Choosing an NP Specialization or Sub-specialty: Your Options & The Selection Process
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One of the great benefits of being a nurse practitioner is that an NP can transition into various specialties. Some specialties require certification such as being a psychiatric-mental health NP, or a family practice NP. There are sub-specialties such as practicing in cardiology or infectious disease. Most of the time, physicians in these specialties are looking for an advanced care provider that they can train for this role.
Each specialty and sub-specialty has its own advantages and disadvantages. NPs with a background in a certain specialty as an RN can easily transition into the same or similar specialty as an NP. The NP salary and patient volume vary per specialty.
When choosing an NP specialty or sub-specialty, the NP should consider their past experiences as a nurse, and if they want to continue working in a similar specialty or try something different. They should contemplate if they would like to prioritize pay, work-life balance, or job satisfaction. They should also examine if they are looking for a field to be comfortable in or one that will challenge them.
Main NP Specialties
Prior to starting NP school, an NP student would need to choose their specialty. This is because each NP program is focused on a specific specialty. So the student would have to apply, for example, to the family nurse practitioner program or the acute care nurse practitioner program. After completing NP school, the student will then take a board exam to obtain national certification in their NP specialty before practicing. The following are the main NP specialties in which an NP can become certified and the type of NP that should pursue each specialty.
Family Practice
A family nurse practitioner (FNP) is competent in seeing patients across the lifespan from newborn to geriatrics. They see patients typically in a primary care outpatient setting. They oversee all aspects of a patient’s medical care, such as referrals and post-hospitalizations.
Working as an FNP is enjoyable for NPs who want to work with various illnesses and age groups. An FNP constantly learns and does not have the mundaneness of seeing the same type of patient every day. At the same time, working in primary care can be challenging because the patient volume is high and FNPs are at greater risk of burnout. Being an FNP enables an NP to sub-specialize in other careers such as occupational health and rheumatology.
Adult-Gerontology
Adult-gerontology nurse practitioners (AGNPs) only work with adults and geriatric patients. They can practice in outpatient settings, acute care, and long-term care. They are needed in private practices, hospitals, and nursing homes.
This is a good specialty for NPs who are interested in working with complex patients and being experts in needs related to aging. A drawback is that AGNPs are not frequently hired to work in urgent care or family practice clinics since they cannot see pediatrics. AGNPs can practice in Medicare Advantage Plan clinics that enable primary care providers to be accountable for the overall health of their geriatric patients. This type of healthcare setting can be rewarding because the NP sees the same patients frequently and can grasp their complex health, while also developing strong relationships with them.
Acute Care (Hospitalist, ER)
An acute care nurse practitioner practices in acute care settings such as hospitals and emergency rooms. They can work as hospitalists and oversee patient admissions. This is ideal for NPs who like working in fast-paced environments.
Hospitalists are compensated well, and acute care NPs can have a schedule where they work seven days on and seven days off. This can be beneficial to NPs who like to have staggered days off to travel. Unfortunately, acute care NPs are unable to practice in the outpatient setting.
Pediatrics
A pediatric nurse practitioner (PNP) works with children of all ages usually in private practice or community health centers. NPs in this specialty are unable to serve or treat adults. Many PNPs find their work rewarding as they manage the care of children from birth to 18 years old and develop relationships with the entire family.
NPs with pediatric experience as an RN will thrive in this specialty. It is also good for NPs who only want to see children and do not want to treat adults. PNPs are one of the lowest-paid specialties, and the patient volume can be high, at times, seeing 40 patients in an eight-hour shift.
Psychiatric-mental Health
Nurse practitioners who work in mental health care are called psychiatric-mental health NPs (PMHNPs). They work in private mental health practices, schools, community health centers, and via telemedicine. Depending on the state, they can fully diagnose and prescribe medications to treat psychiatric disorders.
PMHNPs are one of the highest-paid specialties and are in high demand. They also have the option to work remotely considering the nature of their work. Depending on the practice, PMHNPs can sometimes be pressured into frequently prescribing controlled substances that they are not comfortable with, such as Adderall and Xanax. Some NPs have stated this made them feel like they were “pill pushers.”
Women’s Health
Nurse practitioners who specialize in women’s health provide reproductive and sexual health services, along with gynecological care. They may work in private OB/GYN offices, fertility clinics, and community medical centers.
NPs who are empowered to help other women enjoy practicing as a women’s health NP (WHNP). The pay for WHNPs is usually low and there are not as many job options as FNPs.
