Lower pay hampers nurse practitioner recruitment in primary care

Nurse practitioners are a key plank of government efforts to improve access to primary care.

However, a continuing gap in pay and benefits for nurse practitioners who choose to work in primary care compared to those who work in hospitals, limits recruitment and retention to community settings.

From a zippy online campaign to an economist-authored report, there’s been a groundswell of attention lately to the key role that nurse practitioners (NPs) can play in providing community-level health care.

NPs are registered nurses (RNs) with advanced university education. They can perform many of the same tasks as doctors currently perform, such as diagnosing illness and injury and ordering tests and procedures, and it is widely acknowledged that they can play a key role in helping patients to manage chronic diseases.

Just last month, major reports from two nursing organizations called for greater use of NPs in primary care : Primary Solutions for Primary Care, from the Registered Nurses Association of Ontario, and A Nursing Call to Action produced by an expert committee convened by the Canadian Nurses Association (CNA).

And earlier this year the Commission on the Reform of Ontario Public Services, chaired by economist Don Drummond, recommended that the government maximize opportunities to use NPs in all areas of the health care system in order to “increase efficiency while maintaining excellent care.”

Greater use of NPs in delivering health care services is expected to free up doctors to be able to focus on the more complicated patients who require their expertise.

“There’s been a lot of advocacy for what NPs are able to contribute to the system,” acknowledges Debra Bournes, Chief Nursing Officer for Ontario’s Ministry of Health and Long Term Care.

All this endorsement of NPs fits neatly into the Ontario government’s pledge for a “transformation” that will shift more health care into the community — a commitment articulated in the Excellent Care for All Act.

But there is a snag.

A roadblock to the plans to increase NPs’ presence in community care is the significant salary and benefits gap between the hospital (acute care) sector and the community (primary care) sector. And that gap contributes to NP jobs in primary care going unfilled. While nurse practitioners are not the only professionals where there is a pay gap between the hospital and community sector, this story focuses on the impact of this pay gap on recruiting NPs to work in the community sector.

Salary gap and unfilled community positions

“The government has made a commitment to move programs out of hospitals and into the community, but how are they going to do that without addressing the issue of wages and pensions?” asks Adrianna Tetley, executive director of the Association of Ontario Health Centres. The province hasn’t put forward any strategy to address these issues, she says.

NPs aren’t the only health professionals who are paid less in the community than in hospitals, but they are a key piece to the puzzle.

In late summer 2011, 19% of NP positions were vacant, according to a 2012 report co-authored by the Association of Ontario Health Centres , the Nurse Practitioners Association of Ontario and the Association of Family Health Teams. Comparable figures for NP vacancies in hospitals and public health units were not available.

That report,  Toward a Primary Care Recruitment and Retention Strategy for Ontario,which provided information on vacancies and salary disparity for nurse practitioners along with pharmacists, dieticians, registered nurses and social workers, noted that salaries for these professionals are 5-30% lower in primary care than in hospitals.

For example, the pay range for NPs who work in Family Health Teams delivering primary care was between about $78,000 to $89,000 a year in May 2010. However, key informants who spoke with suggested that NPs in the hospital and public health sector earn anywhere from about $10,000 to over $30,000 more a year in base salary.

“You don’t do this job to get rich, you do it to make a difference,” says Claudia Mariano, the president of the Nurse Practitioners Association of Ontario, a voluntary organization that represents about 1400 of the 2,072 NPs who are registered in Ontario.

“But the current situation has created a lot of disparity,” says Mariano, who’s been an NP for 13 years and a registered nurse (RN) for 25.

They can also join the Healthcare of Ontario Pension Plan, a defined benefit pension plan, while only small number of NPs who work in the community sector can access HOOPP and their access typically comes at the expense of other benefits.

Lack of access to HOOPP creates a “barrier to labour mobility”, states the Strategy report, as hospital- based NPs are reluctant to shift from the hospital to the community sector.

“I’ve been working all my life and never had a pension plan and we are all getting older, thinking about retirement. The last [salary] increase I saw was almost seven years ago,” says Mariano.

