Difference in training

While all three groups are nationally certified and provide quality patient care, their training differs. PA programs require some college education and health care experience. There are 144 accredited PA programs in the United States, with a course of study lasting about 26 months. Graduates sit for an exam administered by the National Commission of Certification of Physician Assistants.

On passing, the PA is certified to practice and becomes a PA-C. To ensure the educational quality of PAs, they must complete 100 hours of continuing education every two years and are expected to recertified  via national exam for the PA-C designation every six years.


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Advanced study for a master’s degree is offered at more than 40 programs, post-graduate study has not been the norm. This previously had not been a requirement, as the PA profession was modeled on the Vietnam medic platform. All programs are now encouraged to award a master’s degree.

Traditionally, registered nurses (RNs) with a BA degree were accepted into a master’s program to become NPs or CNS’s. Today, however, many programs offer the opportunity to complete course work leading to taking the RN licensing exam and then transition directly into the NP master’s program. 

To certify as an NP, graduates take a national certification exam either through the American Academy of Nurse Practitioners or the American Nurses Credentialing Center.  Scope of practice is determined by the state Board of Nursing.  Some states allow for independent practice but the majority require a collaborating physician.

In 2025, all NPs will complete their education with a Doctorate of Nursing Practice (DrNP or DNP) with the goal of producing clinically expert teachers, practitioners, and leaders. This program, which had its beginnings at Columbia University in New York, is available to all advanced practice nurses (NPs, certified registered nurse anesthetists, certified nurse midwives and CNSs). The DNP program is more clinically based  than  the PhD or EdD degrees which have research as a primary focus.

Like the NP, the CNS is a nurse with a master’s degree. Their practices are also governed by the state Board of Nursing. CNS’s are frequently hospital based. Three domains provide a framework for the CNS scope of practice:  patient/family, nursing systems, and organization systems.

The needs of complex, challenging patients are addressed in the first domain. The CNS uses his or her clinical expertise in combination with evidenced based practice to meet these needs.

Direct patient care staff members look to the CNS as a mentor and coach for the second domain.  For the third domain or sphere, the CNS is seen as a project leader and innovator for organizational continuous improvement projects.

Common to all their activities are the primary goals of improved patient care, nursing practice and outcomes.

In their practice, NPs and PAs routinely perform physical assessments, take histories, evaluate test results, diagnose, prescribe and evaluate effectiveness of treatments and interventions.  The scope of practice and training dictates procedures they perform.

The American Academy of Physician Assistants (AAPA) is the national organization for PAs. The American Association of Nephrology Physician Assistants (AANPA) is a subspecialty group in this organization.

There are a number of organizations for the NP.  Those specifically for nephrology include American Nephrology Nurses’ Association (ANNA) and National Kidney Foundation (NKF.

As use of nephrology PAs has increased, so have the educational opportunities.  RPA offers an annual two-day AP educational forum. For the past five years, National Kidney Foundation (NKF) Nephrology 201 has been a regular pre-conference course at the NKF Spring Clinical Meetings. In addition, there is an advanced practice track for attendees. Likewise, AAPA offers nephrology specific topics at their annual meeting. ANNA also includes NP specific lectures at their annual meeting and fall meeting.

While all three nephrology groups (PAs, NPs, and CNS’s) have their own organizations, there was no common meeting ground for them to share their expertise.

In September, 2008, NKF officially formed the Council of APs (NKF/CAP) to meet the unique needs of these providers. The council is dedicated to advancing the profession and improving the lives of patients and families. In less than one year, membership has grown to more than 200 professionals.