NP-PA Turf Fights: Where the Relationship Can Improve

Physician interactions with nurse practitioners (NPs) and physician assistants (PAs) are only going to increase in frequency ― the US Bureau of Labor Statistics forecasts a 40% increase in the NP workforce by 2031, coupled with a 28% rise in PAs.

In recent Medscape reports on the quality of the relationships involving these three healthcare professions, survey respondents mostly gave positive accounts of collaboration, using words such as like “comradery,” “teamwork,” “congenial,” and “cohesion.” But all was not perfect. Where and how could these important healthcare provider relationships improve?

PAs: “Competition and Collaboration” With RNs

One PA respondent complained that NPs get “more opportunities and preference,” another pointed to PA-NP “turf issues,” and a third griped about NPs’ “strong unions,” which have stoked more fighting about practice abilities and available settings.

Robert Blumm, MA, PA-C, a retired surgical and emergency medicine PA who regards himself as an advocate for both PAs and NPs, describes their interaction as a “mixture of competition and collaboration.”

On one hand, the two groups typically “cooperate and do an excellent job, incurring patient errors similar to or less than physician colleagues or senior residents.” On the other hand, Blumm concedes, there is some jealousy among PAs over NPs’ advantage in staffing and hiring decisions, “since they don’t need [direct physician] supervision…and there are limits on how many PAs can be supervised by one physician.”

Most PA-NP interactions are collaborative, although many people emphasize the relatively few conflicts, says Jennifer Orozco, DMSc, PA-C, president and chair of the American Academy of PAs and director of advanced practice providers across Rush University’s hospital system in Chicago.

“We see that a lot in this country,” she says. “People try to drive a wedge, but it’s often a misnomer that there’s a lot of arguing and infighting.”

NPs: Different Backgrounds, Same Goal

NP April Kapu has worked closely with PAs for more than 20 years. “In my experience…they complement one another as health team members, although the education and training are somewhat different,” says Kapu, DNP, ARPN, president of the American Association of Nurse Practitioners.

Some respondents to Medscape surveys noted the different educational trajectories for NPs and PAs. “Doctors and PAs are taught using the same model, but NPs are taught under the nursing model,” wrote a family medicine PA.

In emergency departments where Blumm has worked, intensive care unit NPs have an edge over PAs in terms of preparation, organization, and the tabulation of formulas. On the other hand, some of Blumm’s fellow PAs were also emergency medicine technicians or respiratory therapists, who had “2 years of classroom training, on par with that of medical students.”

Must these differences in training and education foment conflict between NPs and PAs? “We all bring something different to the table,” says Kapu, who also is associate dean for clinical and community partnerships at the Vanderbilt University School of Nursing. “It is important to respect each person’s entry point, education, and training.”

Differing Personalities and Environments

Numerous PA respondents told Medscape that individual personalities and work environments are more likely to trigger issues with NPs than are differences in training.

“It depends on the team and situation and who the people are, not the letters behind their names,” an emergency medicine PA wrote. A surgical PA noted that “group dynamics and work culture differ from place to place,” while a third PA agreed that “it’s personality dependent, not title-dependent.”

No single formula will resolve areas of NP-PA conflict, Orozco says.

“What works in Chicago might not work in rural Colorado or Texas or California, but we do have to come together. The overall focus should be on greater flexibility for PAs and NPs. Patients will fare better.”

Joint Research, Publishing Could Help

About a decade ago, Blumm joined with another PA and an NP to form the American College of Clinicians, the first joint PA-NP national professional organization. Although it disbanded after 6 years, owing to low membership, he hopes a similar collaboration will take off in the future.

“I also recommend that PAs and NPs publish articles together, with research as an excellent place to start,” he adds.

“PAs and NPs should stand together and be a source of healing for all our patients. Regardless of our titles, our responsibility is to bring healing together.”

Batya Swift Yasgur, MA, LSW is a freelance writer with a counseling practice in Teaneck, New Jersey. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom(the memoir of two brave Afghan sisters who told her their story).

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