Mariano says that, as an NP, and in the current economic climate, she has some discomfort talking about money, but adds that the disparity with the acute care sector affects people’s access to care.

Ontario Family Health Teams that include a nurse practitioner are able to accept an additional 800 patients into the practice, according to the report, A Nursing Call to Action.

Before 2005, most NPs in Ontario worked in Community Health Centres. But more NP jobs opened up in 2005 when Family Health Teams were created and in 2007 when the province opened the first NP-led clinic in Sudbury (there are now 22 such clinics in Ontario). The largest proportion of NPs now work in community care (about 44%), while about 38% work in hospitals, with the balance in other health care settings, Bournes said.

Expanding scope of practice for NPs

Recent Ontario legislation has  expanded and clarified the NPs’ scope of practice — instead of waiting for medical directives from a doctor, NPs now have full access to diagnostic testing, can treat, transfer and discharge both in-patients and community out-patients from hospital and, as of this month, admit patients to hospital. Mariano said that this increased responsibility has not been accompanied by any increase in pay.

One of three key strategies in Ontario’s Action Plan for Health Care is to provide better access to primary care, home care and community care so patients can receive the care they need, in the most appropriate place and in a timely manner. Bournes noted that the provincial budget stated that the government is focused on enhancing community-based care to treat patients in alternative settings, like non-profit clinics and at home instead of hospitals, where appropriate.

To address the issue of the vacancy rate for NP positions in the community, the province introduced a Grow your Own NP program in 2006, so that organizations can use the salary allocated to the NP position to support an RN to return to university and upgrade to become an NP, Bournes said. She says that since the program started over 65 RNs have participated in the program, with a majority of positions being in the community.

To address the acute care/community care gap, the first priority of government should be to boost benefits package (from about 20% of salary to 23%) so that health professionals in the community have access to HOOPP pension plan, states the Strategy report from the community care organizations.

While there is a great deal of government efforts to improve access to primary care in the community, and to fund more NPs, the salary and benefits gap continues to be a significant barrier to having more NPs and other providers working in the community.

The comments section is closed.

  • Tara Gill says:

    Wake up, there’s something called inflation and their salaries aren’t keeping pace. I feel like NPs are undervalued. I also think sexism (majority of nurses are female) is going on which is a type of oppression. Which is another example of women not being paid as much as men. NPs need to stop being complacent when being discriminated against.

  • George Lake. says:

    Without N. P. our system of medical care would die, they need a substantial increase in salary, think of the years
    of studying plus the cost which takes years to pay off.

    N.P.take at least 80% of the workload of the doctor

  • Paula Stringer-Hussey says:

    Primary health care NPs should get an increase. When I look on the sunshine list, it makes me sick when I see hospital RN making $124,000 and top wage of a hospital NP at $118,000. Top wages int he community range from $80,000 to $103,000. I agree that they may work nights, weekends and pick up overtime but a NP is responsible for a lot more than a RN when you factor in diagnosing, treating, reviewing and interpreting lab work. If the government wants NPs to flourish and improve Health Care in Canadian communities, equality throughout organizations need to be addressed. A hospital NP (who makes an average of 103-106K) does not do any more or less work than a Family practice NP nor are they responsible for more or less acuity in patient care. If payment were to be different then it should be stipulated that it is based on your certification as a family NP, acute care NP, anesthesiologist NP, pediatric NP, etc. It should not be organization based.

  • RN K says:

    I am an RN with 6 years of ICU experience and struggling with the decision to complete the Primary Nurse Practitioner Program. From what I can conclude based on the discussions, NPs in primary care are underpaid and over-worked, with less benifits and pension plans. Although I am motivated and passionate about increasing my skills and education, it just does not seem to make any sense to invest time and money into this avenue. Money is not the motivating fator, but is it not fair to expect a return for all that it takes to become an NP? As an RN, I am currently making the same amount as an NP with less liability, and a better pension plan and benifits. There trade off is simply ridiculous.

