Setting Sets the Rate
These averages reflect a wide range in individual NP compensation. From the beginning, salary has been a function of setting. Top earners in 2007 were the same as the top earners 10 years ago (Table 4). NPs employed in acute care settings headed the list: Emergency department NPs made an average of $95,157 last year; NPs in neonatal units earned $93,959; and nurse practitioners in other hospital and surgery settings grossed more than $86,000.

In contrast, NPs who earned the least in 2007 worked in educational settings: 12-month college health positions paid an average of $72,236; school NPs earned $71,512; and nurse practitioners who spent most of their time teaching made just $68,624 last year - 16% less than the average NP salary and 28% less than the average emergency department NP.

Fitzgerald chalks up the pay difference to high reimbursements for procedures: The highest paid NPs typically perform expensive procedures more often.

Ownership Aspirations
Right up there with acute care setting salaries are those being earned by NPs who have ventured out on their own. Although the top-earner rankings have shifted a bit over the decade, practice owners have consistently been among the top three. Last year, entrepreneurs brought home an average salary of $89,634.

The real story is that the ranks of practice owners are increasing - and quickly. Although their proportion might appear small (3% of survey respondents said they are owners) their percentage doubled between 2003 (1% of respondents) and 2005 (2%) and increased again by 50% over the past 2 years. And the lure of practice ownership continues to be enticing: In 2007, 11% of respondents said they intend to open their own health care-related practice in the next 5 years.

Suburbs were the most popular location for NP-owned practices (41%), and 12% were owned by men - even though men made up only 8% of all survey respondents. Most owners indicated that they had been nurse practitioners between 6 and 10 years (32%), followed by 3 to 5 years (23%). NPs with less than 2 years of experience in the role made up 6% of practice owners.

Family practices were the top choice for NPs who were owners (41%). Mental health practices came in second (15%).

We wondered at the popularity of mental health as a practice focus for NP owners, since only 4% of survey respondents overall said they practice in a psychiatric-mental health position. Terry Douglass is a pediatric nurse practitioner who owns a practice specializing in pediatric and adolescent mental health. The first explanation that comes to her mind is that mental health offices are easy to set up: They require no special equipment and can be staffed by an NP alone.

Aesthetics and skin care practices were also heavily represented among NP-owned practice settings, accounting for 3% of practices owned by nurse practitioners but only 0.5% of NP practice settings overall. High revenue possibilities for aesthetic procedures and zero reimbursement filings might account for the popularity of this practice choice.

Superspecialization
One important finding of the current survey is that NP subspecialties have proliferated, even since 2005. The 1997 survey included an employment setting category designated "specialty clinic or practice." Over the years, the setting choices have expanded in response to survey responses in previous years. By 2007, the choices included "cardiology clinic," "diabetes/endocrinology clinic," "HIV clinic" and "oncology clinic," among others.

Even with these focused answer choices, 24% of respondents listed "other" as their practice setting. These NPs almost always wrote in an even more specialized setting than the choices listed. For example, instead of choosing "pediatrics," one respondent wrote in "pediatric allergy and asthma clinic," another wrote "pediatric dermatology practice," another "pediatric neurology," and so on.

Fitzgerald says these responses reflect her own experience. At her lectures to NP audiences across the country, she finds that up to 60% of attendees practice in specialties or subspecialties. NP practice mirrors the larger move in U.S. health care away from treating populations (for example, family practice, pediatrics, adult care) to treating conditions (for example, asthma and allergy, cardiology, endocrinology), she explained.

Specialization can allow individual NPs to grow professionally and add to their knowledge, comments Tracy Klein, a family nurse practitioner who is the advanced practice consultant for the Oregon State Board of Nursing. But, she cautions, "NPs who are educated to practice only within a subspecialty will sooner or later run up against a regulatory or practice barrier that prohibits them from transferring and expanding their care."

Klein and Fitzgerald both predict that demand for subspecialty certification will increase among nurse practitioners and regulators. Klein believes that working without specialty credentialing keeps NPs under the thumb of physicians. "The inability to be autonomously credentialed under our own skill set with nursing-sensitive measures restricts us to supervision by other providers, generally MDs, as a proxy," she told ADVANCE.