worthy scope creep thing?). Nurse practitioners tend to argue that they don’t need physicians. PAs, on the other hand, have tried to maintain a team-based approach

But one thing is clear–you can have team-based care without outdated administrative policies. This is what PAs really want and what NPs have overshot. Too many physicians, unfortunately, refuse PA’s attempts to reduce unnecessary burdens thanks to the festering wounds associated with the battle for NP independence. 

Optimal Team Practice vs FPA

While physician assistants are now considered fully responsible for the care they provide (i.e. independent) within the Indian Health System, real progress still lacks in state legislatures. 

North Dakota was one of the first US states to remove the requirement that PAs have a written agreement with a physician. There’s a major catch, however. In order to operate in the streamlined environment, they must practice at licensed facilities (e.g., hospitals and nursing homes), facilities or clinics with a credentialing and privileging process, or physician-owned facilities or practices. North Dakota PAs can own their own practice with the approval of the North Dakota Board of Medicine but PAs with less than 4,000 hours of experience must still have a collaborating physician. That’s not a bad compromise actually. 

Maine recently passed a similar law that requires PAs with less than 4,000 hours of professional experience to practice in a collaborative agreement with a physician while those with more than 4,000 hours may practice without a written agreement. A physician must simply be available for consultation. If the PA is the principal provider in a practice that does not include a physician a practice agreement would still be required. 

A Bridge in My Backyard

Some PAs, feeling their employment prospects contracting, are unhappy with anything short of full independence. I recently heard a representative of my state’s medical society say that if PAs wanted full independence, they could probably get it in a legislature very sensitive to anything that’s anti-competitive in nature. 

What route did we choose to follow? The only one we could–appeasement. We didn’t have the money or the manpower to go up against the physician groups, and they were quite clear that a move for independence (as they defined it) would be an act of war. 

What do NPs do when confronted with organized medicine? They forge ahead. Look at what happened in Florida, for example. The push for independence in Florida began with both PAs and NPs but when physician groups objected, PAs were dropped, and the NP machine rolled on. NPs outnumber PAs 2 to 1. That matters. Add 4 million registered nurses and not even physicians stand a chance. 

O Captain, My Captain!

The discussion of a physician assistant to nurse practitioner bridge and full practice authority versus independence brings up another important question: who should lead the healthcare team? To some, the answer may be obvious–physicians. But not all patients have, or want, the chance to be seen by a physician. 

PAs are vital to rural health care in America. These patients receive quality care from PA-led teams and the outcomes are often indistinguishable from physician-led care. Patients don’t care about credentials as much as they care about competency and compassion. All patients deserve good outcomes from capable providers and there’s no single degree that can offer that without fail but I don’t blame PAs for wanting to do so without all the baggage. 

28 Comments

  1. AJ Benham

    Another difference between the nursing model and the medical model is that a major focus of modern nursing education (i.e, since the days of Florence Nightengale) has been disease prevention, health promotion, and population health . This is in addition to an emphasis on family-centered. care and patient engagement in self-care and decision making. It’s not a coincidence that these approaches have been more widely recognized as part of “medical” care over the past 50 years with the development of the NP role and associated patient satisfaction and cost effectiveness outcomes.

    • Laura

      NP/PA
      If you have either of those titles, congratulations. These type of discussions usually cause a divide and this divide serves no purpose other than for people to attempt to justify their abilities to be a decider. My opinion is that regardless the process of education we all participated in, it moves us in the direction of practicing medicine. There are a variety of reasons medical school is not the path for some of us. I acknowledge the rigorous educational trajectory of medical school with the sacrifice of time and significant financial investment. This acknowledgment, does not minimize the education and hours the PA/NP has realized, rather highlights that Medicine acknowledges there is a gap. This gap is bigger than medical school, this is about access. When the medical community accepts there are bridges to be built, they will benefit from its traffic. Ultimately, we all know humanity will benefit from a team approach to care. Let’s stop squabbling over power and titles, rather build alliances to serve our patients.

  2. Dr. Rhonda Goodman

    You fail to consider the clinical hours earned by the NP student while he or she is a practicing Registered Nurse, prior to entering the NP program. Also count the clinical hours earned whilst an undergraduate nursing student. One must be an RN with a baccalaureate degree for admission into NP programs. Their preparation is richer than what you have represented here.

      • Indeed, when I count up my clinical hours for ADN, BSN AND NP (my university required 900 hours) it is well near 2000 hours. Add to that 20 + years as an RN in acute care, ICU/CCU/NCCU and OR. I also believe that a nurse possesses a special quality, a sense of caring and warmth that not everyone has and that makes a ‘nurse’. I have worked with many a PA that just do not have that type of personality. I don’t mean to offend anyone but PA’s just don’t have what it takes to be a nurse or NP.