    • C says:

      Hi RN K, so have you made a decision? I am a RN with similar experience to you. I also have my MN and am considering going back to do my NP. Given the discrepancy in salary and benefits, I am not sure if it will be the right decision…

  • Donna C says:

    Equal pay for work of equal value.
    When an NP treats diabetes or a sore throat they do it using the exact same recommendations and practices used by physicians.
    Same work, same value = same pay.
    It’s the law.

  • HB says:

    It is time that wage freezes and in equal salaries for all health professionals in Family Health Teams and NP Led Clinics become the same as hospital employees. The difficulty I guess is with all the different professions there is not one union to represent them, the same way teachers seem to be. They are squeeky wheels and seem to get the oil. Hospital employees seem to benefit due to OPSEU and ONA…and the community is being left behind. I do not think the general public realizes the discrepancy. Most health professionals in the community are there for the passion they hold for their jobs and belief that the work should be in the community definitely not to get rich!!!! It is time however for pay equity. Complexity of care in the community is growing. Community health care professionals are not looking after simple cases!!

  • Linda Hill says:

    As an acute care nurse practitioner for years, I am now moving on into primary care. My personal thought is that primary care nurse practitioners have so much more independent autonomy and work much harder than acute care nurse practitioners. Therefore the disparity in salary should be the other way around!!

  • michelle callan says:

    As a Primary health Care Nurse Practitioner my role and responsibility in the community is far greater than it ever was in the hospital yet my salary is very poor to the point that I must realize as a professional that I must leave and return to the hospital. It doesn’t make sense I will have less reponsibility and better benefits, so why would any professional tolerate such conditions. Our CEO certainly received a very hefty raise where we have had nothing over the last 5 years…

    • Linda says:

      Hi Michelle,
      If you see my comment below, I am in agreement. I want to try being a NP in the community.Luckily the manager of my clinic is open to negotiating my salary and benefits. It is crazy how NP’s in the community have so much more responsibility and work so much harder and yet are renumerated so much less. And all the professionals I had at my beck and call while working in hospital compared to community is something I also miss. Good luck going back to acute care. I thrive on autonomy, so wish me luck. Thank God I have the option of going back!

  • Paul says:

    I am a physician.
    I work with 6 NP’s
    They perform an awesome service to a population in need, but they have limitations to both their training and experience (little hospitalized inpatient management exposure for most NPs)
    The salary issue is very difficult because NP’s compare themselves to RN’s, but if you extend that comparison to MD’s. That’s when it gets dicey.
    The NP’s I work with have about 2000-2500 visits per year. When a physician working fee for service sees this number of patients in their office, they make about (2000-2500) X (avg) $40 a visit. This means a physician seeing the same number of patients would make 80,000-100,000. From the governments perspective, it’s hard to understand why you should pay someone more for similar (but not identical) work. The optics are even worse when you take into account that NPs overhead is covered by the government, but over 90% of physicians pay their own overhead and don’t have any benefits.
    Maybe the problem is that RNs are overpaid or that Family Physicians are underpaid. Looking at the whole picture sometimes brings up more issues then first though.

  • Name (required) says:

    how will you feel if some one expect you to replace a co worker and pay you 1/4 of his salary

  • Raj says:

    Primary Care NP’s should have a starting salary of at least 100k. RN’s are making close to 80k, the NP is advancing his/her knowledge extensively and should be provided with a salary that reflects this.

    PLEASE increase the starting salary to 100k!

  • Dr. H. Jass says:

    Lower pay hampers medical student recruitment in primary care as well. Ain’t that a funny coincidence…

  • Amelia says:

    Nurse Practitioners are just as able as Physicians and Doctor’s to deal with patients, they go through almost as many years as just a general doctor would, and deal with patients as any Doctor or Physician would. The job was created so that the Physicians and Doctor’s wouldn’t have to deal with patients that need regular check ups, and waste their time with non-severe cases. None-the-less to help out the community in many ways by allowing the Doctor’s and Physician’s to focus on the more severe cases, but this may just save a few extra lives having all of these positions. Nurse Practitioners have gone through Nursing, have started from the bottom of wiping bums, to getting a master’s degree, and then a doctorate in the Practice of Nursing. Therefore, helping out the community in many ways, mainly doing the job of a Doctor or Physician, I believe that I can’t see any reason why Nurse Practitioners shouldn’t have a huge increase in salary. They are the new generations future in medical care. Support the health of the future children and people of Canada, let us unite as one and give the Nurse Practitioners what they deserve wage wise. I am an adult, going into University, I am not anyone special, that is just my opinion on it. Thank you.