Neonatal
Neonatal nurse practitioners (NNPs) manage patients who are infants up to two years of age. These patients are usually born prematurely or have an illness or birth defect. NNPs work in neonatal ICUs in the hospital setting. Although not required, NPs with a background in the neonatal ICU as an RN will do well in this field.
NNPs have a lot of flexibility with their schedule. They often work 12-hour shifts and can schedule themselves so that they have an entire week or two off in between. After a while, working in this specialty can take a toll on an NP’s emotional health. This is due to witnessing infants pass away or babies suffering through their illness.
NP Sub-specialties
After obtaining an NP specialty certification, the NP can then choose to work in a sub-specialty. Sub-specialties may not require additional certifications but may be available. Generally, the NP can merely be trained by the specialty physician who hires them.
Sub-specialties may also be pursued through an NP fellowship at certain academic hospitals. Below are 20 NP sub-specialties and the advantages and disadvantages of working in each. When choosing an NP sub-specialty, the NP can consider their interest in the subject and outweigh the risks and benefits of each field. When interviewing for the position, they should also evaluate the physician’s aptitude to train them.
Occupational Health
In occupational health, NPs are treating patients with workplace injuries, such as back injuries or lacerations. They may also do the initial work required for physicals. Some facilities offer employee health services, where the NP would see employees for acute visits such as cold symptoms.
Occupational health can be a great sub-specialty because the pay tends to be high and the patient volume tends to be low. A challenge working in this setting is that a third party is interfering with the patient’s care: the employer. So, if a patient has a back injury and the NP wants to give them time off to rest, the employer may suggest having the patient return to work at a desk job instead.
Cardiology
Cardiology NPs provide care for patients with both acute and chronic heart disease. They work in private practice and hospitals. They work alongside cardiologists to oversee stress tests and heart monitoring procedures. NPs who have a background working in cardiology as RNs do well in this field.
One benefit of working in this sector is that the NP is given ample time to complete each visit. The FNP would envy the amount of time cardiology NPs have with their patients. On the other hand, the work environment can sometimes be considered toxic, especially when working with strong personalities.
Aesthetics
A newly popular sub-specialty for NPs is working in aesthetics. These NPs perform cosmetic procedures such as Botox and fillers in this setting. Many NPs are opening up their own med spas to provide these services as they are very profitable. This is an excellent option for NPs with an entrepreneurial spirit. NPs looking to practice traditional medicine would not enjoy working in aesthetics.
Hospice/Palliative Care
Hospice or palliative care NPs typically serve patients in the home, hospital, or long-term care setting. They help prepare patients for the end of life and ensure comfort measures are in place. NPs in this field find the job very rewarding. They enjoy helping patients reflect on their lives.
The hours for this position are flexible and allow the NP to be mobile. An NP would have to be emotionally intelligent and be able to compartmentalize, to avoid being impacted by their job in an emotionally draining way.
Orthopedics/Sports Medicine
Orthopedic physicians train NPs to support their practice in treating patients with musculoskeletal disorders. NPs will evaluate patients post-op from orthopedic surgeries, administer joint injections, or provide casting for fractures. This sub-specialty is procedure-heavy heavy and ideal for NPs who like working with their hands. At the same time, NPs are easily burned out due to high patient volumes and having to be on-call.
HIV/AIDS
An NP can work in an HIV specialty clinic or a community health center to see HIV and AIDS patients. These patients need to be seen for routine labs and pharmacologic management. NPs who like working with vulnerable populations and utilizing community resources may find this sub-specialty fulfilling.
It can be challenging treating these populations as they often have comorbidities such as homelessness, substance abuse disorders, mental health issues, and/or poor compliance.
Infectious Disease
Infectious disease (ID) NPs are trained to treat infections with the most up-to-date diagnostics, antibiotics, and antivirals. This was a popular sub-specialty during the Covid pandemic. ID NPs also work with patients to prevent illness through immunizations. ID is great for NPs who like doing research. Additionally, ID has one of the highest job satisfaction rates.
Pain Management
Working in pain management, an NP focuses on a patient’s chronic pain and manages it through procedures or medications. They perform procedures such as epidural injections and nerve blocks through the training and supervision of physicians. This position is not for NPs who are reluctant to prescribe narcotics chronically. It can be difficult to distinguish between patients in need and those trying to abuse the system.