    • Scott Acree, PA-C

      Unfortunately, that are an increasing number of NP programs that DO NOT require previous RN experience. I am a PA and a preceptor for the UH Univ of Hawaii NP program and I love NP’s but I DO NOT like the programs that offer NP programs with no previous RN experience. Those NP students are NOT prepared. Thanks for the input. We both have a great responsibility to fill in the serious shortfall of MDs in our country with QUALITY Mid level providers!! Please join the voice to require previous experience to those programs!! Scott Acree, PA-C

    • Steven Escaravage MHS, PA-C, RT(R)

      This is a completely inaccurate representation of what is needed to enter a Physician Assistant program. Many programs require a significant amount of patient care contact hours plus a significant amount of shadows hours with an MD or a PA prior to applying to school. Many PA students have worked in other areas of healthcare (nursing included). The amount of clinical training is significantly different when in school. Being a preceptor for NP students and PA students, I have seen first hand the differences in time spent in clinical training. PA students will spend an absolute minimum of 40 hours a week (more like 60- 80 hrs/week) on each of their clinical rotations. NP students spend 1-2 days per week. You are also forgetting that PA students rotate through 7 core training rotations including but not limited to Pediatrics, Emergency Medicine, Primary Care, Internal medicine, General Surgery, Psychiatry, and OB/GYN with many programs offering additional elective rotations in the students area of interests. You are clearly stating PA training is of lesser value than NP training when you speak of “richer preparation.” There is a significant difference working as a nurse and working a provider. This is not to discount the nursing profession as I work alongside many intelligent nurses and NPs. This is merely to shed light on the rigorous training PAs go through in order to practice medicine.

  3. JoAnn Friedrich

    As a P.A. for over 45 years. I have said for many years that we need to unite with the N.P.’s. I have always thought we could work together and make more progress. Let’s face it there are good P.A.’s and good N.P.’s, just as there are good M.D.’s and D.O’s and there are those who frankly one has to wonder how they ever passed their boards. Just as a family practice doctor refers to a specialist when out of their depth, so could this mid level group. I believe that there has always been an underlying physician wish to distract us with a war between us. We are letting chiropractors, naturopaths, podiatrists, optometrists all call themselves doctors. Let’s take the best of each of our two professions and form a new one together that treats the disease. by treating the patient.

  4. D

    I have desired advancement in hospital admin for years but even with a MBA in addition to MMS in PA studies, I won’t be considered because all positions require RN degrees. A PA doesn’t fit into the role of managing nurses at the facilities I have worked at. So yes, I wish I was a nurse and if there was a NP bridge I would pursue it.

  5. I believe that nurses tend to have a special characteristic, a sense of
    caring and warmth that cannot be taught. When I was in my first college nursing program, the 1st of 3, people were kicked out of the program because they were not ‘nursing material’. I guess I might be revealing my age period as I doubt that happens nowadays. I have worked with many a PA who just don’t have that ‘nursing quality’. There is a difference. Re clinical hours, my latest university requirement for NP was 900 hours, add that to the BSN hours plus the Associate degree clinical hours and it adds up close to the PA hours. We NP’s have worked in CCU’s, ICU’s, OR’s and other units and have gained a wealth of knowledge prior to pursuing NP degrees. Patients know and can tell the difference between a PA and an NP. Nothing against PA’s but to integrate them into an NP without having worked as a nurse first would be a huge mistake.

    • Thanks for your comment. Nurses are great. NPs can be great, too. The hours referenced in this article refer to the practice of medicine, not nursing. PAs with thousands of hours working as an EMT, paramedic, nurse, or other medical tech certainly benefit from that experience as well but it’s not equitable to the training and clinical practice as a PA. We believe the same to be true of nursing and NPs.

    • Ceara PA

      This is simply not true. You cannot count nursing hours as experience as a medical provider. They are complete different roles. PA training is very intense and we spend >2000 hours in rotations, thinking and functioning as medical providers, using critical thinking skills to diagnose and treat. Nursing does not count toward this. Pre PA medical work (including nursing) does not count for this either.

  6. Becky Meinecke

    I went to PA school following a 20 year career as an RN in emergency and critical care medicine. I chose the PA route because I wanted to taught on the medical model. I would pursue the PA to NP bridge for the same reasons mentioned in the article. To be able to work without physician oversite and to be eligible for management jobs requiring a nursing degree, ( I am a diploma grad).