  • Name (required) says:

    I am an NP in an NP-led clinic – frankly – I’m doing as good if not a better job than most GPs in my community — they make $300, 000, – I make $89,000 – they have the pay problem – not me -but I went to university for seven years and as an RN made more than this . For the work load, risk, liabilty, and debt I’ve taken on, I feel I should be making at least $125,000. In saying this – my work is my choice and health care sustainability comes first.

  • mattcutt says:

    I have a huge amount of respect for their dedication and knowledge. Our roles are complimentary and collaborative and working together, our patients get superb care in a timely fashion. My physician colleague earns every bit of the 250,000$ he makes annually in salary but given that I carry at least 80% of the caseload and 80% of the level of responsibility for care of our patients, many of whom are very complex and in some cases quite ill, it is a bit unfair I believe that I should make only 30% of his salary.

  • Name (required) says:

    RN make more money than NP at the top of their salary. Everyone should make the same amount of monies. it will help with retention in the rural community.

  • A concerned person says:

    Why is it ok to supply smaller communities with substandard nurse practitioner care vs true physician care? The discussion should be about how to recruit doctors to smaller communities, not nurse practitioners.

    • Robert Fraser MN RN says:

      I’d be curious to know what you mean by “substandard” there has been little to no evidence that NP care is of less quality or safety. In fact, there is a growing body of evidence to the improvement of quality of care, increased visits, and higher self-efficacy of patients through NP primary and community care.

      My perspective that no access to primary care and follow up in the home and community is substandard. That is what I find to be unacceptable, and something that our healthcare system and communities (whether large or small) needs to address.

      %featured%If it can safely be done by a professional that is regulated and we know to be safe we need to consider it, regardless of historical norms. The scope and practice of all healthcare and health related professionals is changing and needs to continue to evolve. We need to focus on patient/family/care-giver needs and outcomes not the needs of professionals and their payment/treatment/scope preference.%featured%

      • the same concerned person says:

        By substandard I mean not trained in medicine but in nursing.

        It is a very big double standard to expose rural people to nurse practitioners when the same thing wouldn’t fly in the big city, or with wealthy powerful people, etc.

        I want you to link the growing body of evidence you are referring to. I want to see for myself because I am unconvinced.

        Primary care follow-up is substandard in the community because we undervalue our primary care physicians. My community is a revolving door because there are no incentives to keep them. We just keep trying to snare foreign doctors who do their time and then go to Toronto.

        As a patient I want a doctor not a nurse.

      • Ash says:

        As a nurse practitioner, or even an experienced (experience being about 5 yrs in nursing), I can tell you that I DEFINITELY have more hands on experience that a new doctor. We also tend to spend more time with patients when in the hospital setting.
        This is in no way meant to be disrespectful to the physicians who I am aware work very hard, and make many sacrifices. It is merely meant to ensure that the patriarchal stereotypes that existed remain exactly where they belong… in the past.
        Unless you have an understanding of RNs and Nurse Practitioners that has as much depth and breadth as the education we take ourselves, remain unbiased pleased! Or, if you are unconvinced, research the amount of clinical time an RN must spend before even becoming an NP. And the clinical patient time an RN spends before even being able to apply to the NP program is all gained as a LICENSED nurse. That means a LIABLE nurse! How many mere hours has random new physician you trust been licensed?
        I again, mean no disrespect to physicians… I am truthfully in the middle of applying for med school. But it is difficult to read this and not see it as not much more than an incredibly old school perspective not backed by medical knowledge. I recently moved from a very small, underserviced town, where I worked as an RN, to Toronto. NP clinics are valued here just as much as there. Perhaps doing some research and then giving an NP a good chance would go a long way.
        Nurse A

      • Vera says:

        In Toronto people may value you much as they would a naturopath, but they know they can easily go for a second opinion to a fully trained doctor at any point in time. If it was such a great option than 100% of people should be using a NP for primary care and we could phase out GPs altogether. They stick them in native communities and underserviced areas and then rationalize that it’s great care when it is not. I suggest if you want to be a doctor than go to medical school. It’s much the same as them now using saying doing housekeeping and such for home care is medical care.

