Despite the flourishing of the two professions on many fronts, dwindling access to jobs was a dirty little secret in 2010. According to an informal poll on advanceweb.com/NPPA, about half of respondents reported having a tough time in 2010 and predicted that it will continue to be difficult to find a great job. Much of the job troubles stem from healthcare organizations and hospitals looking to better control their budgets, says Renee Dahring, MSN, NP, a nurse practitioner and career coach who worked in the recruitment industry for several years. (Read her Career Coach blog at www.advanceweb.com/NPPA.)

"There was a lot of uncertainty in the whole economy and that trickled down into healthcare - hospital and healthcare programs collections were down and that led to trimming some of the staff from their budgets as well," Dahring says. This was compounded by a return to the workforce of NPs and PAs who had been retired or whose financial situation had changed. "That's going to squeeze out some of the new graduates who we saw having a tougher time."

New graduates across every industry have been hit hard by the Great Recession. The National Association of Colleges and Educators reported that new graduate hires in 2010 were down 20% from 2008. And the national unemployment rate hovered in the 9% range for all of 2010.

Temporary Positions: Here to Stay

As healthcare organizations look for ways to save money, they take on fewer new permanent employees - but that doesn't mean they're not hiring. Many organizations turned to offering temporary - locum tenens - jobs to NPs and PAs last year. Sometimes those temporary jobs turned permanent: "There was an element of 'try before you buy' for employers wanting to be really sure before they hire someone," Dahring says. (Read more about locum tenens in Dahring's Career & Workforce column in this issue.)

Locum tenens is a much better deal than one might think; it can be a great opportunity for employees to gauge their own fit in an organization. "I've done them myself, and I don't think I would ever take a job again without the opportunity to try it out," Dahring says. PAs have traditionally embraced the locum tenens concept more readily than NPs, she says, but it's becoming more popular for both professions. It's a traditional option for many RNs and physicians, and it will continue to be. She predicts this will be especially true for physicians, who will feel the sting of continuing cuts in Medicare reimbursement and unmanageable malpractice insurance costs. "Their salaries are dependent on the revenue that the clinic or the hospital is generating. Rather than face that uncertainty, they can go work on a temporary assignment or locum tenens assignment, and their salary is guaranteed regardless," Dahring says. "Many are finding that more attractive right now."

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A Provider Shift

When physicians migrate out of a setting, it opens up a big field for NPs and PAs. Dahring says this is becoming a noticeable trend in hospital hiring, and she's seen it in local hospitals in the Twin Cities area of Minnesota, where she lives: "They're just going through the budget and expecting a decrease in reimbursement and realizing that you get a little more bang for the buck with an NP or PA." So, even a hospital or practice that's trimming its budget might be more likely to hire an NP or PA for a permanent position because of the cost difference.

While the overall U.S. unemployment rate may still be high, the Bureau of Labor Statistics reports that healthcare added 19,000 jobs in November 2010 - most of them in hospitals. Based on the trends Dahring sees, this could easily mean a higher percentage of NPs and PAs employed in hospitals in 2011.

Ann Bures, RN, a nurse recruiter for the University of Maryland Medical Center in Baltimore, says the job outlook for NPs and PAs this year is good. NPs today are working in most areas of the hospital - even in surgical areas, where NPs traditionally are somewhat scarce. PAs are popular in surgical positions and the medical center's physician-run practices. "I certainly see increases in requests for positions to add to various practices within the medical center," Bures says.

But with the good comes the bad. Dahring says NPs and PAs have been accepting salaries that are a little lower than they had been in recent years. Based on information she obtained through her networking and experiences, the recession appears to have caused salaries to decrease by up to $10,000 a year. She compares this drop to the decline in the U.S. housing market.

"It had to burst at some point, and now more people are willing to take a little bit less salary in exchange for the security. People don't want to admit they're taking less, but the truth is people want to pay their mortgage," she says.

"It's still not a bad salary by any means - a lot of people would be darn happy to have that salary - but much like everything, it is sort of leveling off and even pulling back a little because it was sort of overheated," she says.

Another trend Dahring has noticed is that NPs who haven't found work as nurse practitioners go back to work as registered nurses, then take NP jobs with that organization when they become available. "The truth is . the top salary for RNs is close to the beginning NP salary."

Dahring cautions against overemphasizing that NPs and PAs can "do the same thing for less," because that doesn't convey their full value and can fuel critics' claims that the care they provide is "cheap."

"We have to manage our message or someone's going to manage it for us," she says.

What's Hot?

As 2011 begins, family practice appears to be the most secure work setting, Dahring says. So for nurse practitioners, having the family practice certification can be a lifesaver. Employers are looking to hire providers with a broader educational background. "PAs are ahead of the curve because they don't specialize like NPs," she notes. NPs with single specialty certifications in areas like women's health and pediatrics have had a harder time finding positions.

"But NPs sometimes close their mind to specialties" when good opportunities exist, Dahring says. For example, specialties such as endocrinology don't require a specific certification. NPs or PAs can work into specialties with fellowships or with mentoring on the job. Employers are seeking NPs and PAs equally in specialties now, Dahring adds.

Advice for Job Seekers

Perhaps the best advice for this year is that it's time to be flexible and open to a broad range of opportunities. New graduates should focus their search on something they are passionate about. Everyone looking for an NP or PA job should hone their resume and be willing to adjust their expectations about pay and benefits. Don't dash your dreams for the perfect position, but don't leave your blinders on, either.

"Consider part-time jobs that could turn into full-time," Dahring says. "Just be open to what's out there. It goes in cycles. Next thing you know, they'll be hiring new grads all over the place."

Although it's likely to be a real boon for NPs and PAs in the long run, the Patient Protection and Affordable Care Act has made employers skittish. "There is uncertainty around healthcare reform, and the thing about uncertainty is that it's destabilizing," Dahring says. Healthcare organizations are planning for the worst, and they may be conservative in hiring in the near future, without altogether freezing their hiring.

"With healthcare reform, regardless of how it is revised over the next few years, what seems clear is a focus on primary care and, therefore, the need for additional primary care health providers," says Ann LaCamera, RN, MSN, a certified healthcare recruiter.

"This will undoubtedly mean a trend to increased hiring of both nurse practitioners and physician assistants in these settings," LaCamera predicts. "Additionally, with the changes to the maximum hours physician residents can work over a specified period of time, this same group of practitioners will be in a position to fill that gap in hours in acute care settings, creating more employment opportunities."

"Focus your search and don't give up," Dahring advises. Every provider is a piece of the healthcare puzzle. "Be persistent."