    • Amy Lynn Mikesell

      As an NP I would like to have the clinical training and experience that is employed in the PA programs. I too had 20 years going into my NP degree, however, it is quite the difference when you are the provider and not the RN. Why can’t we have either separate programs but better all inclusive instruction and work eligibility on both sides? In the end the one that benefits the most is the patient and the more happy patients, the better the profit margins, the more happy employers ( usually physicians) and the push back will become less of an issue and the medical teams will be more unified overall. Seems like a win across the board. Why do some of the smartest and most innovative people on earth from a professional standpoint exhibit such stubborn, headstrong behavior and make everything twice as hard when unifying both practices seems to be a no brainer?? Just a thought….

  7. Bonnie S Dank, MS, MPH, RN, CRNP-A BC, CS-PMH BC

    I am both an NP and a PA and I do not know why a PA would want to bridge to NP. PA training is far more comprehensive and inclusive. With a little brush up on some nursing theory, a PA could easily pass any of the NP certifications while an NP education is so focused and limited that not a one could pass the PA certification. Then there are the DNPs who don’t even come close to adding real clinical experience but demand that they be called DR. which I believe is fraudulent and misleading to patients who feel that they have the background, training, and education of a physician. I refuse to call a DNP “doctor” in the clinical setting. Better the PAs bridge to medicine and become physicians (we really need primary care and family physicians – even psychiatrists) and NPs are not the ones best qualified to fill the gaps. There must be some medical schools who can assess PA education and experience and fit them into a program. I think that NPs desiring to become MDs would be surprised how little they can transfer to a program.

    • Todd Pillen PA-C/SA, MPAS, DFAAPA

      Great input and parallels my >40 years of observations of RNs who went to PA rather then NP school and NPs who I’ve worked with who observed and realized PA training and abilities as a “healthcare practitioner” far exceeded theirs due to the differences in the training model.

    • Joeli

      Bonnie,

      I teach for a PA program that is in the second year of 8 medical students going through the PA program, instead of the medical school, prior to residency. I hope this signals a shift in thinking for some in the medical community. That PA education is rigorous and applicable to becoming MD, DO, etc.

        • Joeli

          The PA program accepts 8 students from the medical school to attend the PA program including the exams, courses, problem based learning groups, assignments, etc. They are right alongside the PA students in this program. The program calls these students ‘Lincoln Scholars’. They will have supplementary courses following the completion of the PA program. It is in its second year and the full outline of the program is in progress.
          This is not to say that completing PA school is the same as medical school, as I stated, they also have some supplementary classes following the PA program completion. I think it will be interesting to see it play out as the Lincoln Scholar students complete their USMLE step tests, etc. and how they compare to the traditional medical school program here.

          • Wow, that’s interesting. It’s exciting to see how PA education can be used to train physicians but I have to wonder if or when some program will offer seasoned PAs a few supplementary courses and an opportunity to take the USMLE. Thanks for sharing. Please keep us updated.

  8. Amy Lynn Mikesell

    100% Agree!!! I received my NP only after 20 years as a RN/BSN and then after a MSN Ed —I had plenty of varied experiences to draw from and already held another masters degree. There is no way a student can go from no degree to BSN in 3 years (I believe that is how it is done now but I did a 2 year RN followed by a 2 year BSN back to back (I’m old) ) and then go directly to NP school in < 2 years and have any real experiences to draw from or know the culture of the profession well enough to be trying to achieve terminal or near terminal degree status as NP or DNP. Please, as a profession, can we mandate a minimum of 5-7 years experience prior to entry–just my opinion.

  9. April Lowery, PA-C

    I believe to say that Nurses, NP’s have a component of compassion that PA’s do not is inacurate. A compassionate person is a compassionate person regardless of title. A patient will respond to compassion from whomever is delivering it weather it be an MD, NP,PA. I have heard patients state the will never see an MD, NP or PA due to their arrogance, inabilty to listen or relate to patient. Regardless of your title we are all PRACTITIONERS who will eventually need to relate to patients to provide comprehensive care and wellness. PA’s need to be entitled to the same opportunities as an NP as mid level practitioners.

  10. Is the issue really independence for PAs or should NPs have complete independence. Let’s be honest, if it were not for the numbers of nurses, the strength of their lobbyist, the uniformity of their profession they would have never been granted the independence, at least at the pace that they have been, that they have. The article clearly outlines the great difference in clinic hours between the two during the training process, but fails to point out that many PAs have limited medical hours learning detailed medical knowledge prior to their formal PA training. Conversely, some do have extensive patient contact and have broad medical experience. The same can be said for NP candidates. I feel strongly that we need closer relationships with MDs/DOs, not less. This does not mean that we can’t practice very independently, many of us do, but we should never forget who we are. We are Advance Practice Providers that should embrace collaborations with physicians not estrangement.

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