      • T.Wash says:

        You will find just a few examples of the growing body of evidence showing care by NPs resulting in equivalent or improved care and greater patient satisfaction when compared to care by physicians. I understand the desire for direct physician care and I certainly can’t fault anyone for traditional thinking in this regard, but I hope this does shed some light on the great care offered by an ultimately misused body of health care practitioners.

        Horrocks, S., E. Anderson and C. Salisbury. 2002. “Systematic Review of Whether Nurse Practitioners Working in Primary Care Can Provide Equivalent Care to Doctors.” British Medical Journal 324(7341): 819–23.

        Fulton, J. S. and K. Baldwin. 2004. “An Annotated Bibliography Reflecting CNS Practice and Outcomes.” Clinical Nurse Specialist 18(1): 21–39.

        DiCenso, A., D. Bryant-Lukosius, I. Bourgeault, R. Martin-Misener, F. Donald, J. Abelson, S. Kaasalainen, K. Kilpatrick, S. Kioke, N. Carter and P. Harbman. 2010b. Clinical Nurse Specialists and Nurse Practitioners in Canada: A Decision Support Synthesis. December 31, 2010. .

        Russell, G., S. Dabrouge, W. Hogg, R. Geneau, L. Muldoon and M. Tuna. 2009. “Managing Chronic Disease in Ontario Primary Care: The Impact of Organizational Factors.” Annals of Family Medicine 7(4): 309–18.

        Krichbaum, K. 2007. “GAPN Postacute Care Coordination Improves Hip Fracture Outcomes.” Western Journal of Nursing Research 29(5): 523–44.

        Dawes, H.A., T. Docherty, I. Traynor, D.H. Gilmore, A.G. Jardine and R. Knill-Jones. 2007. “Specialist Nurse Supported Discharge in Gynaecology: A Randomised Comparison and Economic Evaluation.” European Journal of Obstetrics Gynecology and Reproductive Biology 130(2): 262–270.

  • Peter goat says:

    It’s disgusting that with my level of university education, I am payed less than the average opp officer or even some ttc drivers ( neither of which require advanced university education or any at all). Canada needs to catch up with the USA, where I would easily be earning three times what I make here ( and where ther aforementioned be making three times less- and deservedly so).

  • Kate says:

    There is a clear and palpable inequity of salary when comparing community NP salary with that of hospital based NPs. As a hospital based NP I am surprised that this does not deter even more nurses from taking on the community role. Community based NPs work just as long and hard as their hospital colleagues do. However, rather than ask the MOH to reimburse more robustly through the current mechanisms, I would suggest that first the current Ontario funding models be revised and realigned. The current mess of a model for funding health care providers in Ontario today has lead to exorbitant health care costs, inefficient systems and is causing animosity between the various providers.
    Perhaps an overhaul would facilitate a funding model that reimburses everyone in a fair and equitable manner and at the same time improves the care Ontario patients receive.

  • Leea Puntanen says:

    Before expanding our scope, renumeration should have been considered. More responsibility = more pay. It’s a no brainer!

  • John G. Abbott says:

    The apparent lack of transparency of information on salaries, benefits, vacanices, etc. between hospital-based NPs and those in the community as well as their relationship to community-based physicians, primary health care teams, etc. speaks to a need for a national observatory on HHR – where all HHR data (all health professionals) is kept, analyzed and reported publicly to help answer some of the questions raised by this article and those who responded.