Urology
Urology NPs treat patients with various illnesses ranging from prostate cancer to erectile dysfunction to urinary incontinence. The NP may follow up with patients post-op in both the hospital and clinic, which may attract NPs who want to work in various settings.
There is a learning curve in urology coming from a nursing perspective, but it can be one of the least stressful sub-specialties. Working in this field can be a disadvantage when the NP has to be on-call.
Addiction Medicine
Some NPs work in addiction medicine where they treat patients with addictions such as opioid dependence and alcoholism. They can practice in outpatient clinics or detox/rehab centers. It can be rewarding watching patients progress from sickness to health.
NPs with a background in mental health will be successful in this field. In some states, NPs may be able to prescribe suboxone or other medications to treat narcotic dependence, after completing an eight-hour mandatory training.
Gastroenterology
Gastroenterology (GI) NPs see patients with diseases concerning the digestive tract from the esophagus to the stomach, to the intestines, and rectum. It is a niche field but involves various disorders. Some GI NPs can even perform procedures such as endoscopies. Job satisfaction is high, but the salary tends to be lower.
Oncology/Hematology
NPs working in oncology or hematology can work in a hospital or clinic. They manage patients with cancer or blood disorders such as anemia. It helps to have a nursing background in oncology before working as an oncology/hematology NP.
Numerous NPs find working in this sector to be satisfying. They are also well-compensated. Sensitive NPs might not do well since many patients may be terminally ill.
Dermatology
Dermatology NPs evaluate acute and chronic skin conditions. They perform procedures such as biopsies and excisions. NPs in dermatology are highly compensated and have incentives such as productivity bonuses. It is ideal for NPs who enjoy doing procedures since it is procedure-heavy. On the other hand, the patient load is high and often leads to burnout among dermatology NPs.
Nephrology
NPs who work with nephrologists manage patients with chronic kidney diseases, cancers, and those needing kidney transplants. NPs with experience working in dialysis as an RN can be successful in nephrology.
One challenge working in nephrology is that the NP may have to travel to multiple sites weekly to see patients. They usually have to see patients in clinics, dialysis centers, and the hospital. This is good for NPs who like the change in environment but bad for NPs who want to be settled in one place.
Pulmonology/Sleep Medicine
NPs working in pulmonology see patients with chronic respiratory disorders such as asthma and chronic obstructive pulmonary disease. They may also serve patients needing sleep studies to manage their sleep apnea. Pulmonology NPs have a good work-life balance and do not find work stressful.
A challenge in this sub-specialty is that the inhalers prescribed are often not covered by the patient’s insurance or have a high copay, leading to poor medication compliance.
Otolaryngology/Allergy
In otolaryngology, NPs evaluate and treat patients with disorders in the ears, nose, or throat. They can also work with allergists to manage chronic allergy symptoms in patients. This sub-specialty involves more practical work than theory, so NPs who do not want to do a lot of critical thinking would fit in well.
Vascular
A vascular NP treats blood vessels in the body including the aorta. Common disorders include peripheral artery disease and aneurysms. Vascular NPs are compensated well but are required to work many hours, which can easily lead to burnout. NPs with a background in cardiology as an RN would do well here.
Rheumatology
Rheumatology NPs serve patients with autoimmune diseases such as lupus or rheumatoid arthritis. There is a severe shortage of rheumatologists so there is a large need for NPs to specialize in this area. Providers in rheumatology have a high rate of job satisfaction. It requires someone to have a lot of patience because patients usually come in with chronic pain or weakness and are seeking answers and improvement.
Neurology
Neurology involves conditions that affect the nervous system such as the brain and spinal cord. NPs who worked on neurology floors in the hospital as an RN can easily succeed in this field. Neurology is in high demand, so there are many opportunities for NPs. However, neurology work can be challenging because symptoms can be vague and treatments are limited.
Endocrinology
Although there are various illnesses in endocrinology, NPs in this field will mostly manage diabetics and patients with thyroid disorders. Nurses with backgrounds as diabetic educators can quickly adapt to this role. Working in endocrinology involves a lot of patient teaching, so it would be ideal for NPs who love educating patients. Sadly, this is one of the lowest-paying sub-specialties.
Sophia Khawly, MSN
WriterSophia Khawly is a traveling nurse practitioner from Miami, Florida. She has been a nurse for 14 years and has worked in nine different states. She likes to travel in her spare time and has visited over 40 countries.
Being a traveling nurse practitioner allows her to combine her love of learning, travel, and serving others. Learn more about Sophia at www.travelingNP.com.