  • renalcolic says:

    I thank Dr. Kiran for her support for NP’ s in primary care. I think that while total numbers are important, numbers alone do not tell the whole story with respect to quality of care, workload, impact on patient health, and value for money. Effectively measuring this is a much more complex equation. For example, is seeing 30 -40 patients a day for 5-15 minutes evidence of good care? It might be but if one is seeing the complex co-morbid patients we see today in primary care I doubt it . I could see 50 patients a day but if they all come back in a week or half of them end up in ER or a walk-in clinic then have \i added value to the system? Is waiting a month to see a primary care practitioner OK as long as the practice roster is at maximum? Does the private psychiatrist who sees 10-15 patients a day provide less impact than the family doctor who sees 30-40 per day? Good indicators are needed and one needs to define exactly what is being measured. Large roster numbers say nothing about quality of care and health outcomes or wider system impacts. By the way Dr. Kiran, evidence regarding what my physician collegue makes per year is available on the most recently published sunshine list if you care to research it under CHC’s you’ll see that in fact plenty of full-time CHC MD’s are making $250,000 in salary. (FHT MD’s, even though paid by the public purse are not even required to publish to the sunshine list but, having worked in one previously I can tell you some of my family MD colleagues were grossing that and then some plus all the deductions and write offs that come with being a professional corporation…not the usual tax bracket!) I should add, that CHC salary is with no overhead, no staff costs, full benefits and pension, education leave, paid vacation 4-6 weeks annually, sick time , disability pension. I should also add that my family physician colleague does no on-call, gets all stat holidays off, all weekends off, and gets every Monday off. He works until 7:30 pm on Wednesdays but does’t come in until 11:00 pm Thursdays. I’m not bitter , in fact I happy that my colleague is fairly paid for the responsibility he shoulders and his years of hard study and training. By the way, I see 10-15 patients daily for acute minor illness, chronic disease management, follow-ups, preventative care, prenatal well baby care etc. In a CHC most of our patients are complex, elderly, mental health, and patients who have been cast off by Fee for Service practices and FHT’s. My family physician colleague sees our CHC patients with more severe illness, difficult diagnosis, and higher acuity. How many? 10-15 patients a day also! Our clinic RN sees patients for vaccines, BP checks, med reviews, wound care, well baby care, case management, intakes of new patients, and triage. She sees 15-25 patients most days and makes 20-30 patient phone calls per day on top of that. So yes, I agree, bring on the studies, as long as they measure what matters.

  • Tara Kiran says:

    Expanding the role of NPs is an important strategy in primary care reform. However, as far as I know, there is currently limited data on NP workload and roster size in Ontario – for either FHTs or CHCs. This makes it hard to evaluate how much NPs contribute to increased primary care capacity and at what cost.

    The article states that “Ontario Family Health Teams that include a nurse practitioner are able to accept an additional 800 patients into the practice”. My understanding is that FHTs who are given funds to hire an NP are expected to roster an additional 800 patients but anecdotal evidence suggests that many FHTs have found this to be an unrealistic target.
    One of the commentators suggests that NPs carry about 80% of the workload of a family physician. I have worked with a number of very talented NPs in both the CHC and FHT setting and I don’t think any maintained a roster size that was 80% of my own. (as an aside, I think top of range for a CHC MD in an urban setting is closer to ~$200K not $250K)

    Ultimately, we need provincial data on average NP roster size and workload in primary care in order to fairly judge capacity and efficiency and engage in rational primary care planning.

    • Courtney says:

      It might be difficult to find that data since NPs aren’t able to roster patients in Ontario.

  • Claudia Mariano says:

    NPs in both community and hospital sectors work regular, though generally longer, hours (i.e., no shifts). The inequity in the compensation between these sectors is the result of a difference in funding from the Ministry of Health, with hospitals receiving more funding for salary and benefits. While we have no hard evidence regarding the vacancy rates for hospital-based NP positions, anecdotal evidence from NPs suggests it is significantly less than the 20% vacancy rate which exists in the community sector.

    In all settings, NPs work collaboratively with teams of health professionals to ensure access to high quality, efficient, health care. The use of the best current evidence is the foundation for NP practice, and enhances collaborative practice with other health professionals.

    Claudia Mariano

  • renalcolic says:

    I love being an NP in a community health centre and I am very impressed that the Ontario Liberal government has been so progressive minded in expanding the roles of a variety of health professionals. There are some fabulous initiatives in place and being developed by Ontario with the goal of improving care for Ontarians and at the same time controlling exponentially rising costs. My goal has never been to replace my family physician colleages with whom I work closely. I have a huge amount of respect for their dedication and knowledge. Our roles are complimentary and collaborative and working together, our patients get superb care in a timely fashion. My physician colleague earns every bit of the 250,000$ he makes annually in salary but given that I carry at least 80% of the caseload and 80% of the level of responsibility for care of our patients, many of whom are very complex and in some cases quite ill, it is a bit unfair I believe that I should make only 30% of his salary. I would not expect to make his wage but my training and expertise is also extensive and from a pay equity perspective I think that the Ontario government needs to look at this issue more fairly. I think that based on equivalent levels of responsibility and required training for positions within the MOH and Ontario government that primary care NP’s should be making at least 120,000$ annually. As Claudio states, nobody is going to get rich being a nurse practitioner but, I would say that relative to what we pay physicians and other highly skilled, high level responsibility professionals, NP’s should be better paid and if we want to attract the best people to the profession there needs to be fair compensation.

  • Don Taylor says:

    This article flags an important issue for discussion, and that is good.

    I agree, NPs are an essential part of delivery of health care and we need more of them, for a host of reasons.

    However, without some additional information, it is hard to tell the size and importance of the apparent pay gap. For example, what is the NP vacancy rate in hospitals, and how do NP retention rates compare between the community and the hospitals? If vacancies are around 19% and/or retention rates are similar for both, then a pay gap, while an issue, likely is not the primary explanation.

    Yes, other things being equal, more skilled and better performing individuals in a particular profession should earn more. But other things often are not equal. For example, are working conditions, commute time, case variety and bureaucracy in the community comparable to hospitals, where 12 hour and rotating shifts are common. If not, then somewhat lower pay might be a reasonable trade-off for regular hours, less bureaucracy, more variety and shorter commute time. Do the skills, experience and performance of community NPs differ, on average, from Hospital NPs? if so, then one would expect the compensation to differ. And when we speak of a pay gap, are talking only about salary, or are we taking all compensation into account (salary, benefits – including pensions/ vacation/short and long term sick leave, overtime provisions, hours of work, etc.?

    Another issue is to what extent there is an imbalance the supply of and need for NPs between the hospital sector and whether labour market dynamics will over a reasonable time period create a more healthy balance. To this point, I wonder why the Ontario Association of Health Centres isn’t developing and implementing its own solutions to this issue, rather than looking to government. One of the attractive features of community health centres is the flexibility to design/package its services and operations to meet the needs of the local community. I’d be concerned that a government solution would reduce this flexibility and increase the bureaucratic overhead.

    Finally, anecdotal evidence, such as the NP who hasn’t had a raise in several years, suggests a troubling inequity. However, evidence-based decision making requires more than that.

    • Leah says:

      The main issue that wasn’t mentioned in the article is the top RN salary is about 80, 000 a year, and the starting NP salary is 74, 000 a year with a top of 89, 000 a year (in the community). The NP is responsible for assessing, diagnosing, and treating patients, a much greater responsibility than any RN job. In addition, the NP not only has an undergrad degree, most have a masters degree, and of course the one year NP certificate. Also important to note, since expanding the scope to open prescribing of medications and access to diagnostic tests, NPs did NOT get a raise to reflect this significant increase in responsibility. OVERALL NPs are under paid, community AND hospital. If you are interested, there is a document comparing work load/responsibility etc of NP, RN, pharmacist, and family physician. It outlines the issue clearly. And yes I agree with your above statement that NP’s in the acute setting who do 12 hour rotating shifts should make more than those who work week days Mon-fri.


Ann Silversides


Ann is a journalist and specializes in health policy, writing and editing for a variety of health research institutes, associations and labour unions.

Andreas Laupacis

Editor-in-chief Emeritus

Andreas founded Healthy Debate in 2011. He is currently the editor-in-chief of the Canadian Medical Association Journal (CMAJ)

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